A new term surfacing over the past several years is putting a contemporary spin on a long-term problem within the workforce. The problem is essentially tied to a work ethic. Do workers fully engage with their work and sometimes go beyond what is expected, or do they do the minimum to get by to retain their jobs and get paid? If it is the latter, these workers are among the “quiet quitters.”
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January 2025Quiet quitting was popularized in 2022 via social media outlets as a term describing workers who opt out of doing more than their assigned job duties and who are psychologically less invested in their work. It is often described in generational terms, seen more in younger workers who are approaching work with a different mentality than older generations, and it’s centered on achieving a better work-life balance. It is often considered part of the fallout of the COVID-19 pandemic, which rearranged work life across sectors. Since its loud surfacing, the term has been described and analyzed in countless publications, all of which critique its current usage and links to long-established problems within the workforce (Harvard Business Review. https://hbr.org/2022/09/when-quiet-quitting-is-worse-than-the-real-thing; The New Yorker. https://www.newyorker.com/culture/2022-in-review/the-year-in-quiet-quitting; Forbes.https://www.forbes.com/sites/allbusiness/2022/12/19/quiet-quitting-is-a-sign-of-a-deeper-problem-heres-what-it-means/; The Atlantic. https://www.theatlantic.com/newsletters/archive/2022/09/quiet-quitting-trend-employee-disengagement/671436/magazines).
In healthcare, the term is also making its rounds. Editorials and studies discussing its relevance and what it means for the healthcare profession globally are an easy Google search away, as are diagnoses and solutions to the problem offered by industry experts (MGM Journal of Medical Sciences. doi:10.4103/mgmj.mgmj_42_23; Plast Surg. doi: 10.1177/22925503231208495; Healthcare Executive. https://healthcareexecutive.org/archives/january-february-2023/quiet-quitting; iHire. https://www.ihire.com/resourcecenter/employer/pages/how-to-identify-and-overcome-quiet-quitting-in-healthcare; insight training solutions. https://insighttrainingsolutions.io/a-silent-crisis-strategies-to-combat-quiet-quitting-in-healthcare/; and NurseDash. https://nursedash.com/blog/employees-quiet-quitting-the-effects-on-healthcare-industry/).
Read these articles, and the ideas that keep popping up in connection with quiet quitting are burnout, employee dissatisfaction, low morale, different generational expectations regarding work, management problems, and the list goes on. Distilled from this montage is a contemporary phenomenon rooted in and reflecting a cultural shift in work attitudes and expectations.
For the otolaryngologists who weighed in on this, changes to the cultural ethos of the workplace are a general theme cited as causing quiet quitting. This comes in the form of physical changes to the workplace brought on by COVID-19 and workers now expecting the option of working remotely. It also comes in the form of policy changes impacting the ethos of medicine more broadly, sometimes in unexpected ways, such as federal regulatory changes to resident work obligations via resident duty hours that may unintentionally lead to a “shift work” mentality among young physicians. Other changes may come in the form of loss of autonomy as physicians join employee-run organizations. And still, other forces creating a disincentive to work harder or engage more fully may come from lower reimbursements for delivery of healthcare services.
Loss of Autonomy
Autonomy is one theme that emerged from talking to these otolaryngologists, all of whom hold leadership roles in their respective practices. Douglas Backous, MD, past president of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), cited the lack of autonomy increasingly experienced by physicians and staff as they join employer-run organizations, and hospitals in particular.
“As you get into employer environments, physicians are losing autonomy, staff are losing autonomy, and multiple layers of hierarchy are being created to where problems can’t be solved,” he said. “When autonomy is impacted, you get people coming into work and doing just what they need to do, not coming in early, not staying late.”
When autonomy is impacted, you get people coming into work and doing just what they need to do, not coming in early, not staying late. — Douglas Backous, MD
He cited the mismatch between the corporate mentality of these organizations, particularly those increasingly owned by private equity groups, and the mentality of people who go into medicine. When the profit motive rules and physicians are judged by and paid based on the volume of patients seen in a day, physicians lose a sense of the autonomy and agency that led them into medicine. “What is being extracted is the ‘art of medicine,’” said Dr. Backous. “When you lose that, you lose those intangible relationship qualities among all healthcare workers.”
He cited the “social trust” that physicians build with their patients and the deep satisfaction that trust carries for both physician and patient. He suggested that when that bond is loosened by the demands of volume-based care versus relationship building between physician and patient, the incentive to work harder is also loosened.
Currently, in private practice with ENT & Allergy Associates, PS, as well as a partner in Proliance Surgeons, a multispecialty group of 35 practices in Seattle, of which he sits on the governing board, Dr. Backous noted that he doesn’t think that monetary incentives are the only or even main incentive to getting physicians and other healthcare workers to engage more. He cited the exodus of workers from large technology companies, such as Google, as belying the notion that high wages encourage engagement.
He returned to the sense of autonomy workers need to feel a part of a team, or village, as he called the team approach to caring for patients. Such autonomy leads people to feel they are making an impact, and that, in turn, leads to better worker engagement. Essential to this feeling is that each person understands and is recognized for their distinct role and responsibility on the team. “As lines get blurred between, for example, responsibilities of physicians versus physician assistants versus nurses, the pathways to creating impact of each of their roles gets reduced, and people then become less engaged,” he said.
Twist on Autonomy—Post-COVID-19 Remote Work?
Ironically, an increase in autonomy may also be at work in creating quiet quitting in some margin of the healthcare workforce—employees who were relegated to remote work during the COVID-19 pandemic and now are resistant to returning to on-site work.
Although some workers may claim that working remotely offers more autonomy and improves work-life balance and, thus, work satisfaction, such autonomy may be viewed as disturbing the cultural ethos of strong teamwork and collaboration needed in the healthcare industry.
Eben Rosenthal, MD, chair of the department of otolaryngology–head and neck surgery at Vanderbilt University Medical School in Nashville, cited the insistence of staff to continue working remotely from home as having a negative impact on the “esprit de corps” among staff and faculty that is essential to maintaining a good culture, one that ultimately benefits patients.
“I feel it is hard to maintain a good culture in an environment where people are working from home and not interacting on a daily basis,” he said, citing the potential conflicts people have when working at home, such as juggling looking after children in the home
with working.
Although reduced productivity may not always result, he said, what does change is the fact that the accessibility and visibility of people working in the office means that they are more often delegated work simply because the remote workers are not physically present. This places an asymmetrical burden on people working on-site and reduces tasks assigned to remote workers.
“This is what I am seeing with quiet quitting,” he said, adding that, for him, the term is really a metaphor for disengagement from work.
“If you have disengaged people, it will affect the whole group and erode the esprit de corps of the team,” he said. He cited the example of nurses calling in sick a lot and being less aware of the added burden on their colleagues who have to pick up the slack. Not only does this impact team morale and the sense of team collaboration, but it ultimately leads to a reduced ability to care for patients.
Studies support this consequence (BMJ Open. https://bmjopen.bmj.com/content/13/11/e077811; J Glob Health. doi: 10.7189/jogh.13.03014; Int J of Clin Studies Med Case Reports. doi: 10.46998/IJCMCR.2023.28.000700). Evidence points to the close association between patient safety and teamwork among healthcare professionals, as well as issues closely tied to quiet quitting, such as job satisfaction. Erosion of teamwork, worker satisfaction, burnout, stress—all of these can lead to an increase in medical errors and a reduction in the quality of patient care.
Dr. Rosenthal has recently mandated the majority of staff to return to on-site work; he wants people to be physically together so they can learn from each other and adapt to changes within the department. He acknowledged the challenge for some workers to comply with this and said some attrition may occur, but emphasized the need to set expectations that all members of the team going forward will spend most of their working week together on site.
Unintended Consequences: Change in Physician Practice
Stephen S. Park, MD, G. Slaughter Fitz-Hugh Professor and chair of the department of otolaryngology–head and neck surgery at the University of Virginia in Charlottesville, said changes in physician practices—with more physicians working in a shift model in which care of a given patient is handled by different physicians—may be an unintended consequence of changes in residency training over the past couple of decades.
He said changes to residency training, or resident duty hour regulation, mandated in 2003 by the Accreditation Council for Graduate Medical Education (ACGME), can contribute to a “shift mentality” among residents that subsequently spills into their practice as young physicians.
“Regulating the number of hours residents train was overdue and needed,” he said. “But as we mandate an exodus of resident physicians from the hospital after a certain amount of clinical time, we can create a bit of a mindset of ‘shift work.’”
“It is imperative that we hold sacred the notion of ownership of the entire patient’s care, always remembering the very high stakes of healthcare,” he added.
He cited the example of a senior attending and resident performing surgery into the very early morning. At dawn, the resident is excused to go home, and the attending returns to seeing patients in a full outpatient clinic. The mandate to restrict duty hours for residents creates a system that allows young physicians in training to disengage from their work even when clinical duties remain. “After graduation, the younger physician will encounter a different working environment where patients are entirely counting on them to personally ensure their well-being,” he said.
Dr. Park is quick to note that he feels the changes are generally a good thing for medical education. “It is now incumbent on leaders in education as well as learners to recognize this as a potential shift in priorities and adapt,” he said, adding that as chair of a department, he sets a priority to cultivate a sense of ownership in education and patient care.
“The resident is not a sidebar in patient care but is an integral part of the team, and the best outcomes rely on all parties being 100% committed,” he said. “Any occasion to cut corners or quit early erodes this process, and the final loser is the practitioner and their future patients.”
Dr. Park said he also sees quiet quitting in faculty, describing it as tied to burnout. “When a person feels overworked, whether true or perceived, the reaction is toward self-preservation, and that leads to working less or compromising quality,” he said.
One driver of burnout and working less among faculty, he said, comes from a decreasing sense of worth. He cited lower Medicare reimbursement rates that leave physicians with the loud message that their work is decreasing in value. “I think in global healthcare, and certainly in our national healthcare, there is a diminishing value placed on a certain amount of effort,” he said.
That diminishing monetary value, he said, can be linked to a sense of declining fulfillment. He noted, however, that for physicians who have an immense sense of self-satisfaction, the effort they put into their work will not drop.
He emphasized that monetary compensation has never been the main driver of those going into medicine, however. Instead, he suggested that physicians need recognition of their effort and worth, particularly in this increasing climate of new rules, regulations, and expectations governing their careers.
Encouraging Engagement
One message that comes through when talking about quiet quitting in otolaryngology, and in healthcare in general, is the essential reminder that the practice of medicine, at its core, is a vocation. People still go into medicine primarily motivated by the desire to help others, as noted in a 2017 survey by the American Medical Association (AMA. https://www.ama-assn.org/press-center/press-releases/survey-us-physicians-overwhelmingly-satisfied-career-choice). The impetus to engage in meaningful work is baked into the profession. That seems a strong base to return to when addressing cracks in the edifice that lead to worker dissatisfaction and disengagement.
Over the past decade, improving the work life of healthcare workers has gained clearer focus as an essential aim of healthcare, along with enhancing patient experience, improving population health, and reducing costs. This quadruple aim recognizes that all four of these components are integral and critical for a healthcare system to function at its best. Organizations can use this basic framework as a starting point as they steer through this latest iteration of employee dissatisfaction with and disengagement from their work in the form of quiet quitting.
Researchers at the Stanford University School of Medicine, in conjunction with the Association of American Medical Colleges in Washington, D.C., also developed a framework that offers organizations a way to identify more clearly the factors contributing to a lack of well-being (e.g., burnout, dissatisfaction) among physicians, factors that promote improved well-being, and key steps toward achieving those factors (Mayo Clinic Proceedings. https://www.mayoclinicproceedings.org/article/S0025-6196(19)30345-3/fulltext). The framework fundamentally sees the need for a cultural change within healthcare systems.
While both of these frameworks look more globally at factors associated with problems linked to quiet quitting but not specifically defined as quiet quitting, organizations that want to identify which employees may be going the quiet quitting route may want to turn to a newly developed quiet quitting scale (AIMS Public Health. doi: 10.3934/publichealth.2023055). The scale has shown strong reliability and validation, but researchers encourage its broader use to increase validation.
Conclusion
Quiet quitting is not new. The level of engagement that workers bring to their work is as varied as the work itself, with some workers deeply engaged and others less so. Temperament, training, life’s vicissitudes, and age all may play a role. What the label quiet quitting may contribute beyond this age-old problem of worker productivity is recognition of a shift underway in work itself—what it means, who is doing it (increasingly automated), and how it is done (artificial intelligence, digitalization). Physicians and other healthcare professionals are being challenged by this shift as the culture of healthcare changes. If quiet quitting shines a spotlight on the need for cultural change within healthcare to improve the well-being of physicians and all healthcare workers, then the label is doing a service.
Mary Beth Nierengarten is a freelance medical writer based in Minnesota