The Resilient Healthcare Organization

How to Reduce Physician and Healthcare Worker Burnout

MD Mayzell

• Publisher: Productivity Press
• Year: 2020
• ISBN:
  9781000038965
• Edition: 1
• Topic: Médecine
• Subtopic: Santé publique, administration et soins

Professional burnout is an epidemic in America. Approximately half of physicians and nurses are affected and at risk for themselves and their patients. Much has been written about professional burnout. The term was originally coined in the 1970s by American psychologist Herbert Freudenberger to describe the consequences of severe stress and high ideals experienced by people working in "helping" professions. Since then, many books have been written to address this looming national public health crisis. But, unfortunately, there has been much less written from a solution standpoint: getting to the root cause of why this is occurring now more than ever.

The Resilient Healthcare Organization engages readers focusing on physicians and healthcare professionals and their experiences and how they overcame a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. The feelings of emotional exhaustion are characterized by depersonalization and perceived ineffectiveness. These are the cardinal features that define "burnout" and affect almost 50% of physicians and 30–70% of nurses.

This book addresses why burnout is viewed as a threat and how it can be fought. The author discusses the contributing factors and solutions at the health system and societal level. Additionally, this book explores the current and future etiology and impacts on physicians and healthcare professionals, with a significant emphasis on solutions at both the individual level and the system level.

Contributors: Patricia S. Normand MD, Bruce Flareau, MD, Kathleen Ferket, MSN, APRN, Daniel Edelman, DO, and Peter B. Angood, MD.

Chapter 1

How We Got Here

George Mayzell

Contents

Overview

Bibliography

Overview

It has always been difficult and challenging to be a healthcare provider. The competition to get into medical or nursing school sets the stage for many sleepless nights and stressful encounters. There is a built-in selection process as well as “on-the-job training” to prepare for a difficult, challenging, but potentially rewarding career. This is what was typically expected when one first decided to venture into a healthcare career. There is a certain personal resiliency required to endure the training process, such as the endless studying, late nights, and difficult patient interactions that prepare the provider to be flexible and tough enough to deal with difficult and challenging encounters, often without sleep.

When you talk to healthcare providers today, most of them feel like they got more than they bargained for when they started on their journeys. No one could have expected the additional administrative burdens and administrative oversight obligations that are now part of everyday medicine. In addition to these challenges, the electronic medical record has arguably not made it easier to deliver healthcare. The merits and advantages can certainly be argued and debated, but few healthcare professionals feel like it has made their job easier or more efficient. And finally, the new business pressures of healthcare economics have driven most physicians into new employment models, which can be challenging and in many cases different from their original career expectations.

ALL of the above have contributed to the increasing stress and pressures of practicing medicine in today’s environment. This has led to a growing concern about physician burnout.

Recently there’s been much debate over the term “burnout.” The consensus is that burnout has a negative connotation and seems to suggest that it is a personal failing – that the person could not endure the stresses and pressures of their work environment. Several new terms have been introduced, including terms such as “moral injury,” and other similar terms.¹ We like the term “disillusionment” since there really seems to be a disconnect between expectations and the new reality. The frustration seems to come from the difficulties in working through all of the non-patient care issues that get in the way of patient care.

What is interesting about burnout is that, if we look back 15 or 20 years, we do not see or recognize the degree of burnout that we see today. Certainly some of it was there, but arguably not anywhere near what we see today. Were physicians working fewer hours? Was there less work/life balance? I don’t think so. Here we postulate that it really is not about the additional work or the additional hours physicians and healthcare workers may be putting in, but more about new stresses, such as the lack of control, lack of respect, administrative burdens, and lack of patient engagement/relationship, that are different today. With this in mind, we have to focus on “what is different” today so that we can mitigate some of these changes.

The term “burnout” was initially coined by Herbert Freudenberger, an American psychologist back in the 1970s. He described the syndrome as “becoming exhausted by making excessive demands on energy, strength, or resources” in the workplace.² While this term is used in the press, perhaps it is not really descriptive. What we are really experiencing is physician and healthcare worker “disillusionment.”

Disillusionment is a misalignment of expectations and autonomy with the current healthcare system. This includes the introduction of new employment models, new patient models, and the use of advanced practice professionals including hospitalists, intensivists, and others. All of these things have fragmented healthcare in ways that could not have been fully anticipated and have affected negatively the experience of the healthcare worker.

All of these pressures and unexpected administrative burdens have made many healthcare providers less than happy with their choice of profession. These changes in pressures, while leading to some dissatisfaction, have to be differentiated from burnout. Whereas the day-to-day stresses of healthcare can sometimes be an adaptive response to external pressures and force an individual to focus on working harder and faster, burnout is much the opposite. Some of the main definers of burnout are physical exhaustion and apathy.^{3 –5} Obviously, this is not productive.

Each year it is estimated that between 300 and 400 doctors commit suicide. This is a physician suicide rate of between 28 and 40 per 100,000, much higher than public suicide rates. Most people believe this number is grossly underestimated. Physician suicide has been documented and noted to be a problem since the 1920s. This suicide rate must be contrasted with the general population’s suicide rate of 12.3 per 100,000. This is a topic that is not generally discussed publicly and may be partially related to depression and substance abuse issues^6,7 (Figure 1.1).

Figure 1.1 What physicians are thinking and saying

The stigma of depression, mental illness, substance abuse, and suicide in physicians is far more significant than in the lay public. People’s faith and confidence in their role as patients are at risk. The stoic rigor of the training teaches physicians to ignore and not seek help for these very real issues.

There is also the very practical issue of medical licensure and the risk of losing continued livelihood. Applying for staff privileges at hospitals, payers, and licensure can be at risk if mental health or substance abuse issues are disclosed.

With this in mind, how do we augment the resiliency that was part of the selection process and training process to become a healthcare clinician? How do we use it to focus energy to ultimately improve care for the patient and well-being for the provider?

Resiliency has been defined by the American Psychological Association as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.”⁸ Sometimes that is how healthcare providers feel, like they have been bent, compressed, and stretched. This resiliency gets us to the new normal, and one hopes it will prevent the catastrophic symptoms of burnout. On the opposite side of the spectrum of burnout is physician and nursing engagement. This is the anti-burnout. Resiliency is the stretchy piece between burnout and engagement that keeps pulling us back to the center and hopefully keeps us grounded.

One of the more challenging issues is that we are still defining the term “burnout.” I think at this point it is generally understood what it is, but the true prevalence and effects are still being sorted through. When investigators looked at the different studies measuring physician burnout, they found much heterogeneity, making it too difficult to categorize consistent themes. The prevalence rates were so varied, including a range of 0% to 80.5%.⁹ This makes it very difficult to assess the true prevalence. Is this a true dichotomy, that is, you have or do not have burnout, or is it a continuous variable with degrees of burnout that can be categorized? There is also a strong overlap between burnout and major depression, which needs to be explored further.⁸

To the world outside of healthcare, it may be hard to understand why healthcare workers burn out. They understand some of the emotional stresses of being a healthcare provider, but they don’t understand the added pressures. They see someone who has dedicated five to ten or more years to education, someone who is above average in intelligence, has a large house with two cars, and sends the kids to private school. They know that there is respect for this person in the community. So what is all this complaining about? (Figure 1.2).

Figure 1.2 What are the sources of burnout?

What they don’t understand is that healthcare workers, and physicians in particular, were not trained for the new complexities of health...