Feature Christmas 2023: Workforce Crisis

Workload and the mysterious law of karma

Jakob Mejdahl Bentin, Frida Run Jonsdottir

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2686 (Published 18 December 2023)Cite this as: BMJ 2023;383:p2686

If good deeds beget good consequences, why do you always get the toughest shifts, ask Jakob Mejdahl Bentin and Frida Run Jonsdottir

Why do some colleagues seem to always have easy shifts, while others face a consistently high workload? Could something more than mere chance be at play? Ancient Indian and Chinese philosophies posit a law of karma—that is, your previous actions, thoughts, and behaviour decide your future.12

Cycles of rebirth (samsara) occur, determined by the accumulation and resolution of karma from past lives, finally culminating in liberation (moksha), according to many schools of Indian religions. Despite no scientific basis, healthcare professionals often speculate about “work karma”—that is, doctors who have done good deeds experience relatively easier shifts. The less than virtuous, those with karmic debt, face more arduous tasks, paperwork, and sleep deprivation.

What goes around comes around

We considered doctors’ working patterns to decide whether karma was at play in a European hospital surgical department. Our retrospective observational study followed STROBE guidelines and continued throughout 2022, not just in the festive season, when workloads can be even more onerous. We had no loss to follow-up and used reliable data with few missing; but it was only one department in one hospital.

A shift was 3 pm to 8 am on weekdays and entire days on weekends (8 am to 8 am. Each shift was staffed by a surgeon, an attending surgeon, and a consultant on standby. Doctors who worked fewer than four shifts in the year were excluded from the dataset, leaving a total of 14 surgeons and eight attending surgeons. Attending surgeons have more experience and a higher rank than a regular surgeon. They have overall responsibility and lead surgical procedures with surgeons as assistants. Shifts were evenly distributed between surgeons and attending surgeons.

We estimated workload using electronic health records as the total time managing acute patients (an estimated 40 minutes each), caring for inpatients (an estimated seven minutes each), caring for departmental patients admitted to intensive care (an estimated 10 minutes each), and doing surgery. Workload was considered for the surgeon and attending surgeon, reflecting the joint effort and shared responsibility. We calculated the average for each combination of surgeon and attending surgeon over the year (fig 1)

The surgeons and attending surgeons had a mean shift workload of 10 hours 29 minutes (standard deviation 59 minutes) over the year. Sixteen of the 22 surgeons studied had average shift workloads over the year within an hour (one standard deviation) of the mean. Two mostly had heavier workloads than this (surgeon 16 and attending surgeon 6), and four mostly had lighter workloads (surgeons 7 and 17; attending surgeons 7 and 8). Two surgeons had very busy shifts (average longer than 12.5 hours’ work), and none experienced idle ones (average less than 8.5 hours’ work). Was this karma in action?

Weekday shifts were significantly busier than at weekends (11 hours 23 minutes versus 8 hours 22 minutes; P<0.001). But these shifts were evenly distributed among doctors. The busiest season was autumn; summer was the least busy.

Do unto others as you would have them do unto you

Could workload be related to experience rather than karma? Might more experience correspond to more efficient performance of tasks and therefore less onerous shifts? Or can more experienced doctors recognise and handle more difficult tasks, which less experienced doctors might defer to others?

We quantified the surgeons’ experience as the number of years since authorisation to practise. Surgeons had a mean 3.5 (standard deviation 2.5) years’ experience, whereas attending surgeons had 13.8 (5.5) years’ experience. We saw no correlation between experience and workload, indicating that karma is independent of experience (see supplementary figure on bmj.com). Both novice and veteran doctors can experience good karma, and all doctors should engage in positive deeds.

Workload for both surgeons on a shift might be influenced by the karma of each individual surgeon and attending surgeon—doctors with bad karma might receive a better shift when paired with a colleague with good karma, and vice versa. We observed that when surgeons were ill and their shift was covered by a colleague (50 of 730 work days; 6.9%), workload was more closely linked to the karma of the covering surgeon than the ill one (see supplementary figure on bmj.com). This aligns with the idea that karma cannot be transferred: it is a personal manifestation of your own previous actions.

Providing cover for a sick colleague might be expected to bring better karma. Covered shifts did tend to be lighter in workload than the doctor’s usual average but this difference was not statistically significant. Doctors who covered at least one shift had significantly better karma than those who did not (mean workload 10 hours 12 minutes versus 12 hours 30 minutes, P=0.01). The positive effect on an individual’s karma did not, however, seem to increase with the number of shifts covered (P=0.17). Karma concerns cause and effect in morality, but our findings cannot establish causality—although collegiality is always to be encouraged.

Reap what you sow

So far we have considered good karma to lead to less work; but many surgeons appreciate spending time in theatre. We considered the distribution between daytime (8 am to 10 pm) and night time (10 pm to 8 am) surgeries; surgical and non-surgical procedures; and primary and secondary surgeries (fig 2).

It could be argued that physicians with heavier workloads actually have good karma. Surgeon 6, for example, has a relatively large proportion of surgery in their workload and spends above average time in the operating theatre, particularly during the day, with a high proportion of primary surgeries, the typical preference of surgeons. 

Conversely, surgeon 7’s karma might be considered bad: although their shifts are relatively idle, they spend minimal time in surgery, mostly performing secondary procedures and non-surgical work. Surgeon 16’s karma might be viewed as even less favourable: a heavy night time workload, minimal theatre time, and mostly secondary procedures.

Thus, the interpretation of karma seems to depend on a specific surgeon’s preferences. Not all work is burdensome: good karma might also give rise to enjoyable work. Having meaningful work at least some of the time might protect against burnout.13

Get back what you put in

the law of karma might provide a philosophical framework for understanding cause and effect, but it would be rash to rely on it to make sense of medical practice or any judgment about a doctor’s morality. A multitude of other reasons explain high workload, including a physician’s skill and efficiency and demand from colleagues and patients.

Although we have not been able to explain the cause of workload differences, none of our observations point directly towards karma. Establishing causality is not possible, and considering karma from previous lives (samsara) would be even trickier. Randomising surgeons to pursuing bad karma and compromising their spiritual liberation (moksha) would be unethical.

Regardless of your belief in karma, heavy workloads can be frustrating, diminish mental and physical wellbeing and job satisfaction, and ultimately lead to burnout. Work karma might defy quantification, but understanding the diverse factors that influence the distribution of workload would be a step towards a system that treats doctors fairly, promotes their wellbeing, and delivers the best possible care to patients.