When I was an intern on the cardiology service, I rarely left before 10 p.m. Call days were longer. One day in the workroom, I noticed my co-intern sniffling as she typed progress notes. Her eyes were red. “Are you OK?” I asked.
She said, “I just cried in the bathroom for about ten minutes. It’s nothing bad; it’s just … I’m so tired. Do you ever feel so tired you just break down? I feel better now, don’t worry.”
All of us have a vague sense of what someone who is “burned out” looks like. Burnout manifests in many different ways: insomnia and nightmares about providing inadequate care, anger at a patient for not getting better, arguing over small details with other staff and, sometimes, crying out of sheer exhaustion in the bathroom. But there is a frustrating lack of specificity in defining burnout, despite widespread recognition that burnout contributes to higher rates of physician attrition, mental health issues and even suicide.
What is burnout? Is it a medical condition? It has an ICD-10 code: Z73.0. A social phenomenon? In 1974, Freudenberger described “burn-out” as more likely in people with certain attributes (“the dedicated and the committed”) in certain work environments. A personal failing? It has been written that burnout is merely a “ status symbol” of industrialized societies, the neurasthenia of the 21st century. Some complain that it is an invention of over-sensitive millennials who don’t understand what hard work is.
Classifying burnout matters because it determines how we can best approach it. If burnout is a medical condition, it can be treated. If burnout is a social phenomenon, it requires a social intervention. If burnout is a personal failing, well, then perhaps we need to take a good, hard look at ourselves. Even the literature on burnout is not consistently clear on what it is. There is a disturbing overlap with depression and anxiety, which are the proverbial elephants in the room. Are burnout and depression on the same spectrum? It is not clear. What is clear is that telling people who are burned out and depressed to “just stop being sad” and “when I was in training, we didn’t complain” is not helpful.
Resilience is often touted as a solution. It has even been suggested that resilience is an emotional competence that should be taught in medical school. But most of us learned perseverance, self-improvement, and coping through difficult experiences, not in the classroom. It is foolhardy to think that a lecture series on resilience will translate well. Instead, students who are already conditioned to never show weakness will hear the implicit message that gaining resilience is a matter of personal effort, and that if they struggle, it is their personal failure.
What of mindfulness? Mindfulness has been shown to improve focus, calmness, and memory over the long run — characteristics of productive, complacent employees. But non-judgment does not promote critical thinking skills. Emotion regulation is not an exercise in compassion, but rather, in emotional coolness. Awareness is not enough for physicians who want to fight back against the injustices their patients face. Mindfulness can be a useful tool in the toolbox of self-care. It is a great response to an acute stressor and can bring temporary relief in a hectic day. What it won’t do is take away the foundational problems in health care.
Is there anything that can heal burnout? Human connection. Returning to that day on the cardiology service, when one of the senior residents overheard my co-intern and I whispering, she spun around in her chair and turned to face the six other residents and interns in the room. “OK, who has not cried this month? Raise your hand.” No one raised their hand. Then, we started to laugh. We opened up about how we were coping and the sick patients that we had. That month on the cardiology service was among the most challenging of my residency, but moments like those made it bearable.
Physicians are most at risk for burnout if they feel like they are the only one experiencing it. How can physicians spend more time building relationships with their patients, supporting each other, engaging each other in their work and sharing their successes and venting frustrations that might otherwise be internalized?
Deliberate action from administrators, politicians, health care providers and patient advocates at the institutional and national level are required to address burnout. A recent NEJM Catalyst survey shows that although 98 percent of health care executives perceive physician burnout to be a moderate or serious problem, many are quoted as saying that their organizations are not doing much to address it. One bluntly describes it as “lip service.”
The four biggest perceived causes of burnout in this survey were increased documentation, increased work productivity expectations, payment/reimbursement and the “erosion of professionalism.” If stakeholders in health care want to make a real commitment to improving physicians’ work and reducing burnout, then they should focus on:
- Reducing the burden of documentation in EHRs and increasing cross-system accessibility
- Recruiting physicians of diverse backgrounds to institutional leadership
- Enforcing anti-discrimination policies and taking reports of sexual harassment seriously
- Making medicine family-friendly by supporting maternity/parental leave and subsidizing child care
- Reducing the costs of board certification and test-taking burden
- Improving health care team safety through violence prevention programs
There are definitely more action points that could be listed. We don’t have to agree on all or any of these. The conversations about these goals should take place in individual institutions as well as the national level and would ideally include physicians at all levels of training.
Being mindful of burnout is not the answer. Taking action to more clearly define it, having honest conversations about personal versions of burnout, and setting tangible goals to strengthen a sense of community and sustainable work environments will allow us to extinguish burnout for good.
Joy Liu is an internal medicine resident who blogs at the Friendly Intern.
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