Commentary
Tackling a Taboo
The first step toward alleviating burnout is talking about it.
By Patricia J.Lindholm, M.D.
Although I have felt burned out a number of times during my career, it culminated one night about 15 years ago. As a family physician in a small community, I had full-time clinic hours, did obstetrical care, had an inpatient hospital practice, and saw nursing home patients. In addition, every week I was required to work one or two 12-hour overnight shifts in the ER. That particular night I was on call to staff the ER when an obstetrical patient of mine was admitted in active labor. As I waited for the delivery, I was paged to the ER because a patient was experiencing an acute myocardial infarction. There was no other physician in the hospital at that time. It was an impossible situation. The workload was excessive, and I had no control over it.
My efforts seemed futile, and my work was not satisfying. I did not have enough hours in the day, intellectual energy, or down time to succeed in my work or in my family life. I became somewhat gruff and short with patients and co-workers. I began to think that patients should just “buck up” and deal with some of their problems without bothering me when I needed sleep or a break. I realized that I had lost the empathy that had led me to enter medicine. I began to contemplate leaving my profession.
It is clear to me now that many physicians feel they are stuck on an ever-accelerating treadmill. I think of my colleagues in various specialties whose patients’ problems do not occur on a 9-to-5 schedule. Many of them also are struggling to meet increasing “productivity” expectations, to handle the added tasks of seeking prior authorizations and making formulary appeals, or to learn to use a new electronic medical record system. They continue to work sleep-deprived on relentless schedules, while relationships with their family members and friends suffer. How often are our colleagues “putting up a good front” in the interest of getting through another day or night? And how can we see past the façade to understand that someone may be crying for help?
The Signs of Burnout
Not to be confused with stress, which is an unavoidable fact of life, burnout has been called “erosion of the soul.” It is a condition that has the following dimensions:
- depersonalization (we feel disconnected from or lack empathy for others—in the case of physicians, patients and/or co-workers);
- a perceived lack of effectiveness in our work, which can lead to cynicism; and
- emotional exhaustion.1
The risk of burnout increases when we are consistently overworked and feel that we lack control over the extent to which the load exceeds our capacity. For physicians, it might manifest in a number of ways:
- Frequently failing to respond to phone messages or pages from the hospital, clinic, or emergency room;
- Refusing to complete medical records in a timely fashion;
- Showing up late for work;
- Belittling or insulting colleagues, nurses, and other staff;
- Storming out of a busy clinic or ER and leaving patients waiting; or
- Making disparaging remarks about a colleague to a patient.
Some who experience burnout spiral into depression and experience the self-loathing that can go with it (that seems to be a particular talent of mine). We feel that we have betrayed our own values and ideals, lost our ability to be empathetic, and become cynical. We conclude that we have failed in our vocation.
Mayo Clinic researchers Dyrbe and Shanafelt have found that about 30 to 40 percent of practicing physicians are experiencing burnout.2 Others have found that levels of burnout among physicians range from 25 to 60 percent. Clearly, this problem is serious and prevalent. Yet, we have been reluctant to discuss it with our colleagues.
A Delicate Subject
For a number of reasons, physicians rarely admit that they are burned out. We fear the stigma associated with admitting any weakness or lack of dedication. In addition, professionally, many of us are loners. We appear to work in teams but, in reality, are each in our own silos, trying to keep our heads above water. We see our own patients, do are own paperwork, and exchange superficial pleasantries as we quickly move from one exam room to another or through the hospital. Most of us do not have access to employee assistance programs, especially if we are self-employed or a partner in a group. Even if we have access, we are reluctant to use the services of a counselor. And so we tend to suffer in silence. Consequently, physicians can feel isolated and helpless.
Reaching out to a colleague who appears burned out can seem even more risky. We fear that the person may become angry or defensive. It’s not surprising that I do not recall being approached by a colleague in respect to my own experiences with burnout.
I have learned, however, that talking to colleagues about this topic can be done. Indeed, many physicians are hungry for an opportunity to share their feelings.
Several years ago, a chaplain colleague and I decided to see if we could start a physician peer support group. Each of us was experiencing a degree of personal and professional distress and could detect distress in others among us. We could see the need for having a safe place where physicians could express what they were feeling and receive support. But we struggled with how best to broach the topic with our colleagues. Chaplain Brad and I met over several weeks to discuss how to put together the group, what to do in the group, who to invite, etc. It seemed that the safest way to start was to extend personal invitations to people we felt might benefit.
Still, bringing up the subject of burnout made me anxious. I worried that these colleagues might take offense, or worse, that I might be the only one who had “needs.” After all, it’s one thing to work professionally in the care of a mutual patient or quality-improvement process. It’s another thing altogether to have a heart-to-heart conversation. But the issue was important to me. And I could sense that others were suffering alone, as I was. In the end, I invited individuals whom my intuition told me might need to talk. In each case, I went to the person’s office, shut the door, and gently stated that I was vaguely aware of some distress in their lives and that I wanted to get some colleagues together who could support each other. To my immense relief, my invitations were gratefully accepted.
During the last three years, our group has grown from four physicians to 10. We meet twice a month and have formed a true community. We do not try to “fix” each other. We just listen to each other’s stories respectfully and compassionately and offer support. The group is so confidential that only the members know the identities of the other participants.
Beginning the Conversation
I’m convinced that if I could start a conversation with colleagues about burnout, other physicians can do the same in their practice communities. A good way to start is to simply listen intently to a colleague in the moments you see them in the doctors’ lounge or after meetings. Being a generous listener is one of the best ways we can help each other. Sometimes, sharing your own experience can free others to acknowledge their difficulties and begin to discuss them.
I have had a number of opportunities to speak to groups of physicians about burnout. At the end of these talks, it’s not unusual for someone from the audience to thank me for opening up about my experience and my depression—topics that were once considered taboo. I also have been blogging about the issue of burnout. I have been surprised many times to hear who has been reading my blog and how they have appreciated the resources I share.
We need to realize that burnout has professional implications for physicians, that when we are burned out, we are not at the top of our game, and thus our patients and the people we work with suffer as well. If we physicians do not heal ourselves, we will be unable to heal our patients or our health care system. We need to start by making burnout and the way we are feeling something we can all talk about. MM
Patricia Lindholm is a family physician at Lake Region Healthcare in Fergus Falls, Minnesota. She blogs about physician well-being at wellphysician.blogspot.com/.
References
1. Maslach C, Jackson SE, Leiter MP, et al. Maslach Burnout Inventory Manual. Third Editing. Consulting Psychologists Press, Mountain View, California. 1996.
2. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011;305(19) 2009-10.