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Dr. Lane is an early career hospitalist, now in her 4th year at a large tertiary care hospital. She has used the knowledge she has gained about knowing herself and her style to build solid, productive relationships with those around her. She applied S.M.A.R.T. goals and has been successful in increasing her RVU’s and was recognized by her hospitalist director as an “up-and-comer.” As a result of her planning, efforts, and attitude, she has been recognized as a valuable member of the hospital system. She has joined committees, recently took over as Chair of one of the committees, and has been asked to be physician lead on a major patient safety initiative at the hospital. Dr. Lane feels exhausted and overwhelmed most of the time, and has noticed a change in her disposition where she now finds herself using harsh tones at times with others at work.

Most physicians enter the medical profession with genuine enthusiasm to care for sick patients. They anticipate the long hours and emotional stress of the training, but few can foresee the true, challenging lifestyle that is common among doctors. More and more, physicians are expected to be responsible not just to their patients by providing careful, conscientious care but also to the larger health care system. There are many work responsibilities outside of direct patient care such as keeping up with evolving evidence-based medicine, the newest performance measures, and current maintenance of licensure requirements that can be overwhelming on their own. Balancing these professional duties with obligations outside of the hospital, like family life, can easily take a toll and lead to burnout .

Defined, burnout is a psychological term referring to feelings of persistent exhaustion and diminished interest in one’s work. The generation of burnout is multifactorial with contributions from prolonged stress at work and also one’s individual disposition to coping with chronic stress. In his essay in The Atlantic, “For the Young Doctor About to Burn Out,” Richard Gunderman suggests that burnout is really a loss of idealism, that “at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice” [1]. Whether from lost idealism or being plagued by too many responsibilities on and off the job, hospitalists are predisposed to burnout. In this chapter, we aim to help you identify contributors to burn out and review techniques to prevent and overcome this common phenomenon.

Symptoms of Burnout

We all expect to feel tired occasionally as we balance the many aspects of our lives. But how do you know if you are approaching burnout? Fatigue, although a symptom of burnout , is a common symptom among Americans. We all expect to feel tired occasionally. Burnout , however, is further characterized by emotional exhaustion, depersonalization, cynicism, and a diminished sense of personal accomplishment [2]. Other symptoms include inability to concentrate, anxiety, insomnia, irritability, feelings of increased dejection and depression, loss of interest in one’s work and or personal life, and increased incidence of substance abuse.

Prevalence of Burnout

Although burnout is common among many professions, it is especially prevalent among physicians . In 2011–2012, medical students, residents/fellows and early career physicians were surveyed for symptoms of burnout, fatigue, depression, suicidal ideation, and quality of life. Results showed that at each stage of training, burnout is more prevalent among medical professionals than their life-stage matched, American peers. Among early career physicians (less than 5 years in practice), results showed that just over half reported burnout , half reported high levels of fatigue, and 40 % reported at least one symptom of depression. Employed peers outside of medicine were half as likely to experience burnout, and reported less fatigue and depressive symptoms [3].

Internists may be at even higher risk for burnout than their physician peers. Specifically, hospitalists may be at particular risk for burnout given the nature of their shift work and numerous patient care and administrative responsibilities. In the 2013 Today’s Hospitalist Compensation and Career Survey, 68 % of hospitalists endorsed significant or very significant personal burnout [4].

Women in Medicine

The presence of women in the general work force and within medicine has been increasing over the last several decades. American medical school graduating classes are now comprised of nearly 50 % women, compared to approximately seven percent in 1966 [5]. However, many women feel more stress balancing work and home life than their married male colleagues. Women are 60 % more likely than men to report burnout proportionate to hours worked >40 h/week [6]. This discrepancy may be due to the so-called double burden with societal pressures for women to maintain traditional roles in the home with more of the responsibilities of child-rearing and household chores, despite working full-time outside of the house. In spite of this increase in burnout, men and women have been found to report similar satisfaction with their careers (76 % vs. 79 %) [7].

Contributing Risk Factors to Burnout

Physicians are often prone to burnout because of the very personality traits that originally attracted them to the profession: drive, competitiveness, desire, and ability to excel [8]. The intrinsic idiosyncrasies of these personality traits coupled with an individual’s personal method of or ability to manage stress can be significant risk factors for burnout . Hospitalists are no strangers to the external stressors that contribute to burnout. Long shifts, overnight shifts, and weekend shifts can affect sleep schedules and personal relationships outside of the hospital. Financial stress from changing compensation targets and levels of reimbursement as well as personal debt can weigh heavily on physicians . Additional stress builds from navigating the hospital bureaucracy and attempting to incorporate administrative responsibilities and paperwork into daily schedules. Finally, stress is generated by work obligations interfering with family needs and friendships. The competing responsibilities, desires, and needs often lead to a perceived lack of control, one of the biggest risk factors for burnout [9].

Consequences of Burnout

A physician affected by burnout does not suffer alone. Other outcomes include:

  • Diminished quality of care: one study showed that burned out residents reporting symptoms of burnout , stress , depression, or anxiety were two to three times more likely to self-report suboptimal patient care practices [10]

  • Diminished physician –patient relationships: stemming from physician depersonalization and withdraw [11]

  • Effect on personal relationships with significant others and children

  • Increased substance abuse: 8–12 % of healthcare professionals develop a substance-related disorder at some point in their lives [12]

  • Increased levels of suicide: male physicians are 2× more likely to commit suicide than average Americans, and female physicians 3× more likely [13]

  • Earlier retirement and decreased time in the work force.

How to Assess for Burnout

There are many scales to evaluate burnout . The most commonly used assessment tool is the Maslach Burnout Inventory (MBI), which is a survey that uses 22 questions to assess an individual’s sense of personal accomplishment, emotional exhaustion, and depersonalization [2]. You can go to http://www.mindgarden.com/products/mbi.htm to learn more or to purchase the MBI. Another commonly used metric is the shorter Short Form 12 (SF12). It uses 12 questions to provide both a physical and a mental health score. You can learn more about this at: http://www.sf-36.org/tools/sf12.shtml.

For the busy hospitalist, it may be easy to self-assess burnout using the previously validated exercise:

  • “Using your own definition of ‘burnout ,’ circle one:

    1. 1.

      I have no symptoms of burnout.

    2. 2.

      I don’t always have as much energy as I once did, but I don’t feel burned out.

    3. 3.

      I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion.

    4. 4.

      The symptoms of burnout that I am experiencing won’t go away.

    5. 5.

      I feel completely burned out and wonder if I can go on.”

  • A score of 3 or higher is indicative of burnout [14].

Combating Burnout with Prevention and Treatment

Ideally, one would be able to take appropriate measures to prevent burnout from ever complicating his or her life professionally or personally. This requires calculated care of one’s own physical and emotional well-being . In a study of physicians ’ own wellness techniques, five major categories of self-protective practices were identified: relationships, religion or spirituality, self-care, work specifics (e.g., choice of specialty, setting limits on hours), and approaches to life (i.e., general philosophical outlooks such as being positive, and aiming to maintain a healthy balance in life). It was concluded that physicians use various approaches, all correlated with improved levels of well-being , but adopting a personal healthy philosophical outlook was most significantly associated with increased psychological well-being [15].

Most people are not identical in how they find joy. You must acknowledge what areas are most important in making you feel whole. Use this knowledge to focus your efforts toward well-being . This can include making a concerted or even scheduled effort to:

  • engage in important relationships with family and friends

  • attend a religious or spiritual home

  • exercise, practice yoga, meditate, simply get outside

  • read for pleasure, learn something interesting

  • cook, perfect your hobbies, travel

  • give back to the community

  • have a personal primary care physician to look after your health

Many of us struggle with self-awareness. The nature of our work often requires that we appear “strong.” We must be able to find comfort in acknowledging when we are overworked so that we can better ask for help, share responsibilities, learn when and how to set limits at work, and learn to say “no.” Many medical organizations and practices are acknowledging the role burnout and physician well-being play in the work environment. One such group is called Renew! They define renewing as a “means to revive values, motivation, and energy and to reformulate and refresh goals and skills.” These efforts can serve as both prevention and treatment for burnout [8]. Many hospitals have physician wellness committees, as well as policies and procedures to serve as guidelines when physicians observe impairment in colleagues or in oneself. However, healthcare workers are notoriously bad at self-policing. A generally accepted code of silence exists among physicians, borne from mutual respect and loyalty that serves to protect one another and to avoid consequences, shame, and social stigmatization.

Perhaps due to the knowledge that many people find it hard to ask for help, a growing number of hospitals and institutions have begun to study the effects of hospital-supported interventions in reducing burnout and improving physician well-being . A recent randomized, controlled trial investigated the impact of a facilitated, small group intervention curriculum compared to unstructured protected time on burnout. The intervention group engaged in guided topics including reflection, self-awareness, mindfulness, and community building and skill acquisition to promote connectedness and meaning in one’s work. Those who completed the curriculum felt an increase in empowerment and engagement and significant decrease in symptoms of burnout [16].

Another study examined mindfulness-based stress reduction (MBSR) that focused on training in the Eastern contemplative practice of mindfulness, a form of meditation derived from the Theravada tradition of Buddhism. Those who engaged in the training experienced a mean reduction in perceived stress (27 % vs. 7 %) and decreased burnout, while feeling increased self-compassion and satisfaction with life (19 % vs. 0 %) versus controls [17]. This suggests that by simply practicing mindfulness, or “seeing with discernment,” one can successfully reduce stress and burnout and improve self-compassion and life satisfaction. Even the simple act of purposefully engaging in positive thinking has been shown to have a beneficial effect on one’s outlook and perspective. This can help with stress reduction and in finding, or refinding, meaning in one’s work.

Benefits of Well-Being

Freeborn’s data suggests that as physician satisfaction and organizational commitment increased, burnout decreased [9]. Happier employees generally provide better and safer care. When physicians rate higher well-being and satisfaction scores, there are a number of correlating benefits. These include:

  • improved patient satisfaction and trust

  • improved quality of care and patient safety

  • improved retention of staff and physicians

  • improved mental and physical health of the provider

  • reduced risk of substance abuse [18]

  • improvement in supportive personal and intimate relationships [19].

Resources for Help

The ACP-ASIM Board of Governors has compiled a list of resources like books, websites, and contact information for experts/workshop leaders trained in combating burnout that can be accessed at: https://www.acponline.org/system/files/documents/about_acp/chapters/dc/phys_burnout.pdf. In addition, most institutions have Employee Assistance Programs that can offer individualized assistance should you feel any symptoms of depression that are concerning to you.

Conclusion

Having a career heavily focused on caring can at times have deleterious effects such as increased burnout . Burnout is just one element of something referred to as compassion fatigue. Remember, self-love is self-preservation. Often, the better we take care of ourselves, the better we can take care of others.