Could burnout and anti-burnout initiatives championed by healthcare institutions be the healthcare equivalent of gaslighting? "Gaslighting" refers to the act of psychologically manipulating someone to question their own sanity, in order to gain some advantage. Intentional or not, it carries significant repercussions for its targets, which in this case may be clinicians in our struggling healthcare system. Dear Doctor: Are You Stressed Out? The term comes from the 1944 film Gaslight, in which a woman's husband regularly dims and brightens the gaslights in their home while he sneaks around in the attic, searching for hidden valuables. When she asks why the gaslights flicker, he insists that they have not changed intensity and that she is only imagining it. The woman's husband invalidates her perceptions and leads her to doubt her sanity. A similar phenomenon is happening today to clinicians regarding the distress they experience as a result of the double binds imposed by the competing allegiances inherent in our healthcare system. Pro-forma surveys, used to identify burnout in other populations and adjusted for healthcare, have been widely used and revealed striking levels of distress in the medical profession. But too often, those results were not an invitation to explore more deeply and to consider whether characterizing doctors' struggles as burnout was accurate. Doctors are finding their work challenging, but we feel that 'burnout' is a misrepresentation. The term "burnout" suggests that doctors are not resilient enough or efficient enough—in essence, that the problem resides within the individual, who is somehow lacking. Doctors are finding their work challenging, but we feel that "burnout" is a misrepresentation. We believe that clinicians are not burned out; instead, they are suffering moral injury. Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the healthcare context, this transgression is caused by the need to accomplish the impossible task of satisfying the patient, hospital, insurer, and ourselves all at once. Moral injury locates the source of the distress, appropriately, external to the physician and within the business framework of healthcare itself. Healthcare systems have looked for easy fixes for physician distress, focusing on wellness (yoga, retreats, and self-care lessons), but this is misguided. Finding solutions requires that we address the problem for what it really is: a challenge inherent in the structure of the healthcare industry. Telling clinicians that they are "burned out" without acknowledging the cause of their distress is gaslighting. Years of tough education and training have honed physician resilience. We know what it takes to be well. Eating healthy food, sleeping enough, getting exercise, and being with family are good ways to maintain physical and mental well-being. Yet, physicians are repeatedly told that the problem is our lack of resilience, and that we are frustrated and disillusioned because we do not take good enough care of ourselves. But how does a healthy diet or a weekend retreat of yoga and meditation bolster our ability to navigate a broken healthcare system? Being a healthcare professional today entails managing the double binds that come from trying to do right by our patients, our employer, the insurer, and ourselves, at the same time. Often, when faced with such choices, we can't choose our patients first. Each time we have to decide to put the needs of our employer, our hospital system, the patient's financial status, or insurer ahead of the needs of our patient, we sustain an insult to our guiding purpose, which is to care for our patients above all else. The accumulation of those insults amasses into moral injury. We are being pulled in many different directions, and almost all of them are away from patient care, which is the thing we dedicated our lives to when we enrolled in medical school. Make no mistake, no nefarious entity is solely responsible for this situation. No single administrator is making decisions expressly intended to harm his or her staff. Rather, the focus on "burnout" and bolstering resilience arose in acknowledgement of physician dissatisfaction. In the absence of an alternative explanation, researchers latched onto "burnout" as an explanation, because the symptoms seemed to fit. Even better, there were well-marketed programs used in other professions, which administrators, who were also overburdened, could turn to for ready solutions to their employees' distress. Unfortunately, surveys confirmed that physicians were struggling, but most of the burnout inventories used did not assess for systems challenges that physicians were pointing out as the source of their distress. Once there was the diagnosis of "burnout," we all failed to revisit that conclusion, even though physicians continue to suffer as burnout interventions abound. One of the reasons for this is that there has been an erosion of the partnership between physicians, other clinicians, administrators, insurers, and national policy-makers in understanding the impact of policy and regulatory changes on clinical work. In most cases, meaningful input from clinicians is lacking before leadership (at many levels) makes decisions about how care is delivered, how physicians are incentivized, or how work hours are allocated. While any one of the decisions that regulators, legislators, and administrators make might be innocuous, the sum of their decisions has become a tangle of contradictory requirements in the treatment room, which in turn has led to an epidemic of moral injury as physicians try to parse the impossible with every patient encounter. The primary challenge for doctors is that we have not made it a priority to shout about our experience. Administrators' primary sin is that they are not listening carefully to what those at the front lines of care are saying, and they are not making substantive changes based on that feedback. The primary challenge for doctors is that we have not made it a priority to shout about our experience. For healthcare organizations to implement changes that truly improve physician well-being, they need to listen to how physicians experience their work life. Clinicians need to participate in focus groups, listening sessions, and truly confidential free-text surveys from leadership asking for unvarnished input. They need to watch their organization stand up in opposition to another performance metric, or another regulatory requirement, or another satisfaction survey, in defense of their staff. They need to see their practice environment change in response to their feedback or in the resources allocated to care. Physicians need to see that administrators are making a concerted effort to understand their distress and make real changes to mitigate the drivers. Administrators also should be included in the experience of delivering care as regular team members on rounds or in the clinic or in the community. Watching clinicians try to develop treatment plans while balancing all of the competing allegiances facing them would be helpful. Watching them do it for 60 hours (or more) every week, all year long, would be eye-opening. That might help them realize that we are experiencing something bigger than "burnout," and that gaslighting us, telling us that wellness initiatives will solve our distress, only alienates their clinicians. The challenges in healthcare are enormous and are felt by all involved—patients, clinicians, and administrators. It's time to make concerted efforts to understand the physician's perspective and the environment of moral distress that is the healthcare industry. Only then can we do what is really necessary: work together in the service of the patients who entrust us with their care. When physicians fail to listen to their patients and consider their unique circumstances, they risk missing important diagnostic and therapeutic opportunities. When organizational leadership doesn't listen carefully to what drives physicians' distress, no meaningful progress can be made toward alleviating it. No amount of healthy dieting, rest, or exercise will fix what ails us. We cannot outrun a dysfunctional healthcare system. Source
