Burnout: What it is, what it isn't, and what to do about it.
Over the last few years, ‘burnout’ has become a more frequently used word in medical and healthcare circles. The term is heard in discussions about conditions, individual practitioners, or new work demands. However, although the term is used often, most people do not have a clear understanding of the condition, its complex aetiology, and the possible consequences of burnout.
Concerningly, within clinics, hospital corridors, and operating theatres, coexistent with the poor understanding of burnout there can be an unvoiced sense that those who become burnt out are somehow ‘not up to it.’ The resulting shame felt by those who suspect they may be suffering with burnout will lead to them hiding, or denying, their symptoms and delaying help. But even those who believe that there is a stigma attached to individual burnout intuitively ‘know’ that organisational practices are implicated in the problem.
Given that burnout is a condition associated with workplaces that can lead to physical and psychological consequences as well as worsened patient outcomes, understanding burnout requires consideration of medical and psychological concepts, treatments for ill-health and interventions to maintain wellbeing, as well as investigation of occupational systems and processes.
Therefore, this article is intended to address these points and lead to a more uniform comprehension of the problem. Hopefully we can facilitate deeper understanding, empathy, and treatment for those afflicted, and enable attention to be focussed on actions that will reduce burnout for those at the coalface.
What it is:
Burnout is a growing problem affecting doctors more than other professions (1) and impairing both the capacity and the quality of one’s work (2). Burnout both contributes to, and results from, our struggling healthcare systems. In addition to poorer work outcomes, burnout has impacts on the doctor’s own physical and psychological health (3), and ramifications to other parts of life such as family relationships (4). With this context in mind, it is essential that we understand a condition which is increasingly part of daily discussions and influencing healthcare systems.
The World Health Organisation listed burnout in the International Classification of Diseases 11th?revision (ICD 11) as a workplace or occupational phenomenon. Although not classified as a disease, it is described as a syndrome that influences an individual’s health status. Burnout results from chronic stress at work and the interactions between work demands, individual capabilities, and organisational processes (5). The unremitting stress causes persistent overactivation of the sympathetic nervous system (6) with a constant ‘fight-flight’ response with chronically increased allostatic load with subsequent adverse health effects (7, 8).
In any person there are many elements to burnout, with contribution from individual make-up and medical training, as well as organisational aspects such as workplace demands, workload, and culture. Further aspects that are a little more difficult to measure can be described as “moral injury”. In this setting an individual’s expectations of mission, fairness, reward (financial and other), behaviour, communication styles, sense of community, and goals are seemingly misaligned with the overarching organisational structure.
The features of burnout are threefold:?1.?Intense energy depletion and emotional exhaustion,?2.?increased mental distance from work and detachment from one’s job with negative or cynical feelings towards the role,?3.?feelings of reduced professional efficacy (9).
Burnout was first coined as a term and concept 50 years ago (10) with the recognition that prolonged workplace stress could impact on an individual with associated decreases in cognitive, judgemental, and emotional capabilities. While burnout can occur in any job, ‘caring’ occupations that involve interpersonal interaction and empathy have a higher incidence. Clearly healthcare is built around empathetic therapeutic relationships, however the first modern profession described as suffering from burnout was in fact that of air traffic controllers when burnout was associated with several fatal air disasters (11).
High rates of burnout are seen in doctors throughout the world. In a systematic review incorporating data from 45 countries in 2018, prevalence ranged up to 80 % (12). The incidence has further risen since the onset of the global Covid 19 pandemic (13). In 2020 the Australian Medical Association reported that 65-75% of Australian doctors have a degree of burnout (14). This means that either you, or a colleague nearby, is likely to be suffering with burnout.
Subsequent risks for those suffering with burnout include alcohol and substance abuse (4), anxiety/depression (15), and higher risk of suicide (16). Burnout causes both physiological and psychological stress (17) and is associated with increased all-cause mortality (18).
When doctors become burnt out there are associated effects on clinical practice with decreased patient satisfaction (19), increased rates of serious medical errors (2, 20), and increased litigation. Clearly, poorer medical staff health and worsened patient outcomes cause organisational-level challenges (21). Concerningly, burnout can commence before one becomes a doctor – first appearing in medical school (22).
The recognition, and estimation of severity, of burnout is based upon psychological scales with the ‘gold-standard’ scale being the original Maslach Burnout Inventory (MBI) (23). The MBI is very influential and has in a sense come to define the concept of burnout, as well as attempt to measure it. First published in 1981 (24), the MBI aligns with the WHO definition of burnout as an occupational phenomenon with measurements in the three domains of:
Whether one is burnt out or not, is a difficult distinction and perhaps best not to consider as a dichotomous outcome. There are degrees of burnout on a continuum, which may vary in any individual with an alteration of personal circumstances or conditions at work. Perhaps most importantly, when high levels of burnout are present there will be reports of frequent or persistent negative associations with work, and burnout becomes an entrenched experience that is very difficult to overcome.
A doctor suffering with severe burnout experiences near-constant exhaustion – both physical and emotional. They become detached from the emotive aspects of their role and may question the value of their job. Without any emotional investment in patients, they will have a ‘depersonalised’ attitude, with a corresponding loss of empathy and compassion. These doctors can develop a belief that their work is inconsequential, and that they cannot enact any change. They may question their own technical and cognitive abilities.
While there are multiple organisational factors other than sheer workload implicated in the genesis of burnout, certain demographic factors can also put a doctor at greater risk. Higher rates are seen in younger doctors, particularly those who are female and unmarried (25). Burnout in female doctors seems to involve more EE than their male counterparts, while male doctors have higher rates of DP (26). And although all doctors are at high risk, there is variation in incidence amongst specialties (27) with those working in emergency medicine and family medicine consistently reporting higher rates of burnout (28).
Different workplace conditions impact on development of burnout with a common precipitant being perceived excessive clerical and bureaucratic demands which seem disrespectful of doctors’ time. An inability to disengage from work – or a need to be constantly accessible – is also recognised as a risk factor (29).
In a similar fashion, introduction of an electronic health record (EHR) has been associated with rising burnout rates (30). In the US, with wide EHR introduction, there is correlation between time spent on EHR and burnout rates (30).?
Burnout has been described as a potentially adaptive response to chronic work stress (31) with the unconscious reduction in empathy levels allowing conservation of psychological resources and energy for ongoing service provision. However, this view seems to diminish the risk that burnout poses in terms of serious personal or professional outcomes.
What it isn’t:
Equally important in understanding burnout is clearly defining what it is not. Firstly, although burnout can predispose to psychological conditions such as anxiety and depression, burnout is not simply a subset or variant of these conditions. Not everyone with burnout becomes depressed, and not all people who are depressed undergo workplace burnout. The psychological components of burnout are inextricably entwined with workplace stressors and demands, and organisational culture and work practices cannot be separated from the three domains of burnout.
One of the features is exhaustion, however burnout is not simply fatigue (32). We all have intermittent episodes of extreme tiredness with the recognition that we need to rest and recover. Burnout is different. It is an unrelenting and unremitting exhaustion where one does not know how, or whether it is possible, to continue. These feelings may be experienced a few times every week, or every day. And rather than fatigue that can be overcome when work demand slows, burnout will not improve or go away if ignored. Unless all the precipitating conditions are uncovered and addressed, burnout will continue and may worsen.
Perhaps most importantly, burnout does not relate to individual weakness, inadequate coping skills, or lack of resilience (33, 34). The chronic workplace stress leads to a complex and unique interplay within each individual. It is too easy to consciously or unconsciously ‘victim-blame’ by assuming that these people are not suited to, or capable of, the roles that they occupy.
Just as canaries were used in coalmines from the late 19th?century to provide early detection of carbon monoxide and other toxic gases before workers were affected, burnout must be viewed as an indication that conditions are not adequate. Therefore, in addition to providing care to those who are suffering, there must be attention to workplace practices, systems, and culture. No-one at the coalface of yesteryear blamed a dead canary for not being resilient enough. Instead, the coalminers and mine operators appreciated the signal that all was not well, indicating a need for change before miners were afflicted. Just as canaries were more sensitive to toxic fumes than humans, burnout affects some doctors earlier than others and the damage experienced by the burnout victims may provide a warning sign to all that working conditions are unsatisfactory.
For organisations and within professions, the burnout epidemic will not dissipate if neglected or shrugged off. The burnout syndrome continues to increase in prevalence and begins to create a self-perpetuating loop where shortages or reduced capability due to burnout lead to extra workload for others, and less time to investigate and repair the damaging work practices that were part of the problem’s genesis. Thus, the crisis becomes more pronounced and urgent, but less likely to be resolved.
What we can do about it:
Acceptance of the Issue:
The vital first step in dealing with the burnout epidemic is acknowledgement that a problem exists, and that the crisis will not be improved without action. This acceptance must come with an understanding that doctors suffering with burnout should not be stigmatised. If one has had the misfortune to be afflicted with burnout it should not also deliver an internal sense of shame.
Those workplaces and groups with high rates of burnout must recognise that they contain conditions that are somehow inherently damaging to those within them. It is not enough to try to ‘fix’ the individual burnout sufferers with external interventions that are separate to normal organisational processes. No matter how well-meaning, treatments or well-being initiatives for burnout victims that are shifted outside the organisation and seen to be distinct from the rest of the workers can further embed an implicit belief that the burnout sufferer is intrinsically flawed.
As a profession we must examine the extent of the problem and be open to new ways – both for dealing with burnout, and for constructing less-damaging systems. With the more widespread recognition that burnout is not an individual problem or weakness, will come an awareness that burnout is indicative of mismatches between any individual’s makeup and work demands. The overarching workplace environment and the way the organisation or institution operates are critical factors in the genesis of burnout. As such, it must be understood that burnout is an organisation-wide problem. Similarly, solutions for burnout will require interventions and changes that start with treating and caring for those affected, through to adoption of new work practices and methods.
Just as burnout results from a combination of individual, workload, and workplace elements, treating and preventing burnout will involve attention to individual practices, work styles and demands, and organisational structure. The causative factors are intertwined, and the cures and solutions must be similarly constructed with attention to all aspects from the person afflicted through to the institution that they work in.
Early Prevention:
As well as doctors having a predilection for burnout due to the empathetic nature of the profession, there may be antecedent factors relating to the make-up of those who enter medicine. Perfectionistic tendencies – common in medical students (35) – and the inherent competitiveness of medical school and insidious isolation for some can lead to higher rates of psychological distress including burnout (36). Medical culture, and the preferred ‘way of being’ for a doctor (37), is first learned in medical school through implicit and explicit teaching (38), and then further embedded in the early years of a young doctor’s career. Part of this enculturation involves how emotional events are experienced, and how emotions are self-regulated (39). The technique of emotional suppression (ES) – adaptive in many situations – can be overused with increasing use of ES linked to higher burnout rates (40). Medical schools, hospitals, and healthcare facilities have a duty to address isolation and unhelpful competitiveness as well as facilitate emotional regulation training and other individual well-being techniques that may prove useful over a career.
Treatment:
Those doctors suffering with severe burnout with associated exhaustion, must rest to recover. Time completely away from work may be part of the solution. Assistance with coexistent problems such as depression will require medical evaluation and treatment. Personal and individualised counselling (41) around work styles and habits must be provided. Individual coaching has a role to play in the treatment and prevention of burnout (42). Attention to work-life balance, relaxation styles, and individual well-being practices must be considered for each doctor suffering with burnout.
Of course, it would be remiss to send a severely burnt-out doctor back into the same work environment with similar work demands. Therefore, the team and organisation will need to craft changes that enable the role to be less damaging (43).
With lesser degrees of burnout, the affected doctors may be able to continue to work with altered duties and priorities, to avoid worsening burnout and subsequent loss of a team-member. Attention to individual well-being needs must be given and an ability to access these interventions on site (44). Work alterations must include all team members. Institutional leadership must have an authentic desire to improve conditions.
Interventions for Burnout:
Introduction of individual well-being initiatives into healthcare settings have often been seen as ‘tokenistic’ (45), superficial, or demeaning, when placed in the context of overwhelming work demands. Part of the problem can be that the measures proposed have been ad hoc (46) with indiscriminate application, off-site location, and without leadership support – thereby reinforcing the unconscious impression that burnout is due to individual weakness, and best addressed by the doctor on their own, rather than seen as an intrinsic part of organisational business.
While no one technique treats burnout in every affected person, there are strategies that have been shown to help reduce rates. These include individual interventions as well as organisation-directed interventions and combined approaches (47).
Individual interventions reduce burnout through optimising personal coping abilities, relaxation skills, or increasing social support. Most commonly these interventions consist of mindfulness-based practices, stress management, and small group discussions. Benefit has for all, albeit with relatively small effect sizes, however no specific individual intervention has been shown to be superior to others (3).
Organisation-directed interventions attempt to modify aspects of the work environment that contribute to burnout, such as resource allocation, workload, scheduling, cultural improvement, and modifying bureaucratic demands. Perhaps as expected, given that burnout is a workplace phenomenon, organisational interventions have been more beneficial in treatment of burnout rates, with greater effect sizes (19, 44). For example, changes which have shown benefit for early career stages include limiting resident on-call hours and ensuring prioritisation of adequate sleep (3).
Combined approaches, with both individual elements and structural components that target both the worker and the workplace, seem logical yet have not been commonly implemented (44). An example of this type of initiative may be a department-wide staff stress management workshop that also incorporates work-flow planning. However, the interventions that have shown the greatest improvement thus far have been organisation level initiatives that have targeted rosters, work hours, schedules, and bureaucratic demands (48). Once again, this is consistent with the underlying causation of burnout being a workplace and work demand related phenomenon.
Changes to systems and work demands:
Organisation and team level changes to job demands and structure must include an ability to disengage when not on duty – being constantly accessible through electronic means has shown correlation with burnout (49). For some doctors to understand that they can and must disengage when off-duty – rather than constantly access electronic results for example – may require more comprehensive handovers, creation of more effective teams, and development of increased trust in colleagues and systems with the knowledge that this self-care is essential for the health of all team members and to aid in patient care.
Of course, no one intervention or activity will be appropriate for every doctor, every team, or every organisation. All organisations must tailor their own unique work practices (50), which protect the health of their doctors. Perhaps a ‘menu’ of different self-care processes can be explored. Tellingly, the reduction in burnout is greater with all interventions when they are seen to be endorsed and respected by the organisation and leadership as part of ‘normal’ activity (48).
Just as each organisation, institution, or even team has different practices (and different rates of burnout), each group will need to identify the best solutions within their own work context. Those organisations which do not provide an environment where individual and team well-being can be prioritised or explored will struggle with ongoing high burnout rates and subsequent difficulty in retention and attraction of staff.
If canaries falter when checking safety, we don’t blame the birds. Instead, we concentrate improvement of working conditions for the benefit of all. The aim must be to produce a workplace where the canaries can continue to sing.
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