Burnout
Burnout
It is a huge problem across medicine, remains stigmatised and most probably under-recognised by sufferers until a crisis occurs. It is not a coincidence that doctors have a higher risk of anxiety, depression, substance abuse and suicide when compared with the wider population.
Following the covid-19 pandemic and the current socio-economic and political uncertainty has meant that our healthcare system is an even more challenging and difficult place in which to work.
In the last training survey, two-thirds of doctors in training said they “always” or “often” feel worn out at the end of the working day and nearly half (44%) are regularly exhausted in the morning at the thought of another day of work.
Stressed or burnt-out?
Stress is a common occurrence within healthcare and is defined as a challenge from which you can recover from. Resilience is a state of ongoing successful recovery from stressors, whether it be psychological, emotional or physical. For example, an uncharacteristically busy day at work or a particularly difficult case but following some rest, debrief or ‘insert other personal positive coping strategy’ you are ok.
Burnout however, is a state of unsuccessful recovery - when you are drained from persistent stressors and can no longer recover. For example, when that busy day becomes every day; those challenging cases are more frequent; there is no debrief; no downtime in which to unwind or no time to engage in positive behaviours or engagement in negative coping strategies. This ultimately leads to a self-perpetuating spiral of worsening health and self-care resulting in burnout.
In most cases, burnout is insidious in onset, creeping up on doctors who are ever more pushed and challenged at work, alongside managing their everyday lives. Coping with increasing challenges are normalised (in recent years it is the norm for the hospital to be in a ‘black’ bed status for example) and that is why burnout is such a challenge to deal with.
The WHO defines burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed.
It has 3 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
Recognition and diagnosis can be a challenge, there are lots of physical and psychological symptoms and affected individuals are often reluctant to seek help due to negative stigma. Non-specific symptoms such as depression, irritability, insomnia, tiredness, and anger are common; and whilst absenteeism is commonplace, so too is presenteeism (the inability to leave work) despite negative consequences often due to poor self esteem and identity outside of work.
The hallmark of burnout is the triad of:
Emotional exhaustion
Depersonalization
Sense of low personal accomplishment
Why does burnout matter?
Burnout has wide-reaching consequences on your own health, the patients we care for and the wider health system.
Impact on your health - increase risk of:
Suicide
Anxiety and depression
MI and CVS disease
Endocrine (HPA) dysfunction
Obesity
Impact to patients:
Decreased patient satisfaction
Increase in errors
More litigation
Wider system impact
Less likely to be consultant
Not contributing to workforce
Sick leave
Poor member of MDT
What makes doctors and medicine so high risk?
Risk factors include:
Age < 55;
Female > Men (unless family and god social support)
Social isolation (home or work)
Coping strategies (negative - alcohol, drugs, food, gambling, shopping, de-prioritising self; positive - exercise, social network, meditation)
Personality - Neuroticism, perfectionism, anxiety, strong self-drive
Medicine is particularly problematic as a result of:
Personality of doctors. To become a doctor and succeed post graduation almost by definition means that doctors have certain characteristic or personality traits that predispose to burnout.
Perfectionism and neuroticism - high self drive and a tendency to strive for perfection, difficulty in accepting critique and appraisal. Setting too high standards for oneself and being very self critical. The feeling like we can do it all and difficulty in delegating and relinquishing some control.
Lack of control - Often as trainees have little control over our lives. Where we live and if we want a NTN, will even take one away from our family support network. Poor and late rota planning adds to this. How many weddings or social events have you missed due to rotas…? Speak to anyone outside of medicine and they are often astounded at the imposition on our lives.
Workplace culture and dysfunction - Doctors are often encouraged to do more and more for your CV. Doctors rotate frequently and as such can struggle to build an inclusive work based culture which is actually engaged with trainees. Before you know it, doctors rotate again. Building relationships to get that project started all over again is more difficult. This is compounded by portfolio requirements and the constant review of progress and comparison against peers - exams, courses, assessment and ARCP, interviews and competition ratios for NTNs
Poor coping strategies - poor sleep, exercise vs alcohol, drugs and more…
Moral injury - the distress experienced following a traumatic event - we can all relate to this working in healthcare but there is a fine balance between too much empathy and emotional harm experienced as a result. Clearly depersonalisation is mal-adaptive but a boundary needs to be present. Additionally, due the pressures the healthcare system is under we are often unable to provide the standard of care to our patients that we wish we could.
What can we do to prevent and treat burnout?
Whilst important, focussing primarily on the individual doctor by way of improving psychological and emotional resilience are unlikely to result in long-term changes and improvements. In fact, it actually adds more pressure and responsibility on the individual to look after one's own mental health and wellbeing. It is an unfair fight in a system that is fraught with issues and pre-disposes doctors to burnout and/or mental ill-health.
Widespread system-based changes probably need to occur if burnout is to be adequately addressed across healthcare. For example, adequate staffing, remuneration, improvements to the working environment - from the access to a working and coherent IT system, a nice staff room, rest facilities and modern buildings to manageable workloads and improvements to other healthcare systems pressures. But political, economic and cultural change are slow and unlikely in the short-term.
Education and awareness can help doctors recognise any features of burnout or recognise key stressors for themselves and how to deal with them, make positive changes or seek help. Education and awareness, can hopefully de-stigmatise burnout amongst doctors and allow for more peer-to-peer support and recognition of the colleague in difficulty before a crisis occurs and an overall more resilient and well-being workforce.
If you are burnt out, seek help, get immediate support and a plan of action to deal with the current situation. Then, establish what needs to change for the future.
Prevention is better than cure…I would ask everyone to take a self check inventory of their personal stressors and rechargers. What is the balance like?
Burnout can also be a result of the imbalance between work and home life. Work could in fact be not too problematic, but if there are lots of stressors at home and no time to recover and look after yourself then relatively minor increases in stressors at work can have a significant impact. Your own personal system needs to have the ability to rest and re-charge both at home and work; from home and from work.
A reverse engineering exercise
Write down what you want a typical day, week or month to look like. Then see how you can achieve that. If life does not currently reflect it; work out how you can change it. Short term ‘stress’ is ok i.e. a stretch of nights but for long term success (and avoidance of burnout) your current life needs to reflect your ideal life, and if it doesn’t, think about what needs to change in order to achieve that.
Is it less than full-time working, a change in specialty, a career break to establish what is important to you, leaving medicine altogether, re-engaging with a hobby, seeing friends and family more…It will be personal to you and requires you to truly reflect on your core values and more.
Sources and resources of help:
First and foremost if you are struggling seek help. This could be a friend or family member, a senior at work, occupational health or the PSW. Your GP can be invaluable or if in a moment of crisis A&E, the Samaritans or any of the above can also help!
Other resources include:
The happyMD.com
Reviewing the literature on burnout - hugely helpful to recognise that you are not unusual/weak or a failure
The inner lives of doctors by Caroline Elton
Ikigai: The Japanese secret to a long and happy life by Héctor García and Francesc Miralles
Dailystoic.com
Brene brown TED talk (links on WARD blog page)
PSW - counseling and psychological support along with practical advice
WARD podcast series - Burnout
Self care (please visit the rest of the website for more useful resources):
Boundary helps – if you can be discrete between home and work it allows some balance. How will I manage if something goes wrong?
Good sleep and sleep hygiene - Matthew Walker - why we sleep
Strive for excellence, not for perfection
Junior doctors are well known for poor self-care and lots of that is the expectations, but remember not to always defer your needs SOMETIMES have to but not always
remember food, sleep and exercise are medicine and do have a big influence on your wellbeing!
Display sympathy and not empathy i.e. acknowledge that awful situation but don’t feel it yourself!