Burnout among doctors
BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3360 (Published 14 July 2017) Cite this as: BMJ 2017;358:j3360
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Spurred on by an article from BMJ Careers in November 2015 on Balint groups (1), as well as recognition of our own rising stress levels, we set up a monthly discussion group open to all oncology registrars in our centre, and facilitated by a medically qualified member of the chaplaincy team (SH). This has evolved into a monthly sandwich lunch taken together with accompanying reflection on any problems arising.
Topics have been wide-ranging, reflecting on all the 3 dimensions of burnout from Lemaire and Wallace’s opening paragraphs (depersonalisation, exhaustion, and professional inefficacy) (2). The group has covered handling of high stress situations (on call, at night), decision-making under pressure, working with uncertainty and rehearsal of difficult discussions. The impact of underfilled rotas, unsupportive colleagues and the absence of ‘team’ have been aired as well as the challenges of combining research and clinical work, dealing with the pressures of raising a young family, revision for exams and coping with emotionally demanding patients. Discussions have also featured the effect of patient complaints and exploration of personal strategies for self-care.
As part of the process, we have asked participants to complete the Oldenburg Burnout Inventory (OLBI), a validated instrument for assessing burnout (3). 11 responses were returned. The median score was 42 (range 29-56, maximum possible score 64); with exhaustion component scores being generally higher than disengagement component scores. 80% of the registrars’ scores were “high to very high” for burnout, according to BMA online OLBI banding.
However, the survey feedback on the value of the debriefing group was highly positive; themes emerging from the comments were those of ‘sharing/openness/honesty’, ‘discussing difficulties/inadequacies’ and ‘support/community’. ‘Silo- demolition’ and ‘abolition of fearful autonomy’ were articulated as well as ‘team building’, ‘catharsis’ and ‘permissive disclosure in an open, non-judgemental environment’.
In contrast to the mention in Lemaire and Wallace’s article of juniors adopting their seniors’ maladaptive behaviours, this reflective peer support group has become embedded in our department, presaging redefinition of the ‘hidden curriculum’. The consultants in the oncology department are now involved in their own similar ‘Safety Net’ group, an opportunity to address the unique challenges faced at this level. The chaplaincy facilitator for our group has also encouraged other departments in the hospital to start their own groups, including paediatrics and neurology. ‘Human resources are the most important asset of any organisation’: our belief is that peer debrief groups will become more widely established across our organisation and others, and that healthcare quality indicators should include the presence of such system level interventions aimed at maintaining doctors’ wellbeing.
References:
1. Murphy CL, Perry J, Luthra VS, Boyle A. How to encourage reflection on the doctor-patient relationship. BMJ Careers 2015. Available from: http://careers.bmj.com/careers/advice/How_to_encourage_reflection_on_the... [accessed 15th August 2017]
2. Lemaire JB, Wallace JE. Burnout among doctors. BMJ 2017;358:j3360.
3. Halbesleben JRB, Demerouti E. The construct validity of an alternative measure of burnout: Investigating the English translation of the Oldenburg Burnout Inventory. Work Stress 2005;19:208–220.
Competing interests: No competing interests
As final year medical students, we read ‘A system level problem requiring a system level response’(1) with interest. During our time at medical school, we have been made acutely aware of the pressure on doctors and the consequences of burnout on both our seniors and our peers. We are concerned about the repercussions of the stressed system not only on current doctors but also on the future generation of doctors. This is a pertinent issue as we see morale plummet in our peers and as we read of increasing numbers of students considering leaving medicine(2).
Burnout affects students both directly (35–45% prevalence(3)), and indirectly due to the consequences of working alongside burnt-out doctors. Factors which contribute to burnout in students are important to recognise not only for the sake of students, but also because they offer further insight into the current problem and possible solutions. Factors cited by the authors which contribute to burnout in doctors (individual, medical profession and healthcare organisation factors) also affect students, and there are further student-specific factors(1).
Students are particularly affected by feeling uncertain about their role in the team, examination pressure, and negative doctor-student interactions(4). Stressful relationships with supervisors and a disregard for personal needs are not only associated with burnout(4) but are unfortunately not an uncommon experience. This is a symptom of a sick system and stretched clinicians, whose emotional reserves have been depleted
Furthermore, advice and role-modelling given by burnt-out seniors may contribute to burnout in students. The authors state that ‘Learners witness and adopt their teachers maladaptive behaviours’(1), and this unfortunately is something we witness frequently. For example, it seems commonplace to encourage students to forge a work-life separation, and to ‘leave the day at the hospital door’. However, does this kind of sentiment give permission, let alone encourage, students to reflect and process difficult emotions; essential in preventing burnout?
Preventing burnout in doctors and students is essential to minimise the risk to the current workforce and their patients, but also to prevent a burnout ‘epidemic’(1) affecting the next generation. The swathes of junior doctors leaving the NHS to work abroad(2) is a testament to the dangers of this. We believe that improving the dialogue between medical student and doctor is a crucial aspect to addressing the problem. Students are responsive to senior clinicians taking an interest in their wellbeing and to positive role modelling(3). However, it is unfair to expect burnt out doctors to have the capacity to engage with medical students on a personal level and to model healthy behaviours. System-level change is required to ease the pressure on senior doctors and allow them to nurture the next generation. This, in time, will help nurture safer and happier doctors who in turn will foster a more supportive culture and be more resilient to burnout when working pressures mount(2).
1. Lemaire JB, Wallace JE. Burnout among doctors. BMJ (Clinical research ed.). England; 2017. p. j3360.
2. Rimmer A. Half of doctors don ’ t go straight into specialty training. 2017;672:1–2.
3. Dyrbye L, Shanafelt T. maintaining well-being A narrative review on burnout experienced by medical students and residents. 2016;132–49.
4. Shanafelt, Tait D; Bradley, Katharine A; Wipf, Joyce E; L. Back A. Burnout and Self-Reported Patient Care in an Internal Medicine Residency Program. 2017;(February 2001).
Competing interests: No competing interests
Individual and organisational interventions will only go so far.
The fundamental problem is the conflict between the system and what the doctor has been trained to do - practise good medicine.
I have just published a book ‘The Tyranny of a System -The NHS ‘. This explains how the NHS has ended up tyrannising the workforce resulting in a dysfunctional and inefficient health service in which burnout is more likely.
The consultants who in the past provided the glue for how hospitals functioned are no longer listened to by anyone other than by their patients.
My suggestion is to reverse the power that management has at the moment in virtue of having the last word where the money goes.
Instead the money should flow from what arises out of what is basic to what looking after patients is about - the doctor/patient encounter - and be seen to do so. This will need medical supervision.
The likely result too is a more efficient NHS.
Competing interests: No competing interests
In the seventies, I was a Registrar in obstetrics and gynaecology at a major London teaching hospital. I was on a one in three rota, effectively working 36 hour shifts in the week and 60 hour shifts at weekends.
One morning, my consultant announced that he would be trekking in the Himalayas for three months and that I would be looking after his large private practice. I received no assistance from the other consultants, not even when my father died during this time.
Was I burned out after this experience? You bet I was. I lasted another six months in the specialty, and spent the next 35 years recovering in general practice.
Ross Ellice
Retired GP
Keston
Kent
Competing interests: No competing interests
The BMJ Confidential series gives an interesting inside view of esteemed medical figures, but it is somewhat disheartening noting the frequency with which “To whom you would most like to apologise?” is answered by a variant of “My partner/children”. For the last 50 profiles where this question was answered, 21 people - 42% - gave this response, usually expanding by explaining the toll their working life had on their home life (1). The remaining 29 respondents apologised to previous patients, colleagues and other family members such as parents.
Together with the BMJ’s recent spotlight on burnout (2), these responses act as a reminder that we all need a life beyond medicine, and that our jobs affect not only us, but those around us.
1. 52 consecutive BMJ Confidential profiles analysed between 22 June 2016 (David Pencheon: Seeking sustainable healthcare. BMJ 2016;353:i3384) and 29 July 2017 (Pali Hungin: Racing beyond the boundary. BMJ 2017;358:j3549) inclusive.
2. Lemaire JB, Wallace JE. Editorial: Burnout damages more than just individuals. BMJ 2017;358:j3360
Competing interests: No competing interests
Lemaire and Wallace demonstrate that until change occurs at a systemic level, tools to tackle burnout such as education and stress reduction techniques supply us with coping strategies rather than solutions.
A striking observation from experience in Australia as a post F2 doctor was the abundance of junior doctors in comparison to NHS staffing levels. When arriving for my first weekend shift in an emergency department similar in size and patient flow to that which I had left in the UK, I was met by a team three times bigger than that which would routinely cover an equivalent NHS department. Doctors in ‘relief’ positions were employed by the hospital on a permanent basis to provide cover for sickness or annual leave.
Both patient care and junior doctor job satisfaction benefitted from the luxury of time. A well staffed department meant cover could easily be organised to attend training days and sickness absence was not accompanied by the guilt of leaving already over worked colleagues a man down.
To enhance doctors wellbeing, we need more doctors. Not only do we need rotas which are fully staffed, but in reality we need more positions than our rotas currently include. As more doctors experience burnout, take sick leave or even leave the profession, the problem will self perpetuate. It’s time we pay attention.
Competing interests: No competing interests
One cause of burnout is an educational system which is not well balanced. A UK GP does the bulk of their training at the beginning of their career. Opportunities for for career development have to fit around a relentless schedule of service. Rather than add another year to GP training, that year could be divided up into study leave breaks to be taken throughout a GP's career.
Competing interests: No competing interests
Burnout syndrome has become an important topic in health-related economics. But more research is still needed to establish the scientific basis for this entity, the criteria by which it might be diagnosed and classified. Until now, there currently exists neither an officially accepted definition (not in ICD-10, DSM-IV or DSM-5) nor a valid instrument for the differential diagnosis of burnout syndrome. There are no controlled trials of treatments for burnout. Most of the studies on its epidemiology provide a low level of evidence.
High-quality controlled studies on burnout syndrome are lacking. A standardized and internationally accepted diagnostic instrument with a validated rating scale should be developed. There a few studies about an association of medical errors by doctors with resident distress, burnout syndrome [1] and lack of sleep. But In view of the current lack of knowledge about burnout syndrome, the term should be used more carefully. Treatments for it should be studied systematically so that their effects can be judged at a high level of evidence. There is an evident, complex relationship between burnout and depressive disorders [2]. Some authors see a burnout syndrome as a risk factor for the development of a depressive disorder [3].
1) West CP et al.: Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. J Amer Med Ass 2006; 296(9): 1071–8.
2 Ahola K et al.: The relationship between job-related burnout and depressive disorders – results from the Finnish Health 2000 Study. J Affect Dis 2005; 88: 55–62
3) Nil R et al.: Burnout – eine Standortbestimmung. Schweiz Arch Neurol Psychiatr 2010; 161: 72–7
Competing interests: No competing interests
Burnout has been defined as a work-induced syndrome combining emotional exhaustion, depersonalisation, and a sense of reduced personal accomplishment. In their editorial, Prs Lemaire and Wallace [1] provide us with an overview of the issue of burnout among doctors. According to these authors, despite heterogeneity in how burnout has been conceived of and assessed in past research, the overall evidence suggests that burnout has reached epidemic levels among physicians. In my estimation, the ‘burnout epidemic view’, although widely relayed in medical journals, is unsubstantiated.
Because there are no diagnostic criteria for burnout, the prevalence of burnout among physicians (or in any other occupational group) cannot be estimated [2]. As pointed out elsewhere, the spotlighted estimates of physician burnout prevalence rely on categorisation criteria that are (a) clinically and theoretically arbitrary, (b) malleable at convenience, and (c) potentially over-inclusive in view of what full-blown burnout has been assumed to be [3, 4]. Such research practices are eminently problematic and leave the ‘burnout epidemic view’ without any valid or reliable basis. Worryingly, the nosological blur surrounding burnout persists for more than 40 years, thus showing strong inertia. Considering that even the ability of burnout measures to specifically assess work-induced suffering is open to question [3, 5-7], it may be time to discuss the very use of the burnout construct in occupational health research.
Given the major problems affecting burnout research, and the well-established overlap of burnout with depression [2, 8], a resource-saving strategy may be to focus on job-related depression rather than burnout. By contrast with burnout, depressive disorders, under their various forms, are diagnosable [4]. Consequently, their prevalence can be accurately estimated. Methods for etiologically linking depression to work stress are available, in both research and clinical settings [2, 9]. Just as burnout, depression can be (a) examined from both a social and an individual standpoint [8] and (b) relevantly approached dimensionally (i.e., on a continuum, as a process) [10]. Regarding the often-raised issue of stigma, it is noteworthy that there is no clear evidence that the burnout label is currently less stigmatizing than the depression label [11, 12]. Interestingly, in a recent interview-based survey (N = 1,600), about eight of ten participants considered work stress a possible cause of depression—the study sample was representative of the general adult population of France in terms of place of residence, gender, age, and family status [13]. Such findings suggest that social representations of depression may be changing favourably among the Occidental public. All in all, focusing on job-related depression may boost research advance and allow us to more effectively protect doctors’ health in the future.
References
1. Lemaire JB, Wallace JE. Burnout among doctors. BMJ 2017;358:j3360. doi:10.1136/bmj.j3360
2. Bianchi R, Schonfeld IS, Vandel P, Laurent E. On the depressive nature of the “burnout syndrome”: a clarification. Eur Psychiatry 2017;41:109-110. doi:10.1016/j.eurpsy.2016.10.008
3. Bianchi R, Schonfeld IS, Laurent E. Can we trust burnout research? Ann Oncol in press. doi:10.1093/annonc/mdx267
4. Bianchi R, Schonfeld IS, Laurent E. Physician burnout is better conceptualised as depression. Lancet 2017;389:1397-1398. doi:10.1016/S0140-6736(17)30897-8
5. Hakanen JJ, Bakker AB. Born and bred to burn out: a life-course view and reflections on job burnout. J Occup Health Psychol 2017;22:354-364. doi:10.1037/ocp0000053
6. Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, Shanafelt TD. Personal life events and medical student burnout: a multicenter study. Acad Med 2006;81:374-384. doi:10.1097/00001888-200604000-00010
7. Verweij H, van der Heijden FM, van Hooff ML, Prins JT, Lagro-Janssen AL, van Ravesteijn H, Speckens AE. The contribution of work characteristics, home characteristics and gender to burnout in medical residents. Adv Health Sci Educ Theory Pract in press. doi:10.1007/s10459-016-9710-9
8. Bianchi R, Schonfeld IS, Laurent E. Burnout or depression: both individual and social issue. Lancet 2017;390:230. doi:10.1016/S0140-6736(17)31606-9
9. Rydmark I, Wahlberg K, Ghatan PH, Modell S, Nygren A, Ingvar M, Asberg M, Heilig M. Neuroendocrine, cognitive and structural imaging characteristics of women on longterm sickleave with job stress-induced depression. Biol Psychiatry 2006;60:867-873. doi:10.1016/j.biopsych.2006.04.029
10. Haslam N, Holland E, Kuppens P. Categories versus dimensions in personality and psychopathology: a quantitative review of taxometric research. Psychol Med 2012;42:903-920. doi:10.1017/S0033291711001966
11. Bianchi R, Verkuilen J, Brisson R, Schonfeld IS, Laurent E. Burnout and depression: label-related stigma, help-seeking, and syndrome overlap. Psychiatry Res 2016;245:91-98. doi:10.1016/j.psychres.2016.08.025
12. Dyrbye LN, Eacker A, Durning SJ, Brazeau C, Moutier C, Massie FS, Satele D, Sloan JA, Shanafelt TD. The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout. Acad Med 2015;90:961-969. doi:10.1097/acm.0000000000000655
13. Angermeyer MC, Millier A, Remuzat C, Refai T, Toumi M. Attitudes and beliefs of the French public about schizophrenia and major depression: results from a vignette-based population survey. BMC Psychiatry 2013;13:313. doi:10.1186/1471-244x-13-313
Competing interests: No competing interests
Fatigue
We read and hear a lot about Fatigue, a subject I have studied and written about for many years. Comparison was made recently with the medical profession and pilots.
There are two types of fatigue, acute and chronic. Both are clinical entities and are a diagnosis. Burn out and stress are just terms describing a chronic fatigue symptom and a chronic fatigue cause. Many managements do not like discussing anything to do with fatigue, as it is seen as an excuse for not working. Some airlines are quite draconian about doing nothing about fatigue prevention or even recognising it. Some aviation authorities’ pay the problem limited lip service, but will take no formal legal steps to prevent it as it would interfere with the commercial side of airline operations. Many airline pilots are worked to the limits and some just over. Many pilots worldwide will not complain for fear of losing their job. This state of affairs can be found in every walk of life.
Some pilots I have had to ground permanently, as their chronic fatigue state will not reverse back to a normal circadian rhythm, enabling them to return to work. Exposure a second time to the same stressors brings the condition back even more quickly than the slower onset of the first illness.
It is no good just talking about it, specific rules and regulations need to be quickly put in place for all people exposed to hard working conditions and where this insidious condition can be recognised early by qualified observers. Surveillance programmes are needed, but above all the condition needs to be recognised as a formal illness, where compensation can be paid if management is found guilty of negligence.
If something is not done about it very soon, there will be accidents, and mistakes will be made, if they have not begun to happen or are happening already.
Yours sincerely
Dr Ian Perry
Consultant in Occupational and Aviation Medicine
Competing interests: No competing interests