by Internet Medical Society

Burnout among physicians is rampant. One-third to one-half of practicing physicians meet the criteria for burnout, and in a large study conducted by the Mayo Clinic, 53% of medical students showed signs of burnout.[1] In addition, 300 to 400 physicians commit suicide each year, which is higher than the rate in the general population.[2] Suicide rates are related to the high rates of depression seen in physicians, which might be linked to burnout.

Too much paperwork, productivity demands, reporting requirements, and the intrusion of business concerns into one's medical practice can all contribute to burnout. Some physicians contend that the seeds of burnout are sown when they raise their right hands during their white-coat ceremonies and take the Hippocratic Oath, solemnly swearing to put the needs of their patients above all else.[1]

And many contend that if physicians are putting patients' needs first, to the detriment of their own health, they are misinterpreting and misreading the oath.

What the oath actually says is, "I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing."[3] It also declares that "into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free."

The remaining three sections of the oath focus on honoring one's teachers, what to avoid when treating patients, and keeping patient information confidential.[3]

That the Hippocratic Oath doesn't actually state that patients must come first doesn't seem to matter. Putting patients above all else is often drummed into students in medical school. And that is the paradigm that their teachers and attendings tend to model. By the time the oath is taken, for many medical students, the notion has already been internalized.

"This expectation of sacrifice can extend to physicians' families, who are likewise trained to understand the interruptive priority of a medical career," note Annie Nedrow, MD, MBA, from Duke Integrative Medicine in Durham, North Carolina, and Nicole A. Steckler, PhD, and Joseph Hardman, MD, from Oregon Health & Science University in Portland.[1]

This "interruptive priority" has governed the way many physicians and physicians-to-be live. It is this single-minded devotion to helping humanity and saving lives that sets the medical profession apart—and above—all others.

"Most physicians are first drawn to the calling, or service aspect of medicine," observe Dr Nedrow and colleagues.[1] "The ability to make a difference in a person's health is compelling and rewarding. This expectation of service is reinforced repeatedly throughout training, starting with the Hippocratic Oath. Yet early in a career, this sense of service may begin to feel more like duty, and the personal sacrifice it requires may feel more like deprivation, even victimization and martyrdom, when self-sacrifice becomes exhausting."

A Call to Revise the Hippocratic Oath

The issue with putting patients first, and with oaths—Hippocratic and otherwise—that promote that idea, are starting to surface among practicing physicians.

Last September, at the American Academy of Family Physicians (AAFP) Congress of Delegates, one item on the agenda was a resolution to update language in the oath that members take when receiving the AAFP Degree of Fellow so that it better reflects the critical importance of work–life balance, which could help stem the ever-increasing rate of physician burnout.[4]

Specialty societies, following in the footsteps of a growing number of medical schools, are using the Hippocratic Oath as a starting point when they develop their own professional oaths.[4] At issue in the AAFP oath was its stipulation "to provide comprehensive care to my patients, placing their welfare above all else."[4]

Tennessee delegate Lee Carter, MD, from Huntingdon, who coauthored a resolution to revise the oath, had previously testified why a revision was necessary.[4]

"Patients should be above insurance companies; patients should be above the hospital administrator; patients should be above anything professional...but our personal lives are different," Dr Carter said.[4]"And the need to balance our professional life with our private life is something we all have to deal with now."

Joseph Freund, MD, from Des Moines, Iowa, who attended the Congress, shared his experience with burnout 25 years earlier, which he ascribed to his efforts to put patients first.[4] He was forced to take a 6-month leave of absence to recover.

"I put the patient above everything else and gave everything else, and there wasn't anything left of me but a shell," Dr Freund testified.[4] "I had no identity outside of being a physician. It was after taking some time off that I realized I needed to spend time on myself as well."

Leaving this dangerous phrase in the new oath will not allow us "to protect ourselves," Dr Freund continued. "I proudly trumpet how wonderful family docs are when I speak to groups and to students. But until that oath is changed, I cannot take that oath and be true to myself."

The resolution passed. The problematic phrase—"to provide comprehensive care to my patients, placing their welfare above all else"—will be changed to read, "to provide comprehensive care to my patients," and the clause requiring physicians to place "their welfare above all else" will be dropped.[4]

Do words have the power to influence people to do things against their will? When the words are part of a solemn oath, perhaps they do. For some physicians, the Hippocratic Oath embodies an ideal of ethical behavior that is impossible to meet, yet they are compelled to try, regardless of how self-destructive it is, because they sincerely vowed to do so.

"Doctors are not burned out; they are just abused," a cardiologist wrote to Medscape. "Of course you have to serve patients, but to do this, you have to serve yourself first! The Hippocratic Oath is history. We all have to know what it says. But at the same time, we must accept that the world today is quite different from the one that existed 2500 years ago, when the oath was written.

A recent Medscape poll of more than 2600 physicians asked whether the focus of the oath to put patients first contributes to burnout. More than one-third of respondents (34%) said it did, 45% said it did not, and 20% were unsure.[5]

Many of the physicians who offered comments said it is not the Hippocratic Oath that fosters burnout, it is the intrusion of business into patient care.

"I do everything I can to put patient issues and concerns at the fore," one respondent, an anesthesiologist, noted. "Sadly, though, since I do not work in a vacuum, I am forced to consider many non-patient-centered, nonclinical, and often even irrelevant matters that may ultimately have an impact on my care of the patient. Does upholding the Hippocratic Oath lead to physician burnout? No. It's trying to do no harm in an environment where many other physicians do not honor their commitment to the Hippocratic Oath."

"Putting patients first is not the problem in burnout," a psychiatrist observed. "Rather, it's the intrusion of the federal bureaucracy and the emergence of corporate-driven (read 'profit-driven') medicine—systems that purport to measure quality and improve efficiency, all in the name of dollars. Doctors are now treating the templates in the EHR and documenting for payment. There is little room left for listening—the cornerstone of effective communication and patient-centered care."

Family physician Dike Drummond, MD, says he thinks that many physicians are framing the problem of burnout the wrong way. As the author of Stop Physician Burnout, Dr Drummond serves as a coach for burned-out physicians, lectures on the subject, and holds retreats for burned-out doctors.

"You are looking for the solution to a problem, when this issue is an obvious dilemma, a never-ending act between the two roles the physician plays: the role of doctor and the role of individual human being," Dr Drummond explains.

"You can't solve a dilemma," he insists. Instead, "you create a strategy to maintain the balance you seek."

"The challenge is when no one shows you the 'off switch' on your doctor programming, and you live as if the saying, 'The patient comes first,' applies 24/7," Dr Drummond elaborates. "This is extremely common because of the conditioning/programming/brainwashing of our medical education."

For some doctors, locating the off switch begins with revising the Hippocratic Oath to acknowledge that doctors are human too.

"We all agree that when you are with a patient, the patient comes first," Dr Drummond says. "But it is impossible to put patients first 24/7/365 and be a healthy human being. This prime directive, and its closely related cousin—'never show weakness'—are two of the root causes of burnout."

In acknowledgement of this, Dr Drummond proposes his own version of the oath:

I promise to put the patient first when I am practicing my craft as a physician.

I promise to attend to my own needs and the needs of my family when I am not practicing medicine for a simple reason: My health, well-being, and energy levels are the single most important determination of the quality of care I provide to my patients. This balance is crucial to the well-being of my patients, my family, and myself.

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