Burnout

Introduction

Burnout among doctors is becoming an increasingly recognised problem. It affects physicians’ performance and general wellbeing¹.

Whereas burnout appears to be inversely related to resilience, it has been associated with imposter syndrome^2,3. All of these terms are difficult to conceptualise but can be defined as follows: burnout is a state whereby there is physical, emotional and psychological exhaustion attributed to chronic work stress, resulting in reduced professional efficacy⁴. Imposter syndrome is another work-related syndrome that is associated with burnout and suicide. It is defined as the inability to internalise personal or professional success, with tendency to attribute this to other external factors such as luck, error, or knowing the appropriate individuals³. Whereas burnout is classified as a phenomenon by the 11th Revision of International Classification of Diseases (ICD 11), imposter syndrome is recognised as a medical condition⁴, and it is prominent among highly successful individuals. On the other hand, resilience is the ability to bounce back from significant adversity or stress⁵.

The scope and impact of the problem

One of the first national reports we have here in the United Kingdom (UK) on burnout comes from the General Medical Council (GMC) survey which was conducted in 2018. This concluded that one fifth of trainers and a quarter of trainees felt burnt out to
high or very high degree¹. Similar trends were seen in 2019 and 2020^6,7. Also, in a cross-sectional study conducted by the British Medical Journal (BMJ) on resilience, burnout and coping mechanisms among 1651 doctors in the UK, 31.5% had high burnout⁵. Similarly, the Royal College of Physicians (RCP) of London and the RCP of Edinburgh conducted a survey in 2018 on the state of wellbeing, involving half of all the substantive consultants⁸. 2,372 (32%) responded to the survey which used the Maslach Burnout Inventory (MBI) (https://nam.edu/valid-reliable-surveyinstruments-measure-burnout-well-work-relateddimensions). Of those, 23% experienced two or more of the six features of burnout almost always or most of the time, while 14% experienced three or more always or most of the time.

On an international scale, similar patterns are seen in other parts of the world⁹. A Medscape survey in 2020 found that 42% of United States (US) physicians reported burnout¹⁰. Consistent percentages among physicians were reported over the years 2018¹¹ and 2019¹². In this 2020 US based survey, 44% of cardiologists were affected. Among the common causes identified for burnout in this survey were: excess bureaucratic tasks, long hours, lack of respect from staff, administrators and colleagues, increasing computerised practice, insufficient reimbursement and compensation, and lack of autonomy.

The emphasis on understanding the phenomenon of burnout comes from its consequences on doctors’ own wellbeing as well as patient care. Burnout is associated with increased incidence of medical errors, suicide and drug and alcohol abuse. There is also an association between burnout and physicians quitting clinical practice, with substantial impact on the health care system as a whole¹³.

Focussing on burnout among cardiologists

A few qualitative studies looked into burnout syndrome among cardiologists in different parts of the world including for example the US, Argentina, Pakistan and Spain^9,14-16.

Focussing on more recent studies, in Nov 2019 the Journal of American College of Cardiology (JACC) published a study on burnout specifically conducted among the cardiologists in the US¹⁷. The American College of Cardiology (ACC) emailed the professional life survey (PLS) to 10,798 cardiologists and fellows in training; 2,313 (21%) responded. Of those who responded, 58% were males and 42% were females. The survey consisted of 10 questions relating to professional wellbeing, using the Mini Z scale (https://edhub.amaassn.org/data/journals/stepsforward/937327/10.1001stepsforward.2017.0010supp3.docx) to measure the emotional component of burnout. Despite the fact that 73.2% of respondents did not report burnout, 49.5% admitted being under stress and lacking energy. 26.8% reported that they were burnt out, and of those, 1.2% felt that they were completely burnt out to the point where they may need possible external help¹⁷.

Burnout in this study was most prevalent in those with 8-21 years of experience in cardiology, whereas the lowest prevalence was noted among those in training (49% versus 10%). 31% of females reported burnout, whereas only 24% of males did. The sub-speciality within cardiology did not seem to have an impact on burnout prevalence¹⁷.

Various factors within the working environment seem to correlate with more frequent reports of burnout (see Table 1).

With the use of multivariable analysis, the factors that were found to independently correlate with less chance of burnout included: family life satisfaction (odd ratio (OR): 0.46; 95% confidence interval (CI):0.34 to 0.63; p ≤ 0.001), having a mentor who served as a career role model (OR: 0.70; 95% CI:0.54 to 0.89; p = 0.004), encouraging cardiology as a career (OR: 0.61; 95% CI: 0.47 to0.89; p ≤ 0.001), and feeling of being treated fairly at work (OR: 0.683; 95% CI: 0.509 to 0.918; p ≤0.011)¹⁷.

In this study, the use of electronic medical records (EMRs) stood out as being among the most important causes of burnout. It was perceived to exert administrative workload and to have a negative impact on work-life balance. Burnt out cardiologists in this study have also reported significant rates of job stress, misalignment of professional values, poor care team efficiency, lack of control over workload, and hectic work atmosphere¹⁷.

How to address the problem

Doctors who suffer from burnout are likely to commit medical errors, and may tend to change their career¹³. Hence, it is clear that burnout impinges on the quality of care provided to patients. Identifying and highlighting the common causes of burnout can help advise on ways to address the issue, and will have a strategic impact on the health system.

Various interventions have been proposed to fight burnout, at both individual and organisational level⁹. Public Health England has flagged up a few factors at organisational level that can be modified or targeted, and that can prevent burnout including: job autonomy and job security, opportunities for flexible working, culture of participation, equality and fairness, staff engagement, strengthened role of line managers, and opportunities for promoting employees’ mental wellbeing¹⁸.

The Mayo Clinic Programme for Support and Solution also suggests a few steps to address the issue of burnout, ranging from acknowledging the problem in the first place, to following measures such as promoting flexibility and work integration, or facilitating and funding organisational science¹⁹.

At an individual level, stress management through cognitive behavioral techniques was found extremely helpful in treating and preventing burnout in healthcare professionals (20). Also, in a randomised controlled trial , a team-based, 12-week, incentivized exercise program had a statistically significant positive effect on quality of life. Burnout was nominally lower in participants than in nonparticipants (24% vs 29%; P=0.17)²¹.

Mindfulness has also been shown to reduce stress and chance of burnout²⁰. It is a self-directed practice that focusses on the conscious awareness of the here and now¹⁸. It uses techniques such as meditation, breathing and yoga, to help individuals manage their thoughts and feelings rather than being overwhelmed with them. It has been incorporated into psychological therapies and stress reduction programmes (e.g. Mindfulness-Based Cognitive Therapy (MBCT) is recommended by the National Institute for Health and Care Excellence (NICE) for the prevention of relapse in recurrent depression²²).

While resilience has been shown to be a protective factor for burnout in some studies, some physicians with high level of resilience were still suffering from some degree of burnout².

The GMC gave some ideas and recommendations on how to address the well-being of doctors. In their 2019 survey, they advised that individuals need to know whom to talk to in their hospitals⁶. This has been followed by a few NHS Trusts, and we have witnessed the evolution of some new roles or bodies in the recent years such as the Guardian of Safe Working, junior doctors’ forums and the Freedom to Speak Up Champions. A social support group is another idea that is perceived to be of help. An initiative called #fightfatiguecampaign¹ was started by the Association of Anaesthetists and was endorsed by the Royal College of Anaesthetists. It included education on fatigue, sleep and how to manage shift working. The campaign increased the awareness about doctors’ need to have access to rest facilities during their shifts. It was an attempt to promote a culture in which the dangers of fatigue are recognised and addressed. It is an example of an intervention that aims to improve working conditions for doctors.

Unfortunately, there is a selection bias in using surveys, and without the use of structured mechanisms to identify burnout or the application of burnout scores on regular intervals, a large number of doctors who could be struggling with burnout are passed without being identified or noticed.

The use of the term “burnout” itself has its problems. It seems to imply failure of the individual, whereas the problem relies on the environment those individuals work in, and the burden of work that falls on them. Hence the president of the RCP encouraged the use of the term “moral injury” instead²³.

Conclusions

Burnout is an increasingly growing concern in the medical field. It has a huge impact on the wellbeing of doctors and on the quality of care provided to patients. Recognising the problem is the first step towards management. It is crucial to promote a culture of mindfulness and self-compassion among doctors, and to increase awareness at an organisation level of the magnitude of the problem in order for those organisations to focus on doctors’ well-being, improve their working conditions (e.g. rota pressures, reimbursement, fair treatment, reduce bureaucratic tasks, etc..), and to create opportunities for them to access mental health support and resilience and stress management courses.

Disclosures

None

References

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