The Limits of Burnout and the Work of Health Care

Of all the terms to describe what ails nurses, physicians, and other clinicians in modern health care systems, none is more enduring than “burnout.” Burnout is unquestionably a “signature affliction” of modern health care practice. When researchers measure burnout according to the three core dimensions of what psychologist Christina Maslach has described as “burnout syndrome”—emotional exhaustion, the feeling that one is treating human beings as things, and a reduced sense of personal accomplishment—the results are alarming. Although prevalence estimates and diagnostic thresholds vary, most studies show that between 30% and 50% of American nurses and physicians exhibit at least one of the three dimensions of burnout. Burnout is associated in both physicians and nurses with lower job satisfaction, medical errors, and unprofessional clinician behavior.

Health systems and health education schools are spending substantial time and money to address the problem of burnout. But what if the concept of burnout is part of the problem?

Burnout is a mechanical metaphor that never quite seems to escape its mechanical origins. Maslach, who introduced the term to the psychological literature, agrees in a recent book that before its adoption into psychology, “burnout . . . was most commonly used in engineering to describe the result when repetitive stress or excessive load on a piece of equipment ruins its ability to function (as when a motor, or light bulb, or rocket booster burns out)” (4). Maslach speculates that this mechanical image was carried by extension into tech-oriented workplaces, as when Silicon Valley startups in the 1970s were commonly called “burnout shops” due to the long hours and total commitment required of workers. When in the 1970s Maslach began hearing clinicians and social service workers in the Bay Area describing themselves as burned out, she made the term a central theme in her own work.

The power of Maslach’s “burnout syndrome” is that it resonates with the experience of many clinicians and social service professionals in workplaces that are themselves modeled on late-modern industrial paradigms, with pre-eminence given to productivity, efficiency, standardization, and quality control. In The Burnout Challenge, for instance, Maslach and Leiter describe “Stan,” an early-career psychologist in a community mental health center. In his three years of work, Stan has changed “from an avid, eager, open-minded, caring person to an extremely cynical, not-giving-a-damn individual.” He copes with this in part by approaching his work, “‘as if working at GM, Delco, or Frigidaire.’ He might as well adopt an assembly-line mindset, because [in his words] ‘that’s what it has become here, a mental health factory!’” (p. 32).

The Limits of Burnout

The problem with the concept of burnout, however, is that it works too well. The mechanical metaphor vividly describes the problem, but unfortunately also constricts our imagination for possible solutions. If a burned-out clinician (or social service worker, or teacher, or any number of others) is a machine in a factory, or at best an industrial worker doing standardized factory work, then the evident solutions will be those that might apply to machines or factory workers: limiting workload and work hours, striving for “work-life balance,” establishing greater control over one’s work situation, “recharging” through rest and activities such as exercise and mindfulness practice, finding meaningful relationships and community inside and outside of work, and so on.

While none of these interventions are inherently wrong or harmful, they all presume the underlying metaphor of the clinician as machine or factory worker, and they fail to challenge the underlying assumption that “work” is, fundamentally, an industrial process to which one must adapt. Even commonly proposed burnout interventions that seem non-mechanistic and humanistic presuppose this industrial model of work. Workplace community promotes worker efficiency and morale; non-work communities buffer the effects of workplace burnout; private personal values help one to clarify when and how to engage in industrial work, and so on. Furthermore, because burnout is often presumed to be a systems-engineering problem, burnout may be solved with systems-engineering solutions, such as health care organizations hiring Chief Wellness Officers, systematically administering wellness surveys to employees, and making organizational changes in response.

Again, none of these interventions are inherently harmful. But given that four decades of measuring and responding to burnout in health care has not appreciably reduced rates of burnout among clinicians, it is worth considering whether any metaphor with industrial, mechanistic roots will ever solve the problems caused when health care operates as an industrial process. The diagnosis may well perpetuate the disease.

Recognizing the limits of the burnout metaphor, many in health care have suggested that a more appropriate term for the struggles of clinicians is not burnout but “moral injury,” a term that was originally used to describe the experiences of war-experienced soldiers and veterans. As Simon G. Talbot and Wendy Dean put it in their widely-circulated introduction of the term into the clinician-wellness debate, burnout is a faulty concept because it individualizes clinicians’ distress and “suggests a failure of resourcefulness and resilience” in them, while moral injury more accurately attributes responsibility to “our broken health care system” that places institutional demands on clinicians that render them “unable to provide high-quality care and healing in the context of health care.” The concept of moral injury has proven popular with clinicians, in no small part because it shifts responsibility and blame from clinicians themselves onto their employers. But the presupposed structure of health care is largely the same. By positing that clinician moral injury arises when clinicians are oppressed by management and by workplace culture, Talbot and Dean reify rather than challenge the basic model of health care practitioners as industrial workers who must navigate labor/management conflicts.

From Productive Machines to Living Creatures

Those who believe that modern health care has become excessively mechanistic, industrial, and dehumanizing, and who long for a different approach, would do well to ensure that our language about human beings is not drawn from the logics of mechanism and industry. Human beings, after all, are not machines but living, organic creatures. We do not “burn out” like candles, engines, or rockets. We do not “refuel” or “recharge” like automobiles or batteries. We should not even strive to be “resilient” like a steel beam under stress. Rather, all of us—clinicians, patients, everyone—are embodied, relational creatures who need nurture, love, and care. We grow thirsty, and seek drink; weary, and seek rest; lonely, and seek connection. In all of this, we act for ends that we perceive will bring meaning and fulfillment to our lives as creatures—sometimes related to our productive work, and sometimes beyond it. The first way to respond to the limits of burnout, then, is to refuse its mechanistic logic and language and to insist on creaturely and organic, not mechanistic and industrial, language for human beings.

Second, responding to the limits of burnout requires a way to place productive work—including the productive work of health care—in its proper place, honoring its goodness without construing it as the organizing end of human life. Here, St. Thomas Aquinas’ thirteenth-century interpretations of the active life (vita activa) and contemplative life (vita contemplativa)—read alongside the interpretations of modern Catholic philosopher Josef Pieper—offer a perspective on how clinicians might understand our work that is markedly different from the industrial underpinnings of the burnout metaphor.[1]

Aquinas on the Active and Contemplative Life

Aquinas did not originate the distinction between the active and contemplative life; in the Summa theologiae he draws heavily on Aristotle and on the moral and spiritual teachings of Gregory the Great and Pseudo-Dionysius. But his discussion comes at an important inflection-point in the Summa, after his extensive treatment of the theological and moral virtues and just before his defense of the religious life, which was of course Aquinas’ own form of life as a Dominican friar. Living in a preindustrial age that required the constant labor of farmers, artisans, and others for community survival, Aquinas asks: to what kind of life are humans called?

His answer is that all humans, in a sense, are called to the contemplative life, a life oriented to the consideration of truth, because contemplation of God is “the end of the whole human life” (STh IIaIIae q. 180 a. 4 resp.). Aquinas continues by quoting Augustine’s affirmation that “the contemplation of God is promised us as being the goal of all our actions and the everlasting perfection of our joys.” He then comments that

This contemplation will be perfect in the life to come, when we shall see God face to face, wherefore it will make us perfectly happy: whereas now the contemplation of the divine truth is competent to us imperfectly, namely “through a glass” and “in a dark manner” (1 Cor. 13:12). Hence it bestows on us a certain inchoate beatitude, which begins now and will be continued in the life to come (STh IIaIIae q. 180 a. 4 resp.).

Humans, that is, find our most perfect fulfillment in the vision of God that is the end-goal of the life of contemplation. Quoting Gregory, Aquinas describes the promise of contemplation in radiant and even erotic terms. The contemplative life “is to cling with our whole mind to the love of God and our neighbor, and to desire nothing beside our Creator” (STh IIaIIae q. 180 a. 1 sed contra). The contemplative life, Aquinas again quotes Gregory, “consists in the love of God, inasmuch as through loving God we are aflame to gaze on his beauty” (STh IIaIIae q. 180 a. 1 resp.). Humans are made for contemplation.

If the contemplative life is the highest form of life, then we might expect Aquinas to have a low view of the active life, the form of life that “provides for the necessities of the present life by means of well-ordered activity” such as farming, making, repairing, parenting, and caregiving—including, of course, caregiving for those who are sick. But that is not the case. Though the contemplative life is more excellent, there are several reasons why for Aquinas the active life is important and good.

First, the active life is good and worthwhile because God’s creation is good and the care of God’s creatures, especially human beings made in the image of God, is worthwhile. It is in the active life that we love our neighbors and love God by loving our neighbors. Aquinas states that in contrast to the contemplative life, which seeks to devote itself to God alone,

The active life, which ministers to our neighbor’s needs, belongs directly to the love of one’s neighbor. And just as out of charity we love our neighbor for God’s sake, so the services we render our neighbor redound to God, according to Matthew 25:40, What you have done . . . to one of these my least [my] brethren, you did it to me (STh IIaIIae q. 188 a. 2 resp.).

Second, the active life is good because it is in the context of the active life that we develop, tend, and display the moral virtues—the dispositions by which we contribute to the flourishing of others and of ourselves—such as justice, courage, and temperance. Following Aristotle, Aquinas argues that what we do shapes who we become: we become just by the doing of just actions, courageous by pursuing the good in the face of danger, temperate by caring rightly for ourselves in the face of temptation, and so on. Because virtue-formation requires action, the active life is the seedbed of the moral virtues. As a busy teacher, scholar, and Dominican friar, Aquinas himself was immersed deeply in the active life, and he strongly defended the role of the active life among members of religious orders (STh IIaIIae q. 188 a. 2). Aquinas observes also that in his preaching and teaching, Jesus himself lived the active life (though built, to be sure, “on abundance of contemplation”; STh IIIa q. 40 a. 1 ad2). The active life is the testing ground on which we are able to develop the intellectual and moral virtues necessary for “quieting and directing the internal passions of the soul” and therefore preparing the way for contemplation. Quoting Gregory, Aquinas affirms that “whoever wishes to hold the fortress of contemplation must train in the camp of action” (STh IIaIIae q. 182 a. 3 resp.).[2]

The active life, then, is good. It is the life that most of us, most of the time, are living. But Aquinas is very clear that properly speaking, the active life is for the contemplative life. The contemplative life is more excellent, Aquinas argues, because God has made humans for the contemplation of divine things, and this contemplation not only leads us to our proper end, in the vision of God, but also is more delightful and more characterized by leisure and rest (STh IIaIIae q. 182 a. 1 resp.).

Action and Contemplation in the Work of Clinicians

How does Aquinas’ medieval account of the active and contemplative life possibly matter for the work of clinicians and for conversations about burnout? It invites us, I believe, into a very different way of inhabiting our work that turns the industrial model inside-out.

First, Aquinas forces us to ask: what is truly real? Do we live in an expressively dead cosmos governed by competition and scarcity, with the wealth and security generated by productive work our best hope for survival? If so, then the activities of contemplation—play, prayer, gentle attention, worship, feasting, rest, sabbath—are at best luxuries to be enjoyed within proper limits and tools that equip us for a lifetime of productivity.

But that is not the cosmos that Aquinas invites us to inhabit. Aquinas is clear: what is most truly real is God, and God’s loving and providential ordering of the world of created things that each, in its own unique way, points back to God as its originating and sustaining cause. The scarcity-driven world that we think we see around us when we are anxious about time and all that we have to do is too small and limited. It is not ultimately true. Like Julian of Norwich, we are invited to see the world as “a little thing, the quantity of a hazelnut, . . . that lasts and shall ever last because God loves it,” and to appreciate with Thomas and Julian that, in her words, “everything has being by the love of God” (Showings 1.5).

The contemplative life has value not because it “recharges” us for productive work, as the industrial model would hold, but because it allows to glimpse, even for a brief time and in a limited way, the world as it really is, charged and held in place by love—to engage, as Josef Pieper puts it, in “universal affirmation of the world as a whole” (p. 26). But if this is how the world really is, then contemplative activity is not a way to prevent burnout. It is rather how we see truthfully so that we might order our lives rightly.

Second, the priority of contemplation helps us to order the active life—including the life of being a clinician, a faith leader, a social service worker, a student, or an academic. If it is true—really true—that love is at the root of all that is, then how might we respond to the world in our work in a way that reflects God’s love for it? We would engage in the productive activity of the active life as a way to exercise love and care for ourselves and for other creatures.

This mission to care well for a world that God loves offers purpose. It also offers criteria to make sense of the kinds of work that are worth doing. We would pursue every opportunity, even and especially in the active life, to seek and to cultivate beauty and to exercise creativity. We would seek common cause with others in promoting the common good, recognizing that we best care for each other not as isolated individuals but in the context of interconnected and interdependent social wholes. We would seek to protect the creation against oppressive and death-dealing powers. We would also resist powers that would threaten our ability to exercise this care and creativity—such as, in modern health care systems, profit- and efficiency-driven scheduling and billing paradigms and dehumanizing work environments.

When these powers threaten, as they do and will, then we are right to individually and collectively resist them, but not for the sake of productivity, “wellness,” or “work-life balance.” We resist them because they are lying to us, obscuring the truth that we live in a cosmos held in existence by care and love. The activities of the contemplative life, including and especially sabbath, are not really about us and our personal well-being. They are about orienting us to what is real, reminding us that love and care, not competition and productivity, are the deepest realities of God’s creation.

The Clinic and the Contemplative Life

All of this may seem abstract and far-removed from the ordinary work of health care, but it is not. I serve as a staff psychiatrist in the Department of Veterans Affairs health care system. I know what it is like to work within a complex health care bureaucracy. On Monday of next week, like every Monday, I will enter my VA outpatient psychiatry clinic room. I will log in to my workstation, open the electronic medical record, and will prepare to welcome my first patient.

But as much as possible, this Monday, I will not think of myself as a productivity-engine or as a laborer plodding through a series of work-related tasks. I will instead take a moment to think of the world as a hazelnut, existing because God loves it. I will remember that neither I nor my patients derive our worth as persons from our productivity or any other marker of social status. I will remember that even my windowless basement clinic room is shot through with rays of divine grace, and that my patients and I alike are loved by God, and called to love in return.

Then I will take a breath. And I will begin.

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