Before the COVID pandemic, the medical community in general, and physicians in particular, were dealing with and continue to deal with a pandemic of its own: Burnout. In 2019, burnout was categorized as a disease by the WHO. It is characterized as:
“…a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”
There are 3 dimensions of burnout:
- Feelings of energy depletion
- Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job
- Reduced professional efficacy
If someone is suffering from any of these dimensions, they are considered burned out. Unlike depression or other mental health diagnoses, burnout is mostly an occupational phenomenon. This is particularly important when examining the effects of COVID on burnout. If any of the factors that lead to burnout is impacted in a negative way, then the impact on burnout is transferrable to the physician. In simple terms:
If A (Causes) leads to B (Burnout), and C (COVID) increases the magnitude of A, then the outcome, B, is also increased.
So let me divide the rest of this blog into three parts: A, B, and C.
A: Causes
Review of the literature identifies several factors that contribute to burnout. When Christina Maslach developed the Maslach Burnout Inventory, she described the three main causes of burnout:
- Unmet expectations
- Lack of control
- Insufficient rewards
From: Maslach C, Zimbardo PG. Burnout: The Cost of Caring. 2003. Malor Books. Lost Altos, CA.
According to a Medscape survey, the translation of these categories in medicine in terms of measurable and identifiable factors have been proven/shown in numerous studies; they include the following:
According to the AMA and research conducted by Medscape, the following risk factors impact burnout:
- Working too many hours: 3% increase each additional hour
- Taking night or weekend call: 3%-9% each shift
- Performing work-related tasks at home: 2% each hour
- Having a work-home conflict: 200%-250%
- Practicing in certain specialties – ER, IM: 300%
- Working in private practice: 20%
- Receiving incentive pay: 130%
- Feeling like a cog in the wheel
- Using computerized physician order entry or enduring other clerical burdens: 29%
- Scrutiny, evaluations, lawsuits, increasing demands
Other causes of burnout are linked to leadership or the lack of it. In 2015, Tait Shanafelt in a landmark study showed:
- “…Mayo has demonstrated the importance of front-line leadership on the well-being and professional satisfaction of physicians.
- For every point upward on a 60-point scale, there was 9% greater staff satisfaction and 3.3% less burnout.
- At the department and division level, 11% of the variation in burnout and 47% of the variation in satisfaction with the organization was explained by the Leader Index of the chairperson.”
From: Shanafelt, T et al. Impact of Organizational Leadership on Physician Burnout and Satisfaction. Mayo Clinic Proceedings. 4/2015 90(4): p. 432-440 4. Swensen, S., et al.
The expression goes: “People quit their bosses, not their jobs.” We know now that poor leadership makes for higher burnout.
- Pressure “is where the outcome is important to you, it is uncertain, and you are accountable and judged for the results. You must deliver the goods or suffer dire consequences. It adversely impacts cognitive success, downgrades behavioral skills, we perform below our capability, often camouflaged and is continually increasing.” Weisenger H, Pawliw-Fry JP. (2015) Performing Under Pressure: The Science of Doing Your Best When It Matters Most. New York, NY: Crown Business.
- Personal characteristics include perfectionism, idealism, certain personality types, racism, and being self-critical.
- Last but not least, physicians lose their purpose and the ability to fulfill our needs. When they are not able to emotionally connect to their patients, demonstrate clinical competency, and be professionally autonomous, they become burned out.
B: Burnout
According to psychologists Herbert Freudenberger and Gail North (Jan. 2019), burnout goes through a 12-stage model:
- Compulsion to prove oneself
- Working hard – with an inability to switch off
- Neglecting basic needs – lack of sleep, lack of healthy eating, lack of social interaction
- Displacement of conflicts – problems are dismissed
- Revision of values – values are skewed, friends and family dismissed, hobbies irrelevant
- Denial of emerging problems
- Withdrawal – social life small or nonexistent
- Odd behavioral changes – changes in behavior obvious to friends and family
- Depersonalization – seeing neither self nor others as valuable
- Inner emptiness
- Depression
- Burnout syndrome – includes mental and physical collapse; medical attention required
How these 12 stages manifest are effectively summarized in one of several landmark studies by Tait Shanafelt.
