To Fight Burnout, Organize

Article · July 20, 2018

The clinician who coined the term “burnout” was not a primary care physician buried under paperwork, nor an emergency physician beset by an unwieldy electronic health record. He was Herbert Freudenberger, a psychologist working in a free clinic in 1974.1 Discussing risk factors for burnout, he wrote about personal characteristics (e.g., “that individual who has a need to give”) and about the monotony of a job once it becomes routine. He also pointed to workers in specific settings — “those of us who work in free clinics, therapeutic communities, hot lines, crisis intervention centers, women’s clinics, gay centers, runaway houses” — drawing a connection between burnout and the experience of caring for marginalized patients.

In recent years, burnout has become a chief concern among physicians and other frontline care providers. But somewhere along the way, the concept was separated from its original free-clinic context. The link between marginalized patients and clinician burnout seems to have gotten lost.

As a fourth-year medical student, I have received ample warning about the sources of burnout: death by a thousand clicks, too many hours at work, feeling like a cog in a machine, too many bureaucratic tasks. As a newcomer to medicine, I feel intimidated by it all. But from what I’ve observed — both during medical school and before enrolling, when I spent several years working in safety-net clinics — Freudenberger’s free-clinic context points to another source of burnout that receives insufficient attention. It is the experience of caring for patients when you know that their socioeconomic and structural circumstances are actively causing harm in ways no medicines can touch.2 As medical students, we are educated about the social determinants of health and increasingly warned about burnout, yet little is made of how the former may contribute to the latter — for example, how clinicians may feel worn down by the poverty and oppression their patients face; may feel powerless when they cannot offer more than, say, a form letter to a landlord explaining that turning off a patient’s heat would be deleterious to her health; and may feel demoralized when they realize that their instruction “Do not take this medication on an empty stomach” translates into patients taking their medications only sporadically because they don’t have enough to eat.

This contributor to burnout is not unique to physicians’ work. In medical school, though, I’ve seen an additional problem that may make it especially painful: we are led (and allow ourselves) to believe that we as individuals have more power than we do. Despite a shift toward team-based care, the image of physicians as singular heroes, as saviors, remains deeply embedded in medical culture.3 To many people, the white coat and the prescription pad represent the highest form of individual agency, the very picture of social power. But eventually, a physician will encounter patients whose health problems derive from a wicked, multigenerational knot of poverty and marginalization, and even the most astute, excellent physician may well find herself outmatched. Facing patients’ adverse social circumstances as an individual clinician is a recipe for disillusionment: the physician who believed she was maximizing her individual agency comes to feel utterly powerless. No longer the lone hero — just alone.

In this link between social determinants of health and burnout, I see a problem, but also a way forward. If individual powerlessness is the crux of this source of burnout, then organizing toward collective action should be part of the solution. Each of us can advocate for our homeless patients to be put on waiting lists for public housing. But what would happen if all doctors with homeless patients organized to demand more affordable housing?

Organizing is both strategic and therapeutic — strategic because our collective labor and voice are greater than the sum of their parts; therapeutic in the sense that the activist Grace Lee Boggs articulated: “Building community is to the collective as spiritual practice is to the individual.” When we recognize ourselves not as individual actors each isolated in an exam room, but as a collective joined in common cause, we start to feel less alone.

Some researchers have asked whether physician advocacy should be seen as a professional obligation or an aspirational goal.4 For me, the link between physician burnout and patient marginalization changes the terms of this debate. Beyond whether we must or should do it for our patients, collective advocacy to address the harmful social determinants of health can buoy physicians’ morale and thus be an act of self-care; organizing toward collective action means looking after both our patients and ourselves.

You have probably heard this parable before: A group of friends comes upon a fast-moving river where they find people drowning. The friends jump in headlong to save as many people as they can. But the drowning people keep coming. As soon as the friends rescue one, another comes into view. Eventually, one friend starts heading upstream. Another, exhausted, yells after her: “Where are you going?” The first one says, “I’m going to find out what’s throwing all these people into the river.”

The classic reading is that this parable is about prevention, but it also points to how upstream determinants contribute to burnout. Here is, I imagine, what happened to the friend who headed upstream: she saw the unending flow of drowning people coming their way. She deduced that there must be some force, hidden around the bend, that was sending people to drown. She noticed herself and her friends getting exhausted, all on the brink of burnout from the urgent, unending work. So she mobilized her friends to go upstream, for the drowners’ sake and for their own.

Obviously, it is not new for frontline clinicians to get fed up, organize, and start heading upstream. It’s what happened when physicians built collective-action organizations like Physicians for Social Responsibility and Physicians for a National Health Program; it’s what happened when clinicians joined the Moral Mondays demonstrations in North Carolina to fight for Medicaid expansion; and it’s what happens every Sunday morning in Boston, when residents and attendings, faced with an overdose epidemic, organize with the group SIFMA NOW to advocate for supervised injection facilities as a harm-reduction strategy.

In SIFMA (Supervised Injection Facilities–MA) NOW, health professionals organize side by side with harm-reduction advocates and people who use drugs. The group enables participants to build solidarity and take action in an otherwise overwhelming crisis. Dinah Applewhite, a resident at Massachusetts General Hospital, reflected at a recent meeting on how organizing can be a balm for her as a physician: “Despite my best efforts in clinic, I’ve had too many patients overdose, get endocarditis, or contract hepatitis C or HIV from unsafe injection practices. Being part of a community of advocates empowers me to fight for solutions to this crisis. It means that I’m energized and grounded, rather than burnt out, by these preventable tragedies.”

The social determinants of health — and physicians’ sense of powerlessness in the face of them — seem crucially missing from the discussion of burnout. This kind of burnout is the feeling you get when you’re trying to rescue the drowning people but they keep coming. And you’re torn between competing exigencies: the proximal needs of the people drowning, and the distal need for naming, fighting, and demanding accountability for the upstream forces that are causing harm.5 Medical students are trained to think from a vantage point of individual agency, and we become stuck there: “What can I do?” begins as an earnest, ambitious question, but it so often spoils to a cynical one. If medical schools and residency programs are serious about burnout, they have to teach us about collective action — teach us to ask, “What can we do?” To fight burnout, we should never worry alone about the social determinants of health that patients face. To fight burnout, organize.


From Harvard Medical School, Boston.

1. Freudenberger HJ. Staff burn-out. J Soc Issues 1974;30:159-165. CrossRef
2. Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med 2016;50:129-135. CrossRef | Medline
3. Berwick DM. Moral choices for today’s physician. JAMA 2017;318:2081-2082. CrossRef | Medline
4. Gruen RL, Pearson SD, Brennan TA. Physician-citizens: public roles and professional obligations. JAMA 2004;291:94-98. CrossRef | Web of Science | Medline
5. Krieger N. Proximal, distal, and the politics of causation: what’s level got to do with it? Am J Public Health 2008;98:221-230. CrossRef | Medline

This Perspective article originally appeared in The New England Journal of Medicine.

New call for submissions ­to NEJM Catalyst

Now inviting longform articles


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Leadership
ajor Themes from Cleveland Clinic Town Halls 2016

Reigniting the Passion to Practice Through a Multi-Pronged Approach

Cleveland Clinic formed the Practice Innovation and Professional Fulfillment Office to create and sustain an environment that allows clinicians and scientists to thrive through barrier removal, culture change, and support for personal well-being.

Percent in Highest Bracket in Patient Satisfaction Scores - Pre-Post Arm Differences for Hospitalists - Duke Coaching Communication Skills Study

Coach, Don’t Just Teach

The effect of one-on-one communication coaching on clinicians’ communication skills and patients’ satisfaction.

Two-Thirds of Organizations Have a Nurse Leader Career Path

Survey Snapshot: Do Nurse Leaders Need Advanced Degrees?

Though NEJM Catalyst Insights Council members acknowledge a lack of advancement opportunities for nurse leaders, two-thirds of their organizations have a nurse leader career path.

Nurse Leaders and Physician Leaders Should Be Considered Equals in Care Delivery - but Views of Nurses and Non-Nurses Differ

Leadership Survey: Nurses as Leaders: Broad Acceptance, Room to Grow

Nurses are traditionally the backbone of patient care. They form the largest percentage of the health care workforce, far outstripping physicians. But are nurses leaders as well as doers?

The CMO Role of the Future - Baptist Health Survey Results

Examining the Continuously Evolving Role of the Chief Medical Officer

Hospital and system leaders need to sharpen the focus of CMO roles to include system-wide considerations beyond the walls of the hospital.

Meyer01_header - Seven Challenges and Seven Potential Solutions for Large-Scale EHR Implementation

Seven Challenges and Seven Solutions for Large-Scale EHR Implementations

Salient lessons learned over multiple electronic health record implementations.

Zuckerberg San Francisco General Hospital ZSFGH A3 thinking Personal Development Plan A3 leader standard work improvement management example board

Changing Leadership Behavior Gets Real Results

Zuckerberg San Francisco General Hospital deployed its new leadership culture, which emphasizes staff decision-making, self-reflection, and clarity in defining problems and goals, to successfully address a crisis involving record-high patient volumes.

Khatri02_pullquote Connectors

The Crucial Role of Connectors in Large Health Care Organizations

Creating a truly collaborative community involves connecting the right people at the right time and in the right places.

Women of Impact Checklist - Advancing Workplace Equity

Lead In: Women of Impact in Health Care on Advancing Equity in the Workplace

Raising the standards of equity and wellness in our workplaces so we effectively advance health for the populations we serve.

Historical and Projected Numbers of Physicians, Nurse Practitioners, and Physician Assistants.

Growing Ranks of Advanced Practice Clinicians — Implications for the Physician Workforce

The number of NPs and PAs is growing rapidly, while physician supply has slowed. This research projects the number of NPs, PAs, and physicians through 2030.


A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »


Leading Transformation

249 Articles

Nobody Wants a Waiting Room

A study in system change.

Team Care

103 Articles

Reigniting the Passion to Practice Through…

Cleveland Clinic formed the Practice Innovation and Professional Fulfillment Office to create and sustain an…

Care Redesign Survey: How Data and…

Data and analytics are a key means for clinicians, clinical leaders, and executives to transform…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now