Burnout, a signal not a sentence

Burnout, a signal not a sentence

Globally, doctors are 2.5 times more likely to commit suicide than the general population, while physician burnout is a leading cause of medical error. The World Health Organization (WHO) states that burnout is ‘a state of vital exhaustion’.

In light of what some are calling a ‘crisis in healthcare’, the WHO now officially recognises burnout as a medical diagnosis. This has resulted in the drafting of a new definition by the WHO that describes burnout as ‘a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed’. This is an important departure from the previous definition in that it is recognised as being associated specifically with workplace stress.

What is burnout?

Burnout is characterised by 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.

Apart from being the leading cause of medical errors, burnout takes a toll on the mental and physical well-being of the individual affected.

Burnout among South African healthcare professionals

Globally, burnout rates among physicians range between 25% and 60%. A South African study by Liebenberg et al found that 81% of physicians in rural areas report burnout, with 31% reporting high burnout measured by all three of the Maslach Burnout InventoryHuman Services Survey (MBI-HSS) subscales (emotional exhaustion, depersonalisation, and personal accomplishments). Furthermore, 48.5% of nurses reported burnout.

Doctors working in the public sector are at greater risk of burnout. Coetzee et al conducted a study among South African anaesthetists working in the public versus the private sector, and found:

Table 1: Public vs private sector burnout

MBI-HSS subscale measurements: Emotional exhaustion Public sector: 45.2% Private sector: 20.9%

MBI-HSS subscale measurements: High depersonalisation Public sector: 50% Private sector: 26.7%

MBI-HSS subscale measurements: Low personal accomplishment Public sector: 46% Private sector: 37.2%

The 2020 Medscape National Physician Report (United States) indicates that female physicians reported more symptoms of burnout (48% female vs 37% male).

A recent study by the Professional Provident Society found that 50% of South African physicians report being depressed due to a combination of being overworked, working long hours and burnout. Depression is one of the leading causes of suicide.

What causes burnout?

Numerous internal and external reasons have been put forward that may contribute to physician burnout:

De Hert lists the following internal reasons for burnout among physicians:

» High idealistic self-expectations

» Perfectionism

» Strong need for recognition

» Always wanting to please other people

» Supressing own needs

» Feeling irreplaceable

» Overestimation to deal with challenges

» View work as the only meaningful activity

» Work becomes a substitute for social life.

Clark identified five external reasons for burnout among physicians in the United States, which may be applicable to South African physicians as well:

1. Clunky workflow epidemic

In the United States, poorly designed electronic health records (EHR) contribute to 50% of burnout rates. Instead of spending time with patients, doctors report that over half of their workday is spend on EHR tasks. This means that they often have to work longer hours to catch up.

2. Overwhelming amount of new tech

The use of technology in the healthcare sector is increasing exponentially. Although the intent is to make managing a practice go smoother, they may in fact actually be causing more stress. Healthcare professionals (HCPs) already have limited time. New technologies demand more time for training, integration, and ensuring proper cybersecurity.

Table 2: Five-stage model for the development of burnout Stage Characteristics

Honeymoon stage (stage 1)

» Job satisfaction stage ñ

» Commitment to job (stage 1) ñ

» Accepting responsibility ñ

» Compulsion to prove oneself ñ

» Substantial energy levels ñ

» Free-flowing creativity ñ

» Unbridled optimism ñ

» High productivity levels

Onset of stress (stage 2)

» Cardiovascular symptoms

» Anxiety

» Inability to focus

» Irritability

» Reduced sleep quality

» Lack of social interaction

» Lower productivity

» Avoidance of decision-making

» Change in appetite

» Fatigue

» Headache

» Neglect of personal needs

Chronic stress (stage 3)

» Persistent tiredness/exhaustion

» Procrastination

» Cynical attitude

» Resentfulness

» Apathy

» Decreased sexual desire

» Denial of problems

» Feeling threatened/pressured

Burnout (stage 4)

» Obsession with problems

» Chronic headaches

» Pessimistic outlook

» Chronic gastrointestinal problems

» Physical symptoms

» Neglect of personal needs

» Self-doubt

» Escapist activities

» Social isolation

» Behavioural changes

» Aggressive behaviour

» Alcohol/drug use

Habitual burnout (stage 5)

» Chronic sadness

» Chronic mental fatigue

» Chronic physical fatigue

» Depression

3. Long hours and sleep deprivation

As a result of having to work longer hours resulting in less sleep, burnout rates of 57% have been reported among HCPs who work more than 72 hours a week. Sleep deprivation influences mood, attention span and memory.

4. Financial stress

Many HPCs start their careers with student debts. In addition, debts accumulate when they try to start their own practice. To meet their financial obligations, they often take on more work. In addition, the threat of a malpractice lawsuit can cause extreme levels of stress.

5. Loss of control

In the past, physicians were the primary decision-makers of patient care. Now they have to cede some of their decision-making powers to administrators, medical schemes, technology and lawyers. This can make them feel as though they have lost autonomy. In the United States, almost 25% of burnout are attributed to the loss of autonomy.

Burnout is a signal, not a sentence

According to an article in the Harvard Review, burnout is a signal that something is wrong and not a long-term sentence. By understanding the signs and causes, you can recover and build a road map for prevention.

Can burnout be prevented?

According to de Hert, a multifactorial prevention approach, and treatment of burnout are required. The approach should focus on the individual’s own personality and attitude, as well as interventions on an organisational level.

On a personal level

If symptoms are minor, recommends de Hert, measures such as changing life habits and optimising work–life balance can make a huge difference.

These measures focus on three Rs:

» Relief from stressors

» Recuperation via relaxation and sport

» Return to reality in terms of abandoning the ideas of perfection.

Minor symptoms (stage 2 and 3)

Personal wellness strategies that have been used successfully in physician burnout programmes include:

» Focus on relationships: Understand the importance of spending quality time with family, friends and significant others. This strategy also includes actively developing connections with colleagues, to share and reflect with them on emotional and existential aspects of being a physician

» Religious belief and/or spiritual practice: Nurture your spirituality. It has been reported that up to 34% of people mentioned this aspect to be important and even essential

» Work attitudes: This has two components. The first one refers to finding meaning and fulfilment in work, the second one to actively choosing and limiting the type of medical practice such as working part-time, being involved in education and/or research, managing schedule and discontinuing unfulfilling aspects of practice

» Self-care: Actively cultivate personal interests and self-awareness in addition to professional and family responsibilities. This also implies actively seeking professional help in case of personal physical and psychological problems or illness. Examples of such practices are, among others, exercise, self-expression activities, adequate nutrition and sleep, regular medical care or professional counselling

» Adapt a specific life philosophy: Develop a philosophical approach to life that is based on a positive outlook where you identify your own values and act accordingly with emphasis on the balance between personal and professional life.

Severe symptoms (stage 4 and 5)

If the symptoms of burnout are severe, psychotherapeutic interventions are recommended. There may also be a place for antidepressants, preferably combined with psychotherapy.

Organisational level

According to de Hert, organisations have to take cognisance of HPC burnout. Create awareness and recognise the problem, he stresses. This can play a crucial role in promoting physicians’ well-being.

He recommends that organisations adopt for example the following strategies that will contribute to the wellness of HPCs:

» Promoting autonomy

» Providing adequate office resources and support staff

» Facilitating a collegial work environment

» Minimising work-home interference by providing flexible scheduling and childcare adapted to irregular work hours.

Conclusion

HPC burnout is a global crisis. Numerous internal and external factors have been proposed as the cause of HPC burnout. Internal factors include long working hours, while external factors include loss of autonomy and financial stress. Various strategies have been put forward on a personal, as well organisational level, to deal with HPC burnout. One of the key pillars is creating awareness and recognising the crisis.

References available on request. SF