Although extreme, the issues health-care professionals are facing today are not entirely new. Throughout the 20th century, politicians, policymakers and professional organizations in Britain, the United States and elsewhere have sought to understand and improve health-care workers’ emotional health and well-being.
And yet, our current conversation often fails to appreciate this longer history and rarely acknowledges the deep-seated, cultural and structural problems baked into our health systems. Observers tend to identify the coronavirus ward as an unprecedented battlefield full of unique challenges. And yet it is a product of long-standing issues: insufficient labor protections, excessive working hours, erosion of professional autonomy and lack of well-funded and institutionalized mental health support for doctors and nurses. Unless these deeper problems are addressed, we will continue to see these essential workers suffer even after the pandemic recedes.
The medical professions of the United Kingdom and the United States share a language and cultural tradition that was forged in the 19th century. In both countries, medicine was practiced by and for wealthy White men who had ample time, space and autonomy to conduct themselves as they saw fit. They articulated their professional identity using the language of vocation, arguing that being a doctor was unlike other jobs because they were driven by a unique commitment to healing their patients.
While the two countries’ health systems followed very different administrative trajectories since World War II, these ideas about autonomy, vocation and exceptionalism have persisted — despite becoming increasingly at odds with the realities of clinical labor. As a result, British and American doctors have very similar histories of overwork and emotional ill-health.
After Britain nationalized its health service in 1948, health care became free at the point of access and most doctors became employees of the state. Trainee surgeons and physicians — referred to as “junior doctors” — had always been expected to live on-site in accommodations provided by the hospital and attend to almost all late-night emergencies. But as the National Health Service (NHS) expanded, patient numbers increased and most junior doctors were soon working an average of 80 to 120 hours a week.
By the 1960s, doctors were increasingly complaining about their working conditions. In 1973, D. Lynch reflected wryly, “Apparently doctors are exempt from fatigue, because the Government has given the consultants an open-ended contract, with one for junior doctors up to 100 hours a week.” M.J. Evans lamented, “Why is it that the caring professions find it so hard to look after its own?” In 1975, junior doctors pushed back, walking out over long hours and inadequate pay for overtime.
This burden fell disproportionately on younger physicians — and, in fact, many more senior doctors invoked long-standing ideas about vocation and professional exceptionalism to critique collective organizing or bargaining. One doctor condemned the new “9-to-5 attitude” that now seemed to prevail, arguing that this was “quite contrary to all that is best in surgical or medical practice.” In the 1970s, H.S. Howie Wood wrote that industrial action over working hours lowered “the dignity of the profession.” In general, hospital consultants were not subjected to the same pressures as their junior colleagues. A more relaxed schedule later on in your career was seen as the reward for intense temporal commitment as a trainee.
Debates over doctors’ well-being in this period were not just preoccupied with the length of time spent at work, but with the degree to which clinicians had professional independence. These concerns came to a head after the first major administrative reorganization of the NHS in 1973, which added new layers of bureaucracy, extra administrative work and restrictions to physician autonomy. One health-care professional wrote to the government in 1976: “It seems that since reorganization our hospitals have become over administered, and this is a cause of unrest among staff.”
Postwar U.S. medicine was also marked by transformations. With the expansion of the federal government, Congress funded the building of new public hospitals through the Hill-Burton Act of 1946. While the U.S. system retained practices like prepaid group insurance, new federal government initiatives, including 1965’s Medicare and Medicaid programs, expanded access to medical care and fueled demand for doctors.
American medical education was changing, too. Originally intended for elite physicians only, medical residencies (graduate programs for doctors, required to complete specialty training) became a standard part of medical training, especially during and after World War II, when doctors with specialized training received higher base salaries than their general practitioner colleagues.
Medical trainees were required to work grueling hours, attend to overnight calls and survive a toxic work culture — often without legal recourse. As Walter Menninger, a scion of the Menninger family of psychiatrists, recorded in his October 1957 diary entry, “we’re getting fed up with the rat race we’re in. But there’s no out.” In response, residents coped with black humor, grit and sometimes collective action — while hoping to make it through and enjoy the prosperous life of an attending physician.
Yet once finished with clinical training, new pressures emerged.
Physicians wrote of the mismatch between their hospital-based training and the mundane realities of daily practice, including one pediatrician in 1963: “Because we are not trained for, and do not understand, the tasks that are presented to us, we end up frustrated, discontented, and angry.” The rigors of private practice (house calls, constant interruptions, bureaucratic paperwork) took a toll on physicians’ personal and family life. Jack McCue noted in 1979, “unpredictability is, in itself, a serious stress, especially when the unpredictable event is an emergency.”
Finally, doctors faced increased societal demands from patient-consumers, who expected an omniscient and always obliging physician. As McCue explained, “the stress of being on a pedestal and on display drives physicians into isolation, so that they have as friends only other physicians and live in communities far from where they practice.”
As in Britain, the U.S. medical community brushed off complaints about how the profession’s structure harmed its workers. One pediatrician in 1963 admonished his younger colleagues for not being “made of sterner stuff.” Others, such as John Henry Pfifferling, a medical anthropologist who became a physician burnout and wellness advocate, spoke of the importance of joy in clinical practice. As he wrote in a 1980 article: “Model physicians — healthy, successful, joyful practitioners — must be studied and their ‘immunologic’ factors [against physician burnout and impairment] identified and reinforced over the entire gamut of work and training settings.”
In both Britain and the U.S., these postwar shifts created more burdens on doctors as health care became a larger sector of the economy and patients came to expect regular visits with health-care providers. More strenuous working conditions coincided with persistent harmful ideas about vocation, increased individualization, losses of professional autonomy and more red tape, which all made health-care workers more vulnerable to eroding social and professional status.
The coronavirus pandemic has certainly exacerbated medical professionals’ stress, burnout and emotional anguish. But like workers in other essential sectors who are suffering under the strain, covid-19 did not create these feelings but accelerated them.
Despite the unimaginable tragedy of this past year, the pandemic also offers health care an opportunity to radically reconsider how doctors work and what they can be asked to endure. Changes that are thoughtful, structural and historically informed could boost the profession. Policymakers have decades of research from which to draw inspiration, and much of what doctors need is remarkably simple and what all workers need: more time, more space and more autonomy.