‘Quiet quitting’ among medical practitioners: a hallmark of burnout, disillusionment and cynicism

‘Quiet quitting’ has become a popularised concept since the recent COVID-19 pandemic, originally coined by corporate recruiter Bryan Creely in a viral Tiktok video. ¹ It is a highly prevalent phenomenon, with a recent Gallup survey reporting >50% of quiet quitters among employed workers in the United States. ² Unlike former ‘hustle cultures’ ³ or the ‘996’ Chinese work culture (9 a.m. to 9 p.m. work shifts, 6-day work week), ⁴ which are models that prioritise work over personal life, ‘quiet quitting’ instead advocates doing the ‘bare minimum’ work necessary, based on pre-assigned tasks and agreed upon job scope.^3,5 In a short span of time, this phenomenon has quickly found its way into the healthcare arena,^3,5,6 which some ascribe as emblematic of burnout that has become highly prevalent among doctors, nurses and allied health professionals. ⁶

Until now, ‘burnout’ among healthcare workers has been extensively studied in literature,^7,8 which describes as a formal clinical syndrome arising from occupational stress characterised by (1) emotional exhaustion, (2) depersonalisation and (3) loss of professional fulfilment,^9,10 and associated with psychiatric sequelae such as depression, anxiety and suicidality in medical practitioners and adverse effects on patient care. ¹¹ However, ‘quiet quitting’, although potentially considered to be a more subtle and insidious manifestation of burnout, remains a lesser understood entity and considered a colloquial terminology with hitherto unclear ramifications on medical practitioners’ well-being and patient outcomes.

Therefore, in this article, we sought to share our perspectives, with reference to relevant literature and articles in this area, on the phenomenon of quiet quitting in medical practice, specifically discussing why it happens, how it is potentially detrimental to both the physicians and patients under their care and potential strategies to address this problem.

Quiet quitting in the medical practice

In a generic sense, the term ‘quiet quitting’ is probably best encapsulated in this definition set forth by Klotz and Bolino in a Harvard Business Review article – ‘opting out of tasks beyond one’s assigned (work) duties and/or becoming less psychologically invested in work’. ¹² In addition, the willingness to ‘engage in activities known as citizenship behaviours … staying late, showing up early, or attending non-mandatory meetings’ has, all but, dissipated in the current work culture. ¹² In practical terms, this implies that the employee is not only religiously guarding pre-defined work scopes, but also consciously diverting inner focus and cognitive-emotional resources away from work-related duties, often appearing disinterested and disengaged.

In healthcare settings, quiet quitting is a real and prevalent phenomenon,^3,5,6 but has not received much attention, presumably because of its less well-defined/established nature. For instance, a simple search of ‘quiet quitting’ on PubMed only reveals 27 search results, of which approximately one-third are not related to healthcare professionals, and hardly any specifically looked at the quiet quitting phenomenon among physicians. In a fairly ominous fashion, a recent editorial highlighted the dual problem of an impending collapse of healthcare systems that are operating on a supply–demand mismatch, and an increasingly dispirited nature of the healthcare workforce. ⁶

In our view, contributors to quiet quitting are probably not dissimilar to that of burnout, given that some ascribe the former practice as emblematic of the latter phenomenon. ⁶ In fact, we posit that quiet quitting might just be an insidious manifestation of burnout demonstrated by individuals who do not have the option to leave their jobs (e.g. for financial or other reasons) and, hence, remain in their current positions while holding disengaged attitudes. ¹³ From a recent review article on contributors of physician burnout, there were a multitude of work-related factors (e.g. long working hours, high intensity of clinical work, frequent overnight call duties, work–life role conflicts, inefficient work processes/environments, administrative/clerical burden, lack of professional autonomy), personal attributes (e.g. younger individuals, having own children to care for, certain personality traits/interpersonal skills) associated with development of burnout. ⁷ Interestingly, while gender was not consistently an independent predictor of burnout across studies, there, nonetheless, seems to be a higher odds of burnout among females as compared with their male counterparts in a head-to-head comparison. ⁷ In 2011, a Norwegian study showed that women tended to have greater exhaustion levels and had burnout attributed to work–home conflicts, whereas men experienced greater disengagement levels, and had burnout predicted by their workload. ¹⁴

Although less studied than burnout, ‘quiet quitting’ has similarly been postulated to reflect employee disillusionment towards the nature of the job (e.g. unreasonable workload, poor work environment, manpower staffing, uninspiring work/lack of autonomy), lack of organisational support or ‘toxic’ work culture, and job prospects (e.g. asymmetric rewards, poor progression).^13,15–17 In our view, it is perhaps the constant exhortation of overstretched medical practitioners to ‘always put their patients first’, and continue to strive to expand their expertise beyond clinical duties (e.g. research, education, innovation, quality improvement, administrative/leadership), without providing them with the necessary support and recognition, that drives significant cynicism towards the profession.

Consequences of quiet quitting in healthcare

In busy clinical environments with high patient loads, quiet quitting by some medical staff often translates to lack of collegial support and willingness to cross-cover for others in their team, as well as ‘performance punishment’ for those who continue to be hardworking and diligent, and yet have to pick up the slack. ³ In turn, many of these high-performers will naturally become demoralised by asymmetric rewards, and experience burnout themselves.

In addition, quiet quitters are unlikely to provide high-quality patient care, which goes beyond merely doing what is minimally necessary to treat patients and not overtly compromise their safety, to render psychoemotional support, show genuine concern, and provide holistic care.^3,13 For example, unlike a quiet quitting physician who might constantly ‘decision satisfice’ (i.e. do whatever is necessary to meet bare minimum clinical standards of practice), a dedicated physician endeavours to find out and address the biopsychosocial needs, values and preferences of their patients, thereby providing high-quality, person-centred care. ¹⁸ Over time, patients may lose trust in their physicians if they perceive a lack of commitment to their care, thereby leading to poorer treatment adherence and eventual outcomes. Moreover, an increased prevalence of quiet quitting physicians may lead to reduced attention to details, causing medical errors or delayed diagnoses/interventions that can have serious medical repercussions.

Mitigating ‘quiet quitting’ in medical practice

We must first recognise that ‘quiet quitting’ is a real phenomenon in healthcare settings that will persist until the underlying root causes are adequately addressed. As Kruse and Tata-Mbeng brilliantly argued, quiet quitting ‘could merely be part of a collective process of workers prioritizing their basic human needs’. ¹⁹ In essence, the way to counter workplace disengagement and quiet quitting of healthcare staff should simply be to focus on the Maslow’s hierarchy of human needs ²⁰ (from basic needs (physiological and safety needs), to psychological (love/belonging and esteem), and self-actualisation (fulfilment) needs). Therefore, healthcare leaders, senior management and organisational human resource teams need to be better versed in organisational psychology, and put in place interventions that truly motivate their staff to invest time and energy in work that is already inherently meaningful. The importance of organisation level interventions in combating burnout is perhaps best encapsulated in Panagioti et al.’s systematic review that found that while recent burnout intervention programmes were generally effective, organisation-directed efforts were significantly more useful than physician-directed efforts, implying that ‘burnout is a problem of the whole health care organization, rather than individuals’. ²¹

Firstly, to address the basic needs of healthcare providers, there must be a concerted effort to mitigate clinical workload (both on-site and off-site work), intensity of clinical work and ensure adequate breaks for rest, meals and personal hygiene. In addition, healthcare workers must feel ‘safe’ when working in clinical environments. Studies have shown that workplace bullying (both work-related and personal bullying) is highly prevalent in healthcare settings – where affected employees experience lower job satisfaction, higher stress and burnout, and healthcare team dynamics and communication are also compromised. ²² Therefore, workplace harassment and bullying must be tackled through multi-pronged strategies involving organisational protection and support for victims of workplace-based violence, ²³ pre-emptive risk assessments, ²⁴ optimisation of healthcare infrastructure and affordability to reduce patient-physician conflicts, ²⁵ and adequate training (e.g. assertiveness training) for healthcare workers to handle workplace-based conflicts. ²³

Secondly, healthcare organisations and leadership must prioritise the well-being and mental health of its medical staff, through cultivating a positive work culture, fostering meaningful inter/intra-professional relationships, and having a robust psychological support system. For example, collegiality at the workplace can be promoted by flattening of professional hierarchies, implementing transformational leadership styles in healthcare teams (that value individual opinions, empowerment of junior staff and shared decision-making), and providing due recognition for high-performing members of the team. ²⁶ On the flipside, ‘performance punishment’, also known as quiet promotion, where high-performing employees are given additional duties and responsibilities without compensation or promotion/recognition, should be avoided. Importantly, having senior staff who are good role models and lead by example helps to inspire and motivate those working under them to be equally invested in their duties. In ‘Leaders Eat Last’, motivational speaker and best-selling author Simon Sinek writes that

the true price of leadership is the willingness to place the needs of others above your own…great leaders truly care about those they are privileged to lead and understand that the true cost of the leadership privilege comes at the expense of self-interest. ²⁷

Besides creating a pleasant working environment, it is also equally important to actively address mental health issues in the healthcare workforce. This includes combating stigma through open dialogue/sharing that normalises/raises awareness of mental health issues, avoiding inappropriate psychiatric ‘name-calling’, and reviewing/removing existing stigmatising practices (e.g. mandatory mental health declarations in medical licensing). ²⁸ Importantly, having peer support systems, ²⁸ on-site occupational health services (physicians and psychologists) and other workplace-based holistic health interventions (e.g. promoting healthy diet, exercise programmes, spiritual/wellness interventions) are all necessary to build a psychologically resilient workforce. ²⁹

Thirdly, to support physician self-actualisation (fulfilment) needs, healthcare organisations need to provide adequate opportunities for physicians to engage in post-graduate training, have adequate professional autonomy without excessive clerical/bureaucratic burden, and develop individual professional niches/interests (e.g. in education, research, healthcare innovation, service/quality improvement) that bring meaning and purpose.^6,17 Therefore, workplace-based initiatives such as setting aside protected clinical time for educational/research endeavours and completion of administrative/clerical tasks, ¹⁵ quality improvement projects that seek to radically reduce/eliminate inefficient or unnecessary work processes, ³⁰ as well as career guidance and commitment to providing adequate traineeship/fellowship positions/opportunities for physicians are crucial in this regard.^31,32

Lastly, in recent years, ‘quiet quitting’ scales^33,34 have actually been developed to interrogate the extent of this problem in various work sectors. It might be helpful to incorporate such scales as part of anonymous organisational feedback during routine internal audits that can help gauge the level of employee work engagement, which can then guide systems review and interventions.

Conclusion

In summary, quiet quitting is a real and potentially dangerous phenomenon in healthcare, as having disengaged and disinterested medical staff performing clinical duties in patient care can have serious repercussions. Health organisation-led interventions are necessary to address the hierarchy of needs of its medical staff to motivate them to remain invested in a profession that is inherently meaningful.

Declarations

Competing Interests

None declared.

Funding

None declared.

Ethics approval

Not applicable.

Guarantor

IKSN.

Contributorship

IKSN wrote the article and conceived the study idea. WGWG, CT and KSHT edited and critically reviewed the article.

Provenance

Not commissioned; peer-reviewed by Francesco Chirico and Anthony Dayan.