It's not the destination you thought you were headed for: so drained by the drive to learn, to qualify, to deliver care, you can’t summon up a drop of emotional energy. You can’t see the person in your patients, just the disease you’re supposed to ease. You look in the mirror, and see someone you secretly fear isn’t up to the job.
This is burnout, and it affects a shocking number of physicians and learners at some point in their careers. According to a poll conducted by the Canadian Medical Association in 2018, burnout is a serious problem in Canada:
Of the 2,547 physicians and 400 medical residents surveyed, 30% reported high levels of burnout, meaning they experienced symptoms of emotional exhaustion and depersonalization at least weekly. Thirty-four percent met criteria for depression. Nearly one in five reported having thoughts of suicide at some point in their lives; 8% thought about suicide in the past 12 months.
Medical residents, female physicians, and doctors in their first five years of practice reported the highest rates of burnout, depression and suicidal thoughts. However, these issues cut across the profession, with no significant differences in rates between regions or specialties.
Using the term burnout to mean a “state of mental and physical exhaustion caused by one's professional life,” was introduced by American psychologist Herbert Freudenberger in a 1974 article in the Journal of Social Issues. According to an article by Wolfgang Kaschka and colleagues Freudenberger’s initial research centred on workers in volunteer aid organizations such as free clinics and shelters, but has since been applied to a broad range of professions.
More recently, in May of 2019, the World Health Organization refined its 1994 definition of burnout. It now reads:
Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
- feelings of energy depletion or exhaustion;
- increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and
- reduced professional efficacy.
The standard definition of burnout used for physicians comes from Christina Maslach and Susan Jackson, creators of the Maslach Burnout Inventory. According to an article by Brian Lacy and Johanna Chan called “Physician Burnout: the Hidden Health Care Crisis,” Maslach and Jackson defined burnout as “a three-dimensional construct involving emotional exhaustion, depersonalization and reduced personal accomplishment.”
Lacy and Chan say emotional exhaustion leaves physicians feeling “overworked, overextended and may describe a sense of having nothing left to give.” It can rob them of their ability to show compassion. “Depersonalization” refers to physicians becoming unfeeling toward both patients and other health care workers and can lead to doctors behaving unprofessionally. Burnout undermines any sense of personal accomplishment, leaving physicians feeling “incompetent, inefficient and unable to complete tasks. Emotions that accompany burnout may include feeling a lack of control or a lack of satisfaction in their work.”
No single thing causes burnout, researchers agree. Rather, in face of a general lack of solid evidence, most attribute burnout to a combination of factors, some individual, many organizational. Alan Card is a psychologist in the University of California at San Diego’s School of Medicine, where he studies healthcare worker safety and wellbeing, among other topics. In an article titled “Physician Burnout: Resilience Training is Only Part of the Solution,” Card distinguishes between avoidable and unavoidable suffering. “Certain sources of psychological stress are an inherent part of a physician’s job,” he writes, noting that not all patients can be cured, difficult decisions have to be made and patients and families may blame physicians for unwelcome results. For those situations, a physician needs to develop resilience.
But some triggers for suffering are avoidable: “overwork and understaffing, a hostile work environment, unsafe working conditions and failure to provide the resources doctors need to provide safe care.” Those triggers are organizational.
In their article, Lacy and Chan say organizational root causes for burnout include issues around pay, the increased clerical burden caused by electronic medical records (we’ve talked about that in “Burnout at your fingertips”) and problems with system administration.
Lacy and Chan say the greatest individual factor in burnout (though clearly driven by organizations) is long working hours. They cite a study of almost 8,000 people by the American College of Surgeons, which found surgeons who worked fewer than 60 hours a week had a 30% burnout rate, those who worked 60 to 80 hours had a 44% burnout rate, while half of surgeons who worked more than 80 hours suffered burnout.
The next most common root cause of burnout, Lacy and Chan say, is “conflict between work and home, including…childcare issues, interruption in family activities, missed family meals and lack of time spent with a spouse or partner.” Burnout, they add, is more likely in two-career marriages, especially if the spouse is also a doctor, and highest of all when two surgeons are married to each other.
In an article on resident burnout, author Laura McCray and her colleagues say burnout among doctors is linked to absenteeism, high turnover and decreased job satisfaction. Half of residents who suffer from burnout meet the criteria for depression and 9% show at-risk alcohol use.
Difficult as burnout is for individuals, the potential impact on patient safety and quality of care is often what drives health care organizations to take notice. “Physicians who are burned out are more likely to have lower patient satisfaction scores,” Lacy and Chan say, as well as “an increased association with medical errors…[which are] associated with longer work hours, more time spent on call and more time in the operating room.” Patients and hospitals, then, are also hurt by burnout.
In his piece on resilience, Alan Card says “The routine working conditions for physicians and trainees would be considered unsafe, unprofessional and even illegal in other safety-critical industries.” That’s the result, he argues, of medicine’s long-standing culture “that pretends physicians are mythic beings who are, or at least should be, supernaturally resilient, infallible and omnipotent.” As a result, “those who seek help are at risk of being seen as weak and not up to the job.”
The paradox, of course, is that those who suffer burnout and don’t seek help may not, in fact, be “up to the job.” They are more likely to face personal crises — marriage and family breakdown, substance abuse and leaving the careers they’ve worked so hard for. Their physical health suffers too —an article in the journal Burnout Research says burned-out workers are more prone to heart disease, infections, musculoskeletal pain and depressive symptoms.
Inevitably, patients and the entire health care system suffer when their practitioners are worn down to the point of emotional crises and illness. Fortunately, there are ways to improve the situation for practitioners, their families and patients alike. We’ll look at them in a second article, Tackling burnout: Steps to rekindling your inner flame.