People who are immersed in a culture, any culture, including physician culture, seem sublimely unaware of its existence and its powerful influence. As they go about their lives, making decisions that they assume are independent of external forces, they view themselves as autonomous, rational thinkers. In doing so, they fail to notice or consider an important fact. They’ve been culturally conditioned to behave just like those around them.
To outsiders looking in, this failure to notice something so evident may seem impossible. Can people really overlook such a dominant force? Research from Harvard University answers this question in the affirmative. Let’s go there now.
It’s 1999, and in a large classroom located on the Harvard campus in Cambridge, Massachusetts, researchers are showing students a grainy VHS video. In it, six students are split into opposing teams of three: one team is dressed in white, the other in black. Both squads have a basketball and are standing in a vacant elevator bank. Those watching this video are instructed to count the passes of the team in white as all six participants weave about in a formation that loosely resembles the warmup routine for the Harlem Globetrotters.
After about a minute, the tape ends, the lights in the classroom come back on, and the students are asked to report the number of passes. Most get the answer correct: thirty-four, or maybe thirty-five—it doesn’t really matter for reasons that will soon become clear. The students are then asked the following question: “Did you happen to notice anything unusual while you were doing the counting task?”
As researchers Daniel Simons of the University of Illinois and Christopher Chabris of Harvard explain it, “We weren’t really interested in pass-counting ability. We were actually testing something else.” That something else appears at about thirty seconds into the video while test takers are diligently following the bouncing balls. From the right side of the screen, someone enters the picture wearing a cheap-looking gorilla costume. This person—a female Harvard student, according to the study’s authors—walks directly into the middle of the passing frenzy, thumps her chest, and then exits to the left of the screen after about nine seconds.
Here’s the incredible and informative part: according to Simons and Chabris, half of the students participating in the study failed to see it happen. As they explain in their best-selling book, The Invisible Gorilla, the researchers have repeated this study hundreds of times for different audiences all over the world. Every time, the results are about the same. Half of the people never see the gorilla. “We think we experience and understand the world as it is, but our thoughts are beset by everyday illusions,” the duo explains.
We think we experience and understand the world as it is, but our thoughts are beset by everyday illusions.
Often, what we see and what we don’t is labeled “selective attention.” When our job is to count passes, we don’t notice anything else, even a gorilla. Under the right circumstances, most people won’t see what’s happening right under their noses, even when it’s completely obvious to others. The same is true of culture. Culture is all around us, and yet we are unable to recognize its impact on our lives.
In American medicine, when doctors “follow the bouncing balls,” they focus on what they can count: the growing number of patients they must see each day, the dwindling minutes they get to spend providing care, the declining rate of reimbursements per procedure, and the outrageous number of computer clicks required to document an office visit. In other words, they see the failures of the healthcare system while failing to notice an equally sizable problem staring them in the face.
Physician culture is medicine’s gorilla. It accompanies doctors everywhere, altering their perceptions and shaping their decisions. And yet they are unaware of its presence. But it needn’t remain this way. Even though physician culture is invisible, doctors don’t have to stay oblivious to its existence. After all, once the participants in the Harvard experiment were told about the primate on the screen, they never again failed to notice their fellow student in that absurd gorilla costume. Once doctors begin to recognize the powerful role physician culture plays in their own practices, they’ll never again overlook it.
A Culture of Burnout
Today, half of all doctors report a troubling constellation of symptoms, which includes exhaustion, dissatisfaction, and a sense of failure. Research concludes these physicians are twice as likely to commit a serious medical error, be sued for malpractice, and report difficulties maintaining healthy interpersonal relationships. These physical and psychological difficulties have been labeled “burnout”, a term first described more than half a century ago by the psychologist Herbert Freudenberger. He noted that burnout most commonly affects people in helping professions who carry high ideals and experience extreme stress.
Today, burnout is a big and burgeoning problem in practically every profession. Among the general population, it affects 28 percent of working Americans. But when we zoom in on physicians, the burnout rate balloons to 44 percent (and even as high as 54 percent in one study). According to a recent Harvard report, physician burnout is “a public health crisis that urgently demands action.” Experts predict that if left unaddressed, it will further erode the mental health of doctors and radically undermine patient care.
Based on national studies, doctors are twice as likely to take their own lives as the general population. Roughly 15 percent of physicians struggle with depression; 20 percent report having had suicidal thoughts.
What Contributes Most to Doctor Burnout?
55% — Too many bureaucratic tasks (e.g., charting, paperwork)
33% — Spending too many hours at work
32% — Lack of respect from administrators, employers, colleagues, or staff
30% — Increasing computerization of practice (EHRs)
29% — Insufficient compensation, reimbursement
24% — Lack of control, autonomy
22% — Feeling like a cog in a wheel
19% — Decreasing reimbursements
17% — Lack of respect from patients
16% — Government regulations
7% — Other
According to the coauthors of a widely cited op-ed on the subject, “Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.” In their quest for a solution, doctors will need to identify and address all the problems contributing to their burnout, not just the systemic ones. Doing so will require them to look in the mirror and acknowledge how their own cultural norms conflict with their vow of doing no harm.
Generation after generation, the culture remains consistent, helping doctors overlook any internal conflict, concern, or guilt they may have about their conduct. Doctors conclude that if everyone is acting the same way, the behaviors they learned must be both acceptable and valuable for patients. By not acknowledging the part they play in burnout culture, they not only harm others, but they hurt themselves as well.
This excerpt is adapted from Uncaring: How the Culture of Medicine Kills Doctors and Patients, by Robert Pearl, MD © 2021 Robert Pearl, PublicAffairs.