Burned Out: Experts Recommend Institutional Interventions, Community Understanding to Increase Physician Well-being

NEW ORLEANS, LA—Electronic health records, pressure to see more patients, fewer opportunities for collegial interaction: all of these modern challenges are pushing more and more physicians to question their choice of career, succumb to depression, and—in the worst of cases—take their own lives. Now is the time, say a growing number of professionals, to take active steps to combat burnout.

Burnout, the umbrella term for a wide variety of symptoms that can affect physician well-being, needs to be addressed not only at the individual level but also by institutions, according to experts speaking at a forum dedicated to the topic last week at the American College of Cardiology (ACC) 2019 Scientific Session.

“On a societal level, folks look at us as physicians and believe we have a recipe for great personal and professional satisfaction. [We’re] highly educated, universally employed, well compensated relative to most professions, [and] engage in the work people believe is important, caring for our fellow human beings who are ill,” said Tait Shanafelt, MD (Stanford Medicine WellMD, Palo Alto, CA), who gave the 50th annual Louis F. Bishop Keynote address. “And yet, what our own medical literature has been chronicling over the last two decades is a different story about the experience of life as a physician—speaking to stress, anxiety, burnout, depression, suicide in physicians—illustrating the day-to-day experience of many physicians doesn't match that external perception.”

Speaking to TCTMD, James Januzzi Jr, MD (Massachusetts General Hospital, Boston), who co-chaired the “intensive” session, explained that the ACC orchestrated it as part of the organization’s focus on physician wellness within its strategic plan. “This intensive is emblematic of the commitment of the College to membership wellness,” he said. “It's important to emphasize that using the term ‘burnout’ is somewhat pejorative. Although it's widely used to describe what physicians and other caregivers are feeling these days, to a large extent, what many feel is important is to acknowledge that the goal here is for wellness, whether it's related to institutional changes or individual changes, rather than putting the negative term on the individual.”

The ‘Occupational Syndrome’

Shanafelt, a hematologist/oncologist and a renowned expert in physician wellness who was hired as his institution’s chief wellness officer in 2017, explained that burnout is not a mental health issue, but rather an “occupational syndrome” comprised of three elements: depersonalization, emotional exhaustion, and low personal accomplishment.

“Depersonalization is that cynicism or sense that the system is working against you providing the care for a patient that they need. It's that moral dimension of a suboptimal system,” he said. “The exhaustion, losing your enthusiasm for your work, [and] low personal accomplishment give you a sense that you're not making a difference. And it doesn't matter whether that perception is accurate or not.

“If you start to feel you're no longer making a difference, even if your colleagues would all tell you you're having just as big of an impact, you're just as effective and compassionate a cardiologist as you've always been, your perception changes—your relationship attitude and the energy with which you approach your work,” he continued. “We all have these feelings to some frequency and some severity. When they begin to come too often and to too severe an extent, they undermine our effectiveness in work.”

Showing research studies of burnout among physicians, Shanafelt said that different specialties are more at risk. “In general, cardiology runs in the middle,” he reported. However, “every specialty has a profile of what part of the work creates the challenge and what types of stress they experience. What an emergency medicine physician needs is very different than what the neurosurgeon wants. This is why we all have to understand the unique challenges of our specialty so that we can come up with that approach to prevent these measures of distress.”

It is important to note that burnout typically peaks 10 to 20 years into a career as a physician, said Shanafelt. This is “probably in part due to the notion that as you master things, they can become mundane and you can lose the sense that you're being challenged at work,” he said. “What it was that was very inspiring to me was the first 10 years in your career likely won't see you through for the full arc of your career. You need to take on new challenges, whether it's learning a new skill [or] moving into leadership, different teaching role, different quality role.”

The main reason why all of this is so important, and why all physicians should care about fixing issues surrounding burnout, relates to physician suicide, he argued. Different studies have shown that the risk of death by suicide for male physicians relative to white-collar male professionals in other fields is 50% higher, and for women, that figure can range from 200% to 300%. “We’ve shown in multiple studies there's a dose-response relationship independent of depression between burnout and suicidal thoughts and we've also shown reversibility,” Shanafelt said, noting that “there are multiple occupational risks for suicide independent of depression in physicians.”

Wellness, Not Personal Resilience

While there no one single solution to solve the burnout problem, he recommends that institutions look at systematic fixes.

“As we’re moving faster, as we're spending our time documenting [electronic health records], never take breaks, you work late, you're in your office doing your documentation, you think twice about asking a colleague to review an interesting or challenging because you they're going home late, the fabric of our profession has been frayed,” said Shanafelt. “This has always been demanding and emotional work, and one of the things that always saw us through were the people sitting to your left and right. As we interact with each other less due to these many forces and we become more isolated, it increases this.”

He talked about several interventions he conducted at his institution in which they ultimately increased the amount of time physicians spent together, whether in conference room meetings or out to dinner paid by the institution, and all of them seemed to decrease physician burnout in the long run. “You having dinner with some colleagues tonight who you see every time you come to a national meeting is the perfect example of this same phenomenon,” Shanafelt said.

Additionally, the mistake that hospitals often make is equating wellness with personal resilience (ie, healthy food in the cafeteria and a culture where everybody exercises), he said. “The bull’s-eye is not eradication of burnout, it's something far more aspirational of creating practice environments that promote high professional fulfillment.”

A culture of wellness is defined by the behaviors and attitudes of hospital leaders and the values of the organization and whether these are aligned more with what the professionals want or the bottom line, Shanafelt said. Hospital administrators need to think about these questions: “How do we support each other? How do we communicate appreciation? What's the flexibility we give our people? What's the voice in decision making we give our people?”

Interventions work, he concluded. “Personal and system interventions are complementary, and we should do both. As we think about embarking on this as an organization, and how and where do we start, I think emphasizing we're all in different places on this road. We have a problem, it matters for our people and our patients, there is a road map to making progress at the organization level. We need to use that data and continue to expand it to make progress.”

Audience member Michael Mansour, MD (Delta Regional Medical Center, Greenville, MS), recommended one course of action toward fixing part of issue. Some states require physicians reapplying for licensure to answer questions about medications they’ve taken or illnesses they’ve been treated for, he said.

Putting aside that this line of questioning goes against the Americans With Disabilities Act, Mansour said what happens is “if physicians know they have to answer that question, they're going to be more hesitant to get the medical help [if they are suffering from] depression—postpartum depression or just depression in general. So I would really encourage you to take this information back and partner with your state medical societies and make sure this is not a limitation to your licensure board that would discourage people from seeking that care.”

Personal Stories

Following Shanafelt’s address, several panel members at different stages of their career told personal stories of how burnout has affected their personal and professional lives.

Claire Duvernoy, MD (VA Ann Arbor Healthcare System, MI), who talked about how she took several months away from work last summer to tend to family, reflected that she was “lucky” to be able to do so.

“I think I struggled a lot with guilt while I was coming to the decision that I needed to do this, like I couldn't let down my colleagues. That was a really big deal for me,” she said. “And being gone for that time and being able to step away, even though I got messages from them saying, ‘Oh, we miss you so much,’ and especially from the fellows that they missed me, which was great actually. It allowed me to come back and have a little bit of distance and not take everything so personally.”

Duvernoy said she also was able to realize that here colleagues were “going to be just fine even if I'm not there. So it’s okay for me to go home, it's okay for me to let go, it’s okay for me to not take it all on my shoulders. I think that was probably the biggest lesson that being away taught me.”

Additionally, Anthony N. DeMaria, MD (University of California, San Diego), reflected that “for those of us who have been in the profession for a long time, oftentimes our colleagues are more forgiving and give us a certain amount of, I don't know if reverence is the right word.”

Still, more-senior cardiologists often feel “the guilt of slowing down and not carrying your load,” he said. “Also the fact that if you want to stay active, you don’t want your colleagues to think of you as an old person. . . . You want to avoid that, so it does put some stress on you.”

On the other side of the spectrum, trainees often face remarks about the seeming impossibility of them facing burnout in the current era of workweek hour restrictions, said panelist and fellow Emily Lau, MD (Massachusetts General Hospital, Boston). “More senior physicians will say, ‘Yes, but we didn't have these work restrictions, so what can you possibly be burned out about?’” she said.

Lau brought up the concept of microaggressions—comparatively small discriminations that accumulate through the course of a person’s daily life—and said that comments like these can detract from a fellow’s overall well-being. In addition to prioritizing patient care, trainees are “dedicated to advancing our own learning,” she said, and yet so often questions about their competency create confrontation that ultimately lead some to question their chosen career.

“It is so painful,” she said. “And yet when you really go back to the core of it all, we all went into cardiology because we're excited about taking care of patients, we're excited about cardiovascular physiology. And it's really such a shame that we’re in this position.”

Lastly, another struggle early career physicians face, especially those at teaching institutions, is balancing the concept of being both a mentor and mentee simultaneously, said panelist Tamara Atkinson, MD (Oregon Health and Science University, Portland). “The most important thing and the advice I give to fellows is when you're looking for a job and a practice, find that practice where you’re going to feel supported,” she said. “Because when you come out of training, you’re going to want that support from your peers.”

Institutional Responsibility

The session had several key takeaway lessons, according to Januzzi. “Wellness may be achieved in any number of different ways, which may vary somewhat from institution to institution and individual to individual, however, there are some key common points to be remembered,” he said.

“First, a substantial percentage of the responsibility toward the interventions needed to improve wellness are very much in the hands of the institution or practices that the physician or other caregivers practice at. Stated another way, although wellness is very much in the hands of the individual as well, a substantial chunk of the pressures that are leading to the loss of wellness relate to institutional or practice-based issues, whether its electronic health records, increasing expectations to practice on a volume basis, such as using work RVUs, these new and growing pressures tend to depersonalize physicians and lead to a sense of professional and personal frustration,” Januzzi explained.

While there are steps that every physician can take to increase his or her personal wellness, “we cannot ignore the important responsibility that integrated health networks, hospitals, individual practices, et cetera, also have in fostering an atmosphere of wellness for their members,” Januzzi stressed.

Regardless of how long a physician has been practicing, “it turns out that a substantial part of wellness is finding purpose in what we do on a daily basis” despite the various annoyances and pressures that tag along, he continued. “It may be that more senior colleagues have developed a sense of professional equanimity that younger colleagues have yet to develop. So for our younger colleagues, we hope to communicate a series of potential lessons to learn, including trying to find the joy in our everyday practice . . . and recognizing that they are walking a path that many have walked and have done well in the long run.”

Pushing forward with the status quo is not going to be a sustainable path. James Januzzi

For his part, Januzzi said he has learned how to find balance in his at times “pressurized, frenetic” career by finding time to step away from work. “My initial concerns about taking some time away occasionally regarding the downsides about missing work or not hitting the deadlines that we talked about were actually misplaced, and I am just as productive as before and with a modest reduction in my level of stress and exhaustion,” he said.

Looking forward, “it is reasonable to expect that changes are coming with respect to the pressures that modern physicians deal with relative to things like the electronic health record and greater pressure to see more and more patients, [but] the truth is those pressures will always be there to one degree or another,” Januzzi concluded. “So it's trying to understand ways to work around those pressures, whether it's through electronic solutions, modifications to the electronic health record, novel practice structures, gainsharing with hospital systems, a better working relationship with hospital leadership, et cetera, these are all important steps that in modern cardiology we need to be taking. . . . Pushing forward with the status quo is not going to be a sustainable path.”