Burnout is the new buzzword in medicine. Physician burnout, PA burnout, nurse burnout. It’s what everyone is talking about and what too many have experienced. But what does it mean exactly? What are the signs of burnout? Can it be treated–or better yet–prevented?
Defining Physician Burnout
Let’s start by trying to define physician burnout. One article in the Journal of Internal Medicine defines it as: “chronic stress associated with emotionally intense work demands for which resources are inadequate”. It’s feeling used and even abused and having nothing left to give.
A 2004 article in JAMA aims to be more specific in prescribing 3 required features of physician burnout: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.
The pace of life for a physician, PA, or NP can be grueling. I’m often at my computer each morning before I leave for work in a last-ditch attempt to close a few notes, result a few labs, or answer a few patient emails. The process continues after hours, as well. Weekends and holidays are no exception. I am one of the lucky ones, however, and I rarely take a telephone-based call.
There have been times in my career when I could hear stories of illness, suffering, tragedy, and abuse without being phased. My tank was full and my armor intact. I actually found it easier to maintain objectivity when I could maintain a certain amount of emotional distance from my patients.
The longer I am in practice, however, the more I yearn for connection and meaning. But those things come at a cost. I have felt that if I could do nothing else, I could at least offer my patients empathy. But lightening a patient’s burden, if only by a marginal amount, means that my load can become more substantial.
What was once my strategy for avoiding burnout is actually considered to be a symptom of the same. When a doctor or PA ceases to see his patients as human beings with innate value and worth and instead starts to see them as objects, she is on the path to emotional exhaustion.
While likely not reaching the level of a DSM diagnosis, depersonalization may be one of the most accurate and early indicators of physician burnout. Other words to describe depersonalization include numbness, callousness, heartlessness, coldness, and insensitivity. The Greek physician Hippocrates, the father of medicine, supposedly said, “Wherever the art of medicine is loved, there is also a love of humanity.” When coldness and insensitivity grip the heart of a physician, she posses neither.
Diminished Feelings of Accomplishment
Health care providers cultivate a host of skills over many years; they are nothing if not accomplished. But burnout can lead an otherwise capable clinician to doubt herself, to consistently discount the positive and dwell on the negative.
According to West, et. al. in the Journal of Internal Medicine, “a sense of reduced personal accomplishment encompasses feelings of ineffectiveness in helping patients with their problems and a lack of value of the results…” This symptom of burnout has also been dubbed professional inefficacy.
Soldiers in the First World War had a name for those among them that developed symptoms of fatigue, tremor, confusion, nightmares, impaired sight and hearing, headache, ringing in the ears, dizziness, poor concentration, loss of memory, and disorders of sleep: they called this new and mysterious disorder: shell shock.
Shell shock was originally thought to be a concussion-type injury to the brain brought on by the blistering force of newly designed explosives. This injury, believed to be physical, was originally found deserving of special recognition–a pin to be worn on the uniform.
But when it was later realized that not all shell-shocked soldiers had been near explosives, the disorder was renamed “neurasthenia,” indicating weakness or failing of the nerves leading to a nervous breakdown. This condition would later come to be known as post-traumatic stress disorder, or PTSD. But even PTSD fails to describe the character and depth of the wounds suffered by combat veterans and many others who have witnessed or been victims of tragedy.
…Or Moral Injury?
Dr. Brett Litz, a psychologist in the Veterans Administration, suggested in a 2009 article that a better term for “the war after the war” was moral injury. “What sometimes happens in war may more accurately be called a moral injury — a deep soul wound that pierces a person’s identity, sense of morality and relationship to society. In short, a threat in a solder’s life,” wrote journalist Diane Silver.
So where do healthcare providers fit in? Surely highly respected and well-salaried physicians have nothing to complain about! They sit in their air-conditioned offices donning a neatly pressed white coat, far from the ugliness and helplessness of war. Drs. Wendy Dean, Simon Talbot, and Zubin Damania believe that rather than designating similar signs and symptoms in clinicians physician burnout; doctors, nurses, and PAs also suffer moral injury.
Let’s Stop Blaming Physicians for Burnout
What is the nature of this moral injury in some of society’s most successful citizens? Dr. Damania writes, “So many of us in healthcare feel overwhelmed, demoralized, exhausted, cynical, afraid, and alone. It has to be our fault, right? We’re not resilient enough, we don’t work hard enough, we’re not efficient enough, we’re not good enough people to be taking care of others. Hell, we can’t even seem to take care of ourselves, let alone everyone else.” These are the first signs of moral injury.
Drs. Dean and Talbot suggest that “the increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.” They continue, “The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.”
I can unfortunately relate.
Physician Assistants Burn Out, Too
Just this afternoon, I spent an untenable amount of time completing a prior authorization for a medication that a patient had been taking for almost a year. The first attempt resulted in a denial based on a lack of specific information regarding her diagnosis. The second attempt resulted in another denial because the medication was supposedly not on their formulary. I was then invited to call and speak with a representative. Before I invested any more time, I decided to call the patient in order to explain the delay. She informed me that she had actually already received the medication followed by a denial notice!
I once had to submit an imaging order 4 different times to meet an insurance company’s expectations. Then there was the time another insurance company withdrew authorization for a test after the patient had already had the test! Yes, unfortunately, insurance companies make money by denying care.
I shy away from worker’s compensation cases because it’s all too easy to forget to whom you owe your allegiance and to whom you really answer–the patient or his employer. Filling out FMLA or temporary disability paperwork has become a dreaded but recurring task. I practice more “medicine” from my desk than in the presence of actual patients.
The nature of the work is no easier. I lost a patient to terminal cancer this week although I had only just diagnosed her the week prior. I felt completely helpless as a young gay patient told me how he was experiencing homelessness and sleeping with strangers just to spend the night indoors. The stories of abuse and neglect are no easier to recount.
I am lucky enough now to work in a clinic that values facetime with patients. I see no more than 15 patients per day these days but I have been expected to care for more than 30 in previous jobs. And that isn’t counting the dozens and dozens of messages, phone calls, labs, and images that need to be reviewed and resulted.
“I don’t get no respect!”
But at least healthcare providers are still situated atop a proverbial pedestal, right? Wrong. Doctors and PAs are now too often viewed as short-order cooks where the slogan is “have it your way” and “the customer is always right.” Slip up and you’ll be crucified online and possibly in court.
Speaking of patients going online, at least no one puts more faith in Google than their doctor [insert sarcasm]. Thankfully, no patient has ever made important decisions regarding vaccines based on internet “research”… None of this is meant to claim that patients ought not to be informed and to advocate for themselves, but only that to some, today’s physician is no more reliable than what can be found online.
I don’t share this to garner sympathy. If I didn’t believe the pros of what I do outweigh the cons, I wouldn’t keep doing it. But things aren’t getting any better. In fact, they’re getting worse.
Statistics on Physician Depression and Suicide
It has been observed since the 1800s that physicians take their own lives more frequently than their non-medical peers. 200 years later, male physicians have suicide rates that are 40% higher than the general population while the rates in female physicians are reported to be up to 130% higher than the general population. This trend is accelerating and it’s beginning earlier and earlier. One study found that 74% of medical residents met the criteria for burnout. Another reported that 27% of medical students had depressive symptoms.
But unfortunately, these individuals suffer in silence. Besides having little time to access the same resources that surround them on a daily basis, physicians and PAs suffering from burnout and depression fear the repercussions of transparency.
Don’t Ask, Don’t Tell
Susan Haney, MD is an Emergency Physician, who in good faith, reported a transient issue to her employer and the Oregon Board of Medical Examiners in 2006–and has regretted it ever since.
Dr. Haney has suffered from depression. Up until 2006, she had managed her condition successfully. In her own words, she says “I had never been hospitalized because of mental illness. I had never missed a day of work due to mental illness.” But then a course of steroids for an asthma exacerbation caused an exacerbation in her symptoms.
Instead of thanking her for her honesty and bravery in divulging a sensitive issue, the Oregon Board of Medical Examiners (BME) barred her from returning to work until a grueling 4-month investigation had concluded.
“[The investigation] required that I disclose intimate personal details of my psychological and psychiatric history to anybody at the BME who requested them. None of the BME staff who investigated me were psychiatrists or psychologists, and most of them were not even health care professionals. My only direct contact with the BME during that time was through an investigator with a background in law enforcement. This investigator successfully discouraged me from seeking legal assistance because of the potential for prolonging the BME investigation and further delaying my return to work. Despite numerous requests, BME staff would not allow me to appear in person or to testify in my own defense.”
When the interrogation concluded, the Board published a public “corrective action order” in the name of “public safety”. Unsurprisingly, Dr. Haney was horrified.
“When I attempted to assert my rights to privacy, autonomy, religious freedom, and appropriate medical and mental health care, the BME threatened me with emergency suspension of my license unless I complied fully with the [physicians health program].” The Board’s “corrective action” haunts Dr. Haney to this day and she continues to be shunned by potential employers and credentialing bodies.
Burnout recovery: How to Treat Physician Burnout and Moral Injury
Recognizing the stages of burnout and moral injury is only the first step. Something must be done. The status quo cannot be allowed to continue. If we are ever able to overcome a physician shortage and continue to provide healthcare in innovative ways, we must first change the taboo surrounding mental health. This is easier said than done.
One 2019 article recommends a few practical interventions for preventing physician burnout in the first place:
- Delegate non-essential duties to support staff
- Data entry
- Prior Authorizations
- Increase appointment times
- Standardize workflows for prescription refills, consult review, etc
Having sufficient support staff is critical. Each clinician needs access to 1-2 full-time MAs or LPNs in order to run an efficient clinic without getting bogged down by non-clinical duties. The next step is having a basic set of standing orders in place. Does your staff have instructions on how to handle:
- Prescription refills
- Normal or negative labs and pathology results
- Patient messages
- Calls for basic medical advice/triage
Creating boundaries between work and home is another way to both prevent and treat physician burnout. Canadian physician William Osler, who is known for pioneering bedside clinical training, believed that the practice of medicine was “a calling, not a business”. But is viewing one’s source of employment as an “external summons” the healthiest way to go? Does having a calling prohibit you from ever stepping away and taking a breath?
Consider the following to create a healthier work-life balance in healthcare:
- Determine your priorities
- If medicine gives you meaning, then focus on your life at work rather than life away from work
- Schedule time for family and friends if you work to live and not live to work
- Leave work at work
- Being on call is terrible, but is to some degree necessary, therefore don’t bring other work-related tasks home (like charting)
- Take a break
- No more working through lunch–take a walk, a nap, or whatever else you’d like to do
- You have vacation time–use it!
None of these suggestions will be able to foster real change in your life without addressing “the basics”. A solid foundation is required to build something of value. Business magnate Richard Branson once said, “The important thing is that you’ve got a strong foundation before you start to try to save the world or help other people.” Ask yourself a few questions to determine the strength of your foundation for building a better life:
- Am I getting the recommended 7-7.5 hours of sleep each night?
- Am I getting enough exercise? (Note, simply being active is not the same as getting regular exercise.)
- Am I eating a healthy, balanced diet?
- Am I investing in my relationships with others?
primum non nocere
Hippocrates, again, is credited with the maxim “first do no harm”. Perhaps it’s time we take our own advice.
How do you prevent and treat burnout and moral injury? Tell us in the comments below!