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June 10, 2021

Humanism Before Heroism in Medicine

Author Affiliations
  • 1Center for Vulnerable Populations, Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
  • 2Department of Medicine, University of California, San Francisco
JAMA. Published online June 10, 2021. doi:10.1001/jama.2021.9569

During the COVID-19 pandemic, heroic clinician narratives have been a prominent feature of media coverage. Health care professionals who worked ceaselessly in intensive care units, sacrificed time with their families to travel to severely affected areas to care for patients with COVID-19, and put themselves in harm’s way have been acknowledged and rightly celebrated.1 For example, New Yorkers had a nightly ritual of cheering and making noise in support of health care workers and offered public support in the form of signs, treats, and other measures of appreciation that referenced the heroism of the health care workforce. However, the pandemic has outlasted these public demonstrations, and heroic narratives ultimately do not serve clinicians or public health.

The concept of heroism suggests performing some exceptional feat, such as an individual who disregards his or her own well-being to benefit others. Heroes are glorified in art, literature, and history, and these heroic narratives serve an important purpose in demonstrating that individuals can accomplish more than seems possible in response to a challenge or threat. For instance, people such as Nelson Mandela, who faced his long imprisonment without complaint and dedicated his life to justice, embody the heroic ideal.

The culture of medicine aligns with heroic narratives by extolling 3 traits: individual skill, willingness to sacrifice, and stoicism in the face of physical and emotional hardship. Medical training rewards individual achievement, whether it is identifying the correct diagnosis or performing a procedure skillfully. Medicine also extols the heroic attribute of sacrifice, recognizing those who go beyond already significant professional obligations. Narratives about medicine often celebrate clinicians giving time beyond their job requirements, as illustrated in a collection of articles on “the heroic work of doctors and health workers.”2 Medical training demands physical endurance; even after duty hour reforms, 80-hour work weeks and long shifts are the norm. In some clinical settings, such as operating rooms, physical demands persist throughout careers. Unspoken messaging in medical and surgical training programs can promote stoic responses to the wrenching emotions in medicine and, at times, can be accompanied by increased cynicism during residency training.3

These 3 heroic attributes of individualism, sacrifice, and stoic endurance can actually undermine the system transformation needed in health care. The individualism inherent in the heroic narrative runs counter to the team-based problem-solving approach to health care delivery that leads to better quality.4 If physicians and other clinicians are willing to make personal sacrifices to circumvent system shortcomings, leaders are less likely to take necessary steps to correct broken systems. Although systematic data are lacking in this area, Ofri observed that physicians often step in to ensure seamless care on their own time and create “workarounds” to get patients what they need in dysfunctional microsystems.5 She contends that medical care in the US relies on this strong sense of professional obligation to function.5 Similarly, if nurses are willing to work double shifts or routinely cover extra patients, chronic understaffing, which is known to be unsafe for patients, persists.

The stoicism that comes with being a hero is also a risk for burnout, defined by the National Academy of Medicine as emotional exhaustion and distress stemming from work.6 Stoicism can lead clinicians to underrecognize their physical and emotional needs and to conceal perceived vulnerabilities. For example, an account of a physician concealing her cancer diagnosis while leading a pandemic response, and her description of the healing effect of sharing the experience of her own illness, highlight the importance of changing culture to support physicians as human beings.7 Moreover, heroic actions and attitudes require an activated mental state that can allow people to perform at a high level for defined periods of time. Sustaining that emotional activation is physically, mentally, and emotionally exhausting. Occupationally related emotional exhaustion and distress, and, in extreme cases, depression, anxiety, and suicide, can result from striving to meet impossible expectations over time. Emergency department physician Dr Lorna Breen, who died by suicide in April 2020, is a recent casualty of this long-standing and deep-seated culture.8 Even when these heroic expectations do not lead to tragic or career-ending consequences, they can contribute to a lack of engagement and satisfaction in work that is highly prevalent among clinicians.9

It is possible that the energy physicians and other clinicians are putting into maintaining stoicism in the face of challenges could be better turned in a positive direction. Clinicians’ creativity and problem-solving skills are underutilized resources for transforming health care. As a hypothetical example, consider a specialist in the community with an idea for a novel digital health approach to support patient self-management for a disease she manages on a routine basis. Her daily work includes routine overbooking of patients, frequent absences among staff, and distracting requests to manage tasks others could do, and she is expected to soldier through without complaint. Imagine if the patient scheduling, on-call, and staffing systems all functioned as intended, and she was able to deliver patient care without contingency planning and unplanned work time. She could have the energy and focus to turn to her idea and serve patients even beyond her practice through her digital self-management tool.

The National Academy of Medicine’s report on clinician well-being provides an approach for reframing the culture, emphasizing humanism instead of heroism. Rather than envisioning medicine as a province of brilliant individuals saving lives without a thought for their personal regard, the aim should be to achieve a culture of teamwork that acknowledges the human needs—both physical and emotional—of clinicians and does not ask them to sacrifice their well-being on a routine basis. Organizational solutions abound, such as information technology–enabled coverage systems, data-supported anticipatory staffing, and team members empowered to a high level of function.6 These precepts extend to medical education, whereby educators can rightsize learners’ workloads, teach and model teamwork and team culture, and, most importantly, demonstrate support for learners and faculty experiencing the stress of their studies or emotional challenges of patient care. Moreover, it is imperative that health systems provide support for clinicians to prevent and mitigate emotional exhaustion and distress, without stigma for seeking help or time away from work.

The COVID-19 pandemic demonstrated that heroism has its place in medicine. After this pandemic year, it is past time for society to support health care professionals’ capacity to respond to emergencies and for medicine and health care systems to encourage and support clinicians to embody teamwork, embrace vulnerability and humanity in the health care workforce, and ask for personal sacrifice only in exceptional rare circumstances. These approaches could transform health and health care and would enable capable professionals to have the fortitude and resilience to respond heroically in an emergency, because they would not have to do so every day.

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Article Information

Corresponding Author: Urmimala Sarkar, MD, MPH, Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, PO Box 1364, SFGH Bldg 10, Ward 13, San Francisco, CA 94143-1364 (Urmimala.Sarkar@ucsf.edu).

Published Online: June 10, 2021. doi:10.1001/jama.2021.9569

Conflict of Interest Disclosures: Dr Cassel reported being the co-chair of the National Academy of Medicine report Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. No other disclosures were reported.

References
1.
Bauchner  H, Easley  TJ; entire editorial and publishing staff of JAMA and the JAMA Network.  Health care heroes of the COVID-19 pandemic.   JAMA. 2020;323(20):2021. doi:10.1001/jama.2020.6197PubMedGoogle ScholarCrossref
2.
Remnick  D. Sunday reading: the heroic work of doctors and health workers. The New Yorker. March 29, 2020. Accessed April 23, 2021. https://www.newyorker.com/books/double-take/sunday-reading-the-heroic-work-of-doctors-and-health-workers
3.
Peng  J, Clarkin  C, Doja  A.  Uncovering cynicism in medical training: a qualitative analysis of medical online discussion forums.   BMJ Open. 2018;8(10):e022883. doi:10.1136/bmjopen-2018-022883PubMedGoogle Scholar
4.
Reiss-Brennan  B, Brunisholz  KD, Dredge  C,  et al.  Association of integrated team-based care with health care quality, utilization, and cost.   JAMA. 2016;316(8):826-834. doi:10.1001/jama.2016.11232PubMedGoogle ScholarCrossref
5.
Ofri  D. The business of health care depends on exploiting doctors and nurses. New York Times. June 8, 2019. Accessed May 24, 2021. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html
6.
Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press; 2019. Accessed April 5, 2021. https://www.ncbi.nlm.nih.gov/books/NBK552613/
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Mourad  MS.  Donning and doffing.   JAMA. 2021;325(6):536. doi:10.1001/jama.2020.26468PubMedGoogle ScholarCrossref
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Moutier  CY, Myers  MF, Feist  JB, Feist  JC, Zisook  S.  Preventing clinician suicide: a call to action during the COVID-19 pandemic and beyond.   Acad Med. 2021;96(5):624-628. doi:10.1097/ACM.0000000000003972PubMedGoogle ScholarCrossref
9.
2021 Physician burnout and suicide report. Medscape. Published 2021. Accessed May 21, 2021. https://www.medscape.com/sites/public/lifestyle/2021
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    5 Comments for this article
    EXPAND ALL
    Humanism and Profit
    Ernest Ciambarella, MD | Cincinnati Children's Hospital
    I am retired now going on four years and it has given me a chance to reflect on my career and medicine in general. They both give me a sense of pride. However I agree that stress prevents us from having the time to come up with better ideas. I would be curious to know from the authors how they think our profit-driven health care system contributes to this lack of innovation.
    CONFLICT OF INTEREST: None Reported
    Stoic is not Silent
    Justin Starren, MD, PhD | Northwestern University
    Heroes may endure hardship for the greater good, but they do not collectively suffer wrongs in silence. The stories of heroes leading revolts against tyrant overlords to protect the downtrodden masses are as common as stories of heroes fighting a foreign threat. Broken systems injure both patients and fellow clinicians. Tolerating the broken systems in silence is not heroism. It is time for clinicians to recognize this. In many countries, a large percentage of politicians started out as physicians. They realized that they could not truly solve their patient's problems by toiling silently in a clinical setting. Perhaps it is time for more clinicians to leave direct patient care and start treating the broken system.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    The Hero Label Didn't Help
    Vickie Leff, MSW, LCSW, APHSW-C | Advanced Palliative & Hospice Social Work Certification Program
    Thank you both for bringing this conversation to JAMA. Many of us in palliative care & hospice have been talking about how using the label "hero" has not been helpful, and in fact has been counterproductive for healthcare providers and clinicians.

    While I appreciate that calling healthcare providers heroes during COVID-19 came from a grateful and appreciative place, we need to call out the unfortunate consequences as well.

    Using the "hero" label can disenfranchise the expectable, normal stress and distress that accompanies working in medicine, in particular serious illness care, during a crisis (and everyday). We
    have learned that the hierarchical prototypical hero ideal can sometimes only serve to obfuscate the responsibility of an institution to provide a moral community, support and normalization of the difficulty that comes with this work.
    Calling someone a "hero" seems to be enough. Then we don't really have to change the system or face difficult conversations. But is "Superman" allowed to attend a debriefing? Is anyone given time to attend? Heroic stereotypes get in the way of asking for assistance, admitting stress or feeling overwhelmed. We must pay attention to the language we are using.

    We know that individuals, teams and institutions - all - have the responsibility to create environments and cultures that see the human and the humanity of the work, and walk away from stereotypes that hinder real systemic change. We must have these honest discussions to bring change.

    Thank you for having this discussion in this forum.

    CONFLICT OF INTEREST: None Reported
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    Heroism or Obligation
    Joao Wilson Rocha, MD | Universidade de São Paulo, ICESP
    The culture of the doctor being praised after taking care of the patient dates back to the beginning of medicine. Before that, as humans still in the age of caves, man was already applauded for taking care of others after being injured by an animal or beaten with his foot on a stone. The feeling of heroism is inevitable after an intubation, surgery or even healing someone from cancer.

    The ego and the feeling of knowing that you made the right choice of profession because such events massage the soul and increase self-esteem as a person.

    During medical
    training we were never taught how to deal with a pandemic and how to deal with countless daily losses. At a time of pandemic, when everything is closed and hospitals are open, it is health professionals working that took us to the movie scene and reminded us of the heroes. Heroes endure hardship for the greater good.

    I was never in favor of such a title at this time because we are doing what we choose as a profession and what we know how to do.

    The title of hero can lead us to mistakes most of the time.

    CONFLICT OF INTEREST: None Reported
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    Humanism Does Exist But Not in All
    Louis Weinstein, MD | Barrier Island Free Medical Clinic
    As i complete my 40th year of an academic clinical Ob Gyn career I am convinced that not all doctors (many will never be a physician) display humanism but all true physicians are truly humanistic. It is a shame that the majority of those individuals who occupy the many large finely furnished administrative offices, of which there are usually more than the number of operating rooms in most hospitals, have forgotten why the majority of us worked so hard to be able to help our fellow human beings. It is time for the next generation of physicians to take the leadership roles that so many of us failed to assume.
    CONFLICT OF INTEREST: None Reported
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