Professional Burnout in Medicine and the Helping Professions

D. T. Wessells Jr., Austin Kutscher, Irene B. Seeland, Florence E. Selder, Daniel J. Cherico, Elizabeth J. Clark, D. T. Wessells Jr., Austin Kutscher, Irene B. Seeland, Florence E. Selder, Daniel J. Cherico, Elizabeth J. Clark

• Publisher: Routledge
• Year: 2013
• Topic: Psychology
• eBook ISBN:
  9781317839804
• Subtopic: Medical Theory, Practice & Reference
• Index: Psychology

Physicians and other helping professionals have created a practical, hands-on book that will aid in the identification and reduction of job stress. Nurses, physicians, thanatologists, and psychotherapists are among the growing number of health care professionals whose physical and mental health are being severely affected by work stress.
This unique volume achieves what no earlier book has attempted for this specialized professional group. It offers a thorough understanding of professional burnout, elaborating how burnout develops and offering a model with which to identify job stressors. Professional Burnout in Medicine and the Helping Professions also offers an in-depth exploration of stress and burnout issues from the perspectives of specific medical and helping profession disciplines--physicians, nurses, social workers, psychotherapists, teachers, consultants, agency and hospital workers, funeral directors, and more.Experts in these fields examine the values, ethics, and morality of individuals, health care organizations, and society that may lead to burnout This in-depth and highly practical volume identifies the stages of disillusionment and offers successful intervention strategies for recognizing the signs and reducing or efficiently managing causative factors.

II. BURNOUT AND THE PROFESSIONAL CARE GIVER

Burnout in the Professional Care Giver: Does the Phoenix Have to Burn or Why Can’t Icarus Stay Aloft?

Robert Lynn

Robert Lynn, MD, is Staff Psychiatrist, Dutchess County Medical Hygiene Clinic, Poughkeepsie, NY.

I’ve never been entirely comfortable with the term burnout, perhaps because I envision a Halley’s Comet, or the famed Phoenix, or the greasers on the street revving up their Harleys, flexing glistening biceps covered with tattoos, and swilling beer by the six pack. Burnout is probably a term more misused than properly used. For example, is it proper to say that someone who has never achieved anything has burned out? I’m not referring to elitism; I’m referring to the idea that burnout occurs only in achievers. Achievers do not have to be professionals; they can also be craftsmen, laborers, and assembly line workers who “have had it.” In one way or another we have all fashioned wings of feathers and wax and, like Icarus, flown too close to a symbolic sun and then plummeted emotionally. This is burnout.

I’m not going to attempt to define burnout. What seems more important is the descriptive etiology and teleology. Perhaps this can enable us to recognize the entity early on and “effect some preventive maintenance,” as the military say. First, let’s look at the protean manifestations of burnout as described quite widely in an already overwhelming body of literature. Variations and gradations of burnout, its signs and symptoms are seen in everyone around us and are never considered anything unusual until we notice a pattern of extremes or exaggerations. We even joke about someone having a psychosomatic headache, or taking a long weekend for mental health purposes, or calling in sick for no good reason. We see it and register it but are loathe to piece it together with other clues to label a co-worker as having burnout, perhaps because of the old rationale, “there but for the grace of God go I.”

We next turn to stress. Lengthy discussions about the physiology of stress can be better comprehended if read within some context. The two major categories of stress are exogenous and endogenous. Exogenous stressors can be concrete, subtle, or obvious. Good examples of exogenous stressors might be changes in a nurse’s shift, the arbitrary transfer to a different service, lack of office space, heavy case loads, or, in the case of a home hospice worker, the travel time to the patient’s home. The endogenous stressors are also an amalgam of the concrete, subtle, and obvious. Mixed in are the intricacies of psychological transference and countertransference. A concrete example is patients who have malignancies which will ultimately limit their lives and profoundly modify the quality of their lives. All the reminders are there: the modifications of the body integrity, the loss of an appendage, alopecia, weight loss, pallor, jaundice. How can we avoid these constant reminders?

Care givers dealing with patients with varying diagnoses of malignancy, whether early stages, stages of active and aggressive therapies, or end stages requiring supportive physical and emotional care, are exposed to incredible endogenous stressors. Doctors, nurses, aides, social workers, and hospice workers confront everything from hopefulness to gloomy despair and, in their day-to-day contact with patient and family, their immersion in the family’s joys and sorrows becomes inevitable. However, the hospice worker’s additional burden is to have missed completely the earlier phases of rejoicing and hopefulness and to be present only at what we, in western culture, consider the tragedy and suffering of waning vitality and the ebbing of life. The closer you get to the family the more you get caught. Remember Josie’s fifth birthday party on the ward (there was not to be a sixth)? She long since ceased wanting a two-wheeler which she knew she could not ride anymore. Remember Mike’s love for soccer, a game he’d never return to again, or Lisa’s early flair for tennis? An episode I’ll never forget was that of a young man who had undergone a forequarter amputation, an intrascapular for a malignancy. His concern was how, if ever, he could ever wear a sport jacket again. It’s an indelible image. The longer you work with patients and families the more you learn of their anxieties and worries, their financial difficulties, work lost, and marital problems. It is indeed the rare care giver who can assume “detached concern” as originally advocated in the training of physicians.

In focusing on the weariness and potential for burnout in care givers, we now have an idea as to its etiology and the external and internal manifestations. I’d like to quote from and recommend an especially brilliant and sensitively insightful paper by Paul Pruyser at the Menninger Foundation (1984):

Sooner or later, health care professionals who deal with conditions entailing much suffering or pain discover that they have to perform a task for themselves in addition to discharging their helping obligations toward their patients. Prone to becoming overwhelmed by the suffering they see around them and fearful of losing their equilibrium, they must undertake an arduous balancing act. When the pain of the world is no longer an abstract philosophical idea but knocks daily at one’s door in concrete self-presentations of suffering individuals, safeguards are needed for the continuity of at least some vital restorative processes, such as undisturbed sleep, access to new energy supplies, and some measure of good cheer. But securing such psychological provisions for oneself is not easy, for the very fact that one feels in dire need of such restorative and equilibrating operations is a sign that one’s psychological state has already moved in the other direction, where insomnia, tiredness, weariness, brooding and a wistful or mournful mood threaten.

His paper also discussed fusion and identification with the patient and how our professional stance and attitudes should protect us from both pitfalls and, at the same time, allow for controlled and limited empathy for the patient’s plight. All of this and learning how to deal with the traps of patient’s transference and our counter-transference take an emotional toll on our lives. The person in jeopardy of burning out is not alone in suffering the ill effects (Maslach 1982). “Others are singed by burnout. Recipients of care of services, co-workers, family and friends … all these people can testify to the costs that the person’s burnout has had for them as well.”

Stress generated by work can permeate our private lives. It can affect all those relationships on which we depend for restoration. The costs of burnout are immeasurable from the waste of a fruitful career that took a long time and much effort to establish to the effects on patients or clients, the recipients of the care givers’ services. We see the results of ineffectual coping strategies or techniques. Burnout is a progressive and chronic state not visible or detected very early because it usually occurs in those strong, self-assured people who mask their weaknesses well.

Burnout is avoidable and preventable but it takes the effort of both the individual and the institution. We can expect that sensitive and flexible supervisory personnel can modify work schedules, case loads, physical creature comforts, payroll and benefits expenditures. Environmental factors, like the use of a team approach to limit and dilute personal emotional stresses, can be created. It’s considered vital to foster an atmosphere where it’s safe to feel and express vulnerability. The use of a group like a team group, which meets weekly as a forum for expressing and sharing both happy and sad experiences with co-workers, is effective. At the original hospice, St. Christopher’s, outside of London, there is a weekly meeting with the well known psychiatrist, Colin Murray Parks, to discuss patients as well as feelings. This gives individual team members the opportunity to share their vulnerability and to have healthy and constructive feedback from the rest of the team. Jobs can be adjusted and case loads managed to limit direct patient care and mix in teaching, writing, supervision and administrative responsibilities. Breaks in the work period such as coffee and lunch breaks should not be used to catch up on work. Work should not even be discussed. The time should be used more effectively by going out for a walk or by reading a book.

To ignore all these mundane things is to invite burnout, which will lead to a turnover of personnel about every two years, and even more often in some positions. Consider the loss of time, energy, and money in recruiting and training. Also, this two-year period is the critical time in which burnout can cause people to drop out from their fields completely and enter other fields remote from people-oriented services.

Maslach (1982) has spoken of personal attributes useful in strategies for prevention of burnout. The emotional stability of the care giver is extremely important. A recent study of hospice workers looked at whether or not the worker worked full time in addition to doing hospice work, what the person’s religious background was, and whether or not a close family member had died of cancer and how recently. The individual who had had trouble in handling losses in his life, reacting with depressions and distancing behaviors or flight from these losses, should not attempt to work them through by working with the terminally ill. Coping skills and the ability to empathize without merging or fusion is vital. Circumspection and introspection, being able to reflect and be in touch with feelings at all times are important. The ability to use a tool like insight meditation can be life-saving.

What can we do in our day-to-day lives to fend off burnout? Consider “decontamination,” or, as Maslach has also put it, “decompression” techniques such as listening to music or books on tapes in the car to help in separating from work. Hobbies are also helpful. Many experts recommend active sports and aerobic exercises, jogging, swimming, yoga. Meditation techniques and relaxation techniques have staunch advocates. And, of course, there’s nothing quite like a journey to a distant shore to recharge one’s batteries. All of these ideas are so simple and basic that we tend to forget them but they are viable ways to fend off burnout. When death comes and whispers to me, “Thy days are ended,” let me say to him, “I have lived in love and not in mere time.” He will ask, “Will thy songs remain?” I shall say, “I know not, but this I know, that, often, when I sang, I found my eternity” (Tagore, Fireflies).

REFERENCES

Bates, E.M. 1975. “Stress in Hospital Personnel.” Medical Journal Aust., 2:765–767.

Freudenberger, H.J. 1975. “The Staff Burnout Syndrome in Alternative Institutions.” Psychotherapy: Theory, Research, and Practice 12(1):73–82.

Friel, M. and Techen, C. 1982. “Counteracting Burnout for the Hospice Care-Giver,” in McConnell: Burnout in the Nursing Profession. New York: CV Mosby, pp. 150–159.

Gardner, E.R. and Hall, R.C.W. 1981. “The Professional Stress Syndrome.” Psychosomatics, 22(8):672–80.

Hall, R.C.W. et al. 1979. “The Professional Burnout Syndrome.” Psychiatric Opinion, 16(4):12–17.

Klagsbrun, S.C. 1970. “Cancer, Emotions, and Nurses.” Amer. Journal Psychiatry, 126(9):1237–41.

Lewiston, N.J. et al. 1981. “Measurement of Hypothetical Burnout in Cystic Fibrosis Caregivers.” Acta Paediatr Scand 70:935–939.

Lief, H.I. and Fox, R. 1963. “Training for ‘Detached Concern’ in Medical Students,” in Lief et al. (eds.): The Psychological Basis of Medical Practice. New York: Harper and Row.

Maslach, C. 1982. Burnout–The Cost of Caring. Englewood Cliffs, NJ: Prentice-Hall.

Pruyser, P.W. 1984. “Existential Impact of Professional Exposure to Life-Threatening or Terminal Illness.” Bull, of the Menninger Clinic, 48(4).

Weisman, A.D. 1981. “Understanding the Cancer Patient: The Syndrome of Caregivers’ Plight.” Psychiatry, 44:161–168.

Wilder, J.F. 1981. “Recognizing Burnout in Health Professionals.” Psychosomatics, 22(8):653–656.

Winer, J.A. and Ferrano, C. 1984. “Residency Training and Emotional Problems of Physicians.” Ill. Med. Journal, 166(1):23–26.

Wise, T.N. and Berlin, R.M. 1981. “Burnout: Stresses in Consultation-Liaison Psychiatry.” Psychosomatics, 22(9):744–751.

The Prevention and Treatment of Professional Burnout

Alan Lyall

Alan Lyall, MD, is Associate Professor of Psychiatry, University of Toronto Medical School. He is also Head of the Outpatient Department and Psychiatrist-in-Charge of Ambulatory Services, Clark Institute of Psychiatry, Toronto, Ontario, Canada.

To paraphrase Shakespeare, “The fault, dear Brutus, is in ourselves” (Julius Caesar)–that we are burned out.

There is an attitude problem that we have perpetuated, and still help to foster throughout society and especially in the helping professions, that leads us to be proud of the fact that we strive to meet unrealistic expectations. If one is a professional athlete, the ability to “play with pain” is a dubious asset since players may not be able to deliver the performance normally expected of them. Yet only a game may be lost.

In the health care system the stakes are much higher and the attitude is much dumber. Yet we traditionally put ourselves and our patients at unnecessary risk by trying to accomplish too much, and we are so proud of our exhaustion that we make no serious effort to remedy the situation.

The fearsome image used to justify this attitude is that people will go untreated, or may even die, if we don’t “carry on regardless.” This is seldom true. Some acceptance of limitations plus some clever planning can usually improve the service to patients and preserve the health of the clinician.

There is a serious misconception at the root of this ongoing, inappropriate behavior, as illustrated in Figure 1. Our experience teaches us that the harder we try the better we do. This is reinforced by parents, teachers, coaches and employers throughout our lives. The implicit assumption is that such a curve extrapolates ever-upward, forever. When stated this way, however, such a proposition is clearly absurd. Yet, very few people want to consider the implications of what really happens to this performance/activation relationship.

FIGURE 1

The truth of the matter is that this relationship conforms to an inverted “U” configuration, as in Figure 2.

The implications of the relationship of activation and performance are tremendously important. Up to a point, our performance does improve as we become more alert and motivated. But then comes the moment of truth (as the curve plateaus) when such increments no longer augment performance. Subjectively our anxieties are raised and we are usually well programmed to “try even harder.” Such a response moves us onto the down slope of the curve and all our incipient fears of failure are fully aroused as we begin, in fact, to fail to meet performance standards.

It is at this point that the subjective experience of stress begins. Up to the apex of the plateau may be what Selye (1976) refers to as eustress and indeed there may be no deleterious effects. However, the concept of eustress can be dangerous since it can be so easily misunderstood as to suggest that stress is good for us. Once decompensation begins and we begin to stay “overactivated” it is decidedly unhealthy (Figure 3). We too often rationalize stress as not being so bad; we even come to be proud of our ability to endure it. This is the nature of the attitudinal trap that we concoct for ourselves and often espouse to others.

FIGURE 2

It is crucial that we train ourselves not to increase our pace once symptoms of stress begin to show, but rather to take decisive and immediate steps to do less so that we quickly move back to the healthy side of the curve.

Part of the ethos of being a “pro” is that we strive to meet a challenge, make extra efforts, and don’t stop until a task is completed. We are justifiably and properly proud of such an attitude and our abilities to come through. What we lose sight of is the fact that there can be too much of a good thing. Even such a virtuous attitude requires balancing and limiting. It is implicit, rather than explicit, in the Hippocratic Oath that the physician be in good health and be able to...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• I. AN OVERVIEW OF BURNOUT
• II. BURNOUT AND THE PROFESSIONAL CARE GIVER
• III. CAUSATION ASPECTS OF BURNOUT
• IV. BURNOUT AND INSTITUTIONAL/AGENCY CENTERS
• V. COMBATTING BURNOUT