Zubin Damania, MD (ZDoggMD) graciously sat down for an interview with the Neurosurgery Blog for the Physician Burnout focus series. He spoke with Kurt A, Yaeger, MD, neurosurgery resident at Mount Sinai Hospital in N.Y., and chatted about neurosurgery and moral injury/burnout.

Dr. Yaeger: Thanks for taking the time to chat with me for the Neurosurgery Blog. As a resident, a lot of your messages really resonate, especially reframing the phrase “burnout” to “moral injury.” Can you tell me about your motivation behind that?

ZDogg: Wendy Dean, MD and Simon G. Talbot, MD, wrote a piece for STAT News, which discussed how physicians aren’t suffering from burning out, they’re suffering from “moral injury.” It resonated with me because I realized that’s really what it is: it’s this conflict that we want to do the right thing. Physicians are very resilient, and yet we fail to be happy and succeed, not for lack of resilience, but because of the system in general. I wanted to draw attention to the fact that there’s a lot of victim shaming and a lot of over-simplification.

Especially as a surgeon, there’s a culture of “suck it up” and “what doesn’t kill you makes you stronger.” It’s part of the culture of medicine to be like that: if you can’t hack it, you can go someplace else. One of my biggest pet peeves are administrators that say, “Ah, you guys should get a massage, some essential oils, and we’ll hire a wellness officer who isn’t a doctor…” Directly in response to the video I made, some PhD wrote in Medical Economics, saying it was “burnout” and not “moral injury.” His title was, get this, the “director of provider well-being.” I thought, there’s so much wrong with that. First of all, you’re not a physician. Second, doctors tend to bristle at the term “provider” because it is an administrative commodification of all health care professionals. So, this is an ongoing problem and why I chose to focus on the terminology.

Dr. Yaeger: Do you think subspecialists like neurosurgeons are more or less prone to moral injury?

ZDogg: I don’t want to speak for my surgical colleagues, but because I have a platform where many medical professionals follow along, I get the sense that everyone is suffering in their own way. It may be that a surgeon’s kind of suffering is that they want to operate, and they want support from a primary care team. Yet they find themselves having to deal with everything because the system is so fragmented, there’s poor communication, everyone is siloed, and nobody has walked in each other’s shoes. Surgeons may feel like they’re patching up the failures of preventative medicine, which creates moral injury. They still have to chart. They have the pressures of trying to run a business and be successful financially. All this while doing good for patients. Thus, I think it’s more universal, though surgeons may compartmentalize a little bit more.

Dr. Yaeger: Do you think the evolution of technology in health care is enhancing the provider experience, or is it making them less productive and less able to spend time with patients?

ZDogg: So, I’m a big fan of technology in general. My whole platform is built on technology that didn’t exist when I was a kid — but as soon as it did exist, I was able to do the things I’ve always wanted to do. So, I’m a believer in that. The problem is, having been to some of these health IT (information technology) conferences like HIMMS (Healthcare Information and Management Systems Society), usually, it’s just a bunch of buzzwords and a bunch of people trying to capitalize on some concept — like building an app that counts steps and then pays you. But the truth is that without actually adding value to the physician’s day, those things are bound to fail. So EHRs (electronic health records) added value to administrators and hospital systems and insurance companies by capturing all this data that they couldn’t see before, but it doesn’t add much for patient care and just adds more to the plates of physicians. I think a lot of technology is seen as doing that currently, but it doesn’t have to be that way.

A good example is a company called Suki, whose creator I interviewed on my show. It’s a startup using artificial intelligence and natural language processing to automate clinical note documentation. Right now, it’s software that has to be invited into the exam room by a doctor. Doctors have to say, “this is something I want to assist me.” Suki designed its technology to take stuff off the doctors’ plates and make their lives easier. I think that’s the technology that’s going to help us.

Finally, I hate the terms telehealth and telemedicine, but some new companies do virtual, text-based primary care. Well, that’s an interesting way to rethink the practice of primary care because most people want the convenience to communicate with the physician the way they communicate with their kids. So, there is a lot of hope, but the parallel to EHRs is that you get the technology wrong, and it creates more work, and that’s the last thing we want.

Dr. Yaeger: What can we do, as professionals in neurosurgery, to lead the charge against moral injury?

ZDogg: Neurosurgeons are highly respected, even among other physicians. They’re are perceived as the apex of diligence with a complex skill set and work-intensive profession. What we haven’t seen yet — because you’re all so busy — is the leadership neurosurgeons can show in helping to reorganize medicine around principles we all care about. I call it the Health 3.0 Movement, where medicine is team-based. Neurosurgeons can be leaders in this — and have the gravitas to do it — so getting involved in organizations such as the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), and getting engaged in social media, can actually make a difference.

Dr. Yaeger: How can neurosurgical department leaders, such as the chairs and program directors, emphasize the wellness of residents without sacrificing education?

ZDogg:  What a great question. What I’ve noticed is that the “elders” in medicine — the Gen Xers and Baby Boomers — like myself, notice young people are coming in and saying, “I’m going to clock in and clock out and hit my work hours. If a particular task doesn’t fit my learning, I’m not going to do it.” The elders notice a general erosion in work ethic, some of which may be a “fragilization” of Millennials and Gen Z with over-parenting, social media — but it’s not their fault. It’s been documented. They’re more anxious and more suicidal because we’ve turned them into fragile creatures rather than anti-fragile, where they get strength from adversity. So I think the first step is for program directors to be open.

It’s hard in neurosurgery because you have to be that focused and that diligent. What that means to me is that we need the leaders to have a little bit of emotional intelligence. To say, yes, there is some suffering here, and to recognize that. But then really, still holding those expectations and saying to trainees, “If this really is a calling, you will put in the effort. If we see that you put in the effort and passion, we will do our best on our end to make work-life integration happen.” Because it’s really not work-life balance, it’s just life. You’re trying to create something that’s sustainable, with a purpose and a calling. You have to show your mentors that this is a calling for you, and your mentors need to return the favor by helping to make this better together. It’s a partnership.

There’s a term, “communalization of pain.” Sometimes you see it in the military. We in medicine tend to suffer in silence, alone. There is a perceived isolation here that creates more moral injury. But, if you have other colleagues who say, “Yes, we are also suffering,” there are ways to communalize the suffering, and it’s healing for everyone. It’s validating that your suffering was witnessed. You’re not just doing it silently. Part of my platform is to help communalize the experience. The reason why our moral injury video had so many views is because it communalizes pain and reminds us that it’s not so much “I’m crazy” as “THIS is crazy.” Residency program directors can help to communalize pain by acknowledging suffering.

Dr. Yaeger: Well, thank you very much for your time. It’s been a great conversation.

ZDogg: It’s been great talking to you, thanks for the opportunity!

ZDoggMD (Zubin Damania, MD) is an internist from the University of California San Francisco (UCSF)/Stanford University and founder of Turntable Health, who speaks out against the dysfunctional U.S. health care system. He has taken to social media to campaign against physician burnout — or moral injury — using the term he prefers. ZDogg was the keynote speaker at the 2019 AANS Annual Meeting. Visit his website for more information.

Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtag #PhysicianBurnout.

Kurt A. Yaeger, MD
Mount Sinai Medical Center
New York, N.Y.