Fifteen Eighty Four

Physicians and other healthcare professionals are facing unprecedented challenges. One of the most critical and potentially devastating challenges is the threat of burnout. That threat has been growing for decades, and the pandemic has significantly intensified it. Burned- out physicians are at risk to themselves and to their patients. Again, the risks apply not just to physicians but other healthcare providers as well.

The following questions are addressed in detail in our book. What is the syndrome of burnout and what is the role of stress in triggering burnout? What are the effects of burnout? Why are physician and other healthcare providers especially at risk? What is the connection between burnout and error? Critically, what can the physician do to reduce the risk of burnout?

First, the syndrome. The World Health Organization defines burnout as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”. Note that stress is the culprit. When the stress is excessive, ongoing, and unmanaged, the individual will eventually show the three defining facets of the syndrome. They will experience complete physical and mental exhaustion. (“I am so wiped out I am barely making it through the day”). They will experience cynicism and depersonalization. (“I just don’t care anymore… it doesn’t mean anything to me”). They will experience a sense of reduced effectiveness. (“I am not making a difference at all”).

The role of stress. A physiological reaction kicks in when we are confronted with a potentially threatening situation that challenges our ability to cope. Known as the “General Adaptation Syndrome”, the internal reaction automatically prepares us for fight or flight. In the short term, the internal activation is exquisitely adaptive. But if the internal reaction is ongoing, the risk is physical breakdown (cardiovascular event, ulcers, migraines) and mental distress (burnout).

Why are doctors and other healthcare workers especially at risk? Two of the main predictors of excessive ongoing stress leading to burnout are high workload and low autonomy, i.e., ability to manage and control the workload. Even before the pandemic an array of factors conspired to make the physician’s job more stressful. The pandemic multiplied those risk factors. Whether one was working on the front lines (e.g., in the ICU) or watching one’s practice languish (e.g., for some private practices), or both (e.g., a primary care doctor working locum tenens), the stress level soared, and so did the risk of burnout.

The syndrome of burnout has a number of negative consequences. One of the main ones, which inspired us to research and write on the topic in the first place, is error. When people are experiencing burnout, they find it harder to concentrate, miss steps, and make more mistakes. When a physician, nurse, or pharmacist makes an error of commission or omission, the consequence of that error can be catastrophic to their patient. Burnout increases the odds of a misdiagnosis, incorrect procedure, wrong patient, wrong site surgery, wrong medication… and on and on. Some years ago, researchers identified the operating room as one of a group of organizational settings identified collectively as High Reliability Organizations (HROs). Such organizations, which include the airlines and nuclear power operations, require high levels of training, certification, and ongoing retraining for their operators. Another critical common denominator of HROs is that the consequences of an error can be catastrophic, even fatal. In recent years we have recognized that is it not just the surgeon in the OR that is of concern. Anyone in the chain of healthcare providers, from primary care physician to nurse to physicians assistant to pharmacist can make mistakes that are potentially devastating to their patients, and again, burnout increases the risks. Critically, data on the extent of burnout among all of the medical professionals in the chain of patient care yield very similar statistics. Essentially all healthcare workers are at high risk for burnout and for the increased incidence of errors as a result.

So, what is a physician to do? The bulk of our book is devoted to evidence-based strategies which we call “solutions” to address the crisis and save the physician who is burned out or on the verge of burnout.

First, physician know thyself. Some personalities are more stress-prone than others (e.g., high Neuroticism, external locus of control, Type A) and those most at risk due to their genetics need to pay special attention to all the strategies we inventory in the book.

Second, practice healthy self-care. In our book, we tie this solution to a closely related one, namely “follow your own advice”. Our point is, physicians know the importance of rest, healthy diet, and exercise, and they invariably advise their patients to practice these lifestyle strategies. They also tell their patients to avoid tobacco, limit alcohol consumption, and in general stay away from practices known to impair health. They advise their patients to talk it out with family and friends, and not to go it alone. They encourage relaxation and restorative techniques such as meditation and yoga. The problem is, by their own acknowledgement in survey after survey, many doctors themselves completely violate the health-promoting/ stress-reducing strategies they preach so well, and in many cases do just the opposite. They push on.

Third, use the resources of the team. The more that team members working collaboratively towards common goals look our for each other as well as themselves, the better off each team member is. The team provides a natural setting for social support. Talking it out with trusted teammates can be as effective as talking it out with family and friends. Remember, social support is one of the most effective means of reducing stress. Plus, teammates can provide more than just emotional support. They may be uniquely positioned to offer actionable counsel, and even to reduce some of the stress-inducing workload on the individual.

Fourth, physicians can often, at least to some extent, rethink and re-engineer the workflows in their work setting. Industrial-Organizational psychologists help organizations streamline and simplify their processes. They can also help doctors reassess the step-by-step processes they follow in their practices, identifying and eliminating duplicated efforts, non-value-added steps, pinch points, and unnecessary or bad handoffs. In the same spirit that process improvement strategies such as just-in-time inventory management have helped manufacturing companies improve quality and productivity and reduce costs, so can the same strategies of reducing or eliminating unnecessary steps and straight-lining work be implemented in the healthcare setting.

Similarly, doctors can look to alternative systems to the prevailing volume-based, fee-for-service model which is predominant in their enterprise. That most common business model requires that doctors see more patients to maintain their income, which means less and less clinical time with each patient, in a vicious cycle.

More broadly, doctors can lobby through their professional associations, up to and including the American Medical Association, for the reduction of burdensome regulations. As one prominent example, the requirement of electronic health records, while no doubt well-intentioned, has imposed a tremendous administrative burden on doctors.

The bottom line? Doctors and other healthcare providers should recognize that their work exposes them to high levels of stress and risk for burnout. They should implement proven stress-reduction strategies that strengthen the body and mind to tolerate stress without breakdown. They should use social support to talk it out, decompress, and get others’ perspectives. They should use the resources of the team. They should re-engineer their work situation to the extent they can, and actively support policy changes that can reduce their workload.  

Title: The Burned Out Physician

Authors: John E. Kello and Joseph A. Allen

ISBN: PB – 9781009055918, HB – 9781316511466