The Coalface of Burnout

You can’t step away from your EpicCare EMR platform for long these days before overhearing someone talking about alarmingly high rates of physician burnout. Burnout in physicians appears to undermine empathy and professionalism, drive professional drop-out and turnover, lead to patient care errors, discourage young physicians from pursuing primary care, and cause significant distress for physicians themselves. The conversation about burnout encompasses the urgent and the humorous. One doctor advises us all to fight burnout like the plague while others approach the topic with more earnestness and pathos.

That’s because burnout is a somewhat flashy, un-scholarly term, and the term can therefore feel a little “soft”, as if it cannot be a “real” problem. It sounds unserious. The pioneers in the field of burnout research, Maslach and Jackson (1), were aware that burnout was a “pop” term when they chose to use it. They retained the word burnout because that was what the people they studied called it. This was the name for the struggles they were having.

I think this is right: the utility of burnout is its comprehensibility. Burnout is the coalface of the problem of physician experience. Burnout stands in for or signals a set of psychological challenges or risks faced by physicians that are far from unserious, including high rates of physician suicide, second-victim experiences, professional drop-out, bereavement, alcohol and drug abuse, moral distress, perfectionism, isolation, family conflict, overwork, exhaustion, detachment, and so on.

In fact, burnout has a very specific definition and is quite reliably measured by self-report. Burnout is a construct comprised of three domains: emotional exhaustion, depersonalization, and a lack of personal accomplishment. Emotional exhaustion is a feeling of being emotionally overextended and entirely drained from work; it’s that experience of having nothing left to give. It can lead to efforts to avoid colleagues, patients, and work-related activities. Depersonalization is an experience of feeling detached from patients and colleagues. It is a feeling that others are objects to be managed rather than people. A lack of personal accomplishment is a feeling of a lack of competence, success, or fulfillment related to work. This physician may feel that work has lost its value or meaning. To a degree, each domain moves independently. For instance, a physician can report that feelings of personal accomplishment are preserved even in the face of extreme emotional exhaustion. This physician could still “count” as burnt out (2).

What causes burnout? Six components of one’s job appear important (3): workload, control, reward, community, fairness, and values. Workload is the sheer amount of work we have to do; control is the degree to which we can make choices about that. Reward means the ability to receive recognition and compensation for that work. Community indicates the quality of the relationships and social contacts we have at work as well as the overall interpersonal climate there. Fairness means the extent to which our workplaces have equitable and consistent rules that apply to all. Finally, values indicates the degree to which our values and those of our workplaces are consonant.

Chesluk and Holmboe’s (4) description of the “fictive schedule” is my favorite symbol for burnout. We can see all six contributors to burnout in the phenomenon of the fictive schedule, which Chesluk and Holmboe developed through ethnographic work in physician practices. They noticed that each morning physicians received the day’s schedule and took time to review their upcoming appointments. A long list of unvarying 15-minute appointments appeared on the print-out or computer screen. Perusing the schedule, physicians explained how the day would actually go. “This patient will take at least half and hour” and “this one’s a real nightmare.” Then, of course, urgent and emergent cases would be “squeezed in” despite the lack of actual space in the schedule. The physicians greeted each patient with a smile, but they lacked time to complete the work involved in taking care of these patients (documentation, billing, checking labs, emailing), and so they spent several hours in the evening catching up. The workplace was not entirely rushed and inflexible. The ethnographers often observed support staff taking spontaneous breaks after an especially busy period (“Whoo! It’s been crazy. I’m going to step outside for a break,”), but no physician was ever observed to take any break at all.

Think of the fictive schedule and check them off: overwork, lack of control, lack of reward (for overtime), isolation instead of community, a lack of fairness (only some people can rest when tired), and a mismatch between the organization’s mission (caring for four patients an hour) and the physician’s (do what must be done to care for the patient). A conflict of values may also be contained in the fact that the schedule is created each day even though everyone recognizes that it is inaccurate. The physician has learned to behave as if the fictive schedule were real, smiling for each patient, ignoring the fact that fifteen minutes is insufficient, catching up in “off time”, and skipping breaks in the day to be as productive as possible. If you were to allow yourself to feel anything at all about this situation, could you avoid feeling exhausted, undervalued, emotionally drained, and resentful of patients?

The fictive schedule focuses our attention on time, but Sinsky and colleagues (5), forwarding a provocative expectation for joy in practice, focus on the menial-ness of the tasks that fill up that time. Bluntly and wisely, they say: “The current practice model in primary care is unsustainable. We question why young people would devote eleven years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training.”

But keeping the six contributors to burnout in mind can be freeing. We can grasp onto many levers for change. For instance, we may immediately think of overwork as the cause of burnout, and it can be extremely difficult to change that, but workload is not burnout’s major or sole determinant. Even if workload could be perfectly managed to never overwhelm, studies show that burnout would not disappear. Developing a warm, supportive climate at work, requesting (if you are not the boss) or practicing (if you are) transparency about rewards, or finding ways to exert a little more control at work can all be helpful. In one study, the largest predictor of burnout was the time spent doing the activity that the physician found most meaningful. Those who spent at least 20% of their time on the activity that was most meaningful had half the rate of burnout as those who spent less than that. That is, consciously doing what you love about being a doctor one day a week could help a great deal (6). “The Physician’s Formulary” (link above) offers a few ideas for avoiding burnout.

In these ways, all this talk about the plague of burnout might remind us to open spaces for accessing and deepening feelings at work. In my experience, most physicians find their relationships with patients to be the fount of meaning in medicine. To that end, in the next post, I plan to write a little about a time-tested approach to deepening one’s experience of the relationship between the doctor and the patient, the Balint group. In the meantime, some of the readings linked from this page are offered as options to reflect, engage, or unplug.

Further Reading:

 

1. Christine A. Sinky et al. (2013), “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices,” Annuals of Family Medicine 11(3): 272-278.

2. Tait D. Shanafelt et al. (2009), “Career Fit and Burnout Among Academic Faculty,” Archives of Internal Medicine 169(10):990-5.

3. Michael Leiter & Christine J. Maslach (1999), “Six Areas of Worklife: A Model of the Organizational Contexts of Burnout,” J Health Hum Serv Adm 21(4): 472-89.

4. Benjamin J. Chesluk & Eric S. Holmboe (2010), “How Teams Work – or Don’t – in Primary Care: A Field Study on Internal Medicine Practices,” Health Affairs 29 (5): 874-79.

5. Christina Maslach & Susan E. Jackson (1984), “Burnout in Organizational Settings,” pp. 133-153, in S. Oskamp (Ed.) Applied Social Psychology Annual Volume 5. Beverly Hills, CA: Sage Publications.

6. Liselotte N. Dyrbye et al. (2013), “Physician Satisfaction and Burnout at Different Career Stages,” Mayo Clin Proc 88(12): 1358-67.