Pass it Forward
The complex relationship of altruism and a career in medicine.
“This is for you,” he said as he gently placed a steaming cup of tea in my hands. He also set a scone on the side table next to me.
“Pass it forward,” he winked and turned on his heel, a spring in his step as he left. A biology professor known for his random acts of kindness.
It was a small gift, but it found me at a particularly low point in college. Like most students, I was stressed with midterms. I was also working on a research project and struggling with the thesis. I had 3 jobs and was working over 30 hours a week on top of a full course load and leading a few student organizations. I wasn’t sure how long I could keep it up to graduate and what I would do if I couldn’t.
It’s often at our low points that God feels a little closer - often through encouraging one another. And sometimes it only takes a small gift to influence our lives for the better.
I decided to pass it forward.
“And if you give even a cup of cold water to one of the least of my followers, you will surely be rewarded.”
-Matthew 10:42 (NLT)
Altruism and Medicine: A Complex Relationship
I wouldn’t be surprised if this phrase “pass it forward” has been repurposed into some sort of cringe-worthy, corporate resiliency training. These courses seem designed to encourage unhealthy altruism and selflessness of physicians in healthcare systems designed to take advantage of them. But for the moment, I’m asking you to suspend that thought to contemplate:
What is healthy altruism in medicine?
What is unhealthy altruism (aka burnout)?
What is the relationship between altruism and burnout?
What does it mean to pass it forward in medicine in a sustainable way?
“Love your neighbor as yourself."
Mark 12:31 NIV
Altruism & Medicine
1) unselfish regard for or devotion to the welfare of others
2) behavior by an animal that is not beneficial to or may be harmful to itself but that benefits others of its species
Altruism is a desirable virtue to live out. In the Christian faith, we see it in many bible verses such as Luke 6:31. Or even more clearly in Philippians 2:3-4 “Don’t be selfish; don’t try to impress others. Be humble, thinking of others as better than yourselves. Don’t look out only for your own interests, but take an interest in others, too.” We called to practice altruism.
But when does altruism go too far and become unhealthy?
“For my yoke is easy and my burden is light.”
-Matthew 11:30
What is the relationship between altruism and burnout?
to cause to fail, wear out, or become exhausted especially from overwork or overuse
Burnout may result from altruism that is harmful to oneself (e.g., overwork). We know burnout negatively impacts physicians, which may lead to negative consequences for patients (e.g., lack of care). Should we therefore avoid self-sacrifice or altruism in the name of avoiding burnout?
Self-sacrifice is not always a bad thing. If we are to think of others as better than ourselves, we may be called to offer some of our own resources to benefit someone else. In medicine, this might look like calling a patient in distress on our lunch break or leaving the office a little later because we gave extra time to a patient that needed it.
While these acts of kindness do involve some self-sacrifice, it feels sustainable when they occur infrequently or when we are well-rested and able to pour into others generously. When the self-sacrifice is regularly done in our own strength without time to rest, and/or with a focus of pleasing others, it may lead to burnout. This is particularly true when combined with other factors.
“The etiology [of burnout] is complex and suggests interplay between multilevel factors, some intrinsic—for example, perfectionism, altruism, or excess empathy—and others extrinsic—largely outside the individual’s control, such as organizational culture, work-life balance, and catastrophic events such as the global pandemic.”
Additionally, physicians experiencing burnout were shown to demonstrate less altruism. So not only can excess altruism lead to burnout, but burnout leads to less altruism.
So burnout may be related to altruism - but it is more complex than simply excess altruism. Organizational factors and other tendencies like perfectionism and excess empathy play a role in the development of burnout as well.
In order to avoid burnout, are we to avoid altruism altogether?
Most tend to agree altruism belongs in medicine. It is closely related to the ethos of beneficence - the intention to benefit the patient - in medical ethics.
As is perhaps the case with any virtue taken to the extreme, altruism may become unhealthy (i.e., lead to burnout) when taken too far in our own (imperfect) strength.
Therefore, we must learn to “pass it forward” or practice altruism in a way that is sustainable.
"Do to others as you would have them do to you.”
Luke 6:31 NIV
What is Healthy or Sustainable Altruism?
Four main factors play a distinguishing role between healthy and unhealthy altruism:
Motivation
Rest
Source of strength
Organizational factors
The motivation or spirit of altruism matters. When motivation is off-center (even when it may be unconscious!) it actually turns altruistic acts into those that are people-pleasing or self-serving. We might ask: “What is my motivation for doing this?” Fear, anxiety, or desire for approval are all drivers of people-pleasing. Whereas altruism is driven primarily by intrinsic factors such as our values or desire to care.
Adequate rest is needed for sustainable altruism. At the end of the day, we are human and there’s a reason rest is a part of the 10 commandments. It’s necessary. Altruism without rest is unsustainable.
Some level of strength or energy is needed to for the expression of altruism. While rest can refill the cup to continue to pour out onto others, the cup (our strength) is only so big. It can quench the thirst of a few, but it is not meant to quench the thirst of the masses on its own. This is where dependency on a God whose strength far exceeds our own comes into play. Some needs are not ours to meet. Recognizing those cases that exceed our own strength and giving it to one whose strength is infinite is vital to sustainable altruism.
“But we have this treasure in jars of clay to show that this all-surpassing power is from God and not from us.”
-2 Corinthians 4:7
And of course, organizational factors impact the sustainability of altruism. An organization that operates with the expectation of overwork is on the path to burning out its employees. An organizational culture that encourages and protects time for rest and a reasonable workload is key to sustainable altruism.
What does it mean to “pass it forward” as a physician?
To “pass it forward” is to care for those around us. As physicians, we can practice altruism in a way that is sustainable without leading to burnout. Checking our motivation, scheduling adequate downtime for rest, remembering the One our strength comes from, and - as much as possible - being a part of organizations that operationalize sustainable altruism are essential.
“Don’t be selfish; don’t try to impress others. Be humble, thinking of others as better than yourselves. Don’t look out only for your own interests, but take an interest in others, too.”
-Philippians 2:3-4
What does passing it forward mean to you?
As one who suffered burnout TWICE in my career, I’ve thought about it a great deal. One issue is an overreliance in oneself rather than in God. This is Hard one to wrap one’s head around, since we tend to admire self sacrifice and hard work. In this view, hard work must be accompanied by prayer and meditation, contemplating all the while what is being accomplished and are we doing God’s will.