Physician Burnout
It always begins with ‘The Call.’ That inchoate tug upon the soul that says “follow me.” Almost as if in love, one is lead by his heart in pursuit of that which he can not quite articulate. Thus embarks the student as he answers the call to a career in medicine. Indeed, a similar process occurs in the life of the future nurse, teacher, minister and counselor. Work flows effortlessly in the beginning, but after five or ten years, it seems less spontaneous. Now, more energy needs to be supplied just to keep the ball rolling. Eventually, one feels sentenced by the gods to the fate of Sisyphus (condemned to ceaselessly rolling a rock to the top of a mountain, when the stone would fall back). How did it all end so badly?
The rates of burnout have been reported in the range of 30 to 60 percent, depending upon the study (1). No field of medicine is immune to its affect: students, residents, academic faculty and private practitioners all succumb. The tangible symptoms first described by (Christina) Maslach include emotional exhaustion, depersonalization and a diminished sense of accomplishment (2). The clinician now finds himself exhausted at every patient encounter and increasingly devoid of compassion. The final straw is the lack of any sense of efficacy which wields a mortal blow to his idealism. Although burnout can occur in any individual in society, its effects are especially lethal to the inherent perfectionism of the clinician. The psychological template of the physician is only too willing to carry the burden of excessive responsibility.
The technological advance of medicine has created an environment of excessive work, both in volume and acuity. The skills to be mastered have increased exponentially and stand in contradistinction to the finitude of resources. The toxic brew is topped off by the unrealistic and often excessive demands of patients.
Increasingly, statistics from physician resource committees decry the result. Job dissatisfaction among hospital nurses is four times that of the general population (3). Twenty percent of nurses surveyed plan on leaving their jobs within one year (3). Up to twelve percent of healthcare professionals develop substance abuse problems (4). Rates of suicide are considerably higher than those of the population at large (5). And, seventy percent of physicians are currently pessimistic about the future (6). Despite the toxicity, the 800-pound elephant appears invisible.
From what power can one find succor? Efforts combating the burnout problem have been initiated in the last fifteen years at major institutions in Canada and the United States. One of the earliest programs to address burnout in medicine was inaugurated at the University of Ottawa in 1995. Within the next five years, a similar endeavor was launched at Vanderbilt University. The initial efforts were addressed to the results of burnout as manifested by the dysfunctional clinician, but proactive efforts to prevent the development of burnout were instantiated.
The two-pronged assault upon burnout must take into account both system and individual factors. In the instance of the former, hospital administrators must bring technology to bear to streamline throughput (the amount of work to be done within a given time period) and judiciously husband resources. In the latter case, the clinician must draw from within himself those energies toward renewal. Time management, healthy lifestyles and application of cognitive thinking practices have all been employed in the clinician wellness renaissance (7). Time honored practices of emotional and spiritual development have proven worthy allies as well.
The summum bonum (the highest good), however, has proven to be the strategy of renewal for the entire culture of each individual healthcare system. To wit, Ottawa and Vanderbilt have taken the wholesale reinvigoration of their facilities. The aim is to change the ethos and create a functional community. To this end, small groups have been created to allow clinicians to engage in ‘mindfulness’ (8), reflective writing, meditation, and ‘circles of trust’ (9). These efforts gesture toward and kindle the nascent instincts of shared humanity in all of us. The healing and nurturance of the self, instantiated in these groups, begets a rebirth which allows restoration of compassion and a development of empathy. Truly the ‘wounded healer’ described by Henri Nouwen can now be set free to fully attend and minister to those patients under his care (10).
The outcomes of a functional and vibrant healthcare environment can be seen clearly in the faces and the souls of both the clinicians and the patients. Clinicians no longer encumbered with the decay of burnout are more caring, efficient and inclined to continue their service longer (1). The metrics of healthcare delivery as gauged in quality improvement suggest improvement (11). Not only is the process more efficient and satisfying, but patient safety is improved (11). All of these factors result in greater patient satisfaction; and, it would not be unreasonable to anticipate a reduction in litigiousness (11).
On a local level, and quite unique for a private institution, is the current vision of the Methodist Stone Oak Hospital. Under the guidance of the CEO Dean Alexander and COO Jeannette Skinner, an ad hoc group of clinicians has started a wellness program. Its effects will be comprehensive and far-reaching; but its main advantage is its relatively small size and the quality of its professional staff. The “this is the way we have always done it” mentality simply does not exist at MSOH. Efforts are ongoing to learn from, and partner with, the pioneers working at other healthcare facilities. Eloquent is the statement by Cole and Carlin from the University of Texas at Houston Medical School in their text, Faculty Health in Academic Medicine (12):
“No amount of complaining about institutional callousness and lack of support can substitute for individuals personally grappling with their own priorities, their own physical, emotional and spiritual well-being.”
We can only echo this sentiment and proclaim “Carpe Diem!”
George A. Ford III, MD, FACP is a BCMS member Internal Medicine physician with 30 years of practice experience.
1Krasner et. al., “Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians”. JAMA, 2009; 302 (12): 1284-1293.
2Maslach, C et. al., Maslach Burnout Inventory Manual (Third Edition), Palo Alto, CA: Consulting Psychologists Press, 1996.
3Aiken, Linda et. al., “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction”. JAMA, 2002; 288 (16): 1987-1993.
4McCall, Susan, “Chemically Dependent Health Professionals”. WJM, 2001; 174: 50-54.
5Dyrbye, Liselotte et.al., “Burnout and Suicidal Ideation Among U.S. Medical Students”,
6Annals of Internal Medicine, 2008; 149 (5): 334-341.
7Gunderson, Linda, “Physician Burnout”. Annals of Internal Medicine, 2001; 135 (2): 145-148.
8Wicks, Robert J., Overcoming Secondary Stress in Medical and Nursing Practice. Oxford, Oxford University Press; 2006.
9Epstein, Ronald, “Mindful Practice”, JAMA, 1999; 282 (9): 833-839.
10Palmer, Parker, A Hidden Wholeness. San Francisco, Jossey-Bass; 2004.
11Nouwen, Henri, The Wounded Healer. New York, Image Books, Doubleday; 1979.
12Shanafelt, Tait, “Enhancing Meaning in Work”, JAMA, 2009; 302 (12): 1338-1340.
13Cole, Thomas et. al., editors, Faculty Health in Academic Medicine. Totowa, NJ, Humana Press, 2009. p. 154.
