Burnout Beating You?

Posted on Feb 22, 2011 in Heal Thyself | 0 comments

Beat Burnout BEFORE it Beats You

 

 

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Burnout: exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration

—Merriam-Webster’s Dictionary

While burnout isn’t a recognized clinical psychological disorder, there are some similar features between burnout and diagnosable conditions such as depression, anxiety disorders, or mood disorders. However, burnout is much more common than these other conditions; in fact, it’s estimated that 25% to 60% of practicing physicians experience burnout.[1] As proposed by Maslach and colleagues, burnout “represents an erosion in values, dignity, spirit, and will—an erosion of the human soul. It is a malady that spreads gradually and continuously over time, putting people into a downward spiral from which it’s hard to recover.”[2] Burnout is caused by excessive and prolonged stress, leaving you overwhelmed and unable to meet the constant demands of work, home, and life in general.

Who’s at Risk?

No one is exempt; especially those in the healthcare profession.

Up to 60% of practicing physicians report symptoms of burnout,[3] with women physicians reporting rates 1.6 times higher than men.[4] Male physicians have historically committed suicide at twice the rate of average Americans—women physicians exceeding that by three to five times higher.[5] Insurers have seen disability claims by physicians climb by more than 60% since 1990,[6] and another study reports that up to 55% of 3400 Canadian physicians were in advanced stages of burnout.[7]

And it doesn’t wait for you to complete medical school or your internship. In 2009, 4% of entering medical residents were diagnosed with depression. While this is comparable to the general population, the diagnosis jumped to 25% by the end of their first year.[8] In a 2009 survey of all medical students attending seven U.S. medical schools (overall response rate, 2682/4400), 24% were emotionally exhausted, while 53% were ‘burned out.’[9] Another study showed a strong association between burnout and suicidal ideation with medical students.[10] Similar findings were also noted with primary care physicians.[3,11]

According to 85% of physicians, their family life suffers from the emotional demands of their profession and 30% would change their profession today if they could.[6] The Physicians’ Foundation surveyed more than 12,000 primary care physicians and found that 78% felt medicine is “no longer rewarding” or is “less rewarding” and 45% said they would retire if they could afford it.[12] If they were to begin their careers again, 30% to 50% said they would not attend medical school.[13]

Causes of Burnout

Along with significant innovations in diagnostic tools and treatment modalities, today’s medical practice is fraught with myriad factors contributing to burnout. A combination of professional stressors—including the challenges of balancing work and personal life, increasing workplace responsibilities with more limited resources, and complex relationships within the practice environment and with patients—can cause you to submerse yourself in work until you have nothing left to give.

The frustrations of too much time spent on paperwork, too little time spent with patients, the daily hassles with insurance companies over claims discrepancies, potential for litigation, and increased demands from the public are endemic to an increasingly pressured healthcare system. However, studies suggest that the single most important predictor of problems in resilience and accomplishment among physicians is their sense of lacking control over their schedule and hours they work.[14] In addition, the following individual factors are just a few of the key contributors to burnout:

Occupational: Explosion of new treatment options; expanding new patient care guidelines; relentless night shifts; long hours of work; excessive administrative tasks; malpractice risk/suits; concern over fraud and abuse; high patient volume; dealing with life-threatening conditions; dealing with patient suffering/death; lack of autonomy.

Organizational: Diminished resources or social support; lack of input or feedback; declining reimbursements; financial cuts/deficits; competition; Medicare/Medicaid audits; demands from insurance companies to cut costs.

Relational: Leadership/management; devaluation of doctor-patient relationship; being reduced to “servicing consumers”[15]; unrealistic patient expectations; marital problems; family stresses.

Personality: Locus of control—ie, feeling that events, luck, or someone else is responsible for what happens to you, eg, schedules or hours worked; dedicated; conscientious; responsible; motivated; idealist/perfectionist; compulsive.

Other contributors include the critical boss, the incurable client, and lack of recognition. Ambiguity can contribute too, whether due to lack of information, the absence of clear goals, or no-win situations featuring incompatible demands, and conflicts among values or roles.[16]

Symptoms of Burnout

The three classic components of burnout are emotional exhaustion, depersonalization, and low personal accomplishment.[17] These manifest in a variety of symptoms (see Box 1).

When clinicians become burned out, they often lose their empathy and depersonalize those they work with and their patients, even blaming their patients for being sick.[13] This burnout leads to poorer quality of care, patient dissatisfaction, increased medical errors, and then possible lawsuits.

Why Clinician Burnout Matters

The stress and dissatisfaction of modern-day medical practice has a high impact not only for you and your family, but also for your patients and patient outcomes, your employer, and the healthcare delivery system budget. One in six primary care doctors have left their field mid-career, with more than 20% stating long hours and administrative problems as the cause, according to the American College of Physicians and the American Board of Internal Medicine.[18] Estimated costs to replace primary care physicians leaving their practice are over $250,000 per physician.[3]

In addition to its personal toll, burnout in a clinician matters because of its strong negative effect on patients. In 1999, The Institute of Medicine reported between 48,000 and 98,000 Americans die each year due to preventable adverse events; fatigue and sleepiness are implicated as contributors to those medical errors.[1]

Beating burnout enables you to reconnect with compassion, which improves patient relationships. Studies have shown that improved rapport and relationships will lead to better patient compliance.[19] Compassion and good rapport don’t necessarily require much more time, either. In fact, 40 seconds of compassionate communication from a physician has been shown to reduce patient anxiety.[20]

How to Beat Burnout

Promoting your personal and professional well-being is the key to preventing burnout. Anderson Spickard of Vanderbilt University said it well, “Physicians must be guided from the earliest years of training to cultivate methods of personal renewal, emotional self-awareness, connection with social support systems, and a sense of mastery and meaning in their work. It is not incidental to medicine, but it is at the core of the deepest values of the profession to first, do no harm. Doing no harm begins with one’s self.”[21]

Winners of the American Medical Association Foundation’s Pride in the Professions Award shared their techniques for avoiding burnout. They stated that self-awareness, setting limits, spending time with their family and friends, getting physical exercise, cultivating relaxation, and humor can all balance burnout. Balance is the theme, and the challenge—and these winners feel it’s impossible without humor and laughter.[13] But this balance is not only your responsibility, you need the help of medical organizations, societies, and your workplace.[21, 22] Suggestions such as mentoring programs, voluntary support groups facilitated by outside professionals, membership to a fitness center, requirements that all clinicians have their own primary care physicians, flexible scheduling, continuing medical education programs on topics associated with your well-being, and paperwork reduction can all contribute to that balance.[21]

While prevention is definitely the best medicine, what can you do if you’re in the early stages of burnout? The good news is that recovery from burnout is possible. One aspect is the ‘Three R Approach’: recognize—watch for the warning signs; reverse—undo the damage done by managing your stress and seek support; and, resilience—build your resilience by taking care of yourself physically and emotionally.[23]

Physician, Heal Thyself

Perhaps the more difficult barrier to clinician recovery is resistance to admitting that a problem exists. One study showed about one-third of physicians do not have a personal physician from whom to seek care.[24] Many have a hard time asking for help, in part because of concerns related to the legal aspects of a diagnosis that implies mental illness. At last check, 80% of state medical boards ask about mental illness on applications and 47% on renewals.[25]

In addition to the discrimination with their medical licenses, for those clinicians who do seek help, they often are met with negative responses with medical privileges and professional advancement. So the treatment may readily be available for them, however, they are facing regulatory and workplace barriers that may dissuade them from getting the help they need.[22]

The cure for burnout is obviously not to fix the broken healthcare system or develop a serenely ideal practice. Although possible, these are unlikely to happen. A clinician can, however, seek to go from detached concern to engaged concern.[19]

Rachel Naomi Remen, MD, is a pioneer in avoiding burnout. She teaches courses at the UCSF School of Medicine, called “The Healer’s Art,” to medical students about how to offer stronger emotional support to their patients, colleagues, and themselves. She tells a story about a patient––her father––who was anxious and frightened awaiting surgery. The day before his procedure, he suddenly began to feel “really confident.” What changed? The surgeon had stopped by, introduced himself, grasped both of his patient’s hands in his own and asked, “Are you feeling strong?” Feeling his hands held that way, the patient nodded. “I am too,” the surgeon said, giving a squeeze. “I’ll see you tomorrow in the operating room.” The patient’s attitude was completely transformed in less than 50 seconds.[19]

By paying attention to your own needs, you can regain interest and compassion. This will help to reestablish personal connections with patients. And isn’t that the reason you went to medical school in the first place?

Resources

Burnout Self-Test–Check yourself for burnout
Bring Your Life Into Balance–Stress-busting, mood-boosting toolkit. Includes a step-by-step guide to the toolkit and short videos to help you with skill building.
Ideas for Managing Stress and Extinguishing Burnout–Written for physicians, contains eight tips for preventing burnout. (AAFP)
The Road to Resilience –Prevent burnout by building your resilience to stress and adversity. (APA)

Suggested Reading

• Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, Stress-Related Diseases and Coping by biologist Robert M. Sapolsky
• Kitchen Table Wisdom, Stories that Heal by Rachel Naomi Remen, MD
• The Medical Marriage: Sustaining Healthy Relationships for Physicians and Their Families by Wayne M. Sotile, PhD, and Mary O. Sotile
• Doctors’ Marriages: A Look at the Problems and Their Solutions by Michael F. Myers, MD
• Learned Optimism: How to Change Your Mind and Your Life by Martin Seligman, PhD
• I Don’t Want to Talk About It: Overcoming the Secret Legacy of Male Depression by Terrence Real
• The Successful Physician: A Productivity Handbook for Practitioners by Marshall Zaslove, MD

Published on February 22, 2011

References

1. West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-1300.
2. Maslach C, Leiter MP. The Truth About Burnout. San Francisco, CA: Jossey-Bass Inc., Publishers; 1997:17.
3. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293.
4. McMurray JE, Linzer M, Konrad TR, et al. The work lives of women physicians: results from the physician work life study. J Gen Intern Med. 2000;15:372-380.
5. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004;161:2295-2302.
6. Davis KG. Balancing act: preventing burnout. Fam Pract Manag. 2000:7(4). Web archive http://www.aafp.org/fpm/20000400/70prev.html.
7. Boudreau RA, Grieco RL, Cahoon SL, et al. The pandemic from within: two surveys of physician burnout in Canada. J Comm Ment Health. 2006;25(2):71-88.
8. Sen S, Kranzler HR, Krystal JH, et al. A prospective cohort study investigating factors associated with depression during medical internship. Arch Gen Psychiatry. 2010;67(6):557-565.
9. Dyrbye LN, Massie FS Jr, Eacher A, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA.2010;304(11):1173-1180.
10. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-341.
11. Linzer M, Manwell L, Williams E, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med. 2009;151(1):28-36.
12. Commins J. Unhappy docs provide roadmap for recuiting, retention. HealthLeadersMedia Web Site. http://www.healthleadersmedia.com/print/HR-224169/Unhappy-Docs-Provide-Roadmap-for-Recruiting-Retention. Published December 1, 2008. Accessed February 2, 2011.
13. Meldrum H. Exemplary physicians’ strategies for avoiding burnout. Health Care Manager. 2010;29(4):324-331.
14. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007;109(4):949-955.
15. Neuwirth Z. Reclaiming the lost meanings of medicine. Med J Austalia. 2002;176(2):77-79.
16. Potter B. Burnout situations. Overcoming Job Burnout: How to Renew Enthusiasm for Work. 3rd ed. Berkeley, CA: Ronin Publishing; 2005.
17. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
18. Bylsma WH, Arnold GK, Fortna GS, Lipner RS. Where have all the general internists gone? J Gen Intern Med. 2010;25(10):1020-1023.
19. Evans K. Finding meaning in medicine. Greater Good Science Center Web site. http://greatergood.berkeley.edu/article/item/finding_meaning_in_medicine. 2007. Accessed February 4, 2011.
20. Zeckhausen W. 8 ideas for managing stress and extinguishing burnout. Fam Pract Mgmt. 2002;9(4).
21. Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288(12):1447-1450.
22. Balch CM, Freischlag JA, Shanafelt TD. Stress and burnout among surgeons. Arch Surg. 2009;144(4):371-376.
23. Smith M, Jaffe-Gill E, Segal J, Segal R. Preventing burnout: signs, symptoms, causes, and coping strategies. HelpGuide.org Web site. http://www.helpguide.org/mental/burnout_signs_symptoms.htm. Updated November 2010. Accessed February 2, 2011.
24. Gross CP, Mead LA, Ford DE, Klag MJ. Physician, heal thyself? Regular source of care and use of preventive health services among physicians. Arch Intern Med. 2000;160(21):3209-3214.
25. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.