Getting to the guts of physician burnout: A resident’s perspective

August 1, 2018
Rich Joseph, MD, MBA
Volume 95, Issue 15

To date, we have taken an all-too-comfortable approach in our response to burnout. We are addressing the problem the same way that we handle disease-from a reactive, cerebral, and overly academic angle.

Here at Brigham and Women’s Hospital in Boston, our Wellness Committee recently assembled a panel on trainee burnout and depression. Together, we nodded vigorously, leaned in attentively, and let our guards down as spirited laughter mixed with cathartic tears. We work long days and nights side-by-side on the wards yet feel profound loneliness in what we wrongly perceive as solitary struggles. Through the power of vulnerability, a shared reality emerged. Here in Boston, a bastion of the old guard, we started to dissect the polished veneer.

A litany of data proves the extent to which burnout, with co-morbid depression, is afflicting physicians nationwide. Burnout rates are now twice as high in medicine as in other professions, according to a recent NEJM article. In 2014, a national survey by the Mayo Clinic found that 54 percent of U.S. physicians reported at least one symptom of burnout.

Not only does burnout harm clinicians, it hurts our patients. Studies suggest a link between burnout and increased rates of medical errors, malpractice suits, and healthcare-associated infections. The AMA and leading healthcare executives have sounded the alarm, calling physician burnout a public health crisis.Various programs are now underway toincrease the visibility of burnout, to elucidate the challenges to well-being, and to spotlight potential solutions. 

To date, however, we have taken an all-too-comfortable approach in our response to burnout. We are addressing the problem the same way that we handle disease-from a reactive, cerebral, and overly academic angle. We publish inordinate numbers of studies to describe the problem. We develop lists of presenting signs and symptoms along with the diagnostic criteria. And now we are devising so-called “interventions” to treat burnout. We are pathologizing burnout into another sterile ICD-10 code. 

In reality, burnout is a charged topic that challenges our professional identity. Admitting burnout feels self-indulgent to a group of professionals who by nature strive to be selfless. Caring for patients is a tremendous privilege, and focusing on our own issues feels almost blasphemous. We see how ill and vulnerable many of our patients are, and by comparison, who are we to complain? Our education and training still idolize workaholism and martyrdom. And our promotion system still rewards it.

Yet burnout is crushing our colleagues and polluting the healthcare system. Since finishing medical school two years ago, my five best friends all have left medical training. Half of my colleagues in our residency program identify as burned out at any moment in time, as reported during a recent Society of General Internal Medicine conference.This coincides with national data published in 2014 in Academic Medicine showing that half of residents leave their training already burned out. Each year, more than 25 percent of medical students and residents experience depression and more than 10 percent have contemplated suicide, according to a 2005 study in NEJM. Burnout is real. And it is raw-a gaping wound on our profession’s conscience. 

While our traditional approach-data gathering, defining, and deliberating-may have exposed the extent of the burnout phenomenon, it will be inadequate to design and scale solutions. If we pathologize burnout, we risk mistaking a fundamentally system-driven problem for an individual defect, further isolating those who are struggling. We are then apt to spend time and resources applying Band-Aids rather than galvanizing cultural and structural reform.

Plausible solutions to physician burnout will instead demand radical honesty, interprofessional collaboration, collective action, and rousing campaigns. It’s time to transition from talk to tactics, from analysis to action, and from intellectualizing to innovating.

Let’s begin with what we control: our professional norms, how we interact with each other, how we train, the values we espouse and display. This will require radical honesty about the ways in which medical training sets the stage for burnout. Medical school incentivizes perfectionism, which breeds competition and impedes our ability to work collectively. The antiquated postgraduate training system relies largely on the learned helplessness of residents and fellows. Academic promotion is predicated on individual contribution. We must revamp the traditions that dilute our capacity to confront burnout together. Let’s also recognize that we are not independent actors in this system, nor alone in our struggle. Nurses and allied health professionals are also burning out. We are thrust into the same workplaces with different incentives, responsibilities, and skillsets. Yet fundamentally we are all caregivers working toward the same end. Burnout presents an opportunity to build interprofessional empathy, strengthen team dynamics, and improve workplace culture. 

Within our institutions, all providers-across specialties, levels of training, and professions-must demand C-suite investment that is not only verbal but financial. Replacing a physician costs two to three times an annual physician salary, according to a 2017 JAMA study. Our work environments must support not work-life balance but work-life integration. In addition toinvesting in the latest medical technology, offer child care, build an on-site gym, provide free meals, and revamp workrooms. Leaders of health delivery systems must think more deliberately about how to retain talent with the recognition that this impacts the bottom line.

As we tackle what we need to change, we must remain mindful of how we will change. The ideal approach is likely a combination of dynamic adaptability with rigorous scrutiny. Design thinking, for example, facilitates rapid innovation through an iterative cycle of need finding, small-scale prototyping, and constant feedback. Once solutions gain traction, then we layer on evaluative research to measure metrics like patient reported outcomes, professional satisfaction, performance, and retention.

Only when our workforce unites through shared empathy, builds a supportive culture, and pioneers collaborative solutions will we be positioned to tackle the external impositions- paperwork, time constraints, meaningful use, etc.-that we often blame for burnout. Our voice is powerful. We should harness and channel it to bring change through grassroots campaigns, leadership in our institutions and professional societies, and political engagement. 

To begin, share your story. We had all heard the report that half of residents in our program are burned out. But our panel transformed burnout from an abstract banality to a living discussion with faces and feelings. Patient stories bring color and meaning to disease. The same is true of our own accounts of burnout. Your story is your scalpel. Dissect away. 

Rich Joseph, MD, MBA, is currently a resident within the Primary Care Residency Program at Brigham & Women’s Hospital. This training program is a collaboration between the internal medicine residency at Brigham & Women’s Hospital, Harvard Vanguard Medical Associates at Atrius Health, the Department of Population Medicine at Harvard Medical School, and the Harvard Pilgrim Health Care Institute.

 

 

 

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