How managers can learn from the exodus in the caring professions, canaries in the burnout mine

Carin-Isabel Knoop
20 min readMar 30
on the left Superwoman as a female doctor wearing white scrubs, with superman letter S on chest; on the right a visual of doctors around a table, “summoning” someone: Diverse gender and demographic medical doctors, in white scrubs with stethoscope, in a board meeting with managers, burning out, in the style of video game the wolf among us, drawn by David Bogan, directed by Wes Anderson, cinematic still
Flight or fright (photo credit to Antonio Sadaric and midjourney)

As much as we like to say that things are never a matter of life or death to de-escalate a situation in the business world, medical doctors face such stressors daily. Their almost superhuman capability is often overlooked until we find ourselves in the role of patients.

We explore how physicians, especially emergency room (ER) physicians, have suffered in the pandemic and how to distill lessons for managers whose jobs increasingly entail supporting struggling employees under continued expectations of high productivity. The news is dire. Today about 18% of emergency management positions are unfilled (vs. 0.5% in 2021. What is happening, and are there lessons in how ER doctors experience their work that all workers should understand and for which leaders (managers) should be planning now?

Who are doctors in our imagination?

The popularity of medical drama and drama-comedies about physicians reflects our fascination for their craft.

Most readers will know the show “Scrubs” from the early 2000s as a witty yet human perspective on residents and practicing doctors. Scrubs offers a glimpse into the stress of working in a fast-paced, high-pressure environment. From dealing with life-or-death situations to navigating complex interpersonal relationships, the show captures the full spectrum of daily experiences that doctors, surgeons, and nurses face. In our post-covid world, where healthcare workers have been pushed to their limits, Scrubs is more relevant than ever (see here for a summary of takeaways!). It reminds us that even in the darkest times, there is always room for laughter and human connection, but it also portrays the “rush” that can become addictive in some fields of medicine.

The TV show “Frasier” from the 1990s portrays the day-to-day struggles of psychiatrists dealing with patients, but it also highlights the emotional toll that the job can take. From dealing with complex patients to juggling personal and professional relationships, the show offers a realistic depiction of working in psychiatry — and increasingly as a manager.

What is it like to be a doctor in real life?

Several features of medical lives and teaching are unique.

First, they tend to be mission-driven. Many might have had the luxury of choosing their profession based on such a calling. They know the enormous good they can provide — exponentially, for their patients/students, families, and communities, some at high risk.

They are also frontline workers facing other people the whole day. In addition to their primary customers (patients/students), they often have to manage the expectations of family members, who are often tempted to blame the doctor or teacher instead of taking responsibility themselves.

As a result, their lives resemble the American arcade game of “whack-a-mole” — as soon as you feel that you handle one situation, another one pops up. And that happens all day, every day.

In addition, unlike many office workers, they are not on their phones or attending to personal things at work — and spend their spare time doing errands instead of recuperating. When doctors and teachers work, they work — they are on stage, being watched, judged, obeyed or ignored. Across from them, often are people more and more on their phones or disconnected and disinterested.

This is not to say that technology has neither changed their lives nor distracted them. Many of us have lost our doctors to their screens — they glance at us quickly while navigating and populating the Electronic Health Records (EHRs) now choreographing their interactions.

in addition, like educators, they are often managed by people who don’t understand their businesses and get in the way. Part of the administration is related to more and more compliance and imperatives related to social advances in diversity, equity, and inclusion. But it is also driven to maximize efficiencies for cost savings and profits.

Some hospital administrators are paid more than doctors, and while the number of doctors matched population growth (about 150%) from 1975 to 2010, there was a 3,200% increase in the number of healthcare administrators. Physicians aren’t shy about voicing their concerns and can be readily found doing so on platforms such as Twitter.

Chart from the Bureau of Labor Statistics data showing that number of physicians grew about 150% between 1970 and 2015 vs nearly 3000% for hospital administrators

“See one, do one, teach one.”

Lastly, doctors are expected to teach. And because of the volume of material to learn as well as the procedures teaching is an insurance policy for the collective skills and knowledge of the profession above and beyond what is on the standardized test for progression. This means connecting directly with less experienced doctors at more junior stages of development and doing so often with individuals of different backgrounds and lived experience.

Misunderstandings and bias are real risks, and much has been written post the #metoo movement about men being more reluctant to mentor women. And, as with teachers today, this means navigating social concerns as well as helicopter parents (yes, they persist into medical school and even residency!), and risk being mocked on social media.

Finally, it requires being invested in paying forward at a time when we are most interested in collecting now. However, as a medical colleague noted recently, “the doctors’ lounge isn’t billable.”

What is stressing the system to the point of failure?

depicts diagram of stress strain curve with elastic limit, stress point, and breaking point
From https://en.wikipedia.org/wiki/Stress%E2%80%93strain_curve#/media/File:Stress_strain_ductile.svg, accessed April 2022

Using an analogy from engineering to illustrate the impact of poorly managed stress at work, humans, like materials, have different materials and can be stressed up to a point — they reach an ultimate stress point (no going back to how the material was) until the rupture point (complete failure). Some individuals recognize where they are on the curve and can step back or walk away — if their work and personal circumstances allow it.

Particularly damaged were the cohorts of ER staff, including doctors. They had to save lives while being affected by the squeezed hospital revenues, societal forces (anti-vax, anti-expert, covid paranoia), work demands (shifts on nights, weekends, and holidays), and the social shame (internally among the world of medicine) of not being the popular residency.

There are several other reasons why many seem unable to withstand the strain of additional pressure.

Some are financial. These include hospital closures, mainly in hospital settings, post-Covid financial strain across the system, and a growing number of for-profit hospitals. Private equity has also consolidated many practices in bigger networks focused on profitability. According to PitchBook, since 2012, PE firms have poured nearly $1 trillion into nearly 8,000 healthcare transactions. Doctors who stay on are employees — and start to behave like ones. There are increased expectations (productivity). Germane here are Relative Value Units (RVUs) and scale, a methodology used by the Centers for Medicare & Medicaid Services (CMS) and private payers to determine physician payment.

Some relate to perceived inefficiency. Doctors complain about spending more time on “paperwork”: mostly filling out charts and managing EHRs. EHRs take a long time to fill but often cannot be accessed across different departments and medical practices. Also, the data is recorded in a standard way when many doctors take notes in personal ways that helps them organize the data they are collecting.

Risk has increased. Doctors are always at higher risk of infection and disease, but this was much higher in Covid, in addition to fungal infections, MRSA and other issues. In addition, agitated, aggressive, and intoxicated patients or family members can be a danger to themselves and to others in a clinical setting. Therefore doctors exposed to threatening people, for example, ER doctors, but also psychiatrists as well as those who provide reproductive care, have long been targets of personal attacks.

Finally, litigation has increased. “All of this has always been part of our jobs,” a doctor reported, “but the more we are tasked with the impossible, and blamed when unable to achieve it, the more keenly aware we are that every malpractice lawsuit needs a face, and that face will soon be ours.”

Disrespect is rampant. Doctors used to have a prominent standing in society. While many still do, the profession has been undermined by a lack of trust in authority across the board and access to medical information online. Patients, having googled their symptoms, might come in convinced of a particular diagnosis. As patients, we are clients who always want to be right. A polarized and angry society brings the world to the doctor’s office.

Distrust corrodes relationships. Some are skeptical of intentions, sometimes perhaps rightly but not always. Doctors might be accused of pushing the most expensive treatments (not because they are the best for the patient but because they make them the most money) or the latest treatments (that might not be proven or better than the old ones). Of course, doctors can be scoundrels and profit-maximizers. Yet Most patients don’t understand that doctors are not paid to get most lab tests. Payments for Blood work, MRI/CT scans done by the Primary care doctor or by anyone do not go to that doctor. Those payments go to the lab or to the radiologist who almost for sure works for a hospital or for a clinic.

Unrealistic expectations and demands from patients. Doctors who go above and beyond what is reasonable to accommodate patients and try to help might need more time on some patients than expected. As patients, however, we don’t want to wait. We all want a 5-minute wait, 20-minute exam, 30 minutes to ask questions of the doctor, and for all of that to take 15 minutes. Yet we don't come prepared with our list of medications, we are not good at telling our history nor describing our complaints.

Finally, doctors bear some responsibility and suffer from “self-inflicted wounds” from the profession. Most doctors endure years — decades — of grueling training that requires discipline, sacrifice, and a drive for perfection to compete for entrance to medical school, placement in residencies, etc.

When the stress-strain curve breaks the soul

The flip side of being exceptional and all-knowing can be arrogance or self-righteousness — which sets up the “hero” narrative of excessive self-reliance. Some pathologies that might propel success, like neuroticism and narcissism, wind up derailing individuals not able to understand the cost of success until they and their loved ones are hurt and if they are improperly coached, supported, and strained.

All this amounts to multi-organ failure. The workplace feels fractured by technology, the teaching is impaired by fear of actual or fear of psychological harm, the work is denatured by an excessive demand for efficiency, and the trust is eroded by a false sense of competence from googling or sourcing from social media. The body of work for physicians fails from these vital organs shutting down.

Particularly impacted were the cohorts of ER staff, including doctors. They had to save lives while being affected by squeezed hospital revenues, societal forces (anti-vax, anti-expert, covid paranoia), work demands (shifts on nights, weekends, and holidays), and the social shame (internally in the world of medicine) of not being the popular residency.

What tools can we take for managers?

Once you start blaming yourself for deaths that aren’t your fault, my friend… that’s a slippery slope that you can’t come back from it. Trust me, I’ve seen it ruin a hell a lot of good doctors, and I will not let it happen to you. (Dr Cox in Scrubs)

Swiss army knife wearing white scrubs as a doctor, multiple functions
The multitasking doctor’s kit (photo credit to Antonio Sadaric and midjourney)

Managers and ER physicians often create a superhuman vision of themselves to cope with their jobs’ tremendous pressure and demands. Being the superhero seems safe. This superhuman identity may include an unwavering commitment to work, the ability to handle any situation, and ample energy and motivation. However, this idealized self-image can lead to narcissistic behavior, preluding burnout and disconnection from their authentic self, which is integrated and reality-based.

To avoid burnout and maintain a healthy work-life balance, managers and healthcare professionals can adjust their personal brands towards a more realistic, human brand. We use the term “human brand” to refer to the holistic representation of an individual, including their personal and professional life, reputation, and interactions with others. It is the way others perceive and interact with a person and is influenced by things like personality, values, and behavior.

A personal brand is typically focused on how an individual presents herself professionally, such as skills and accomplishments, while a human brand encompasses an individual’s entire being and includes their personal life and the nature of interactions with others.

A personal brand becomes a human brand once the individual behind the concept expands the scope of promotional efforts to include personal values, beliefs, and interactions with others. This means recognizing their limitations, acknowledging their vulnerabilities, and accepting that they are not invincible. By doing so, they can create a more authentic and relatable brand that connects with others on a human level.

For example, a manager who shares their struggles with work-life balance and openly discusses their efforts to maintain a healthy lifestyle can create a culture of openness and vulnerability in the workplace. Similarly, healthcare professionals discussing their experiences with burnout and mental health can create a more empathetic and supportive environment for their colleagues and patients.

By embracing a more human brand, managers and healthcare professionals can not only reduce the risk of burnout but also build stronger connections with their colleagues and patients. This can lead to a more fulfilling and sustainable career in the long run.

To lower these risks, we highlight some practical takeaways for managers, especially those in high-pressure, high-performance workplaces:

1. Prioritizing work above all else is unsustainable over a longer period and projecting yourself as perfect, indispensable, and all-knowing

2. Say NO sometimes allows you to say yes for a longer period

3. Practice cognitive empathy to serve others better and support mental health

4. Learn from each other, especially from failures

5. Introduce more sustainability to the workplace by understanding what job resources you need

6. Intervene early if possible

7. Encourage employees to think of their contributions to bad workplaces and provide them with tools to change

MANAGEMENT TIP #1: PRIORITIZING WORK ABOVE ALL ELSE IS UNSUSTAINABLE OVER A LONGER PERIOD, AND PROJECTING YOURSELF AS PERFECT, ALL-KNOWING, AND INDISPENSABLE

Maybe the best thing to do is stop trying to figure out where you’re going and just enjoy where you’re at. (JD in Scrubs)

Despite being in vastly different professions, high-performing managers and ER doctors share some behaviors that increase their stress levels. And higher stress levels over extended periods contribute to burnout.

“Purpose” and “deeply responsible business” is in fashion. We are being encouraged to find purpose and meaning at work because we have lost it in our hearts. Leaders are being encouraged to use purpose to rekindle disengaged workers. Being mission is driven is a blessing until we feel that the mission is a ploy to drive productivity.

One of the most significant risks here is the tendency to prioritize work above all else. High-performing managers invest much time accumulating impressive projects for their professional resumes to cultivate a stronger personal brand. And personal branding in the modern workplace eerily resemble narcissistic tendencies, continuously cultivating the myth of the hero. Both managers and healthcare professionals can get caught up in the idea that they need to work harder and longer than everyone to succeed.

Prioritizing work above all else can lead to the point of total failure on the stress-strain curve, a culture of overwork and burnout, where individuals feel like they can never take a break or prioritize their personal needs, as their professional social identity takes over their personal identity.

MANAGEMENT TIP #2: SAYING NO SOMETIMES CAN ALLOW YOU TO SAY YES FOR LONGER.

Sometimes in life when you get what you want, you end up missing what you left behind. (JD in Scrubs)

Taking on too much responsibility can contribute to burnout. Managers and doctors are all in positions of significant responsibility, where their decisions can have serious consequences.

In the absence of system-level interventions to ensure human capital sustainability (which is NOT sending pizzas or having mandatory resilience training on off hours), individuals absorb the shocks. They take on more and more responsibility, even when it becomes unsustainable. This can lead to a constant feeling of being overwhelmed and exhausted, which in turn can contribute to burnout. When this tendency is extended to teams with whom they work, a significant level of impatience and lack of understanding quickly leads to conflict in high-pressure environments.

Finally, both high-performing managers and healthcare professionals often struggle with setting boundaries. Managers may feel like they need to be available to their team 24/7 (and sometimes are contractually obligated), while doctors may feel like they need to be on call at all times (and oftentimes are). This can make it difficult for them to disconnect from work and prioritize their well-being.

Over time, this can contribute to feelings of burnout and exhaustion, emphasizing the importance of using management skills and continuous development of leadership capabilities. Multiple avenues of access via technology (by both work and family) facilitate this, and the complexity makes it hard to know which gadget and which app to turn off.

MANAGEMENT TIP #3: PRACTICE COGNITIVE EMPATHY TO SERVE OTHERS BETTER AND SUPPORT MENTAL HEALTH

The highest form of knowledge is empathy, for it requires us to suspend our egos and live in another’s world. (attributed to Plato)

Empathy is the key mechanism in storytelling that helps the audience connect to the protagonist and see the world through their eyes. It helps convey the intended meaning, thanks to the mechanism of identity transportation, where readers envision the worlds of the protagonist through their own experiences. Empathy leads to prosocial behavior, which is central in the caring professions.

Empathy is a powerful tool that medical doctors use to connect with their patients, but it takes a particular form, which managers might appreciate practicing too. This cognitive empathy requires managing our emotions and being unconnected enough to do what the patient needs but not be so cold and dismissive as to get in the way of developing a healing and therapeutic relationship.

Empathy for the patient’s or family’s situation is reasonable and is ok, BUT the doctor must remember the role of empathy is to understand the patient to help with the presenting problem. Excessively sympathetic doctors and managers are at risk of clouded judgment or impaired critical thinking skills. As are “Spock-like” robotic doctors who are out of tune with the person they are treating. In both instances, however, you can be a decent human and try to get the patient as a person, support the family and have an empathetic response to financial and familial concerns, and weigh the pros and cons for all concerned.

When a patient is in pain or distress, a doctor’s ability to empathize appropriately can make all the difference. But it’s not just about making patients feel better — empathy helps physicians put patients at ease, improving diagnoses and compliance with treatment plans. This is also true in management, it would be easy if we just took away the pain and made customers or clients feel better. Like managers, physicians must unearth the root causes of problems and make plans to address them, even if it prolongs pain in the near term. (Never take away abdominal pain in the ER before the surgeon has signed off!)

And whether managing or diagnosing, good professionals try to dedramatize. Yes, things are difficult, but many doctors and managers across space and time have faced harder challenges with fewer resources.

MANAGEMENT TIP #4: LEARN FROM EACH OTHER

For the man who has nothing to hide, but still wants to. (JD in Scrubs)

Observing how ER physicians and psychiatrists deal with situations and modern-day taboos that are seldom welcome in conversations offers impressive insights. Dealing with intensely emotional situations provoked by mutilations, severe trauma, and even violent deaths, in the context of nudity and cutting on live bodies, is a difficult endeavor. The stress-strain curve can run to its extremes quickly. Society trusts physicians to maintain “bedside manners” with their patients and their families. It is our “meets expectations” for health care. And, these extreme experiences can provide valuable insights for managers on handling difficult workplace situations.

Healthcare professionals are trained to deliver bad news to patients and their families, often having to do so multiple times daily while maintaining natural human compassion for people in distress. They have developed effective communication strategies and emotional regulation techniques that can be applied in other fields, keeping them mentally healthy amidst the problematic situations they encounter.

Medical professionals work in high-pressure, fast-paced environments that require continuous learning and adaptation to new situations. One way they achieve this is through debriefing sessions after critical incidents or high-stress situations (morbidity and mortality conferences). These preceded the AAR (or After Action Reviews) of the military, now being adopted by business schools and management. During these sessions, team members discuss what went well, what didn’t, and what can be improved next time. Managers can apply this approach by implementing similar debriefing sessions after important projects or challenging situations in the workplace.

Sessions focusing on the resolution after critical incidents can encourage reflection, knowledge sharing, and collaborative problem-solving. In addition, managers can encourage the use of peer coaching and mentoring programs to facilitate learning and knowledge transfer within the organization. By adopting these practices, managers can create a culture of continuous learning and improvement in their workplace, ultimately leading to increased job satisfaction and reduced burnout among employees. However, as one of our medical colleagues pointed out, a medical colleague noted this recently, “the doctors’ lounge isn’t billable.”

MANAGEMENT TIP #5: INTRODUCE MORE SUSTAINABILITY TO THE WORKPLACE BY UNDERSTANDING WHAT JOB RESOURCES YOU NEED

And who’s to say this isn’t what happens? Who can tell me that my fantasies won’t come true? Just this once… (JD in Scrubs)

Complex workplace dynamics require contextual interventions to yield effective results. A relatively underused perspective is the job demands-resources (JD-R) theory by Profs Arnold Bakker, Wilmar B. Schaufeli, and Evangelia Demerouti, developed almost 20 years ago.

Authors suggest that every job should be observed as a set of job demands and available job resources. Job demands are physical, psychological, social, or organizational aspects that require sustained physical or psychological effort and are associated with certain costs. Job resources are the physical, psychological, social, or organizational aspects of a job that can help to achieve work goals, reduce job demands, and/or promote personal growth and development.

For both high-performing managers and healthcare professionals, job demands can include long work hours, high workloads, high levels of responsibility, and exposure to events they don't control. In contrast, job resources can include supportive colleagues, autonomy, control over work tasks, and access to necessary additional resources in innovative resource management approaches.

Meaningful job design interventions can help managers and physicians understand what is demanded from them and what resources they need to meet those demands. While sometimes it is impossible to introduce additional resources due to their limited nature, a thorough review of job demands and activities can help redesign the work.

By focusing on increasing job resources and reducing job demands, managers and healthcare professionals can improve their work engagement and well-being and reduce their intensity of burnout. For example, managers can provide healthcare professionals with the necessary resources to perform their jobs effectively, such as adequate staffing and equipment.

MANAGEMENT TIP #6: EARLY INTERVENTION IS BEST

… we all want to believe that what we do is very important, that people hang on to our very word, that they care what we think. The truth is, you should consider yourself lucky if you even occasionally get to make someone-anyone-feel a little better. (JD in Scrubs)

Observing how ER physicians use early interventions can provide valuable insights for managers in other industries on addressing issues early in the workplace. In the medical field, early intervention is critical for addressing health issues before they become more severe and difficult to manage.

As with ER docs, the modern manager needs to quickly recognize a person in crisis and keep themselves and their teams safe. The modern and diverse workplace appears to lack inclusive leadership practices, resulting in frequent discord instead of progressive discourse. The backlash of disgruntled employees on social media can significantly damage a company’s employer brand and reputation and reduce employee morale, resulting in increased stress and a sense of danger that needs to be addressed appropriately.

Managers can implement regular check-ins with employees to monitor their well-being and provide necessary support.

A proactive approach to addressing issues can help prevent burnout and improve employee well-being. By doing so, managers can identify and address potential problems before they become more significant.

However, such interventions are predefined with managers’ ability to create a supportive work environment where employees feel comfortable openly discussing their concerns and issues. Managers ought to grow their capacity for empathy here. By focusing on the person's fit with the work, they will help the workplace and the workers. Managers can provide training and resources to employees to help them identify and address issues early on and actively work on creating a psychologically safe working environment where employees feel comfortable talking about the challenges they encounter and their mental health.

MANAGEMENT TIP #7: ENCOURAGE EMPLOYEES TO THINK ABOUT THEIR CONTRIBUTIONS TO BAD WORKPLACES AND SUPPORT CHANGE.

The problem with people who only want what they can’t have is that once they have what they want, they don’t want it anymore. (JD in Scrubs)

Patient behavior was worsening before the pandemic and has not improved, partly because we have all emerged feral from the pandemic but also because patients are more depressed and anxious than before. And so are students and employees. They display more aggressive behavior, black-and-white thinking, despair, and catastrophizing.

Instead, we need more empathy and acceptance of imperfection. Bad decisions happen to good managers. Employees and bosses came with their individuality. For example, managers can be neurodivergent, too. Yet we expect them to be charming, charismatic, and predictable — hard always to be on and available. We must provide more margin of error in our human supply chain and practice Kant’s Categorical Imperative.

A new Hippocratic Oath? First, do not harm — not to others and … not to yourself.

Given the diminished trust in business, a 2008 Harvard Business Review piece on making management a true profession by Professor Rakesh Khurana and then HBS Dean Nitin Nohria explored having managers sign a version of the Hippocratic Oath.

This oath, from 400 BC, provides a normative framework that shapes doctors’ identity, conduct, and orientation toward society. One of its famous tenets, which postdates the oath actually, is “first do no harm.” A good aim for doctors and managers alike. But as they serve us, it is also important that we do what we can to ensure they can exercise their important professions without harming themselves — that they can cross the finish line without losing their minds and our losing their talents.

As the Scrubs theme song cautions:

Well, I know what I’ve been told
You gotta know just when to fold

But I can’t do this all on my own
No, I know, I’m no Superman
I’m no Superman

That’s right

You’ve crossed the finish line
Won the race but lost your mind
Was it worth it after all?

— — — —

Powered by flawed natural intelligence, this post compiles our thoughts and research, and conversations with practitioners. We would love to hear your stories and feedback!

Carin-Isabel Knoop leads the Harvard Business School’s research and case writing group and has helped HBS faculty members write more than 200 case studies on organizations and managers worldwide. Learning about managers’ challenges pushed her to improve their lives, leading to the publication of Compassionate Management of Mental Health at Work with Professor John A Quelch (Springer, 2018). She also co-founded HSIO (Human Sustainability Inside Out). She enjoys soft-serve ice cream, pragmatic idealists, and postcard writing.

David “Daven” E. Morrison III, MD is a Chicago-based psychiatrist whose practice concentrates on leadership and executive functioning. He has developed two assessment tools for leadership teams, and works full time with many industries as well as municipal government and within multiple levels of management and management structures. A Clinical Assistant Professor at Chicago Medical School, past president of the Academy of Organizational and Occupational Psychiatry (AOOP), he has co-authored texts for managers on fraud The A.B.C.s of Behavioral Forensics (Wiley), and psychiatric workplace disruption, Psychiatric Dysfunction in the Workplace (Oxford).

Antonio Sadaric is passionately curious about organizational symbolism, corporate cultism and general mechanisms of social learning in various contexts. His consulting work at BUFFED focuses on leadership upskilling and helping (fin)tech scale-ups humanize organizational development. Co-author of Capt. Bossman’s Workplace Stories — the world’s first picture book for professionals.

Carin-Isabel Knoop

Harvard Business School Executive Director, passionate about human sustainability@work. Pragmatic optimist devoted to helping all who care for others.