Sacrifice and Self

Editor’s note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members. The pursuit of a medical career requires commitment and dedication, with many years filled with rigorous training, long hours, and emotionally demanding experiences. A key motivation for medical professionals undertaking this difficult path is their commitment to healing relationships with patients, which for most clinicians represent the most meaningful aspect of their job roles. These healing relationships align with the altruistic aspects of service to others in medicine that not only ensure a proper focus on patients’ needs but also reinforce the core values and provide the intrinsic rewards that support the deep engagement this work requires.1 In recent years, increasing awareness of challenges to this deep engagement across medical careers has emerged as we better understand burnout, professional dissatisfaction, and other barriers to professional fulfillment.2 Within the background of intense demands across a career in medicine, individual discretionary effort—the “above and beyond” contribution of time and energy—by physicians and other clinicians is increasingly necessary to meet the responsibilities that accompany being a member of the health professions, including the needs of patients. In fact, as resources in health care systems do not keep pace with escalating patient complexity and needs, these systems have become dependent on this discretionary effort. At some point, physicians and other health care professionals can no longer meet these demands, and many seek solutions to protect themselves from the ultimately destructive level of sacrifice required. Unfortunately, some of these solutions may also result in diminished connection with the healing relationships with patients that are so central to meaningful work in medicine.1 Beyond medicine, the concept of “quiet quitting” has gained popular attention in recent years, especially since the COVID-19 pandemic. According to an article by Harter,3 more than 50% of the U.S. workforce has engaged in this trend of people doing the bare minimum to meet their job descriptions and declining to go beyond those parameters. Common drivers of quiet quitting include illusory efforts to promote workplace well-being, impersonal leadership strategies that do not value employees as individuals, lack of alignment between individual and organizational values, and continual overwork.4 Importantly, these are all well-recognized contributors to burnout in medicine as well, with relevance from the beginning of medical training.2 In medicine, quiet quitting may manifest in several ways. Physicians and other health care professionals, both in practice and in training, may seek to reduce their work effort (full-time equivalent), limit clinical time, or more broadly avoid the emotional labor essential to optimal medical practice.5 Each of these actions reflects disengagement from healing relationships with patients. Given the overlap between drivers of quiet quitting and burnout, clinicians may also disengage from patients as they experience the essential domains of burnout: emotional exhaustion, depersonalization, and reduced sense of personal accomplishment in their work. Paradoxically, these efforts to mitigate distress may diminish meaning and further separate clinicians from the intrinsic rewards helping to make their discretionary effort sustainable. The study by Smeets et al6 considers these issues through the lens of medical students progressing through their early training. As expected, they began with a sense of determination, but this threatened to deteriorate if they did not feel valued as human beings through the process. In particular, clinical experiences sparked intrinsic motivation, but limits to personal sacrifice and attendant costs served to attenuate engagement. How such attenuated engagement is demonstrated can be diverse, following multiple paths according to highly individual experiences. Diminished engagement may be overt, such as through training program discontinuation, career changes, and reduced full-time equivalent hours as previously noted. It may also be covert through quiet quitting to protect core aspects of self while meeting the minimal limits of satisfactory job performance. This level of performance is fundamentally misaligned with the initial feelings of determination and commitment medical students reported in the study by Smeets et al.6 Rather than bemoaning the loss of professionalism such choices are often viewed as exhibiting, it is important to more accurately identify this response as a defense against the harms of an untenable system. Furthermore, these actions often generate deep feelings of conflict, guilt, and moral distress for both trainees and practicing health care professionals. As previously noted, caring for patients is a critical source of meaning for clinicians, and withdrawing from these activities can actually compound the harms that attempts to reduce engagement are intended to address. In considering this, we need to contemplate whether these are truly unprofessional actions or responses to deep issues that represent opportunities for our systems to reflect on where they need to improve. Furthermore, these choices have serious implications for our ability to meet patient needs as a health care system. Current projections suggest an increasing shortfall of physicians during the coming decade,7 and reduced patient care effort and engagement would exacerbate these concerning projections. Related to these predicted increases in work demands, an additional factor that requires reassessment is the workload and common culture of overwork in medicine. Physicians work longer hours than the general working public,8 take few vacations, and often work while on vacation.9 The overall task load of physician work is also higher than nearly all other professions.10,11 Each of these work experiences is associated with burnout, adding to their burden on health care professionals. These observations raise the question of whether quiet quitting in medicine actually represents a shift away from patients or should more accurately be viewed as an attempt to return to more appropriate and sustainable levels of work effort. Several potential solutions are apparent given the commonalities among drivers of quiet quitting and burnout. Existing strategies to promote well-being12 would be expected to help reduce the risk of quiet quitting as well because learning and working environments within which clinicians can thrive serve to nurture the intrinsic motivations attracting individuals to a medical career. These approaches include efforts to (1) ensure healthy work environments with sustainable workloads that do not require undue discretionary effort, (2) provide opportunities for personal growth during training and practice, (3) promote a sense of community and even belonging at work, (4) prioritize being valued as an essential feature of each member of the health care team’s experience at work, and (5) elevate meaningful work as a foundational priority in medicine.13 As the effects of these initiatives are evaluated, the problem of quiet quitting also highlights the importance of including engagement as one key dimension of larger well-being assessment. Medicine offers a highly rewarding career rich with deep meaning and fulfillment derived from close healing relationships with patients and their families. When the demands of this profession become excessive, approaches to cope with these demands, such as quiet quitting, may represent immediate survival strategies. Such strategies may be paradoxically detrimental to clinician and patient well-being in the long term because they separate clinicians from a primary source of meaning in their work. Therefore, improvements to learning and working environments that value health care professionals and support their ability to meet the demands of this challenging career without depleting their discretionary reserves are essential

Medical education · MEDLINE · Political science · Sacrifice · Empathy and Medical Education · Healthcare professionals’ stress and burnout · Innovations in Medical Education · Medicine · Philosophy · Psychology

• Clinical Empathy as Emotional Labor in the Patient-Physician Relationship

  Eric B Larson•JAMA•2005

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• From Quiet Quitting to Open Dialogue in Medical Education

  Annemieke G J M Smeets, Annelies E van Ede et al.•Academic Medicine•2025

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