Social Commentary

With my Internal block wrapping up and no exams or evaluations on the immediate horizon, I've had a chance to do some more reading than normal. Since, like most people my age, I'm addicted to the internet, this has mostly consisted of reading internet articles. A few are worth mentioning and deserve a response.

1) I'm a freelance writer. I refuse to work for free by Yasmin Nair - via Vox.com

I'm a huge fan of Vox's "First Person" series, which has done a great job of bringing compelling or non-mainstream viewpoints to print. Part of the reason I'm a fan is that it lets me read a number of well-written pieces that I completely disagree with. This is one of them.

The central argument here is that the massive growth in people writing for free is causing writing to be viewed more like a hobby, leaving professional writers like her out in the cold while simultaneous degrading the quality of popularly-read writing. In particular, the author believes that this shift toward unpaid writers is perpetuating societal inequality, in a number of ways, whether it's editors profiting off unpaid work, or poorer individuals squeezed out of the writing marketplace by richer writers who earn money in other vocations and write on their free time.

On one hand, I acknowledge that the old model of writing is dying. It's undoubtedly hard to earn a living doing nothing but writing, especially when you exclude journalism as well as creative works like novels or poetry. Where I disagree is that I'm not sure that's a bad thing and I'm very skeptical that, on the whole, this contributes to inequality.

I write for free. It is a hobby for me. I'm not going to stop doing something I enjoy because someone else would like to be paid for doing something similar. The thing is, there are authors who do make a living off their writing. These are usually fairly exceptional authors in one way or another, either because they produce a very high quality of writing, have particularly unique or compelling insights, or appeal to a specific group of individuals. They deserve to be paid for their services. However, most writers are not exceptional and, as such, there's not much of a monetary demand for their work. I don't see much problem with that - if an author isn't offering value beyond what others are more than willing to provide for free, there's no justification for paying them.

The analogy I draw is sports. I like playing basketball. I'm not very good. Certainly no one would pay to watch me play. NBA players do get paid because they're amazing and fun to watch. Rec-league players like me don't, and a fellow rec-league player has no right to get upset because they aren't earning a salary for playing the game.

Where there is cause for concern is where a person's writing is earning money, just not for them. In the sports analogy, that would be college basketball. In the Vox piece, that is places like the Huffington Post. That's a fair criticism - executives shouldn't be raking in the cash at the expense of those actually doing the work - but there are shades of grey in there. Editing, producing, publishing, and advertising is hard, grueling work. It's not hard to get people to write without compensation (it's fun), but very hard to get people to maintain a publication for free (it's less fun). For example, she faults OpenDemocracy for having a paid staff, but their salaries are hardly extravagant and reducing those salaries would provide almost no funds for their writers.

As for inequality, I'm sympathetic to the notion that free writing shifts the balance of publications towards wealthier individuals who can afford to write for free. However, I think that narrow view misses the broader gains for inequality from increasingly free writing. For one, low writing costs means low consumer costs. Anyone can read what I write! It's free! Whereas in the past writing may have been prohibitively expensive to consume for those with lower socioeconomic status, anyone with access to a computer can now read a huge amount of information from a wide variety of authors. I have trouble reconciling the benefit of paying authors more with the downsides of charging consumers more. Writing shouldn't be only the purview of the rich, but good ideas shouldn't only for the eyes of the wealthy either.

2) Don’t Give Up! by Gregory Shumer - via NEJM Journal Watch

This article concerns a now-senior resident reflecting on the difficulties they had when starting medical school and how they persevered through those difficulties to get to where they are. Medical school - and life in general - have challenges and rising to those challenges is laudable. While not a controversial viewpoint, it is good to read a reminder that hard work and dedication can make trials in life manageable.

So why am I mentioning this article at all, if it's point is relatively simple and one I agree with? Because the author put their struggles in the context of systemic burnout among physicians. More importantly, he proposed solutions to burnout including "try to keep those feelings at bay" and "a greater commitment to [your] long-term goals". There's an attitude in parts of medicine that ascribes burnout to personal failings on the part of trainees or physicians. Going along with that, any solutions to burnout are targeted at individuals, presumably trying to correct or prevent those failings. Even the author's relatively helpful suggestions, "some personal time, a change of direction, or a conversation with someone you trust and admire as a mentor", all buy into this notion of burnout as fundamentally the responsibility of individual physicians.

However, burnout isn't a personal failing, it's a systemic problem. I have no qualms about revealing that halfway through clerkship, 6 months into it now, I've had symptoms of burnout for at least half that time, no less than 3 months in total. I really haven't been struggling in my duties during clerkship, and in some ways I've been excelling, yet I'm still burnt out more often than not. Trying harder isn't going to change the fact that I'm sleep-deprived, or give me more time with my loved ones, fix the many broken parts I see in medicine, or make medical education more effective - I'm already doing all I can to manage the elements to being a medical student that are causing me to be burnt out, but most of them are completely beyond my control.

I'm glad that the author was able to redouble their efforts and push through their initial challenges when starting medicine. However, that's not going to help the vast majority of people dealing with burnout and I find it incredibly misguided, if not outright dangerous, to continue to put the responsibility of dealing with physician or trainee burnout primarily on the shoulders of those experiencing it. They're already doing what they can to avoid it - no one wants to be burnt out! Burnout is a systemic problem, and it will only be solved with systemic change.

Burnout Culture

Really wanted to highlight a post via KevinMD of a burnt-out surgeon. First, I think it gives a good description of how medicine leads to burnout, namely that it's a long process. Individual  moments certainly stand out and can precipitate reactions like a breakdown or quitting, but a physician is set up to break long before any one event pushes them over the edge.

Second, stresses on a physician are multi-factorial. One of the commentators provides a nice framework to categorize the stresses:

1) Workload - too much work, long hours, not enough time for each task
2) Control - limited autonomy, limited schedule control
3) Reward - insufficient monetary, non-monetary, or personal compensation
4) Community - lack of sense of belonging, difficult coworkers or bosses, habitual conflict
5) Fairness - unequal treatment between physicians, or unjustified treatment of all physicians
6) Values - work that conflicts with your broader ideals

Every job has concerns related to some of these categories. What the burned-out surgeon's story makes clear is that many physicians are having stress in almost all these areas: long hours, too much work in those long hours, little schedule control, inadequate support from colleagues, the list goes on. Each physician will have their own mix of personal stresses, but it doesn't tend to be a single one that causes a physician to become burned out, it's the combination of stresses that does it.

Some stresses in medicine are going to be unavoidable. A regular, 40 hour work week for all physicians probably isn't viable without massively slashing overall compensation or having physicians provide horribly substandard care. Full schedule control is impossible in many specialties. Some conflicts between physicians are necessary, even productive.

Yet, there are a lot of stresses physicians face that could be minimized or eliminated. 40 hour weeks may not be feasible, but that doesn't make 60, 70, or 80 hour weeks necessary. Coverage for 24/7 services requires people working when they'd probably rather not and while night shifts are never good for a person's health, many workplaces figure out how to employ people at all hours of the day without causing the system-wide levels of stress seen in medicine. Open conflict between physicians is actually quite uncommon I've found, yet a degree of animosity towards other physicians and healthcare workers seems to run deep and it's completely unnecessary.

The author of the article is American, and the US healthcare system does have its differences relative to Canada, but the contributors to stress are very similar. The major salient difference may work in our favour - while in the US, physicians are often hospital or clinic employees, subject to the whims of their employers, Canadian physicians typically function as independent contractors of sorts, with more collective leeway to make positive changes to reduce our own stress. While our American colleagues are largely confined to railing against the system controlled by non-doctors, Canadian physicians just need to convince each other that this is a problem worth addressing.

However, as the piece laid out, fellow physicians can be the greatest obstacle in taking care of ourselves. Calls for help frequently go unanswered and resentment absolutely exists for those who work less in an effort to recover from or prevent symptoms of burnout.

I think we're getting there, all barriers aside, and while change has been frustratingly slow, it's at least moving in the right direction. Yet, as anecdotes like this make clear, there's good reason to pick up the pace.