What does burnout mean? The term is commonly employed by staff in medicine and other industries, but does it mean anything more than having a bad day? And is it serious?
“I’m so burned out. I’ve got to get off this unit,” said the social worker.”
What does burnout mean? The term is commonly employed by staff in medicine and other industries, but does it mean anything more than having a bad day? And is it serious? It must be, as this exceptional social worker had tears in her eyes when she shared her statement with everyone in a morning staff meeting. The staff around her quickly realized it wasn’t a complaint. For that individual, it was a crisis.
My social-work colleague was suffering, and she knew it was decreasing her effectiveness at work. We were working in a large, rapid-paced inpatient psychiatric unit with high case volumes, and she felt powerless to impact the homelessness and other external factors that often precipitated our patients’ cycle of frequent rehospitalization. Gradually this led her to develop a chronic feeling of low personal accomplishment.
Burnout is endemic to the practice of medicine—a gratifying but emotionally exhausting profession.
Daily hearing patient stories of traumatization left her emotionally exhausted, so that when she went home she had nothing left to give her family, and she felt “checked out.” To protect herself against further emotional injury and feeling further burned out, she began to experience depersonalization. Rather than seeing each patient as an individual, like herself, with a unique story, she began to see them as objects in a queue that she was to move towards discharge as rapidly as possible. Subsequently, she had moved away from her natural empathy for our patients, and as she worked with the area’s most vulnerable patients, they could sense she had checked out. This led them to feel as if they were afterthoughts, and sometimes it made them angry. They were certainly less likely to engage with her and to trust the strong treatment plans she was still able to design.
Unfortunately for us, burnout is endemic to the practice of medicine—a gratifying but emotionally exhausting profession. Many researchers feel it has increased in prevalence over the last decade, primarily with economic and logistical changes in medicine, resulting in increased patient loads and increased demand for a higher number of clinic visits per day, along with decreased appointment times, decreased autonomy, and decreased control over our external working environments. Other stressors include feeling enslaved by health-care organizations’ focus on competitive ratings in terms of patient wait times, Press Ganey scores, and easily quantified measures of health-care quality, such as smoking cessation rates and vaccination rates.
Several years ago, a survey of American Medical Association members identified the prevalence of burnout in practicing physicians in the US to be approaching 46 percent.1 Not surprisingly, the prevalence of burnout in specialties with high volume, rapid-paced care (e.g., emergency medicine) or extended work hours (e.g., general surgery) was significantly higher. Research has consistently shown that the number of hours worked, number of patient visits per day, and call frequency are all correlated with the prevalence of burnout.2 For reasons we do not yet understand, burnout is more common among younger providers than it is with senior physicians.
If burnout continues long term, some believe it can precipitate more serious diseases. Burnout is associated with an increased likelihood of meeting diagnostic criteria for major depressive disorder or alcohol use disorders, such as alcohol abuse or dependence.3 It has been associated with increased likelihood of an episode of significant suicidal ideation in both attending level physicians and fourth year medical students.4
Finally, the presence of continued burnout has been shown to increase the likelihood of the affected person making a significant medical error5 in the near future. Furthermore, when physicians lose their ability to tap into their natural empathy, patients are less likely to follow their behavioral recommendations. Patient satisfaction scores decrease, as do patients’ general health outcomes and their compliance with health-care advice. And unfortunately, over the long term, burnout increases the likelihood that providers will leave the field due to their chronic disillusionment.6 This happened with my social-work friend. Sadly for her colleagues, within several months after that memorable staff meeting, she elected to move to a career much different than mental health-care delivery, and she never returned.
NOW THE GOOD NEWS
Research is growing concerning strategies to target burnout. While many physicians have experienced or will experience burnout at some point, the good news is that it is often a transient state. Individuals can do several things to combat burnout, all of which revolve around maintaining a healthy work/life balance. Utilizing vacation time is important, as is having the courage to exercise what control you can over work hours and call frequency. Reflective writing on meaningful clinical experiences and sharing these experiences with colleagues has also been shown to be helpful.
LOCAL NORTHWEST RESOURCES
In addition, multiple researchers have shown that learning and implementing the practice of mindfulness meditation can combat and prevent the development of burnout.7 As a result, for the last several years UW Medicine has been offering to its faculty members and their families a free six-week course on mindfulness-based meditation. Read more about mindfulnessbased resources on page 28, and see the insert included in this issue on the Physician’s Desktop Guide to MBSR.
Individuals who don’t have access to a wellness program through their own organizations are now turning to their state physician health program for assistance. Over the last five years, the Washington Physicians Health Program (WPHP) has been assisting physicians who self-refer for burnout, helping them restore their work-life balance and find help through psychotherapy or other means so they can regain the joy they once felt in the practice of medicine. WPHP has also been offering mindfulness workshops around the state for physicians interested in building an individual wellness practice to protect against the advent of burnout. Physicians’ significant others are also welcome to participate. Like the UW mindfulness offerings, registration fees for these five-week workshops are heavily discounted compared to what they would cost attendees in the general community. WPHP will likely hold five to seven additional workshops in 2016.
Lastly, WPHP is piloting a new mindfulness offering in Compassion Cultivation Training (CCT) in October 2015. Designed at Stanford University by a multidisciplinary team of neuroscientists and psychologists, CCT draws originally from compassion practices found in Tibetan Buddhist traditions and trainings. While prior mindfulness training is not mandatory to benefit from CCT, this workshop builds on mindfulness practices to improve resilience, well-being, and tolerance of challenging individuals, feelings, and situations. Individuals working in high-stress environments or with high-stress problems outside of their direct control have reported benefit from CCT workshops. These individuals include trauma victims, PTSD patients, cancersupport community groups, hospice staff, and various health-care groups in Southern California.
FEDERATION OF STATE PHYSICIAN HEALTH PROGRAMS
The Federation of State Physician Health Programs, Inc. (FSPHP), is a nonprofit corporation whose purpose is to provide a forum for education and exchange of information among state programs; to develop common objectives and goals; to develop standards; to enhance awareness of issues related to physician health and impairment; to provide advocacy for physicians and their health issues at local, state, and national levels; and to assist state programs in their quest to protect the public.
The mission of FSPHP is to support physician health programs in improving the health of medical professionals, thereby contributing to quality patient care. Their Web site offers the following health programs for physicians by state:
Idaho Physician Recovery Network Southworth Associates
Health Professionals’ Services Program
Washington Physicians Health Program
Wyoming Professional Assistance Program, Inc.
1 Tait D. Shanafelt, Sonja Boone, Litjen Tan, Lotte N. Dyrbye, Wayne Sotile, Daniel Satele, Colin P. West, Jeff Sloan, and Michael R. Oreskovich, “Burnout and Satisfaction with Work-Life Balance among US Physicians Relative to the General US Population,” Archives of Internal Medicine, October 8, 2012,Vol. 172, No. 18:1377–1385.
2 Charles M. Balch, Tait D. Shanafelt, Lotte N. Dyrbye, Jeffrey A. Sloan, Thomas R. Russell, Gerald J. Bechamps, and Julie A. Freischlag, “Surgeon Distress as Calibrated by Hours Worked and Nights on Call,” Journal of the American College of Surgeons, June 29, 2010, Vol. 211: 609–19.
3 Michael R. Oreskovich, Krista L. Kaups, Charles M. Balch, John B. Hanks, Daniel Satele, Jeff Sloan , Charles Meredith, Amanda Buhl, Lotte N. Dyrbye, and Tait D. Shanafelt, “Prevalence of Alcohol Use Disorders among American Surgeons,” Archives of Surgery, February 2012, Vol. 147, No. 2:168–74.
4 Liselotte N. Dyrbye, Matthew R. Thomas, F. Stanford Massle, David V. Power, Anne Eacker, William Harper, Steven Duming, Christine Moutler, Daniel W. Szydlo, Paul J. Novotny, Jeffrey A. Sloan, and Tait D. Shanafelt, Burnout and Suicidal Ideation among US Medical Student,”. Annals of Internal Medicine, September 2, 2008, Vol. 149, No. 5: 334–341.
5 Colin P. West, Angelina D. Tan, Thomas M. Habermann, Jeff A. Sloan, and Tait D. Shanafelt, “Association of Resident Fatigue and Distress with Perceived Medical Errors,” JAMA, September 23, 2009, Vol. 302, No. 12: 1294–1300.
6 Abhiram Sharma, Donald M. Sharp, Leslie G. Walker, John R. T. Monson, “Stress and Burnout among Colorectal Surgeons and Colorectal Nurse Specialists Working in the National Health Service,” Colorectal Disease, May 2008, Vol. 10: 397–406.
7 Michael S. Krasner, Ronald M. Epstein, Howard B. Beckman, Melissa Wendland, Christopher Mooney, Timothy E. Quill, and Anthony L. Suchman, “Association of an Educational Program in Mindful Communication with Burnout , Empathy and Attitudes among Primary Care Physicians,” JAMA , September 23,2009, Vol. 302, No. 12: 1284–1293.