A Marxist analysis of physician burnout

The art of medicine is the pursuit of the ultimate human connection between those in need and those able to offer aid, and becoming a physician is one of the greatest callings in life. Certainly, the stress of training, long hours, and difficult cases can make for some tough times. But the financial, emotional, and even spiritual rewards are more than worth it for the opportunity to make a real, recognized difference in the lives of thousands of patients and their families. 

If you’re scoffing at those words right now, you might be among the approximately 50% of physicians who are currently experiencing burnout.  

Burnout is often described as a “long-term stress reaction” that can lead to emotional exhaustion, feelings of decreased personal satisfaction, and depersonalization. But that simple definition hides an incredibly complex, cyclical storm of experiences and emotions that may result in serious issues for both patient and provider, including poor quality of care and medical errors for patients, early exits from the profession, and even frightening rates of suicide among physicians. 

It’s no wonder that health system leaders, professional societies, technology developers, and other key stakeholders have been starting to take burnout more seriously in recent years, particularly since a dramatic spike during the pandemic. 

But their efforts haven’t always been effective, often because they haven’t been able to fully understand the true roots of burnout and how to address them.  

That’s because burnout isn’t really about AI assistants or yoga classes. It’s about those feelings of frustration, anger, sadness, and longing that might arise from going back and reading that first paragraph again.  

Too often, the modern experience of being a physician simply doesn’t live up to its promises, leading to alienation, lack of direction, and loss of autonomy – and that’s a systemic failing that goes far beyond what any individual health system’s wellness offerings or technology packages can solve. 

Instead, industry leaders need to think about collective action, a phrase that might inadvertently lead them to a somewhat surprising way of looking at how burnout arises and how to mitigate its impacts on workers and their patients. 

Yes, we’re talking about Marxism.  

While this isn’t the first time healthcare thinkers have raised the idea that Marxist theories on the proletariat could be applied to the problem of burnout, a recent article by researchers from a group of leading academic centers and professional organizations could breathe new life into this interesting argument.  

The rise of the clinical proletariat

The physician experience over the past century closely mirrors Karl Marx’s views of the class struggles between workers and their overseers, says Monica Cuddy, PhD, a measurement scientist in the Office of Research Strategy at the National Board of Medical Examiners and an author of the paper.   

“Medicine has really shifted from being an independent, solo practice profession, where the physician is largely autonomous in his or her decisions about patients, to something that has become very corporatized and full of red tape created by layers of internal and external decision-makers,” she explained.  

“As a result, we’ve introduced third parties that profit and benefit from the labor of the workers – the physicians – while the workers themselves are seeing reduced benefits in terms of control over the care they provide patients and satisfaction in their jobs. There’s a greater component of alienation not only from the economic conditions of the work, but also from the human value of the work, than there has been in the past.” 

Increased documentation requirements are a good example. To many physicians, documentation appears to only benefit health plans or health systems, leading to minimal financial reimbursement and reducing the time available to spend directly with patients. 

While many entities have focused on making the documentation faster and easier to complete using digital solutions, that doesn’t change the fact that many physicians resent the existence of the requirements in the first place and the restrictions on their autonomy that they represent. As a result, physicians may not feel that much better, in the long run, that it only takes five minutes instead of fifteen minutes to get through them. 

The struggle against exploitation of the worker is coming to a tipping point

Burnout affected close to two-thirds of physicians during its pandemic peak, bringing issues of alienation and dissatisfaction to the headlines of major news outlets and even to the halls of Congress with the Dr. Lorna Breen Act, which provides resources to study and address the issue.  

While the prevalence of burnout has dropped slightly in the post-COVID era, physicians aren’t letting up on their momentum to advocate for meaningful change. 

“In the paper, we talk about Marx’s idea of a collective consciousness among the working class, and how that emerges in times of heightened economic exploitation,” said Cuddy. “We’re in a phase right now where a type of consciousness among physicians is getting stronger as they reach their limits with burnout and the consequences of burnout for patient care are becoming really clear.”  

“Within Marx’s framework, this can be a positive or negative thing, depending on where you stand in the system. For the workers, it can bring a sense of solidarity that can catalyze collective action toward making shared improvements – for example, in other historical cases, unionization has arisen from similar situations. For the third parties benefiting from the proletariat’s labor, it can threaten their control over professional work and their bottom line.”   

In this atmosphere of heightened attention to burnout, physician-led advocacy is crucial for putting pressure on third parties to rethink systemic pain points. And it’s starting to be effective. 

For example, as of mid-2024, ten states, as well as CMS and Congress have all taken action on prior authorizations, notorious as a source of physician frustration, with proposed laws and rules to streamline requirements that give health plans the power to delay or deny physician-recommended care, inadvertently or otherwise. 

Reducing friction by building bridges between the physicians and third parties

But advocacy for the proletariat must go further and be more deeply integrated into the system if it is to truly have an impact on the far-reaching implications of burnout, argues the research team. Structured advocacy for the rights of the workers needs to be infused into every point of the decision-making process via dedicated individuals who have the clinical experience and business savvy to bring both sides closer together. 

“Including physicians with diverse backgrounds in administrative leadership positions is one part of the solution,” suggested Cuddy. “Such structural positions are very unique and important, with a real opportunity to build bridges between the clinical physician base and the business executive leadership. They can advocate for physicians through the eyes of a clinician and become a mitigating force with third parties to help them rethink some of the relationships and requirements that are leading to burnout.” 

“It’s a challenging role, because physician administrators are in the middle of two very strong, often opposing forces,” she acknowledged. “But if they have a history of understanding the call to provide patient care, and the importance of leveraging clinical insights and experiences to deliver the best possible care in every situation, they can do a great deal to inform how we need to shift the models of care delivery, physician compensation, and the patient-physician experience.” 

Creating more roles for physicians within the administrative and corporate structures of health systems, health plans, technology companies, and regulatory bodies could help to reduce conflict and create a more unified sense of purpose across all layers of the healthcare ecosystem. It’s one part of the solution, but it could be a crucial one for catalyzing the right conversations about what clinicians really want and need from their partners in care. 

“Overall, I believe it’s a step in the right direction that we’re putting language around these issues and exploring frameworks that allow us to have deeper, more meaningful, and more actionable conversations around what burnout means and how best to mitigate it,” said Cuddy. “It’s a very complex problem that will require a range of solutions, but whatever we can do to work together toward improvements will be valuable for patients and providers alike.”   

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.