The modern healthcare environment has become an increasingly difficult place to work for physicians. While we enter medicine with the primary goal of helping others, most of us have either encountered some degree of burnout ourselves or seen colleagues, in clinics or hospital hallways or across conference room tables, show the heavy wear and weight of burnout. An epidemic even prior to COVID, with levels of burnout approaching and exceeding 50% prevalence across medical subspecialties, the depth and extent of the problem has only surged with the pandemic. And while the evidence mounts as to the impact of burnout on patient care and work productivity, physicians increasingly and intimately experience the personal drain on morale, relationships, family interactions, and future outlook.

Much has been written about system-based solutions to burnout. While undoubtedly these are crucial foundations for change, physicians can see the entrenched economic and administrative barriers to deep positive transformation, many laid bare by the COVID pandemic. Indeed, these systemic changes may take significant time and effort to institute as the business of healthcare reconciles itself with the values of the profession and the physicians who do the job on the frontline.  

As physicians, we can feel a tension between feeling like the reasons we’re unhappy are external and job-related, but also wanting to make personal changes to avoid or improve stress and burnout. Calls to heal the healers and improve wellness abound, but real support and solutions are elusive. Available articles and blogs citing work-life-balance, healthy living habits, and stress reduction as solutions can seem thin and vague, failing to appreciate the complexity of the problem and the real-life challenge of making deep changes. Medical schools and continuing medical education similarly rarely touch on these topics in depth.

At Resilience in Healthcare (RIH), we understand the need for practical and impactful approaches, combinations of frameworks and skills, that address the most challenging areas of our clinical lives. Dr. Christophe Gimmler, a former hospitalist and current outpatient internist who also works as a community psychotherapist, and Teja Patil who works both as a hospitalist and physician coach, have spent over five years at the intersection of clinical medicine, mental health, and education. RIH has developed a novel curriculum teaching cognitive, attentional, emotional, and relational skills which are foundational to preventing burnout and fostering well-being for physicians at every level. These skills enable physicians to manage daily stress and emotion, connect effectively with patients and colleagues, navigate conflict, access presence under pressure, and maintain ongoing intellectual curiosity and kindness in the midst of challenge.

In this article we will discuss the definition, causes, and symptoms of burnout, in addition to describing key solutions to this critical problem.

What is Physician Burnout?

The syndrome of burnout, initially framed and described by Christine Maslach, a social psychologist, in the 1970’s for research purposes, results from the chronic stress of emotionally intense work coupled with inadequate resources and is characterized by three cardinal issues: (1)

1. Emotional Exhaustion: a deep sense of depletion and pervasive lack of energy or attention to give to others. Thoughts like “I feel used up” may occur.

2. Depersonalization: A detached attitude wherein we may treat patients as objects, problems, or with distance and even callousness. Compassion fatigue sets in and whereas we used to move towards suffering in others to help, we start to move away to protect ourselves. A sense of “I don’t really care” or “ I wish this patient would get out of my office” might develop.

3. Reduced Sense of Personal Accomplishment: A sense of ineffectiveness that leads to feelings of helplessness, futility, and decreased self-esteem that can spill over from the work context to a more general life frame. Thoughts such as “What’s the point?” or “I’m terrible at this” may arise.

Does this sound familiar? In addition to Maslach’s three-part research framework, burnout in particular clinicians can present in various manners. Depending on individual patterns of coping with physician stress, burnout can look like depression, severe anxiety, chronic irritation or anger, addictive behaviors with drugs, food, or media, or withdrawn “checked out” presentations. These manifestations of burnout most often develop over a year or more, but can occur over shorter periods of months under severe or multiple stresses.

Many of the terms used for framing this problem, from “burnout” itself to “depression” can feel blaming, as if we have a personal weakness and are simply not “resilient” enough. At RIH, we recognize that physicians are innately resilient and that it’s rather the modern healthcare system which under-supports physicians while overworking them, not unlike the military or firefighters, which leads predictably to burnout: it is a collective problem, not an individual failing! (2)

Signs & Symptoms of Burnout in Healthcare

Given Maslach’s threefold framework for burnout alongside familiar syndromes involving depression, anxiety, anger, and addiction, the signs and symptoms of burnout may be predictable or familiar to you.

The Mayo Clinic offers the following screening questions to help spot burnout: (3)

• Have you become cynical or critical at work?

• Do you drag yourself to work and have trouble getting started?

• Have you become irritable or impatient with co-workers, customers or clients?

• Do you lack the energy to be consistently productive?

• Do you find it hard to concentrate?

• Do you lack satisfaction from your achievements?

• Do you feel disillusioned about your job?

• Are you using food, drugs or alcohol to feel better or to simply not feel?

• Have your sleep habits changed?

• Are you troubled by unexplained headaches, bowel problems, or other physical complaints?

In addition to the Mayo Clinic questionnaire which helps to self-identify signs of burnout, we can also identify signs of burnout in our colleagues. Common behavioral signs of burnout include: (4)

• Tendency to isolate (avoiding conversation, sharing, or socializing)

• Flat affect/ being withdrawn

• Poor judgment calls

• Procrastination

• Frustration (Easy to anger, disproportionate emotional outbursts to minor triggers)

• Substance abuse

• Skipping work

What Causes Physician Burnout?

One central challenge to addressing burnout is the diversity of its origins and the complexity of their interaction. A review of over 30 studies of top drivers of high burnout rates offers the full spectrum of critical factors. (5)

It can be helpful to orient towards three distinct domains under which these different causes fall, each of which highlights an important dimension of the problem.

Efficiency of Practice:  This domain relates to workplace systems, metrics, processes, practices within a healthcare organization that ideally promote quality care, patient safety, and effective workflow and include administrative support and leadership. Oft cited causes in this area include:

·       Increased Clinical Work Hours: patient volume, acuity, and complexity

·       Documentation/EHR (electronic health record) demands and constraints

·       Increased administrative duties: patient email/phone messages, forms (i.e. disability or home care), and insurance/billing

Workplace Culture: This category describes your insitution’s or group’s values and actions that promote self-care, personal and professional growth, communication, and compassion that clinicians then hold for themselves, their colleagues, and their patients. (6) Major areas of concern in this category include:

·       Decreased communication

·       Increased work environment conflict with colleagues and patients

·       Isolation and degraded sense of community

·       Lack of understanding support when errors occur

·       Work-life balance      

Individual Resilience: This component includes individual physicians’ attitudes, skills, and behaviors that support their wellbeing and resilience. It can be subdivided into intrapersonal skills (relating to one’s own wellbeing) and interpersonal skills which refer to relationships. (7) Frequent issues of concern here include:

·       Angry, demanding, or highly emotional patients and families

·       High levels of perceived stress and urgency throughout the work day

·       Clinical uncertainty and fear of making errors

·       Sense of loss of control (over external and internal factors) 

Importantly, these professional areas of challenge can easily be exacerbated by significant personal stressors such as marital conflict, financial pressure, or medical conditions.

Widespread Impacts

Beyond the pervasive burden of personal suffering, this table lists additional consequences of burnout on the individual physician, patient care, the larger healthcare system. (8)

Approaches to Prevent Burnout 

While Dr. Francis Peabody once stated that “the key to patient care is caring for the patient,” a quote we may have heard as medical students, an updated version of this for modern healthcare might be “the key to patient care is caring for the physician!” We are the essential contact point, resource, and bridge for care.

Systems-based improvements are critical to successful institutional change and major evolution of organization and leadership must proceed. At the same time, burnout is a deep and pervasive problem that needs to be engaged longitudinally by individual clinicians and our practice groups. The following seven approaches, addressing both individual and interpersonal skills as well as the culture of practice, amount to core competencies that all physicians and groups can learn and develop over time to prevent burnout and progressively create more flexibility, efficacy, and satisfaction in their professional lives. These are powerful skill sets that, however, require supportive facilitation to learn, cultivate, and implement.  

Strategies to Support Personal Resiliency

1. Meditation, Body-based Practice, and Self-Care

Healthy self-care habits- comprised of sleep hygiene, nutrition, and exercise- while seemingly the most basic, can be both the most challenging to institute and uphold as well as the most impactful. Beyond self-care, the underpinnings of resilience are daily practices that support our awareness of and connectivity to ourselves: They keep us centered in ourselves, particularly as patients and colleagues are continually pulling on our reserves of attention and energy. Meditative and somatic (body-based) practices gradually bring us into relaxed but alert states that can withstand challenging work situations. Meditation practice helps solidify attention, decrease distraction and reactivity, and support calm. Somatic practices- those in which we connect to sensate, physical experience- also aid us detaching from stressful thoughts and automatic behaviors, and find balance within our work day.

2. Establishing Healthy Professional Boundaries

Patient care can feel like a constant stream or questions, demands, and stresses. Patients and fellow clinicians can cross our boundaries in small ways (i.e. interrupt with a non-urgent question) or larger ways (i.e. demand a medication or diagnostic test, or comment on our appearance). We get precious little support in learning how to say “no” without feeling uncaring, selfish, or even mean. Being a team player can be overemphasized in medicine relative to intentionally supporting our sense of autonomy and managing our time and energy realistically. Many physicians can develop overly loose boundaries where we automatically accept or acquiesce to demands, leaving us vulnerable to overextension and exhaustion. Alternatively, some of us establish rigid boundaries where we consistently refuse, close down, or withdraw making it difficult to connect with and understand others. Learning to sense when our boundaries are being crossed and then developing approaches to consciously set boundaries that are adaptive and feel “right” to us can be enormously resourcing and empowering.

3. Mindful Regulation of Stress States

Our autonomic nervous system has evolved over millennia to rapidly detect and automatically respond to threats… like tigers and bears! But in the modern world, very few threats are as immediate and deadly as predators. The very unconscious processes that helped us survive in the jungles of the past can lead to disproportionate levels of ongoing stress or overwhelm, triggered by relatively minor disturbances (i.e. a rude comment or unreasonable demand). These same processes then prompt unconscious patterned reactions like angry criticism, anxious avoidance, submission, paralysis, or confused overwhelm. Understanding how these unconscious processes manifest in our own personal experience then allows us to detect them earlier, sooth and regulate our stress. This then creates space for us to intentionally choose more adaptive responses. This movement towards greater awareness of stress states and approaches to regulating them enables us to both feel less dysregulated (i.e. angry, anxious or overwhelmed) and feel more relaxed, connected, and flexible in our responses to work life, thereby keeping us in a more optimally adaptive and efficacious workflow.

4. Managing Strong Emotional Reactions 

The flow of our days can be significantly disturbed when we have strong emotional responses like anger, fear, and sadness which feel unpredictable, disproportionate, and uncontrollable. They arise in response to a broad array of challenging situations and people we encounter in our practice. The science of emotion can be an invaluable framework from which to see these “emotional episodes” as a sequence of triggering, emotional experience, and behavior. Using a tool known as the Emotional Episode Timeline, we can learn step-by-step: to discern our personal emotional sequencing, thereby opening up the possibilities of managing our triggers, understanding our unconscious emotional conditioning or programming, becoming more present and tolerant to emotional experience, and responding in manners that are more constructive and connecting and less destructive and distancing. As with stress states, these skills can radically change our experience of day-to-day emotional scenarios and lead to a sense of awareness, stability, choice, and agency.

5. Navigating Conflict with Patients and Colleagues

Physicians experience, more than anyone else, the heightened sense of conflict inherent in contemporary healthcare. The very definition of managed care includes the increased limitation (i.e. management) of resource as well as the resulting competition for time, personnel, appointments, hospital admissions, access to procedures/medications, and reimbursement to name a few. Without any training in how to approach conflict, we do the best we can, succeeding or failing largely in isolation, trying to get by without damaging relationships or ourselves. We often feel caught in the middle of competing patient, provider, and system personalities and agendas- somehow responsible for all of it. Most of us, when faced with conflict, fall into familiar, reactive coping patterns such as anger, criticism, avoidance, or submission.  Learning to frame conflict as an opportunity to choose and balance between three priorities- preserving the relationship, establishing our boundaries, and negotiating for change- can profoundly help us skillfully navigate conflict. Getting support in practicing each of these three paths paves the way for physicians to more consciously and confidently address conflict.

Strategies to Improve Workplace Culture

1. Enhance Community through Balint Groups

One of the most degraded core features of most fields of contemporary medicine involves our sense of community, of shared experience. The opportunity to meet, learn from one another, discuss cases, process challenging interactions, and share concerns or feelings has greatly diminished. Furthermore, when formal or informal group conversations do arise, they can move easily into toxic venting or judgmental second-guessing. Balint groups are structured group processes that have been shown to improve physician wellbeing by bringing providers together to focus on relationship-centered care. They are designed for physicians (and can include other healthcare professionals) to share personally or relationally challenging cases in a context where colleagues safely, intuitively, and collaboratively explore their perceptions and feelings about the case. This process promotes empathy, expands perspective, and deepens insight and self-awareness- all the while playing out within an evolving group cohesion that heightens group camaraderie.

2. Create a Culture of Support with Peer Counseling Skills

Physicians all have experiences at work that are upsetting, and, indeed, the nature of medicine is that it brings us into intimately contact with the suffering, death, disability, loss, and trauma of others. We may not feel that friends and family can fully understand us as physicians, or that we don’t want to burden them. The upset we feel rarely rises to the level of requiring professional counseling or therapy. At the same time, confiding in colleagues can lead to them trying to teach us, advise us, or fix our problem for us. This familiar style of feedback can leave us feeling unheard, unsupported and unsatisfied if not unsafe! Learning and practicing key skills, such as active and observational listening, reflecting, and open and honest questioning, can vastly expand our capacity to simply receive and support colleagues who are having difficulty, without the burden of feeling responsible or of having to fix them.

The Upshot

The trajectory of contemporary healthcare, with all of its advances in diagnostics, therapeutics, and economic efficiencies, is leading to the spreading prevalence of physician dissatisfaction and burnout. The COVID pandemic has added to this surge and exposed the vulnerabilities of the very providers who are charged with keeping people well and treating their illnesses. Systems-based problems combine with individual and medical cultural challenges to present a real threat to physician wellness. The trauma of the syndrome of burnout can present along a continuum of severity and in various forms such as depression, anxiety or overwhelming stress, addictive behaviors, pervasive anger, or withdrawn isolation. 

While most physicians both draw upon and develop formidable strengths and capacities throughout our training and early careers, modern healthcare has come to resemble military and first-responder professions which invite if not demand additional ongoing education and practice to prevent damaging stress and burnout. RIH can offer expert multi-dimensional support- synthesizing insightful wisdom from medicine, psychology, and education- to develop cognitive, attentional, emotional, and relational skillsets to prevent burnout and foster resiliency in your medical practice. In this way, rather than being progressively diminished, physicians can learn and grow in the face of the challenges of medicine, leading to greater presence, confidence, efficacy, and fulfillment over the spans of their careers.

References:

1. Maslach C, Leiter MP. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. San Francisco: Jossey-Bass; 1997.

2. West CP, Dyrbye LN, Sinsky C, Trockel M, Tutty M, Nedelec L, Carlasare LE, Shanafelt TD. Resilience and Burnout Among Physicians and the General US Working Population. JAMA Netw Open. 2020 Jul 1;3(7):e209385. doi: 10.1001/jamanetworkopen.2020.9385. PMID: 32614425; PMCID: PMC7333021.

3. Know the signs of job burnout. (2021). Retrieved 14 June 2021, from https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642

4. “Nurse Burnout: Everything You Need to Know about Nurse Burnout.” Nurse Burnout, Well-Being Index, www.mywellbeingindex.org/nurse-burnout.

5. Azam, Kamran, Anwar Khan, and Muhammad Toqeer Alam. "Causes and adverse impact of physician burnout: a systematic review." J Coll Physicians Surg Pak 27.8 (2017): 495-501.

6. “Physician Burnout.” Agency for Healthcare Research and Quality, July 2017, www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html.

7. Shanafelt TD, West C, Zhao C, et al. Relationship between increased personal well-being and enhanced empathy among internal medicine residents. J Gen Intern Med. 2005;20(7):559–564.

8. West, CP, Dyrbye, LN, Shanafelt, TD. (Mayo Clinic, Rochester, MN; and Stanford University Medical Center, Stanford, CA, USA). Physician burnout: contributors, consequences and solutions (Review). J Intern Med 2018; 283: 516– 529.