Burnout seems to stalk healthcare workers; between a third and a half of doctors and nurses had symptoms of burnout BEFORE the COVID-19 pandemic. Major medical associations have recognized burnout as a serious problem and the condition is being added to ICD-11 as an “occupational phenomenon.” How did we get ourselves into this situation? How has burnout gotten so bad? In this episode, the first #HistMedConsultService, I’m joined by historians of healthcare and emotions Agnes Arnold-Forster and Sam Schotland to historicize burnout. Along the way, we’ll talk about the different structural factors that have colored burnout in North America and the United Kingdom; the disgruntled pediatrician syndrome, physician “impairment”, whether burnout is a disease, and what we might all be able to do to make everyone less miserable.
Sources:
- https://www.nejm.org/doi/pdf/10.1056/NEJMp2112095
- https://www.washingtonpost.com/outlook/2021/04/29/covid-19-only-exacerbated-longer-pattern-healthcare-worker-stress/
Transcript:
Agnes (00:00):
Sure. Um, hello, I’m Dr. Agnes Arnold foster. I’m a historian of medicine, healthcare, the emotions and work. Um, I now have a job at the London school of hygiene and tropical medicine working in the history of British healthcare policy. Um, and I have been working on the history of healthcare professional being the past four or five years now, mostly looking at the UK, but also, um, increasingly looking over the Atlantic to, uh, north American colleagues, particularly cause I just spent seven months living and working in Montreal, Canada. So I feel like maybe I have slightly more insight than I did before. <laugh> towards like outside of the pond.
Sam (00:40):
I’m Sam Charland. I am an MD PhD student in the history of science and medicine at Yale university and the university university of Michigan medical school. I’m a historian of medicine, capitalism and emotions in 20th century United States. My research is also on the, on the history of healthcare workers wellbeing, and it’s, I’ve been doing that for the last two years. So I’m much following an Agnes’s trail, blazing footsteps. I am current I’m currently on my surgery rotation, so I I’m deep, I’m deep in the bowels of the medical system.
Adam (01:11):
You are experiencing it firsthand. And, uh, just for context from everybody else, Agnes and Sam wrote an amazing piece for the Washington post about historicizing burnout and in particular, in context of the pan, uh, let’s just hop into it. Um, one of, so people for the last like five years, people have been asking me to do something on burnout and it’s always been intimidating to me because burnout has a very now, uh, I guess, a criticized definition that people don’t like to, to stray from. And it’s similar when talking about any other emotional state, like talking about depression, um, people like to have clinical descriptions and just study that. And one reason why I am so attracted to your work is you’re really putting this discussion about burnout in a much larger historical context. So this is a very broad question. Can you talk a little bit about your work and, and what that means to
Sam (01:56):
You? Well, Adam, as, as you’ve very, very much suggest burnout is very much medicalized and invoked as sort of this natural condition that we see often in with occupational distress. And there have been significant debates over whether or not this is a medical condition, whether or not this is, this is about the working environment. And you can, you can see these in, in recent debates over I C D 11, arguing about the, the relative, the ontology of the, um, condition. So for, I think for both of us and I’ll, I’ll, I’ll speak for, uh, my perspective, at least as an American historian. What I’m interested in and is, is trying to write what we would call sort of a pre-history of the kinds of discussions that are, that are going on surrounding the emotional costs of care in American medicine. The kinds of questions I I’m fundamentally interested in are how have doctors, social scientists and the lay public made sense articulated and ultimately tried to shape, uh, implement policies surrounding how doctors, uh, regulate their, uh, respective affect and emotions.
Sam (03:00):
What does in turn, does that tell us about changes in the structure of clinical practice, the practical business of medicine itself, changing notions of masculinity, gender in the family, commun in com what we would call communities of emotion. One of the things that, um, I have learned, and especially in, in working with, uh, Agnes, is, is that when we, when we talk about emotions, historically, these are, these are not imutable entities. The, these are things that are, that are socially defined and art and articulated. And because it’s history change over time, burnout is isn’t this a historical definition? I mean, yes, it coined by Herbert Friedenberg, who was a clinical psychologist in 19, in the 1970s, in the, in York bonds to the stresses that, um, people were facing in the free, uh, clinic movement. But, uh, it very much follows within a longer genealogy of ideas about overwork and devotion to duty and vocation.
Agnes (03:51):
Absolutely. I mean, I think Sam really got to the heart there of what it, but it means to be a historian of, of both medicine and the emotions, right. Which is to see these things that are, um, have acquired an aura of as Sam puts it imutability or kind of permanence or a historicalness. Um, and that actually both emotions and medicine, both the kind of content of clinical practice, but also the sort of structures and myths around healthcare are profoundly historical. And have Sam said changed dramatically over the course of history. I mean, even this is sort of taking a very broad brushstroke look at it, but something like happiness and only really became something that societies or individuals sought to achieve in their lives or sought to be a kind of like cultural or social normal expectation around enlightenment. And, and so they were idea that people should expect to be, have a sense of wellbeing or satisfaction with their lives is itself a kind of historical phenomenon.
Agnes (04:48):
It kind of has no permanence in like the sort of great mass of human history and, and burnout is another example of these sorts of deeply historical contingent, socially contingent, culturally contingent feelings. Um, and it didn’t crop up in the 1970s. It wasn’t kind of invented or named or articulated or diagnosed for the first time in the 1970s, just by coincidence or as a product of kind of like a natural progression or teleology. It was in response to very specific kind of 1970s things like different ideas about, about, um, stress, about healthcare as a system, as an industry. Um, and other kind of more like material qualities of healthcare, you know, healthcare changed very much over the middle decades of the 20th century. It became increasingly systematized industrialized, which, you know, had both to both good and ill effect. Um, but one, the consequences of that is that you increasingly see you increasingly had healthcare professionals seeing themselves as workers, as laborers, as people within a system, within a structure, rather than kind of the, in like the independent gentleman physician of earlier periods, both of these identities are of course, you know, to certain extent, myths, right.
Agnes (06:02):
Kind of like imaginings, right? They’re not necessarily, they don’t necessarily always reflect the reality of people’s day to day working lives, but there are big historical and big kind of cultural and political and economic, um, sort of sways of stuff that underpinned is sort of what feel like very biological or physiological transitions. Um, and none of that is by the way to say that like the body has no place in all of this, right? It’s not the weird, well speaking for myself anyway, I’m not rejecting out hand that there is a certain degree of like biological essentialism in these things or that the break like brain chemistry doesn’t exist or have a certain sort of exert some sort of influence say the way we feel and process the world. But what I would say is that culture and society, it is impossible to pass or understand or communicate how we feel about things, whether that’s good or bad, or, you know, pathological or normal and healthy without doing so through this, you know, deeply, um, murky lens of society and culture.
Agnes (06:57):
And so the history of emotions and the kind of intersection that me and Sam sit at between the history of medicine and history of emotions is all about kind of unpacking that like really murky mist between sort of biology and culture about, you know, how do we process these sorts of, you know, how, how the way that we thought about our bodies and our minds and our emotions changed so dramatically over time. And I, and, and also partly like why have some things achieved the kind of status of natural or achieve the kind of status of, oh, that’s a clinical diagnosis that we can now make, you know, why that thing and not another, you know, why do we diagnose something, someone with burnout and not with, you know, frustration or some other kind of like emotional response to normal life that we see as part and parcel of the every day and working at the moment on the history of nostalgia, which is a great example of this, um, which in the 19th century and before was a disease that killed people.
Agnes (07:49):
It was a pathological diagnosis. The last person to di be diagnosed with and die from nostalgia did so in the Western front in 1917 in France. But obviously now we see nostalgia. It was a very normal, um, every day, um, emotional response to change or transition or something. Um, and it is absolutely not a diagnosis. It is not a pathology. It is a part of normal life. Um, so nostalgia sort gone in that other direction and burnout right. Reversed itself, but all sorts, there are all sorts of examples of, of emotion having these kinds of histories or emotional states or emotional kind of diagnoses having these sorts of histories. Um, and that’s why our job is so fun. <laugh>
Adam (08:28):
You, uh, you have a very receptive audience here of, uh, of diseases being social, uh, <laugh> social constructs. So hopefully, hopefully you won’t have too many people disagreeing with you on that. I wanna talk about the construction of the idea of burnout because the language of burnout comes in the 1970s. But one thing that both of your work has shown is that we’re having very similar discussions using different language in the decades really starting. It seems, I, I mean, starting in the early mid 20th century, which is, is that accurate? Yes, absolutely. And how, what sort of language and what sort of like nos logical construct are physicians using to talk about their mental health in this period? So starting in the, the early mid 20th century.
Agnes (09:09):
Yeah. Well, so I can speak with, um, more authority about Britain. Um, but there’s a lot of common between, um, Britain and the United States or elsewhere north America, um, and Europe, but the technology most often used in Britain in the kind 1940s and 1950s and 1960s is morale, um, which feels sort of, you know, quite antiquated, but very much had this idea that there was a certain degree of gumption. And like, I suppose what we had now refer to as resilience that keep that you had to kind of keep, um, healthcare professionals morale up, um, and that there are various sort of drains on that morale. There were sort of like, this was a kind of finite resource that could be sapped or replenished. Um, and there’s an increasing anxiety that staff morale amongst the healthcare professionals in Britain, in the NH, the national health service was declining, particularly after the foundation of the NHS in 1948.
Agnes (10:00):
And as medicine became, as I mentioned before, more industrialized, more systematized, more nationalized <laugh> that, that was again, turning doctors from these, um, you know, sort of gentlemanly family doctors, high status hospital, um, consultants into this kind of car draw of a workforce that was now being deployed in certain ways to serve certain national, um, needs. And that much like the army, which again also has its own sort of sense of morale that you have to keep up the medical army. The medical equivalent was also having its morale drained by certain kind of big structural forces that were going on in, in British healthcare at the time. Um, and we can probably come back to the parallels between the linguistic or cultural parallels between the army and healthcare, um, later, because it is a relationship that crops up repeatedly through history, energy did so in the 19th century before as well. Um, but yeah, morale is really determined. People are using, which is also very different from burnout, right? Because it’s not a pathological condition, right. It’s not a diagnosis, it’s not something that you can be therapized out of. Um, and in some ways it’s more, um, I’m more sympathetic, I suppose, to the idea of morale than burnout, because morale is about a kind of, um, larger population level, right. Condition rather than an individualized,
Adam (11:20):
Right. An army is affected by low morale, not an individual it’s, it’s the solutions by nature have to be structural.
Agnes (11:26):
Exactly. Yeah. And the way that people were talking about morale was not so much, oh, this guy in this hospital has low morale. It was the NHS workforce as a whole has low morale. And this is something we need to address yeah. At a population level at a national level, at a public health level, rather than yeah, exactly. Like dealing with individual doctors who might need, you know, certain types of therapies or whatever,
Adam (11:46):
Uh, Sam, any, so in north America, any difference in this sort of language in this period, it’s very interesting. So, um, in the United States and
Sam (11:53):
North America more broadly, um, morale, isn’t the language that’s being used is quite interesting. It’s far more, uh, um, if we, if we want to use anachronistic language about more individual responses in the late 19th, early 20th C in the, in the states as, uh, historian, Rupe, uh, like has shown doctors were, or, uh, talking about is the issues Sur surrounding physicians, suicide, uh, commitment to duty. And certainly by the time you get to the early mid 20th century, people are, are the language of stress and strain pops up frequently. Now of, of course, when we think of stress again, um, referring to this sort of tension between naturalizing it a biological condition versus just trying to describe something, uh, Hansell the, the, the great, um, physiologist was doing quite a bit of, uh, of his work on the, sort of on what we think of as the stress access in the hypo pituitary terms for our medical, for a medical audience, and trying to make sense of stress and of a longer tradition of physiological tradition of, of understanding things that like a Walter B Canon would call fight or flight and trying to make sense of this.
Sam (12:56):
So this language around stress is certainly, I mean, certainly people are using stress like very casually, but it enter, it enters into the American medical profession in the forties, in the fifties. Uh, and certainly, certainly, I mean, if you, if you look earlier, I wouldn’t be surprised if, if you found stuff, but certainly by the forties and the forties, fifties, and sixties, stress reign, discontent, dissatisfaction, these are all terms that are, that are being bandied and used by a variety of different actors. And it’s interesting be because, uh, I’ve talked to, I’ve talked to Agnes about this, depending on which terms people are, are using suggest or inform their partic a particular, uh, political leanings or, or philosophy. Um, so for example, I, Adam, I, I see, you’re getting very excited about this, for example, uh, and this is not just for doctors, but this is for nurses who there was a lot of, there was a lot of interest in the 1930s, but really post world war II in ideas about, um, nursing satisfaction.
Sam (13:48):
And there are different nursing theorists who are relying upon different business theorists to, to more or less talk, talk about what counts as satisfaction, what doesn’t count as satisfaction or dissatisfaction. And when you go through the primary sources, it’s very clear that they have different allegiances to these D these competing ideas. And similarly in medicine, uh, the people in nursing are, are citing certain kinds of business theorists and the Medi and the medical people are citing different kinds of business theorists. So that’s also quite, that’s also quite interesting. So what we mean by content dissatisfaction, TDM, um, disgruntlement, um, there’s a great term that I, I have found I have a paper that’s forth forthcoming, uh, which, which looks at so sort of, um, uh, this, this idea that, that was being coined in post world war II, American pediatrics of the quote unquote disgruntled pediatrician syndrome.
Sam (14:35):
Yes. It really was a, yes, it really was a thing going, I mean, is this a pathologic diagnosis? Would it not, not an emotional state? This is actually a purported diagnosis. Its interesting. Yeah, it’s, it’s interesting cause it’s meant sort of facetious, but it, it, but it, but it blurs the distinctions between a pathological diagnosis and a, a social condition and, and the context in which that is happening is that in post world war II in the post war two world war II, United United States, you’re seeing increasing specialization, you see new emphasis on, on, on children’s health in terms of with the decline of transformation of certain kinds of classic childhood infectious diseases. That’s of course not to say in the thirties, through the fifties and sixties that you, you don’t see, uh, rubella and polio and, and other things, but certainly certainly with, with, um, vaccination of public health and most importantly, PA public health measures that you, you see the decline in, uh, other infectious diseases, but you see all these changes going on in, in American pediatrics.
Sam (15:28):
So you have the rise of specialization, you have changes in, in disease, demographics, you have new areas of expertise. People are, are becoming increasingly interested in, um, development and behavior of, of ch on the psychological issues of children. And you also, and you also see, uh, new distributions of, of work in an acute mismatch between practice of hospital medicine that you, you would get as a resident. Um, what we think of a, uh, as sort of residency training also is a relatively new invention in terms of graduate medical ed training or formalized. As we think of like in the 18, 1890s, there’s certainly precursors to this for far earlier, but what we think of as residency training. But anyway, it’s in, in this, in this context that you have all these pediatricians who are, who are getting very upset and they’re like, this is not what I signed up for.
Sam (16:13):
I, I don’t want to have to, to deal with the clinic, the clinical TDM. I don’t wanna have to deal with how with certain kinds of house calls, I don’t wanna have to deal with anxious mothers, which of course is a tension between is a classic theme and the history of, and the history of children’s health, uh, and history of medicine, more broadly about expert experts versus layman. And about the, the inform, the informed patient of inform the informed consumer. And it’s in this, it’s in this context that, that, uh, pediatricians like starting in the fifties are start writing, writing about the fact that the they’re so dissatisfied to the point that people, uh, that you, you hear the language of disgruntlement, uh, and there’s, and there’s a fierce, fierce debate about this. Cause, um, there are editorials being swap back and forth and back and forth arguing about, uh, oh, are you’re not made of Sterner stuff.
Sam (16:58):
You, you need, you need to grow a pair and, and keep going, or no, no, no, no, no, you, you, uh, I think there there’s something to this. No, no, no, no, no, there’s definitely not something to this. So they’re fighting back. So they’re very clear that that there’s something very much at stake at the, in the soul of, of, of American pediatrics or even American medicine broadly. Uh, and certainly what’s interesting about this is that this language courses through American pediatrics, all the way into the 1980s, in which by the early 19, late 1970s, 19 early 1980s, there’s even term there’s even, uh, overlap between or, or between terms like burnout and the disgruntled pediatrician syndrome even mentioned in abstracts, there’s this, uh, one abstract that, that, that talks about essentially how, uh, the disgruntled pediatrician syndrome is, is a, a big problem. And we wanna understand pediatrician burnout. So there, these competing ideas are very much overlapping and they reflect these sort of older genealogies and, and, and things that that are, are intersecting. So yeah, so physicians, healthcare workers are, are articulating their own notions of discontent and disgruntlement and, and, and that’s of course, just from a workforce perspective. And, and then in terms of how it gets medicalized, that’s a whole, that’s a whole other discussion, which we can, we can get into.
Adam (18:04):
And for both of you, correct me, if I’m am wrong in this assumption, it sounds like the way for, um, when there are great debates about how we should provide healthcare to a population where infectious disease is no longer the main driver of human mortality, there’s two different understandings or different understandings in the UK and the United States UK, and understanding a very militarized understanding of as a workforce in general, which at least in me makes sense, given that there at least seemed to be a consensus on the way to provide healthcare in the United States, a much more individualized understanding of physician distress. It sounds like mm-hmm <affirmative>. And again, that seems at least to me, in my, um, you know, my understanding of postwar debates on, on health systems that seems to mirror the debate that was going on in the United States at the, at the time on how we should provide healthcare. Do you agree with that? Or is that overly I’m sure it’s overly simplified, but is that at least somewhat accurate?
Agnes (18:56):
I mean, I would say that, um, in Britain you definitely have these sorts of parallel strands, right? Because one of the things about the national health service is that it was sort of introduced in spite of doctors rather than because of doctors. And so a lot of doctors with very against the nationalization of their practice, or as a kind of, um, demeaning, a kind of reduction in their social status that they’d worked very hard to acquire, um, and famously ni Bevin, as opposed to have stuffed their mouths with gold to prevent, to kind of encourage them to, to come within the healthcare system. And general practitioners are ill op you know, are not employees of the state, but run their own independent organizations, um, GP practices. Um, and so there is a kind of, there’s a sort of tension right between how people are kind of talking about the NHS as a whole and how individual doctors, specifically doctors are conceptualizing their own work and their own emotional wellbeing.
Agnes (19:50):
The wouldn’t necessarily use that phrase because you also have these other big sort of trends that are going on at the time in terms of like things like occupational health and trade unionism, which you really don’t see quite the same in the United States. You don’t see them, obviously doesn’t follow quite the same trajectory. Um, most doctors in the UK are, and nurses are members of the trade union in Britain. And that’s obviously not the gay is in the U in the us. Um, so you have this sort of shift in the, kind of around the 1940s when people start doing less and less manual, um, jobs and more and more office space work, um, and increasing turn in occupational health towards, you know, the kind of pressures of the mind or emotional consequences of labor rather than the physical consequences of labor and occupational health is often driven through trade unions.
Agnes (20:35):
And so there are very powerful trade unions in Britain, particularly in healthcare, um, who advocate for kind of collective measures or kind of collective standards and increasingly powerful junior doctors. So people at the very outside of their careers, it’s obviously quite different again in the us and the UK in terms of the like medical career path, but nonetheless who are often very, um, powerful advocates to their own kind of collective wellbeing rather than their own individual wellbeing. But there is also that kind of pattern of a very individualistic kind of old style doctor who still conceptualizes what they do as not really work, but as a kind of vocation or as a calling or as a sort of, you know, as something very different, you know, they would not want to be lumped into the sort of Traian movement of the postwar period. They are not the same as, or they would not see themselves as the same as minor Israeli workers.
Agnes (21:22):
Other aspects of the kind of postwar social democratic state are different and they are special. And so therefore the problems they face are also unique and also individualistic. Um, and often those sorts of problems are reactions to precisely this kind of systematization of healthcare, right? There’s people see, there’s sort of opposition to this idea that, you know, that we should be seeing healthcare in this sort of like industrial sort of machine kind of process of the delivery of healthcare, the nationalization standardization of healthcare. Um, and so while I do think there are some very powerful alternative narratives that happen in, in Britain, in the postal period that are very, very different from the United States and kind of mean that we sort of end up in quite different places. There is also this other very powerful strand of thinking that I think aligns with the all kind of like more America model, which is this sort, very individualistic, very kind of like the disgruntled pediatrician, exactly.
Agnes (22:14):
Whether they didn’t use that language in Britain, they’re definitely gonna be, I’ve done all history of interviews with people and read primary source material that talks about exactly that in that exactly those sorts of terms, like how dare you, you know, impeded my work as a expert professional who is know equipped and capable of deciding my own passion of work or, you know, whatever I don’t need government or policy makers telling me how to run my day, how dare you, this is the kind of source of my disgruntlement rather than, oh, this is a kind of statewide problem of, of a collective workforce, if that makes sense. Well,
Adam (22:44):
That makes perfect sense. I’m I’m curious. I, so when do we start to see, cause because one of, of the, one of the things about the burnout discussion is that burnout, I think explicitly pathologizes a lot of this. When do we start to see that transition from talking about emotional states from talking about morale, to talking about, uh, burnout as, as more of a, of a pathology of, of what, I mean, as Sam talked about in the beginning of what we’re now starting to talk about as a disease,
Agnes (23:09):
It’s a kind of easy answer in some ways, or like maybe a simplistic one. And again, this is a broad brush stroke response, but like 1980s, neoliberalism is really the kind of moment when, um, these very individualistic and very pathologizing and medicalized narratives kind of come into play particularly in Britain. And that’s also part of a product of like a very different care under Thatcher. The conservative government in the 1980s obviously changes the way the healthcare is run and conceptualize and thought about. Um, and there is kind of a tend shift in the way that at least in kind of medical journals and other kind of pieces of medical primary source material from the era, the way that like things like wellbeing and burnout are discussed. And you see, I’ve written a little bit about the emergence of resilience as a kind of rhetoric and as a kind of bit of terminology, which I think is very, is not the same as burnout obviously, but it has a lot of similarities in terms of how it, what kind of image it presents of an individual worker or as in kind of who is responsible for somebody’s wellbeing and under kind of resilience rhetoric it’s often seen as a kind of personal quality that someone either possesses or doesn’t possess and that a quality that perhaps can be selected trained for and assessed rather than something that like, you know, the, there are lots of, um, other kind of healthcare thinkers more recently, especially who start started to talk about resilience as a, you know, you have a resilience organization or you have a resilient, um, workforce rather than a resilient individual, which, you know, definitely tracks more closely to the way that I would think about a sort of useful and productive way of talking about those terms.
Agnes (24:42):
Um, but resilience rhetoric really only emerges. It emerge late eighties over the nineties and into the early two thousands. Um, and it’s very hard not to see that as part of a kind of broader, um, individualization of, in all sorts of areas of life economics, do politics, do you know, popular culture or whatever. Um, so I would say that that is the kind of real turning point in a way people start to think about the emotional health of healthcare in Britain, but also in the United States. I think there is an increasing kind of medicalization that happens around that kind of time. I have more to say on the topic of medicalization, but I’ll come back to it, apex <laugh> I feel like I’m jumping the gun, but yeah,
Sam (25:18):
Yeah, no, I, I completely, I completely agree. I completely agree with Agne the way I would frame it is that cer certainly a social understanding of can addition ver versus a medical understanding or medicalization, certainly people are, are talking, um, uh, by the 1950s through the seventies, there’s this flurry of studies focusing on, uh, on doctors, mental health. And, um, they’re interested, they’re interested in questions of, of mental health, uh, of addiction of impairment and these anxieties re reflect questions about substance use. Also anxiety is about, about the decline of the, the American, the quote unquote golden age of American medicine. Uh, which of, of course like, like as Agnes says is yet another myth that needs to be punctured. Um, never existed, never existed, never golden age has never existed stories. We tell ourselves, oh, that our current anxiety indeed very much indeed Dr.
Sam (26:10):
Rodman <laugh> yeah. You, you know, all the things I get on about just a little bit, just a little bit. So, um, you have, you have all these anxieties that are percolating by the time you get to, to burn by the time that burnout is sort is sort, is sort of being discussed in the 1970s. Certainly the colloquial understanding burnout is showing is showing up in, in the late sixties. I mean, I mean, you have Graham green writing a, about a burnt out case, the, the British author, and certainly, um, these terms were, were being in invo, uh, being in invoked and used in pars elsewhere, uh, like ag, like Agne says it’s in the it’s in the seventies. Uh, the rise of, of burnout is in this is, is at this very particular moment, uh, in us history as well, as well as in, in sort of Anglo American history in, in which this is after sort of, uh, this is post industrialization, uh, certain kinds of jobs that, that in manufacturing and steel and, and other and other sectors are drying up and then certainly have been in the forties and the fifties.
Sam (27:07):
And this is, I leave this all to the, the historians of capitalism, but it’s at this moment that you see PE uh, people turning into as Agnes, but it’s to more office space jobs and se and human services. So there’s, this post-industrial turn for labor, but there’s also this turn to emotion work. And that’s why it’s so interesting in, in, in the seventies that, that people grasp onto burnout, especially because, I mean, when the term, when the term is introduced in the, in the seventies, the context as I think we alluded to earlier in, in our discussion was in the free clinic movement in, in, in which you have social workers, uh, aids, clinical psychologists, and others who, who are trying to help those individuals who are struggling with, with substance use disorders and getting adequate healthcare, all of that, and, and just, and feeling depleted and having a, a sense, no matter how much they, they do that, there there’s something that’s missing and, and Freiberger, the psychologists do coins.
Sam (28:01):
This term thinks of it as a Sy as this sort of drum. So it very much plays into these changes in sort of postindustrial labor. It, it plays into ideas about in individualization and certainly by the, the seventies and into the eighties, you, you, um, uh, with neoliberal, uh, in the states with the rise of, of Reagan and political supporters, you sort, you see this sort of transformation as well, certainly by the eighties and nine, these, uh, you can see this, this emphasis on burnout, but the indivi, the individualistic tendency, the atomizing tendencies within the United States are, or even early, like you can see earlier too. Would
Adam (28:35):
You guys wanna talk about medicalizing and pathologizing now? Because I think that’s what the last, let’s say, 15, the debate, the debate since I’ve been a practicing physician have been
Agnes (28:43):
About. Absolutely. Um, I mean, I think one of the, I suppose the like big, well, it’s like caveat, but it’s an important thing to kind of recognize when we’re talking about these things is that I definitely think it can come across as though I am very against medicalization as a process, right. That I think it’s bad that they are these new, emotional problems that are pathologized and diagnosed and then whatever. Um, but I don’t think there is anything inherently wrong with medicalization. I think the problem is, is that what you do next? Um, you know, what do you do with that thing that’s being medicalized? Because I think one of the things that, you know, lots of people who, um, have various different like mental, uh, health disorders or, or psychiatric disorders often actually feel as though they are under medicalized, right? That there aren’t, they aren’t sufficient be managed.
Agnes (29:26):
They aren’t being managed by their healthcare professionals appropriately. And there is stigma around, you know, psychiatric care, psychiatric, psychiatric, psychiatric drugs, all those sorts of things. And so the problem isn’t like medicalization because medicalization could lead to, you know, much more effective and compassionate and interventionist treatment that resolves these problems in a really fundamental and caring way. But I think one of the problems that you see that Sam and I have talked about this before in the healthcare kind of world, is that you have this increasing pathologization of particular emotional responses to working conditions and the solution is not okay, well, we’re gonna provide, you know, robust, therapeutic support we’re going to provide in, you know, so a big, um, there was a big move in the 1970s in Britain to provide in-house counseling services for all healthcare professionals. In all hospitals, the occupational health would have a whole kind of emotional health arm to it that it would be very, um, you know, sort of interventionist and kind of like proactive about caring for the emotional health and wellbeing and the mental ill health of its a it staff that never really happened partly because of funding constraints, but that kind of response to medicalization, right.
Agnes (30:29):
I think would be great. <laugh>, you know, that would be a solution to a problem that would be identify identifying a problem and then finding a solution to it. But I think what actually happens is that you have a kind of partial medicalization where you have the diagnosis and the identification of the problem without the kind of like appropriate medical response to that problem. So you often, so Sam has written, Sam can talk about this in greater detail, but you know, you have the identification of doctors and other healthcare professionals with certain, you know, the diagnosis of certain mental illnesses or substance use problems or depression, suicide idea. And then you have, okay, well therefore they are unfit to practice as doctors and they’re excluded from the profession rather than saying, okay, well, we’ve got a, you know, a Carter of people that have a series of like medicalized problems, we’re gonna use the great weight of medicine to resolve them.
Agnes (31:16):
Um, and I think that is where I think the kind of like promise of medicalization falls down and it’s not the, like in the first place, but the solutions that are then, um, proposed, um, and that is coupled where they think, you know, some other problems of solutions, which are often very piecemeal patchwork, again, very individualistic again, rather than structural or, or, or collective, or sort of understand sort of sources of these. A lot of these problems, you know, burnout is often a risk response to, you know, working conditions, right. And so the solution then is not, you know, there’s nothing wrong with medicalizing burnout per se, but if the solution to that medicalization is okay, well you need to go and sort yourself off somewhere else, or, you know, you need to go and like undertake some sort of like therapeutic treatment on your own time, um, rather than saying, okay, well, we’re gonna a provide you with the emotional support. You, you need them to deserve one B fix the problems that are, you know, structural and inherent in the first place. Um, so yeah, I suppose my issue is not with medicalization, but with like kind of like incomplete medicalization or kind of abortive medicalization that doesn’t actually do the thing doesn’t fix the problem it’s identified in the first place.
Sam (32:21):
Yeah. Agnes, you put it beautifully. I think, I think so, Adam, I’m gonna, what I’m gonna have to add is, is, I mean, I think a Agnes is I think encapsulated pretty much everything. I was gonna say, uh, a board of medicalization or incomplete medicalization. That’s exactly right. One thing to, uh, to add, I, I think which will hopefully make the, the discussion in the us little, perhaps a little more, more nuanced than my part is that certainly yes, there there’s this emphasis on individualism, but a lot of the, a lot of the efforts to promote, ultimately what we will think of as physician wellbeing are coming from organized medicine because the stakes are very real because if your doctors are unhappy and they’re, and the boogeyman of the UK much more attractive, or, uh, if, if, um, they’re facing malpractice suits in the 19, in the 1970s or, um, substance or dealing with substance use, uh, that’s a threat to the autonomy and the legitimacy of the profession.
Sam (33:12):
It requires the profession to have a response. Now, of course, what does that really mean? Certainly by 1973, uh, the, the American medical association is promoting a, a lot of, uh, model legislation and conferences on the impair on the quote unquote, the impaired physician. And so, and certainly a, a lot of the, uh, the intellectual history in terms of stuff that would be developed on physician wellbeing. I is being done under, uh, the EISs of the AMA of course, how much the, the AMA pushes for this or implements implements. This is another question and it, I think it, arguably we can argue that there’s certain parallels to what’s going on today. So I, I would say that, and then in, in terms of the incomplete medicalization, yeah. As I agonist, um, referred to, I I’ve written, I’ve written about how in, in the latter half of the 20th century were increasing, um, medicalizing or di uh, diagnosing, um, physician depression, SU uh, death by suicide anxiety, um, and, and, and substance use.
Sam (34:13):
And the response was very much, okay, well, if, if we, if we medicalize this, we can, we can get ahead of the American can people. And the, our solution is we’re, we’re going, we’re gonna create what we now think of physician, uh, health programs. We’re, uh, we’ll try to rehabilitate people. We’ll also have a disciplinary arm of the, me, of our, our, our state medical societies and the federal boards that will, that will also deal with this. But at the same, at the same time, the people who are pushing, uh, more robust, uh, mental health and rehabilitation had, interestingly had not intended for it to be as pun, uh, for these measures to be as punitive as they ultimately would become. It’s very much a story of historical contingency of what could have been when I’ve been lucky enough to, to talk to some of the veterans of these debates who are now, who are now in their seventies and eighties, they’re they talk about it? It’s like, oh yeah, what we did was great. We, we had this issue and, and, and, and we started to deal with, to deal with it. And of course, when you, when you talk further and you say, well, uh, the PHPs are perhaps are going, are being interpreted in ways that they weren’t intended. They were like, oh, that’s not good. That’s not, that’s not what we intended. So yeah, it’s, it’s, it’s there, there is this, there is this, this fundamental tension at, at play. I
Agnes (35:24):
Think that just to quickly make kind of sweeping statement about it, if you are a historian of medicine, is that you’re constantly battling these like very simplistic narratives about the past. So either that the past was, you know, this sort of nostalgic rose vision of a golden age, you know, I, you know, it was all better then, um, or you have these ideas that like the problems we are facing and the solutions we’re coming up with, and the debates we’re having now are brand new, and we’ve never had these discussions ever before. There’s never been a moment in the past that maybe as you know, Sam said was actually very promising and there were these great ideas as it never came, came to fruition or did come to fruition, but everyone’s forgotten about it. Um, and so I think that that is like one of the things that is like interesting to me, especially as someone who works on the history of medicine, but also spends a lot of time with currently practicing healthcare professionals and policy makers is that, you know, the, the past can be deployed to serve all these sorts of different like needs, right.
Agnes (36:17):
That there are people who are like characterizing their current, like sort of situation in very stark terms, by comparison, by comparison, to, to what they think has gone before. And actually often they have no idea what went before. <laugh>, you know, very sort of sweeping sort of statements about, you know, what did or did not happen. Um, and, you know, it’s, it is a great, this past can be a great resource, right? Cause it can be both the kind of corrective and misunderstandings, but also can be a source for like great ideas that didn’t kind of come sort of figure out. Um, you know, I think it’d be great if there were like in-house counseling services for all healthcare professionals and, you know, didn’t have a direct line to the, um, GM C our, our regulatory body in the UK. Um, and that was an idea and just never happened, but, you know, it’d be good if it did <laugh>. I mean, it does actually the protection NHS now does have a practitioner health program that basically does do that. Um, but there’s only SAP in the last couple of years,
Adam (37:04):
But yeah, that is the reason why I haven’t talked about burnout at all until you, until I have you guys on the show because I have so much trouble with the way we de historicize burnout. And I think it’s harmful. Yeah, well,
Agnes (37:14):
Exactly. I mean that, that side, so the thing I was gonna say is that exactly. I think what you just said, Adam, is that these historical narratives, you know, the reason that they get my backup is not because I’m particularly protective or defensive about my, you know, chosen field. Although obviously I am, um, it’s because they do actually do real harm and they do harm to precise, to the things that current, you know, wellbeing activists or whatever are trying to, you know, they’re trying to fix, right. And that’s because if you have this vision of a medical past, like a nostalgic vision of medical past, where you say, well, there are these certain models of healthcare, there are certain systems of healthcare, you know, that, that actually were like, blisful that nobody in the 1960s was ever unhappy or discontented or miserable, or some version of burnout or depressed or suicidal or whatever.
Agnes (37:59):
Then you think that the solution to the current problem is to return to something that looked like that, or that we need to recreate some of these sorts of visions of what medicine worked, how medicine worked, how medicine functioned, and that is in itself, like incredibly harmful. Um, I’ll give you like an example. So one of the project I worked on before my current role, um, I was working specifically on surgeons, surgeons, ideas about their emotions and emotional health. Um, and there, there it’s very powerful narratives in Britain, but they also happen in the, in the us whereby surgeons think that the real problem they’re facing now, the kind of problem that caused the sort of decline in emotional health is a decline in, uh, autonomy and decline in deference and decline in hospital hierarchy, right? That those are the things that have made being a surgeon much worse.
Agnes (38:43):
Obviously this is a generalization, there are a lot surgeons who do not think like this, but generally speaking that is like, I hear that over and over again, these are the big problems with the, you know, decline. This is why surgeons are so unhappy or so discontent with their current working position as these three factors, but you don’t have to spend very much time at all in the archive to recognize that in the kind of golden age of autonomy hierarchy in deference, you have surgeons who are just as miserable and just as unhappy as they are today, they just have different sort of sources and, and, and, and consequences and frameworks for thinking about that sort of ERY or dissatisfaction. And so if you, if you, if your model of the medical pastor is like, oh, well, there was this good old days where everything, everyone was, you know, happy and, you know, happy go lucky or whatever, um, then you think, oh, well, we have to go back to that. But the medical, uh, historical evidence just quite simply like counters that entirely. Um, and so I think it does matter, you know, how people think about the, the past of these things. It’s not just about writing good history, which obviously I think is an important goal in and of itself, but also it does have kind of bad consequences for how we think about wellbeing, how we improve the state of the emotional health and wellbeing of the healthcare workforce. In other Britain of the United States.
Adam (39:49):
I was gonna ask both of you a very unfair question, but, uh, make it clear that it’s an unfair question. Sure. Do you, do you have something
Sam (39:55):
To say first though, say what I was gonna say is, is I think one of the tremendous problems and is sort of talking about, um, this tension, again, this tension between the quantitative and the qualitative and qualitative metrics for, how do you, uh, uh, how do you talk about emotional stress or burnout and, uh, and what counts as legitimate knowledge? You have studies starting in the fifties with like abundant data, talking about healthcare workers, distress and emotions, and all the way into the 1980s, where you have this thing called the, the national physician suicide study run by the AMA gathering res of data. So much, so much data on this. And yet the thing is, is the reality, uh, is that, um, this much of this work is dismissed by contemporary audience is because it’s not seen as rigorous enough or robust enough. And, and it raises questions about what, not, what knowledge counts as robust, uh, and what, what knowledge is can see is seen as valid, which of course raises the question about, well, why are historians, why don’t we have a, a history of medicine consult service that we can page?
Sam (40:55):
Uh, that’s just as legitimate as, as the biostatistician that, that we keep on, uh, on retainer or the, um, interventional radiologist who, who does a tips procedure, uh, agonist. I can tell you about that. The tips thing later, it’s, it’s, it’s a HIPPA, it’s a hepatobiliary thing. It’s, it’s for treating portal hypertension. Anyway, we’ll get to that later. Anyway, uh, um, that was, yeah, that was mainly for Adam, but, um, I get it. Yeah. Yeah. So I, I think for, for me, I, I, I, I, I, I think there, there’s a, there’s a real qua of the kind of role that historians and humanists and social scientists can play in influencing and affecting healthcare policy.
Adam (41:33):
I’m gonna page the historical, the medical historian consult service now, and I’m gonna actually start with Agnes and then throw the same question to Sam, cuz Sam is experiencing a very different context because he’s being acculturated in medicine right now. So Agnes and Sam, my question for you, imagine that the healthcare leaders of the United States or the UK have asked your opinion as medical historians, who study physician wellbeing, taking a historical perspective and they are taking you seriously, and they want to know what your recommendations looking at, you know, historical and societal contingencies, what would you suggest to help? I mean, I don’t even know if it makes sense to talk about combating burnout, but to make physicians less miserable and nursing and other healthcare by, but physicians in particular given the, uh, this for the American college of physicians.
Agnes (42:17):
Um, so I definitely have some unpopular opinions on this <laugh> topic. Good. Um, I’ve got two main things and I’m very happy to argue with people about them, by the way, in case any of your listeners think that I’m big tutorial, I’m happy to debate. The first one is the robust working time restrictions. So, um, I think that that needs to be, I don’t have to go into it. I think that is, I think that speaks for itself. <laugh> yeah. We’re talking about, you know, working conditions that is a structural intervention that is designed to improve the working conditions of people. Every other discipline, every other profession has a version of working time restrictions. I don’t see why doctors should be any different there obviously do need to be, you know, substantial other policy interventions that make that possible and practicable practicable. Um, but that is I’m, that’s what I’m saying and I’m sticking with it.
Agnes (43:02):
Um, and there is also precedent for it, right? The European union introduced their European working time directive. Um, it’s opposed in Britain. I think it’s good. I think it’s a good thing too. I think that the doctors and other healthcare professional us should be part of trades. I think collective bargaining is the only way to improve working conditions. It has historically been proven as a way of improving health working conditions. And again, I don’t really understand why, uh, well, I do understand why, but I, I think it is, um, an obvious, uh, not solution to the problem, but a way of addressing kind of conceptualize the problem in a different way. And both of those things, um, are part and parcel of a broader kind of maybe conceptual shift that I would like to see that I think is happening to a certain extent, um, which is a reconceptualization of healthcare labor as precisely that labor, um, as not the sort of special practices of an elite profess or, or a vocation or any of this kind of stuff, but as a, as a job that has limits and restrictions and can be delineated from your life.
Agnes (44:06):
Um, so that thing of like work life balance, um, also requires a kind of, sort of a recom compartmentalization of what your different areas of your life are. Um, and I also just finish back that by saying that academics, um, are also terrible at this. I’m
Adam (44:20):
Terrible at this <laugh>. I mean, it’s Sunday morning right now.
Agnes (44:23):
I know exactly who am I to say that I’m sitting here <laugh> um, but yeah, I would, I mean, I think, you know, definitely those glass houses shouldn’t so this first Don, but those would be my, um, my recommendations and they probably will be unpopular, but I’m sticking
Adam (44:38):
With them. Right, Sam, and now you especially taking into context that you are both a historian of medicine and now also a third year medical student, uh, in <laugh> immersed in a process that is designed to break you down as a and being, and rebuild you into something else.
Sam (44:53):
Yes. Again, again, relying upon military metaphor again, relying upon military metaphors. Yeah. It’s I I’ve I’ve I wholeheartedly endorsed everything. Agnes has, uh, has said, um, in the, in the United States, the committee of interns and, and residents, the CI R uh, S E I U move to fight for, uh, resident protections, uh, whether, whether it’s mental health or working hours or, or, or sufficient pay to be able to pay for cost of living and for robust mental health and the fight for social justice and health equity and, and without the pro the profession are, I think, I think are a very pro are very promising way, way to do this. And certainly the early his, and the early history of physician wellbeing, many of the mid 20 20th century efforts to promote healthcare worker or, or, or, or essentially residents, uh, house staff unions. Some by the time you get to the seven, by the time you get to the seventies, people are, are, are talking about, uh, substance use and impairment.
Sam (45:50):
And of course, the way that handled and how that plays out of course is different from the kinds of invocations that modern day, uh, or, or, or contemporary residents are saying that we need to the solution to, uh, resident burnout is, is not another, is not another wellness session, but it’s, it’s appropriate wages, robust mental healthcare, and restricted work, working hours and condition. I thoroughly endorse everything ag Agne says, secondly, I, I would, I would say, um, and I think, I think this is very much, I think this very much reflects the efforts to essentially eliminate, uh, the stigmatizing language with within state medical societies and, and, and credentialing. And this is happening in, in multiple facets with whether, uh, whether it’s for whether it’s fitness, for duty exams to work that the lure foundation has been, uh, has, has been, uh, promoting in terms of eliminating this kind of language on a national level.
Sam (46:46):
Of course, all of this is being done on a, on a state by state, uh, a state by state level. And, and of course, interestingly, the places that are fi have been fighting for these changes or incidentally placed, or hotbeds historical or historical hotbeds, where these kinds of, uh, laws and policies were being implemented originally in the sixties and seventies and the eighties. So there, there was some interest. So the historical geographies of this are quite are quite interesting. So yes, I would, I, I think my two solutions would be, um, greater protections for doctors, unionization, uh, a change in culture. Of course. What does that really mean is, is debatable. And finally the, uh, dis dismantling structural barriers to, uh, emotional health and wellbeing that, um, all healthcare workers face. Can
Adam (47:28):
I attempt to sum up, uh, what we’ve talked about in one sentence to see, and also talk about why I’ve been so uneasy about a lot of our modern discourse around burnout. So physician unhappiness, human beings, <laugh> human beings have been unhappy for a long time to understand physician unhappiness and the concept of burnout. However, takes it’s contingent on both societal and larger cultural and work
Agnes (47:51):
Contexts. And, uh, the way that we need to understand burnout in the 21st century is not as a comparison to a non-existent house in time, but as a reaction to larger factors, uh, most of which are outside of the individual, even though we’re talking about a, uh, an individual emotional reaction, um, is that accurate? Absolutely. Could you please write, um, my next abstract.