Strategies to prevent burnoutBMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7192.2 (Published 01 May 1999) Cite this as: BMJ 1999;318:S2-7192
Burnout is one of the potential hazards of a medical career. Chris Johnstone, who is now enjoying part time work in psychiatry and runs courses on preventing burnout at Bristol University, looks at what we can do to reduce the risk.
Ten years ago, I crashed into a rock-face. I'd fallen asleep at the wheel of my car while on holiday in Scotland. My car was a write off, but I escaped with a grazed knee. At that time, I'd been working for several years as a junior hospital doctor, most recently in a busy obstetrics unit. For some time, I'd had the feeling that my life had gone sour: I felt empty inside, I was losing my ability to care, and I hated what my job was doing to me. The car accident seemed like a message: if you keep driving on and on when you need to stop, you're likely to crash. I was severely burnt out, and it took a crisis to prompt necessary change. When I got back from my holiday I handed in my resignation. While many doctors do leave the profession well before retirement age, we may not have to reach the point of choosing between medicine and having a life. Instead, we can practise strategies to prevent burnout and protect our quality of life at work.
Awareness of the problem
Burnout is “a state of physical, emotional and mental exhaustion caused by long term involvement in situations that are emotionally demanding.”(1)
While we may all feel worn out by work at times, burnout is when we feel so chronically ground down that our life and work suffer. Doctors are a high risk group: a recent study of general practitioners showed that nearly 60% felt that their physical health had suffered as a result of overwork.(2) In its more severe forms burnout leads to a lack of interest in work, complete disillusionment, hostility to patients, and feelings of hopelessness. Both the sufferer and the service lose out.
Symptoms of burnout
Loss of energy
Loss of interest in work
Loss of optimism
Hostility to patients
Nothing left to give
Dreading going to work
The first strategy for preventing burnout is to be aware of it as a potential problem. If we recognise that we work in an area of high risk, we can take steps to protect ourselves. Awareness is also needed at an organisational level, for burnout is as much a problem of organisations as of individuals. For example, high staff turnover, high levels of absenteeism, low morale, and poor service delivery are all organisational symptoms of burnout.
Some would argue that pressure is good for you, as it can improve performance. This is true up to a point, but the key is knowing where that point is and whether you have stepped beyond it. I think of those circus performers who spin plates on sticks. With just one plate, we may get complacent or bored. It is when we feel challenged that we wake up and our performance improves. At peak performance, we are spinning so many plates that our adrenaline rises and we are completely absorbed.
But each additional plate after that pushes us into overload, experienced as stress. When we spin too many plates for too long our performance suffers, we get worn down, and plates fall.
A graph can be drawn to represent this relation ship between pressure and performance. Self monitoring involves asking ourselves at regular intervals where we are on this graph. We can learn to recognise the warning signs of stress, and take action before plates start dropping.This may involve accepting that, when in overload, we can often achieve more by trying to do less.
Identify main stresses
What are the things that most wind us up or grind us down? Specifying what we find difficult puts us in a better position to change it. For example, if we identify interruptions as the most stressful aspect of busy clinics, then we can take steps to tackle this. A problem solving approach is useful, in which we list as many possible responses as we can think of and then choose options that move us forward. Doing something about a problem can make us feel better, even if our action is only a small step in the right direction.
Reviewing expectations and obligations
Like a hedge that needs to be cut back from time to time, our commitments need regular review and pruning in order to prevent overload. It is worth listing all the roles that we play in our life and then identifying the demands we experience from them. When two roles conflict we may be squeezed between competing demands that can't all be met. When it is difficult to juggle all the needs of home and work, or of different teams we belong to, something has to go. For each of the demands listed, ask yourself what the consequences would be if you didn't meet them. Who would notice, who would lose out, and who would benefit? By doing this, you can prioritise those areas that matter most to you.
Assertiveness and negotiation skills are often needed to protect ourselves from overcommitment. Being clear with people makes them less likely to have expectations that we can't meet. However, it is the expectations we have of ourselves that can put us under most pressure. Difficulty in meeting high personal standards can create intense psychological strain, especially if we are caught between the feelings of “I must” and “I can't.” It is good to have ideals, but it is wearing when we can't keep up with them; this explains why idealistic people can be at greatest risk of burnout. Make a list of all your “must dos” and “should dos” and see how many are always achievable by fallible human beings.
A positive emotional bank balance
There are things that nourish us and things that drain us. If, over time, we are more drained than nourished, our inner reserves will run dry. If we are constantly giving out, we also need to have as much coming back in. This concept is commonly accepted in personal finance, but it is rarely applied to emotional energy. Doctors listen, care, attend, encourage, and support. But what of our needs? A useful exercise is to list the aspects of our life or work that drain us and then write another list of those aspects that give us what we need in order to thrive. How does the balance look? Paying attention to our own needs is not selfish, it is the essential maintenance that allows us to continue to care.
One of the things that feeds us is the experience of success. If we don't get this we are likely to become disillusioned. How do you define success in your work? Is it easy to measure? Are you likely to notice it? If patients get well we may not see them again, but if they don't get better they will return to tell us about it. This creates a bias in reporting in which we are more likely to hear about our failures than our successes. Patients are increasingly invited to make complaints if they are dissatisfied with an area of service. We also need to build in mechanisms for hearing about the times we get it right.
A potent cause of burnout is feeling that, no matter how hard we try, we can't make any real impact in our work. We are more likely to feel this when we are overloaded and under- resourced. It is therefore important to have clear goals that are achievable in our work. These goals must be ones we value, and we need a way of knowing when we have achieved them.
Reviewing support networks
Many doctors are good at asking for support when they need technical information about a clinical matter. However, it is harder to ask for help when we risk exposing an area of weakness or vulnerability. Difficulties in coping are often perceived as personal failure rather than as in the nature of the work or as symptoms of an organisational problem. If everyone puts on a brave face, you can have a team in which every member is struggling but each thinks that he or she is the only one with a problem. This leads to suffering in isolation, which increases the risk of burnout. Who do you turn to when you are in need? Good support networks, both formal and informal, help protect against burnout.
Burnout is a problem not just of individuals, but also of healthcare teams and services. The most effective preventive strategies involve both personal and organisational measures. On a personal level, a career in medicine is like running a marathon. We need to choose a pace and a path that we can sustain for the long haul.
I thank Elisabeth Winkler for her comments on this article.