The American College of Surgeons recently announced its new well-being initiative for surgeons. This wellness program has lofty goals:
[The ACS] recognizes the need to foster well-being, resilience, and work-life integration for all surgeons, regardless of their career stage. Fostering the growth of both the surgical expertise and the person as a whole is paramount.
On the face of it, this sounds awesome — resilience, well-being, work-life integration, and fostering growth of the person as a whole — coming at a time when surgeons and other physicians are burning out and leaving their work in droves, and when the suicide rate among physicians is twice that of the national population.
But wellness programs don’t work — at least, not in the way that increases actual physician wellness. What they do instead is keep physicians indentured to the system that burns them out in the first place. (Though my focus in this essay is on physicians, my concerns about wellness programs also apply to nurses and other health care workers.)
Let’s start with the data. Research into physician wellness has grown exponentially in the last three decades.
And what this research has found is underwhelming. For example, in a study at the University of Texas Southwestern in Dallas, a wellness initiative produced no statistically significant improvement in just about every measure of wellness or burnout that they used. (My favorite part of the report is the authors' conclusion, with no hint of irony, that "implementation of a structured wellness program was associated with a decrease in resident burnout and an increase in overall resident wellness.")
Another study, published last year in Military Medicine, found no significant improvement in measures of burnout after a military-civilian obstetrics and gynecology residency program in the Midwest began its own wellness initiative. What the researchers did find, however, was that, after the wellness initiative started, the proportion of trainees who thought their training program "prioritized wellness" went from 53% to 94%.
Which is a tautology. And which may explain why other researchers have concluded that more than 99% of residency training directors think wellness should be a priority in their programs.
Blaming doctors increases suicides
If wellness programs had no negative effects on physicians, if they were just a case of trying something and finding out it doesn't work, then this wouldn't be a story. Science is full of examples of trying something that should work only to find that it doesn't.
But that's not the case with physician wellness programs. In her chilling 2018 article on 758 physician suicides, Pamela Wible wrote this:
Blaming doctors increases suicides. Words such as "burnout" are often employed by medical institutions to shift blame to doctors for their emotional distress while deflecting attention from unsafe working conditions.
According to Wible, shifting the blame to doctors by using words like "burnout" can increase their suicide rate. The evidence supports her: putting the blame on the victim is associated with an increase — not a decrease — in subsequent mental health issues.
With that in mind, read how the American College of Surgeons plans to improve physician well-being:
The ACS advocates for pathways for physicians who ask for help before serious events and consequences occur, or physicians who are receptive to help when approached by leadership, peers, colleagues, family, friends, and other support systems.
The ACS's plan relies on physicians themselves asking for help or being judged "receptive" to help. Either way, the onus lies on the physician — exactly what Wible described.
Here's the thing: Physicians aren't burnt out because of issues under their control. They aren't burnt out because they don't do enough yoga, don't meditate enough, don't breathe deeply enough, don't talk to the right counselors, don't prioritize their own well-being, or don't find the right pathways.
By defining burnout as something over which individual physicians have control — wellness — they shift the blame for any one physician's depression onto the physician and away from the things that actively burn out doctors: unsafe working conditions, moral injury, and a system built on their backs.
No amount of mindfulness can compensate for that.
Physician wellness programs are a means of control
The thing is, even Wible's indictment doesn't go far enough. A few years ago, Danielle Ofri, a primary care physician, wrote in the New York Times that the very business of medicine is built on the exploitation of doctors and nurses:
If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don't shirk. The system knows it, too, and takes advantage.
Ofri is right. The way health care is built in the U.S. leads to an uncomfortable truth: For this enterprise to work, it needs its providers to remain in the system. It relies on them keeping their heads down, day in and day out, avoiding asking questions, and showing up for the sake of their patients.
In other words, it needs them to remain subjugated to the system built on their backs. Because otherwise, the entire enterprise would crumble.
Health care could accomplish physician retention by reversing the structural issues that continue to burn doctors out: the moral injury, the unsafe working conditions, the throughput-driven and profit-motivated provision of health care, and more.
But that's hard. Instead, it's easier to keep physicians captive — and that's what the system has chosen. Consciously or otherwise, it employs a tactic used to great effect by other high-control groups such as cults.
An individual who is told that their lack of wellness is because of things they haven't done, who is told that if they do the right things — the yoga, the breathing, the mindfulness, the email management, the work-life balance — they'll feel better, and who then still feels the pain can only conclude that they have failed. There must be something wrong with them.
To quote Daniel Miller, an associate professor of religion and social thought at Landmark College, "The more that you can tell somebody who doesn't feel complete or fixed or whole that the reason they don't feel that is because of some shortcoming on their part, the more control over them you have."
As long as the burden of wellness continues to be pushed onto battered or broken physicians, then the very concept of wellness becomes an instrument of subjugation. How? By setting up a vicious cycle.
- A physician burns out.
- The physician is told they need to do things to combat the burnout (even though the evidence suggests those things don't work).
- The burnout doesn't go away. Instead, because fixing burnout is the physician's responsibility, it deepens.
- The only recourse for the physician is to return to step 2, or to quit.
The system must be tried
The comedian Dave Chappelle once said, "if a system is corrupt, then the people who adhere to the system and are incentivized by that system are not criminals. They are victims, and the system itself must be tried."
Physicians are burnt out because the entire medical system is built on exploiting the ethics that brought them into the field in the first place. It's built on taking advantage of the fact that they don't unionize, don't strike, and don't demand change.
Instead, they keep their heads down, showing up, day in and day out, for the sake of the patients who give them their trust. They feel — and not always incorrectly — that their patients may suffer if they do otherwise.
To find these physicians guilty of their own burnout perpetuates the vicious cycle. Instead, it's the system itself — the one that creates burnout in the first place — that must be put on trial.
Until then, no yoga, deep breathing, mindfulness, or email management will save doctors. It'll just keep us docile and under control.
Mark G. Shrime is a lecturer in global health and social medicine at Harvard Medical School, the international chief medical officer of Mercy Ships, and the author of "Solving for Why: A Surgeon's Journey to Discover the Transformative Power of Purpose" (Twelve/Hachette, 2022). An earlier version of this essay was published on Medium.
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