In 1981, the psychologist Christina Maslach, working with several colleagues, set out to create a test to measure occupational burnout. Eventually termed the Maslach Inventory, the scale assessed the risk of burnout by testing subjects along three basic dimensions: emotional exhaustion, depersonalization and personal accomplishment. The first set of questions, nine in total, measured the feeling of being chronically overextended or emotionally fatigued in the workplace. The second, with five items, tried to capture the feeling of becoming detached or disconnected from the recipient of your services: toddlers in the case of kindergarten teachers, or patients in the case of doctors (“I haven’t even touched a patient,” as the resident put it). The final dimension that Maslach identified, through eight questions, was a loss of personal accomplishment, a feeling that nothing was being achieved.
Perhaps Maslach was inspired by Viktor Frankl’s book “Man’s Search for Meaning.” An Austrian neurologist and psychologist, Frankl had been sent to the Auschwitz concentration camp and then held at Kaufering, a camp affiliated with Dachau. He became preoccupied with the experience of survivorship: What allows some humans to acquire resilience in the face of the most brutal and dehumanizing experiences? Frankl traced the roots of resilience not to success or power but to a sense of purpose and the acquisition of meaning. Later writers, including Daniel Pink, expanded Frankl’s concept of meaning along three dimensions: purpose, mastery and autonomy. We acquire resilience when we find purpose in our work. We seek mastery — expertise, skills, commitment and recognition — in our domains. And we need autonomy — independence — in what we do.
What happened to our anatomy group? B. finished his residency swiftly and dove headlong into translational research (“translating” insights from basic sciences into human therapeutics). He now ranks among the world’s authorities on a group of strange, recently defined diseases in which a single cell can take over the whole blood system, hovering on the verge of cancer but never quite tipping into frank malignancy. S. is largely a laboratory-scientist-cum-doctor who tries to understand how tumors become metastatic. G., whom I am least in touch with, is a psychiatrist who specializes in a particular area of children’s and adult’s anxiety disorders. My own path meandered and trifurcated: I run a laboratory with a focus on leukemias and stem cells; I write books; I run trials and see patients, but in a capacity that doesn’t involve typing endless notes into computers. Other doctors, who didn’t have research-oriented practices, enhanced their professional lives by concentrating on specific realms of interest. A family doctor I know carved out a niche in his clinic to focus on middle-aged H.I.V.-infected patients. All of us escaped burnout, but narrowly — only, perhaps, by finding personal, often deeply specialized purpose in our work.
Others were not as fortunate. By the end of internship and residency, a slow trickle of my classmates began to leave medicine (some joined tech firms in Silicon Valley; some became entrepreneurs). My closest friend from those years joined a neuroscience lab but then left to become a full-time parent. By 2018, there was a barrage of discontent. In one study, 42 percent of doctors reported feeling burned out. The worst affected were obstetricians, internists and intensivists — doctors in subspecialties that require work in emergency-oriented conditions, and those who confront frequent lawsuits, and those who require constant documentation, surveillance and billing. The least affected were plastic surgeons and ophthalmologists — doctors who inhabit procedure- or skill-oriented domains. The most common reasons listed for burning out were the overwhelming strains of bureaucracy and paperwork, the vast quantity of time spent at work and a lack of respect from administrators and employers. Lack of adequate compensation was fifth on the list. Among doctors, too, it seemed, resilience and survivorship tracked along the same essential dimensions: meaning, mastery and autonomy.