Four hundred physicians in the US take their own lives every year, a rate twice the general population. About half the physician population is experiencing burnout per available data. Burnout is defined as work-related emotional exhaustion, depersonalization, and a sense of diminished accomplishment. The issue is not limited to physicians in the US. When I talk to my physician friends in India and in other countries, it’s obvious they have high levels of burnout as well. Wellbeing goes well beyond absence of burnout, and recent initiatives at national and organizational levels are steps in the right direction. Last week, the National Academy of Medicine released a discussion paper: Burnout Among Health Care Professionals A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. The paper highlights the extent of burnout among physicians, nurses and other healthcare professionals (high levels), why we should be concerned (for patients – medical errors, healthcare associated infections, dissatisfaction, higher mortality; for healthcare professionals – lower perceived interpersonal teamwork, higher rates of depression, substance abuse and suicide; for organizations – greater costs of care, lower quality and safety and lower patient satisfaction), factors driving the burnout, and what research and interventions are needed to address the issue.
There are some unique issues in academic medicine as I see them. This is a summary of my experiences and those of my friends with whom I have had some deep conversations.
Threats to one’s wellbeing/ factors contributing to burnout:
1. Unrealistic expectations of oneself and/ or the work environment. Aspiring to be a triple threat or a quadruple threat is old school and harmful to an academic physician’s mental health.
2. Not enough conversations in the work environment about values – what it means to be a clinician, an educator, a researcher, or a physician leader/ administrator in current times.
3. Inadequate role modeling of work-life integration. You really can’t avoid making a personal phone call during work hours or avoid reviewing draft manuscripts while getting a pedicure, for example. Unhealthy competition and unnecessary comparisons between colleagues is a major factor here.
4. Documentation needs, regulatory and compliance needs, misguided financial policies and directives, and not having enough control over these external drivers of healthcare.
5. Discomfort with women, minorities, immigrants – these issues are mostly subtle, but they tend to become cumulative over time. Faculty physicians who face issues that relatively few people face (e.g., having a child with a rare disease, infertility) may feel isolated in the larger social environment at work. Overt discrimination is rare, but it happens.
6. Not having enough social time at work, which prevents one from building key relationships
7. Bullies, manipulators, mansplainers, bigots, and perpetual sympathy-seekers. Thankfully, these individuals comprise a very small proportion, but they can create toxicity in the work environment.
8. Being at the sharp end of patient frustration when the physician has little control over the factors causing the individual patient’s dissatisfaction.
These are some of the things that have worked for me and some of my friends and colleagues who have managed to feel well and stay productive despite threats above.
1. Self-monitoring and acting towards wellness so that one can take better care of others – ‘putting oxygen on yourself first before putting oxygen on others around you’.
2. Focusing on work-life integration. People who model good work-life integration don’t apologize for eating breakfast or glorify being too busy to eat breakfast.
3. Standing up to or walking away from bad behaviors (including gossip, unhealthy competition), setting boundaries, having a sense for what’s within control and what’s not within control, and working through issues
4. Taking care of one’s health – all aspects – spiritual, physical, emotional, cognitive and social
5. Prioritizing (it’s true what they say that no one has a thousand things to do. Everyone has only two things to do – make a list of priorities, and do the next most important thing on the list).
6. Maintaining social relationships one can count on.
7. Having a good sense for what is worthwhile and meaningful at work, and playing to one’s strengths and natural inclinations.
8. As the last resort, moving to a new work environment and starting all over.
For obvious reasons, having a healthy lifestyle at an individual physician-level is necessary but not sufficient. The November 5, 2016 issue of Lancet featured physician burnout as its major theme. Colin P. West and colleagues conducted a systematic literature review and found that interventions to reduce burnout resulted in reduction of overall burnout from 54% to 44%, high emotional exhaustion from 38% to 24%, and high depersonalization from 38% to 34% among participating physicians. Both individual-focused and structural or organizational strategies can result in clinically meaningful reductions in burnout among physicians. They concluded that further research is needed to establish which interventions are most eﬀective in speciﬁc populations, as well as how individual and organizational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions. The editorial for this paper notes that we cannot risk taking a dichotomous approach – an individual and a systems approach, as there may be institutional practices that can predispose to physician burnout. For example, large organizations have anti-bullying policies in place. All programs to reduce burnout share the initial step of enhancement of awareness. Ronald M Epstein and Michael R Privitera in their commentary note that burnout is not an acute self-limited illness and it has an uncertain prognosis. They note that although physicians tend to name external causes like productivity pressures and loss of control, psychological factors need to be given adequate attention. Most importantly, they say we should not wait for perfect understanding before acting because too much is at stake.
Phyllis Marie Jensen and colleagues in their paper on building physician resilience identified four main aspects of physician resilience: 1) attitudes and perspectives, which include valuing the physician role, maintaining interest, developing self-awareness, and accepting personal limitations; 2) balance and prioritization, which include setting limits, taking effective approaches to continuing professional development, and honoring the self; 3) practice management style, which includes sound business management, having good staff, and using effective practice arrangements; and 4) supportive relations, which include positive personal relationships, effective professional relationships, and good communication.
I’ll conclude my summary of the topic by saying that a question that I started asking my team at the beginning of rounds was very well received. “How are you doing on your wellness score today? What have you done in the last 24 hours for your wellness?” One fellow said she now lists ‘something for my wellness’ on her to-do list for the day. Healthcare organizations are on the hook for addressing this burning platform issue!
Here are some helpful links and articles:
4. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Colin P West, Liselotte N Dyrbye, Patricia J Erwin, and Tait D Shanafelt. Lancet 2016; 388: 2272–81.
5. Jensen P et al. Building physician resilience. http://europepmc.org/articles/PMC2377221/