A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
The World Health Organization defines burnout in its International Classification of Diseases as chronic workplace stress that has not been adequately managed, resulting in depletion, mental distancing from one’s job, and reduced efficacy. Physician burnout rates were already high prior to the COVID-19 pandemic, and since then have reached alarming new highs. A Medscape report highlighted a study, conducted prior to the pandemic, from a Mayo Clinic journal, which showed that 46 percent of respondents in the U.S. had at least one symptom of burnout – that percentage has escalated to 60 to 80 percent today. Though burnout has made its mark across all specialties, it has deeply charred anesthesiologists and others on the intensive care team, who make life-and-death decisions every day, often in very difficult emergency situations and for long shifts at a time.
While the pandemic has increased stress in everyone’s lives, physicians by virtue of their work are exposed to a plethora of emotions, including the need to rescue the patient, a sense of failure and frustration when a patient’s illness progresses, feelings of powerlessness against illness and its associated losses and grief, and becoming emotionally involved in a patient’s struggle, all while juggling our own everyday stresses associated with family life, children and personal relationships. On top of that, serving on the front lines of the pandemic added several new challenges and unrelenting pressures. Being forced to triage dying patients, separate loved ones in their final moments, and deciding which patients get life-saving medications has taken a physical and emotional toll. Burnout rates are higher among women in health care, especially those who are married with children, but are less among those whose spouse can support them with child care.
The strategies physicians have used in the past to manage burnout and fortify ourselves, such as turning to family, friends, social and institutional support, were suddenly taken away by the pandemic. Moreover, as the pandemic continues, public adulation of health care workers has waned and been replaced by frustration with the health care system. Social and conventional media outlets spewing misinformation, often politically motivated, has led to public anger and attacks against physicians who were once hailed as health care heroes. Nurses in scrubs have been physically attacked in public places. Some medical centers have even started providing panic buttons to their physicians. Anti-vaccination propaganda has taken a firm foothold leading to a protracted pandemic. It is difficult enough for physicians to help people with life-threatening illnesses. Doing so while fighting misinformation, prejudice, and distrust has caused many to leave the workforce. A study found that 50 percent of physicians in the U.S. and across Europe have decided to reduce their working hours after the pandemic.
Not only does burnout decrease professional efficacy and in turn, patient satisfaction, but it is also deleterious to the physician. A study on burnout syndrome and wellbeing in anesthesiologists found that burnout causes many consequences, including sleep disorders, lack of sleep due to increased working hours, increased cardiovascular risk, diabetes, obesity, acceleration of the rate of biological aging, alcoholism, drug addiction, and suicide ideation. All too often we see signs of anxiety, depression, a personal sense of failure, and other mental health issues as a result of protracted burnout.
So, what can be done?
In general, four levels of change are recommended to reduce the risk of physician burnout:
1. Modify organizational structure and work processes. One study suggested that training medical assistants and physician assistants to do history taking, medication reconciliation, vaccination administration, and visit scheduling, while allowing physicians to do physical exams and medical decision-making, resulted in a drop in the burnout rate from 53 percent to 13 percent. Changes to policies and practices with the aim of improving teamwork, as opposed to practices with increased clinical burden on physicians, as well as new approaches to work evaluation and increased supervisory work are also useful techniques. This way, physicians may feel a reduction in job demand and gain more job control.
2. Mindfulness, physical and cognitive techniques to improve physician wellbeing. Professional development programs and continuing medical education can help physicians better adapt to the changing work environment. Hiring enough personnel so that no one is too burdened is crucial at the practice level, and providing wellness checks, mindfulness, and cognitive-behavioral techniques can be beneficial at an individual level.
3. Better workplace support and the two-edged sword called electronic medical records (EMR). Modifying call schedules and providing appropriate financial incentives tailored to physicians’ personal lives, such as increased pay for additional and holiday calls, subsidized childcare, and the ability to opt-out of calls for decreased pay, can decrease emotional exhaustion and improve personal satisfaction. Additionally, peer support in developing resilience techniques (such as workplace social interactions, team building activities, and celebrations) has been shown to increase workplace satisfaction, even with a challenging work schedule.
EMR records were developed to streamline health care services. But many physicians are finishing a long grueling day at work only to go home and finish working on patient letters and records for several additional hours. Dedicated time during work hours to manage records and EMR can contribute to improved physician satisfaction.
4. Streamline regulatory paperwork. Physicians spend quality time on paperwork for quality programs initiated by Medicare, Medicaid, and private insurance companies. Such programs cause burnout by preventing physicians from spending time with their patients. As per a Mayo Clinic study, U.S. physicians spend an average of 2.6 hours per week complying with external quality measures. This is enough time to see approximately nine additional patients in an outpatient setting. The duplication in paperwork leads to frustration and burnout.
Patients can contribute to the solution, too!
It seems almost superfluous to say, but patients must also be patient. If the physician does not get to a patient at a certain time, he or she might be dealing with another patient of greater complexity. Communicating effectively helps improve patient understanding, satisfaction, and the physician-patient relationship, which helps to reduce emotional exhaustion for the physician.
Patients can also prepare questions prior to a visit so that they don’t have to spend as much time following up with the provider afterward. The fewer emails and phone calls a provider has coming in, the more quickly they’re able to respond, which creates less frustration and stress. Additionally, encouraging patients to arrive at their appointments on time creates a smoother workflow.
Advocating for physician wellbeing
The American Society of Anesthesiologists (ASA) has developed a suite of resources to support physician wellbeing.
Ultimately, patients need doctors to help them be healthy, and need their doctors to be healthy to help them! Unless interventions are done now, our health care system risks a downward spiral. While the pandemic has brought increased levels of stress and burnout, it has prompted us to take action on mitigating this serious issue. Hospitals, practices, administrators, and physicians must realize that working together to combat burnout is essential for the health of our entire health care system.
Lalitha Sundararaman is an anesthesiologist.
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