Mind the fire: Managing and preventing burnout

When I was a palliative care fellow, my co-fellows and I would periodically check in with each other to see how “crispy” we were feeling, or even more telling, just comment to each other on how crispy we were looking. We were, of course, referring to our levels of burnout.

What is burnout?

Burnout is defined as a psychological syndrome, a form of mental distress, that occurs in response to chronic interpersonal stressors on the job. In physicians, burnout has been associated with poorer health, decreased work performance and medical errors. The key components include emotional exhaustion, depersonalization, and a sense of ineffectiveness or lack of personal accomplishment. Emotional exhaustion describes the overall feeling of depletion of one’s emotional and physical resources and being overextended. It promotes a response to distance oneself from one’s work. Depersonalization refers to an attitude of detachment toward various aspects of one’s job, also as another way to cope and distance oneself. The lack of personal accomplishment refers to an overall low sense of efficacy and competence, and while related to emotional exhaustion and depersonalization, a lack of personal accomplishment can arise from inadequate resources to do one’s job.

Compassion fatigue is a syndrome that has begun to be recognized as a secondary post-traumatic stress disorder. It is distinct from burnout and specifically involves the relationship between the clinician and the patient. Symptoms include hyperarousal, avoidance and re-experiencing, and while compassion fatigue has been less studied, it has been known to lead to burnout.

Studies among oncologists have demonstrated overall higher rates of burnout compared with other physician groups and allied health professionals, as high as 56% to 61% in some studies. In the general physician population, risk factors for physician burnout include solo practice; long work hours; lack of control over scheduling and the pace of work; managerial responsibility; dealing with patients’ suffering; isolation due to gender or cultural differences; and lack of support for work/life balance.

In a Lancet Oncology review on stress and burnout, Lyckholm described these particular causes of stress and burnout for oncologists: insufficient vacation time, repeated losses, unrealistic expectations placed on oncologists, a sense of failure, feelings of frustration and anger, and the complexities of reimbursement and other managed care issues. (Lyckholm was featured in a 2008 HemOncToday “Point/Counterpoint” on burnout.)

Stephanie Harman

In addition to the overall components of burnout, there are more specific signs and symptoms, including cynicism, questioning beliefs, interpersonal conflicts, addictive behaviors, frequent illness and sleep disturbances. Burnout can also be experienced on a team-level, as evidenced by low morale, staff conflicts, overall impaired performance and high turnover.

The consequences of burnout can include emotional depletion and self-neglect alongside the occupational losses in productivity and quality of care, but more serious effects can occur. Warning signs that warrant professional intervention include persistent signs/symptoms of depression, persistent sleep disturbances, breaches of professional boundaries, self-prescribing of sedative-hypnotic agents and substance abuse. We owe it to ourselves and to our colleagues and our patients to get help.

Strategies to prevent burnout

On a practical level, there are some occupational and pragmatic strategies to help address burnout if it exists, as well as prevent its occurrence. Helpful professional activities include adequate supervision and mentoring, continuing education and communication training, and participation in research. Setting limits at work in terms of workload and time can also help improve burnout. However, in their 2009 Journal of the American Medical Association review on burnout, Kearney and colleagues noted that only establishing boundaries may not address compassion fatigue or improve symptoms of depersonalization. Recently, there has been more study of positive strategies and the promotion of self-care, rather than focusing strategies purely on damage control.

Attention to health

The practice of wellness strategies has been demonstrated to reduce burnout, including practical strategies such as adequate sleep (including recovery sleep after call) and rest. The role of rest takes on the flip side of inadequate vacation contributing to burnout, but “rest” can also be thought of on a much smaller scale, such as taking a break every 90 minutes to do something different from the work that you are doing, whether it’s taking a walk outside or eating a snack.

Empathy, connection to patients

Kearney also described how trauma therapists suggest that empathy accompanied by self-awareness and appropriate boundaries can invigorate the clinician rather than deplete them. This provides some encouragement that we can connect to our patients without having to experience a subsequent depletion. Clinicians can also grow and be enriched in witnessing their patients and families progress through difficult circumstances.

Self-awareness

Multiple studies have investigated developing self-awareness to prevent burnout. Self-awareness refers to self-knowledge, as well as awareness of one’s subjective experience, the patient’s needs and the external environment. Both mindfulness and reflective writing are techniques to promote self-awareness and have been demonstrated to help reduce and avoid burnout.

A recent JAMA study by Krasner and colleagues described overall improvement in physician burnout for a group of primary care physicians through the intervention of a CME course on mindfulness, including both mindfulness meditation and reflective writing. Mindfulness techniques can also help reduce stress of an entire team.

The practice of self-reflection is also related to debriefing stressful or emotional events, another strategy to prevent burnout. More formal forums for debriefing and discussion, such as Schwartz Rounds, can mitigate burnout on a more institutional level.

Stephanie Harman, MD, is a Palliative Care Physician at Stanford University Medical Center and Director of its Inpatient Palliative Care Service.

For more information:

• Kearney MK et al. JAMA. 2009;301:1155-1164.
• Krasner MS et al. JAMA. 2009;302:1284-1293.
• Lyckholm L. Lancet Oncology. 2001;2:750-775.