My interest in the topic of physician wellness dates to my residency. We were required to do a project, and I opted to survey my colleagues about their health habits and concerns. I was not surprised to find that residents were unable to commit to the health recommendations we give our patients. For example, only 25 percent of respondents met the American Heart Association recommendations for physical activity. Access to healthy meals was another concern. The response at the time was to point out that vending machines were available during overnight calls, not a good source for nutritious food. Thirty percent of my colleagues had been treated for depression in the preceding year. Others described feeling anxious, depressed even suicidal but did not have the time to seek care or did not feel comfortable asking for help. Fortunately, the conversation is evolving, and we are beginning to recognize the need to address physician wellness and the conditions that place us at risk for burnout. The pandemic has emphasized the urgent need to address these issues.
Historically, much of the discussion around burnout and physician wellness placed the onus on individual providers, advising resiliency training and mindfulness, among other approaches. However, the issue of burnout is not solely an individual problem but rather a systemic issue. There is a growing body of research and recognized institutional policies to support caregivers.
In their recent Lancet commentary, Drs. Linzer and Poplau discuss the challenges of burnout and moral injury (MI) among health care workers. Moral injury occurs when an individual feels constrained in pursuit of ethical care. It is the result of contradictions to our deeply held moral beliefs. As an example, understaffing limits the ability to offer high-quality care. Moral injury and burnout are highly correlated; both contribute to a provider’s intent to leave practice.
In their podcast Moral Matters, Dr. Wendy Dean and Dr. Simon Talbot explore moral injury through a variety of guest interviews covering topics from how metrics influence institutional priorities to a discussion on what leads people to speak up when faced with a moral challenge and personal stories from those on the frontlines of the pandemic. They offer a great avenue to further explore the issues leading to moral distress among health care providers.
Studies on stress and burnout find that chaotic work cultures, misalignment of personal values with organizational leadership, time pressures, and lack of control elevate the risk of burnout. Since the arrival of COVID-19, concerns around exposure to infection and the risk of spreading it to loved ones are added sources of stress. The pandemic has also emphasized the underlying disparities in health care access, a source of moral distress for many providers. The polarization and political divisiveness have further aggravated health care workers’ stress levels.
Research has uncovered important mitigating factors, including feeling valued by the organization and sharing a mission. However, it is not simply a matter of verbalizing appreciation; the staff must feel heard. If they are left without the needed support to do the work, then people do not feel valued. Organizations must respond in concrete ways to demonstrate their appreciation for their workers, asking, “How can we help? What do you need?” Then, there must be follow-through to mitigate stressors. Maintaining the staff’s trust should be an essential priority; once lost, it is very hard to regain.
Organizations have struggled to respond to these challenges, often resulting in high turnover and the associated expenses of replacing staff. Moving forward will require a partnership between providers and executive leadership. Recommendations include making burnout and moral injury organizational priorities with regular assessments to identify the levels of burnout/MI among medical staff. Mental health support and suicide prevention should be offered, assuring staff that help is available and removing the stigma of asking for help. Other suggestions emphasize providing time for meaningful clinician-patient engagement, workload assessment, enhanced efficiency, flexible scheduling to improve work-life balance, and a supportive, compassionate organizational culture. These approaches offer a wise investment in sustaining our health care workforce for the future.
Aldebra Schroll is a family physician.
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