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Physician Burnout: The Four Horsemen of the Physician Burnout Apocalypse


physician burnout four horsemen of the physician burnout apocalypse optPhysician Burnout: The Four Horsemen of the Burnout Apocalypse

Physician Burnout is a constant, prevalent, looming threat over doctors everywhere. Over the last 20 years surveys have shown an average of 1 in 3 doctors suffering from physician burnout on any given office day – worldwide, regardless of specialty. The question is why?

Yes, the nature of our work is difficult, stressful and draining AND there are other parts to this Venn Diagram of physician burnout – and some of them are hidden.

In my work with hundreds of over stressed physicians I have isolated one of the major invisible causes of physician burnout – the pervasive mental conditioning of our training process.

Call it the “brainwashing” of our medical education if you will

In this article I will show you four “flavors” of this conditioning – how and why they develop and how they contribute to our physician burnout epidemic.


The Brainwashing of Medical Education

Yes, indeed, we are most certainly brainwashed by our medical education. There is a set of attitudes and behaviors that are expected of us while in training that become subconscious and automatic by the time we are board certified.  These automatic behaviors set us up for physician burnout in private practice.

Here are the four flavors I routinely see in my over stressed physician clients.

NOTE: None of our instructors, professors or attendings has ever tried to “brainwash” you consciously and on purpose. The expectations and attitudes that create this subconscious programming are built into nearly every facet of our medical education as NORMAL and “the way things have always been done around here”.  To most physicians in private practice the programming is invisible and unrecognized and the automatic behaviors it produces are dysfunctional and baffling. You will see in a second why this “brainwashing” virtually guarantees physician burnout in your 40’s and 50’s if it continues to sit in your blind spot.

The Four Horsemen of the Physician Burnout Apocalypse

Here they are in all their glory … see if they feel familiar to you.

=> Workaholic
=> Superhero
=> Emotion Free
=> Lone Ranger

These four behaviors are actually functional – even essential – when we use them to get through a rough night on call or a particularly onerous clinical rotation. However, they go much deeper than that in most doctors.

The process of becoming a doctor is so extremely challenging to most of us that we cannot help but feel our survival is threatened from time to time. So these four behaviors/attitudes get driven into our mental programming as a Survival Mechanism. We learn them at a deep subconscious level and can’t turn them off.

How deeply are we brainwashed?

Basic training in the military is 8 weeks. In that time they can condition an 18 year old to take a bullet on command. Medical education is a minimum of 7 years. (how long did it take you from your first day in medical school to your first day in private practice?) I believe there is no more thorough conditioning program on the planet than becoming a doctor.

If your only tool is a hammer, every thing looks like a nail

– and that is the problem. Not everything in a doctor’s world is a nail … especially after you graduate to private practice and the rest of your life. Physician burnout results when these four become “overused strengths”.

Being a workaholic superhero emotion-free lone ranger is an absolute requirement to make it through a 72 hour shift in your residency and it is NOT a great way to

- Be in a loving relationship

- Raise your kids

- Get your own needs met

- Or live your life



I help my clients see this conditioning when it appears as automatic behavior that is driving their physician burnout …

– when they are using this set of hammers to drive things that are NOT nails.

Here are a few examples:


=> When your only response to a challenge or “problem” in your practice is to work harder — that is your workaholic programming. I can assure you there are other ways to address almost any practice issue that do NOT involve you personally working harder.


=> When you feel like every challenge for your patients, your staff, your family and yourself sits on your shoulders and you “should” be able to solve them all — that is your Superhero programming. You are human. You are not a god. Learn to say, “I don’t know the answer to that” or “I wish I could help here, I wonder what you will decide to do?” and let things go that are outside your control. Breathe.


=> When you have strong feelings of fear, sadness, anguish, helplessness, love, joy, compassion, empathy … don’t stuff them. That is just your emotion free programming . AND please don’t feel guilty for having them in the first place. You are human, you will have feelings. This is part of what makes life rich, juicy and worth living. Let them flow. Don’t bottle them up. And never be afraid to tell someone what you are feeling in the moment – especially your work team – it lets them know you are not superhuman.


=> When you micromanage, can’t let things go and drive you and everyone around you crazy by having to do everything yourself — that is just your Lone Ranger programming. Yes, you are ultimately responsible for the outcomes in your practice (and your life) and you CAN ask for support. You can delegate and create systems that will take away some of your burden while delivering the quality you demand. It is possible.


For most of us these four horsemen and their automatic behaviors are deeply subconscious. Remember that you spent a minimum of 7 years installing them in your psyche – deliberately, consciously, through thousands of hours of dedicated study and on the job training. No wonder they poke there heads into all areas of your life – and not always in a good way. AND this is not the only risk factor for physician burnout.

Our Brainwashing is only ONE of the Four Main Causes of Physician Burnout

So the way I visualize the causes physician burnout is like this — and it is a four part Venn Diagram

physician burnout causes the big four opt

1) Physician Burnout Cause #1

The stressful, draining nature of the clinical practice of medicine. We have a tough job to begin with. Lots of responsibility and very little control. If clinical medicine was the only thing we had to worry about, physician burnout levels would be higher than a “normal” person — turns out it is only one of the big four.

2) Physician Burnout Cause #2

All the other demands placed on us in private practice that have nothing to do with clinical medicine.
Documentation/EMR, billing, the business of medicine, compensation formulas, practice politics, political uncertainty, our leadership roles we are unprepared for — and many other non-clinical hassles.

3) Physician Burnout Cause #3

The care and feeding of our larger life outside of medicine.
Getting our own physical and emotional needs met, our significant other and family relationships, our personal finances – everything outside of our career. We put this off throughout our training and now our ability to avoid physician burnout hinges on creating this work-life balance.

4) Physician Burnout Cause #4

And last, but certainly not least, our subconscious programming/brainwashing and the four horsemen I have laid out here. Their automatic behavior often throws gas on the fires created by stressors 1-3.  A recipe for physician burnout.


Next Steps:

Here’s a simple way to expose your own brainwashing and lower your physician burnout risk.

Whenever you find an area of your practice or life that is NOT WORKING the way you would like …
Ask yourself:
“How am I perhaps acting like a workaholic, superhero, emotion-free, lone ranger here?”

When you notice one of the four horsemen beneath your automatic behavior in this area …
“What might I do differently that will get me more of what I really want?”


PLEASE LEAVE A COMMENT below and tell me how you have noticed physician burnout and these four horsemen in your life.

Physician burnout
, medical education, programming, brainwashing, four horsemen




Very helpfull 
Posted @ Monday, November 04, 2013 12:16 AM by Andrew Opfell MD
Hmmm... food for thought. I am clearly riding with at least three of the horesmen of the Docalypse: might be time to get down and walk before I fall off the horse. Thanks. 
Posted @ Saturday, January 04, 2014 7:57 AM by Stephen Myers
Hi Dr Drummond, I stumbled across your website one evening when I felt like running away from all my charts I had to do, cell phone buzzing, patients in labor, my own family needs etc and I was so very happy to find your practical advice. I needed to read this particular article about the four horsemen and having that superhero mentality. That is very much me! Every little problem/ pain/question I hear about from patients, friends or my family seems to nag at me to solve it, tell them the why or the how. It is good to be reminded I am not a god, and everything going on on others lives is not my responsibility! I'm so happy I found you!
Posted @ Wednesday, February 12, 2014 11:03 PM by Stacie
Thanks for your comment Stacie. Here is the next blog post for you to be able to turn that programming off. 
~ Dike
Posted @ Thursday, February 13, 2014 11:44 AM by Dike Drummond MD
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