Is "burnout" burning out?

I don't know how I missed this, but Dr. Tait Shanafelt and his research team published their most recent nationwide survey of physician burnout in the Mayo Clinic Proceedings this past July ("Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2023").  I've mentioned the burnout issue a few times in the past (see "Don't ask me to to take resilience training!"), and most studies still suggesting that approximately half of the physicians in the U.S. meet at least one of the three criteria for burnout in the Maslach Burnout Inventory (more on this point below).  Dr. Shanafelt has published extensively in this area, and his team has longitudinally measured the prevalence of burnout at 3-year intervals since 2011.  In addition, they conducted an off-cycle survey (about 15 months after the 2020 survey) to assess the impact of the COVID-19 pandemic on professional burnout.

Importantly, according to the MBI, which is the most commonly used scale to measure burnout today, an individual meets criteria for burnout when he or she meets threshold criteria in each of the three categories - emotional exhaustion, depersonalization, and a sense of a loss of personal accomplishment.  The media has erroneously reported in the past that "nearly half of physicians in the U.S. are burned out."  Unfortunately, this statement is technically not correct, and it would be more accurate to state that "nearly half of the physicians in the U.S. meet at least one criteria for burnout."

Using both online and mailed surveys, Dr. Shanafelt and his team surveyed a diverse and representative sample of U.S. physicians.  The response rate was low (less than 10%, or just over 7,600 physicians), but they were able to measure burnout using two of the three metrics included in the MBI - they substituted a previously used survey of personal accomplishment that was more specific to physicians.  They found that burnout in US physicians peaked during the middle of the COVID-19 pandemic with the 2021 survey.  However, relative to 2021 and 2014 (the previous high water mark), burnout at the end of 2023 had decreased and was similar to levels reported in the 2017 survey.  Overall, 45% of physicians reported at least 1 symptom of burnout, compared to 62.8% in the 2021 survey.  When compared physicians to the general U.S. workforce, physicians remained at higher levels of burnout.

Dr. Shanafelt and his team also reported updated survey results of burnout in U.S. residents and fellows (physicians who have graduated from medical school and are training in a particular specialty).  Those survey results were published in the journal, Academic Medicine (see "Changes in Burnout and Satisfaction With Work-Life Integration Among U.S. Residents and Fellows and the General U.S. Working Population Between 2012 and 2023") in December 2025.  Again, burnout among U.S. trainees was lower in 2023 compared to results found in a survey conducted in 2012. Despite this improvement, trainees remain at higher risk for burnout than workers in other fields.

If these results hold up to further scrutiny and follow-up studies, then that is an encouraging development.  Burnout is a major issue that needs to be addressed, and many health care organizations have invested heavily in programs that have tried to address burnout in the entire health care workforce, not just physicians.  However, two results are important to acknowledge.  First, close to half of all physicians still report at least one symptom of burnout, and that is still too high of a percentage.  Second, burnout continues to be higher amongst physicians compared to the general workforce.  We have to do better.

So, back to my question.  Is "burnout" burning out?  Probably not, but perhaps we have reached (and hopefully passed) the peak - and that is progress.  As Winston Churchill once said, "Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning."

"The only clue to what man can do is what man has done..."

My wife and I recently watched the 2025 film, "Nuremburg", starring Rami Malek, Russell Crowe, and Michael Shannon (among other notable stars).  The film is advertised as a psychological thriller and historical drama that tells the story of U.S. Army psychiatrist Douglas Kelley (played by Rami Malek) who was assigned to investigate the personalities and monitor the mental status of Hermann Göring (played by Russell Crowe) and other high-ranking Nazis in preparation for and during the Nuremberg trials, following the end of World War II.  The film is based on the 2013 book, The Nazi and the Psychiatrist by Jack El-Hai.  Both the film and the book are superb, and I highly recommend them.

The film ends with what I thought was an poignant and powerful quote by the English historian and philosopher, R. G. Collingwood, "The only clue to what man can do is what man has done."  The quote comes from Collingwood's posthumously published book, The Idea of History and makes the point that humans are capable of many things, both good and bad (in this particular story's case, very bad), and if you need to be convinced that this is so, all you have to do is look at history.

I really liked the quote, so after hearing it, I did what I frequently do - I wrote it down and looked it up.  As it turns out, the film's production team took the quote slightly out of context.  Here is the entire quote from Collingwood's book:

"Knowing yourself means knowing first, what it is to be a person; secondly, knowing what it is to be the kind of person you are; and thirdly, knowing what it is to be the person you are and nobody else is.  Knowing yourself means knowing what you can do; and since nobody knows what they can do until they try, the only clue to what man can do is what man has done.  The value of history, then, is that it teaches us what man has done and thus what man is."

Did you notice anything different?  The original quote, with the proper context, sounds much more positive.  Even though the shortened quote fit perfectly with the theme of  "Nuremburg", I'm not the meaning I took from the quote at the end of the movie fit with Collingwood's original meaning and intent.  And that is one of the main problems I have with using shortened quotes without providing any context.  Context matters.  Original meaning matters.  We should be more careful when we use shortened quotes from other sources.

Overall, my message today should not detract from how powerful the movie was in conveying what happened during a very difficult period of history.  It's a great movie that I would highly recommend.

"Be an optimist without being a fool"

I read a great book by Heidi Grant recently called Nine Things Successful People Do Differently.  Dr. Grant also wrote an article for Harvard Business Review with the same title which summarizes the book.  To be honest, the book version is relatively short (it's just 112 pages), so I'd recommend taking a little extra time to read the book instead of the article.  There's a lot to discuss about the book, so I will save most of her "nine things" for a future post.  Today I want to focus on what Dr. Grant and others call "realistic optimism" (see also Dr. Grant's 2011 HBR article, "Be an optimist without being a fool").  

Is it better to be an optimist or a pessimist?  Opinions differ.  Norman Vincent Peale, who wrote a best-seller in 2003 called The Power of Positive Thinking once said, "Shoot for the moon.  Even if you miss, you'll land among the stars."  On the other hand, the 19th century English novelist and poet Thomas Hardy wrote, "Pessimism is, in brief, playing the sure game.  You cannot lose at it; you may gain. It is the only view of life in which you can never be disappointed.  Having reckoned what to do in the worst possible circumstances, when better arise, as they may, life becomes child’s play."

Studies show that most of us tend towards being more optimistic than pessimistic.  In fact, the neuroscientist Tali Sharot wrote an article for Time magazine in 2011 and cited research that 80% of the population tends to think positively about the future, even when confronted with evidence to the contrary.  In an article published in the journal Current Biology, Sharot wrote, "When it comes to predicting what will happen to us tomorrow, next week, or fifty years from now, we overestimate the likelihood of positive events, and underestimate the likelihood of negative events.  For example, we underrate our chances of getting divorced, being in a car accident, or suffering from cancer.  We also expect to live longer than objective measures would warrant, overestimate our success in the job market, and believe that our children will be especially talented."  Our brains seem to be wired for positivity and hope (see Sharot's TED talk from 2012 on "The Optimism Bias")!

So, if our brains are truly wired for optimism, wouldn't it be better to stay consistent with our natural biologic state and stay positive?  The answer is not as straightforward as you may think.  The author Chris Loper suggests that optimism and pessimism lie along a spectrum:  

On the far left of the spectrum is unrealistic pessimism, which describes individuals who always believe that the worst is going to happen.  Loper says that this way of thinking is clearly not healthy.  However, just as unhealthy is unrestrained positive thinking, or unrealistic optimism, which lies at the far right end of the spectrum.  Believing that good things will always happen or things will always turn in your favor no matter what is simply unrealistic too.  When you always expect good things to happen, there's a good chance that you will be disappointed when they don't happen (expectations don't always match with reality).

Realistic pessimism describes individuals who always err on the side of caution.  They have an accurate assessment of reality, but at the same time, they can envision positive outcomes, even if they tend to give negative outcomes more weight.  There are likely situations where it is better to be a realistic pessimist.  For example, how many times have I wrote about the high reliability organization principle of preoccupation with failure?  If you are making a decision that involves a lot of risk, being cautious and thinking about all of the bad things that could happen is probably warranted.  However, realistic pessimists are also afraid to leave their comfort zone, take risks, and try new things.  Personal growth and development often requires just that, and we tend to learn when we make mistakes.

Realistic optimism describes individuals who stay positive about the future, yet realistic about what it will take to achieve their success.  Realistic optimists understand the difference between a belief that they will achieve their goals and succeed and a belief that they will easily achieve their goals and succeed.  They acknowledge that careful planning, choosing the right strategy, attention to detail, hard work and effort, and persistence are all critical to making success happen.  

The psychologist Gabriele Oettingen (see "Expectation, fantasy, and weight loss" published in the journal Cognitive Therapy and Research) asked a group of individuals enrolled in a weight-loss program how likely they felt that they would reach their goal weight.  The individuals who were confident that they would success lost 26 pounds more than the self-doubters ("the power of positive thinking").  Dr. Oettingen also asked the individuals to imagine what the road to success would be like and how much effort it would require.  Those individuals who believed that they would easily achieve their goal weight lost pounds less than those who thought it would be hard work to achieve their goal weight, even though they would succeed in the end.  She has found this same pattern of realistic optimism in studies of students looking for high-paying jobs after college, singles looking to find their romantic soul mate, and even adults recovering from hip replacement surgery.  

Dr. Grant writes, "Believing that the road to success will be rocky leads to greater success because it forces you to take action.  People who are confident that they will succeed, and equally confident that success won't come easily, put in more effort, plan how they'll deal with problems before they arise, and persist longer in the face of difficulty."

I will end this post, as I frequently do, with a quote.  Walt Disney once said, "I always like to look on the optimistic side of life, but I am realistic enough to know that life is a complex matter."  Being realistic AND optimistic is one of Dr. Grant's nine key ingredients to success.

Better football, better health?

The 2026 FIFA World Cup is just over a month away!  The Fédération Internationale de Football Association (FIFA) holds the World Cup, a tournament between men's national football (soccer) teams, every four years.  The reigning champions are Argentina, who won their third title at the 2022 World Cup by defeating France.  This year's tournament will take place from June 11 to July 19, 2026, and it will be jointly hosted by the United States, Mexico, and Canada (the first time that the World Cup has been hosted by three countries).  Forty-eight countries will be playing in the tournament this year, which is also the first time that this many teams have played in the tournament.

Bill Shankley, a former World Cup player for Scotland and manager of the Liverpool Football Club (a team that currently plays in the English Premier League) from 1959-1974 reportedly once said, "Some people think football is a matter of life and death...I can assure them it is much more serious than that."  He may have had more of a point than he originally thought or intended.  Researchers John Appley and Andrew Street published a study in the Journal of Health Services Research & Policy in 2001 which compared the rankings for the international teams of 176 countries against the rankings for the same countries on the World Health Organization health performance index.  According to their data, if a national team does well, the country is also likely to have a good health system.

Importantly, the paper started out as a joke.  Andrew Street told Roger Dobson, writing for the British Medical Journal, "The intention was to sow doubt about supposedly sophisticated attempts by the World Health Organization to measure health system performance.  But there are some serious messages.  The most notable is that data can be misused to prove almost anything you like - such as that countries with better football teams will have better health systems.  Just because the WHO analysis looks sophisticated, it does not mean it is right."

I am reminded of the famous association between a country's per capita chocolate consumption and the number of Nobel Prizes received by its citizens, published a few years ago in the New England Journal of Medicine (see "Chocolate Consumption, Cognitive Function, and Nobel Laureates"), which I mentioned in a previous blog post (see "Michael Jordan, Chocolate, Coffee, and the Nobel Prize"):

There are a couple of important take-home points to emphasize here.  First, data can be massaged to show just about anything, so be careful about making any definitive statements or conclusions from any "big data" analysis.  Second, correlation does not prove causation.  The way to improve a country's overall health is not to strengthen the country's national football team.  

Third and perhaps most important, evaluating a country's overall healthcare system is a lot more nuanced than most people think.  As I have stated a number of times in previous posts (see, in particular, "Measure What Matters"), most commonly cited metrics of a country's healthcare performance have more to do with measuring the overall health of the country's population than with the quality of their healthcare delivery system.

Chimpanzee War

We can learn a lot about human behavior by studying other animal species, particularly primates.  Humans are indeed part of the primate family.  Chimpanzees are one of our closest animal relatives, sharing close to 98% of our DNA.  In fact,  if you consider just the portions of our genome that code for proteins, we share 99% of our DNA with chimpanzees - most of the differences in our DNA involve portions of the genome that do not code for proteins.  It's believed that Homo sapiens (that's us) shared a common ancestor with chimpanzees over 6-7 million years ago.

I first mentioned a book by the late primatologist Frans de Waal called Chimpanzee Politics in a blog post in 2019 ("A cup of Joe, rough sandpaper, a soft chair, and a clipboard is all you need").  The book is about animal behavior, specifically the group behavior of the chimpanzees living at the Royal Burgers Zoo in Arnhem in the Netherlands.  During a study that lasted for several years, de Waal described a number of Machiavellian tendencies of the group, leading to his "Machiavellian intelligence hypothesis" (also known as the "social brain hypothesis" or "social intelligence hypothesis"), which posits that the challenges involved in navigating complex group dynamics in society is a major driving force in the evolution of human intelligence.  In order to succeed within social groups, individuals must strike a balance between cooperation and competition with the other individuals in the group, resorting to what some refer to as "soft skills" rather than brute force.  Apparently, the book has been highly recommended by a number of management and leadership experts, and it was reportedly very influential on former U.S. Speaker of the House New Gingrich during the 1990's.  It's a fascinating book that is well worth the investment of time, and I added it to my Leadership Reverie Reading List in 2022.  

I mention Chimpanzee Politics in the context of a recent CNN article that I read by Taylor Nicioli ("Chimpanzees in Uganda are in a ‘civil war,’ and researchers are unsure how it will end").  Nicioli's article is, in turn, based on a new research study published in the journal Science ("Lethal conflict after group fission in wild chimpanzees").  Apparently, scientists working with the Ngogo Chimpanzee Project in Uganda’s Kibale National Park have observed the start of a "civil war" between two sub-clusters of what was once a single, albeit large group of chimpanzees living there.

Wars have been fought throughout history for all different kinds of reasons.  The "cultural marker hypothesis" claims that differences in ethnicity, religion, language, and other cultural markers anchor group identity in such a way that favors cooperation and cohesion between members within the group and competition and even outright hostility to members outside the group.  One problem with the "cultural marker hypothesis" is that it fails to explain how conflict occurs inside a group, such as a revolution or civil war.  As the scientists working with the Ngogo Chimpanzee Project have recently found out, shifting allegiances and rivalries can occur within a group as well, even to the extent that can generate intra-group conflict and fracture the group.  

Aaron Sandel, the co-director of the Ngogo Chimpanzee Project and lead author on the Science paper, and the research team analyzed more than 20 years of data and identified three key stages that led to the fission of the group and eventual lethal aggression: (i) an abrupt shift from cohesion to polarization that created two distinct sub-groups or clusters within the greater group; (ii) a slow (2 year) period of increasing avoidance between the two groups; and (iii) lethal aggression between the two sub-groups or clusters.  

The chimpanzees at Ngogo were part of a single, large group when the study first began in 1995.  Despite belonging to the single, large group, there were two distinct sub-groups or clusters, which the researchers called the Western cluster and the Central cluster.   While members within each cluster spent more time together, they did interact with members of the other cluster.  Until around 2014, about 30% of individuals switched clusters from one year to the next.  The two clusters shared the same territory, as well as the same set of reproductive partners - 44% of infants were conceived by males and females belonging to different clusters.  

There was an episode occurring on June 24, 2015 in which two groups of males from the Western and Central clusters approached each other near the center of the territory.  The males from the Western cluster ran away when the males from the Central cluster chased them, and for the next six weeks, both clusters avoided each other.  Nicioli writes, "The once close-knit group of chimps were suddenly treating each other like strangers."  Sandel remembers fellow researcher John Mitani, "What's going on?" Mitani replied, "I don't know."  Sandel says, "And that also stuck with me, because this is one of the world’s experts on chimps. He’d studied these chimps for two decades. But we were seeing something new."

Sandel believes that single event "planted the seeds of polarization" that eventually led to the group's downfall, which is what the data subsequently showed.  From 2015 to 2018, the two clusters became more distinct.  The Western and Central clusters began to coalesce in separate territories - what was once the center of the larger group's shared territory became a distinct border between the two clusters.  After 2015, all of the infants born in the group were conceived by males and females from the same cluster.  

Beginning in 2018, males within the Central cluster began to conduct "patrols" towards males in the Western cluster, and aggressive interactions became more frequent.  After 2018, Western chimpanzees began to attack and kill males from the Central cluster.  Beginning in 2021, lethal aggression expanded to infants.  The single group had permanently splintered into two.

What was notable to me from this study was that the Ngogo group had grown significantly in size over the course of the study.  By the time that signs of group disharmony appeared around 2015, there were over 200 chimpanzees in the group, which far exceeded the size of other chimpanzee groups reported elsewhere.  The research team also had noted that five adult males and one adult female had died after exhibiting clinical signs of illness, just before the event in June, 2015.  The loss of even weakly connected nodes in the overall network could have disrupted the social network.  There was also a change in the alpha (dominant) male in 2015, which also coincided with the first separation of the two clusters.  Either explanation is possible, but the research team will likely never know for certain.

Sandel and his team concluded, "If chimpanzee groups can polarize, split, and engage in lethal aggression without human-type cultural markers, then relational dynamics may play a larger causal role in human conflict than assumed."  Moreover, while it is tempting to attribute polarization between groups to ethnic, religious, or political differences, Sandel and his fellow researchers suggest, "Focusing entirely on these cultural factors overlooks social processes that shape human behavior - processes also present in one of our closest animal relatives.  In some cases, it may be in the small, daily acts of reconciliation and reunion between individuals that we find opportunities for peace."

"Why the U.S. spends so much on healthcare"

Andrew Mollica and Anna Wilde Mathews wrote an interesting article for The Wall Street Journal recently in order to help explain why the U.S. spends so much on healthcare compared to all of our peer countries.  They first cite well-known statistics that Americans spend more on healthcare than anyone else in the world.  Healthcare expenditures account for approximately 18% of the U.S. Gross Domestic Product.  We spend, on average, about twice as much money per person (approximately $14,775 per person per year) on health care every year compared to other large, wealthy countries (approximately $7,860 per person per year) (see "How does health spending in the U.S. compare to other countries?"), which once prompted legendary investor and CEO of Berkshire Hathaway Warren Buffet to call health care costs "the tapeworm of economic competitiveness".

According to data (from 2023) from the Center for Medicare and Medicaid Services and The Commonwealth Fund, here is how every dollar is spent on U.S. healthcare:

As you can see, Americans spend about 10 cents per every dollar on administrative costs.  While that doesn't sound like much, it's about five times more than the average that other countries spend on administrative costs.  The United States also spends as much on administrative costs as it does on long-term care costs, which is also a mismatch compared to what other countries spend on long-term care.  For example, Sweden spends 22x as much on long-term care compared to what it spends on administrative costs.

While I think Mollica and Mathews oversimplify what is in reality a more complicated issue, here are the factors that they say make U.S. healthcare the most expensive in the world:

1. Prescription drugs cost a lot more in America

"Most other nations force drugmakers to accept lower rates, while the U.S. government generally doesn't."

2. Big hospitals can charge higher rates because of consolidation

"Many cities and communities are now dominated by a single hospital system, partly because hospitals have been merging in recent years.  The consolidation has given hospital systems leverage to command higher rates during negotiations with health insurers.  The insurers would lose business if powerful hospitals shut them out."

3. The U.S. spends far more than outer countries on administration

"The costs include functions like billing, claims processing and customer service."

4. Labor costs are higher

"American doctors and nurses generally make more than their counterparts in other countries."

5. Americans are using more healthcare

"Healthcare utilization has grown faster than prices in the most recent years."

Five for Impact...

My wife and I recently went on a Spring Break trip to California.  Our first stop was one of our favorite places in the world to visit, Coronado, California.  We spent Easter weekend there before driving north about six hours to visit the Central Coast region of California.  We toured the beautiful Hearst Castle in San Simeon and did a wine tasting at the Hearst Ranch Winery.  After a couple of days in the Central Coast, we drove back down to San Diego and stayed for a few days at a hotel in Rancho Bernardo, where we briefly lived now almost 30 years ago.  It was a great trip!  We both needed the break, and we spent a lot of time resting, relaxing, and reminiscing.  Even better, we spent a lot of time just talking, which is something that we don't always get to do with both of our busy professional lives.

During one of our deeper conversations, my wife asked me, "Who would you say are the five individuals who've had the most impact on your life?"  

Her very thought-provoking question led me to ask one important clarifying question, "Do you mean impact on my personal life, professional life, or both?"  

She responded, "Your life.  Both.  Your life is both your personal one and professional one."

Spoiler alert.  I'm not going to share my list with you today.  First, it was really hard for me to narrow my list to just five.  I've been blessed with having known several individuals in my life who've made a significant impact on who I am today, including my family of course.  And, as I've shared several times in these blog pages, I've been fortunate to have a number of individuals who've provided me with mentorship throughout both my personal and professional life.  Second, because I had to limit my list to just five, I don't want to offend anyone for having left them off my list.  Third, and perhaps most importantly, the list really wasn't the point of my wife's question.  She just wanted me to think about all of the individuals in my life who've made a difference for me.

What was really nice about this exercise is that once I started to think about who would be on my list, I remembered a number of individuals who've made an impact on my life that I have forgotten over the years.  I remembered a few teachers who always supported me and challenged me to be a better version of myself.  I also remembered a few of my coaches, some of whom were also my teachers in school.  As I reflected, there were some individuals in my life with whom I had relatively little contact with when you look at my life in total, yet these same individuals made such an incredible impact on the person who I've become today that it was hard not to consider them for my list.

I found this exercise to be very meaningful, and I think you will too.  Think about all the individuals that you've encountered in your life and the impact that they have made on you.  Just for the purposes of this exercise, include only the people who've you personally encountered.  Leave out famous individuals who have inspired you - these individuals are important too, but I want you to focus on just the individuals you lived and who you encountered during your own life.  Now try to limit the list to just five.

I hope you find this exercise to be as rewarding for you as I did.  I want to thank my wife for asking the question and inspiring this blog post.  She knows that she is on my list!