Monday, June 11, 2007

The gasoline on the fire...

Burnout: A psychological term for long-term exhaustion and disinterest, in the context of work.

In the six months since I started this blog I've received a number of comments and emails from people who tell me they enjoy reading because they think this is one of the few physician blogs out there not suffering from burnout. In reality it may be that people mistake venting, present in many blogs and as much as possible absent from this blog, as burnout. Regardless, it's interesting that many people, of both medical and non-medical backgrounds, perceive so many doctors as being burned out. Burnout is an important issue for both individual doctors, who change careers, loose income, and live unhappy lives as it's end result, and also for the public because burnout chips away at an already precarious physician supply, and disengages otherwise excellent docs from the business of caring for patients. It's certainly an issue worthy of examination.

For most doctors (myself included) burnout is an idea that's loaded with personal experience, either our own or our colleagues. A year ago I found myself in a situation at work where I was at risk of burning out, and as a result had to do a great deal of forced introspection about the causes of and solutions for burnout. Much of the discussion below is based on my own experience, rather than any formal research.

Burnout is an issue that is well hidden in medical training. The general assumption during medical school is that everyone should be grateful to be there and that since medicine is a noble calling that everyone will surely love what they do. Sure there might me a lecture or two over the four years of medical school on career satisfaction, but like most of the soft content (meaning non-testable, and non-scientific), these lectures are poorly attended and easily dismissed. Even with these lectures in place most young medical trainees view themselves as different than their predecessors. With different priorities, different work styles, and different career choices, many young doctors enter practice feeling that they are not at any risk for burnout.

Medical students and residents are frequently confronted by burned out doctors during their training. These are the doctors who wander the halls spewing hatred about their patients, their colleagues, their hospital, their career, their medical association, their salary, to any and all who will listen. They are also the quietly unhappy doctors who trudge on, day after day, but in quiet moments advise trainees to select a different field, or a different road then they. Throughout medical training thoughtful introspection is actively discouraged in favor of the long view, and delayed gratification. The end result is that young doctors, after completing their residency, enter a field with a very high rate of burnout, ill equipped to either identify or deal with potential problems. Their only role models when it comes to burnout have been the frustrated, burned out docs who loudly, or meekly trudged on. Because any ability or willingness to self reflect has been thoroughly quashed during their training, they have trouble both identifying and coping with work related stress. Some enter practice already shouldering a fair amount of burnout accumulated during difficult residencies.

Although there are many causes for burnout I will focus on only 2 (lack of power/voice, and vicarious traumatization) that I believe are major contributors in the medical workplace, and for physicians in particular.

Lack of power is an issue that leads to burnout in any workplace. When you don't feel your decisions or effort is appreciated or acted on by those around you, when you don't have any control over your workplace, it's difficult to feel that the work you are doing is worthwhile. Medical residents, who are typically told where to be, when to be there, and that their efforts (however well intentioned) are simply inadequate are particularly vulnerable to this stress. Practicing physicians often have more control over their time, and more ability to make their own decisions, but can suffer similar stress in their workplace. Doctors who work in large organizations are often treated like replaceable cogs in a large machine, and although they may see real front line issues in their workplace their attempts at solutions frequently fail to percolate upwards through the filters of bureaucracy. People who feel their job is irrelevant tend to simply go through the motions, and get little personal satisfaction from work. It's a recipe for burnout.

Vicarious traumatization is an issue that many physicians are unfamiliar with. Put simply, it is that idea that being in the presence of someones suffering (particularly in an intimate way such as the doctor-patient relationship), can cause suffering of it's own. Overt examples include being present at the unexpected death of a young person, or being involved in a case with an unexpected bad outcome. More subtle examples include caring for patients who have been severely abused and hearing their stories in detail, witnessing the results of significant violence, and caring for patients on an inevitable collision course with tragedy. Unfortunately many doctors view ideas like this as intolerably flakey and prefer the age old methods of denial and compartmentalization in dealing with any unwanted personal emotional response. Particularly at risk environments for this type of burnout include any place where abnormal events occur with such regularity that they become normalized. Any workplace where tragedy is met with responses like 'Get used to it, it happens all the time here, and we don't have time to stop and talk about it.' is likely to be full of this type of burnout. Normalization of the abnormal also poses a significant risk for trainees who work in many environments for only a short time and who may not be able to participate in any of informal support mechanisms that might exist. Most doctors are exposed to situations that put them at risk for vicarious trauma. Unfortunately most are also well schooled in suppressing any such response and not dealing with their own emotional well-being. Again, a recipe for burnout.

Dealing with situations that cause burnout, and dealing with actual burnout is difficult. It requires introspection. It requires recognition that doctors do have emotional (and non-rational) internal responses to stressful situations. It requires developing workplaces that are responsive to the concerns of front line workers, and have active programs to deal with unusual (or usual) stresses. It requires that abnormal situations be named abnormal, and debriefed accordingly (workplaces that say this is impossible because they don't have enough time have a staffing problem). It requires that doctors participate in debriefing. In workplaces where these supports don't exist, it requires individuals to carefully consider whether they can maintain their own health in such an environment.

In my own situation, after a careful examination of the particular stresses of my workplace I made the decision to change my environment. I stepped out of a job that I enjoyed, but had some significant and major stresses that I felt could not be overcome. After debating the issue for a while, I felt that the most healthy thing for me was to move on (hence a northern adventure slated to begin this summer began about 6 months early). I think that part of why this blog is devoid of burnout is because I am actively trying to address issues that could lead to burnout upfront.

Burnout is a challenging issue. It forces us to confront our own reactions and feelings, and to make some difficult decisions. It always troubles me when I read about doctors who hate their job. Almost invariably they are suffering from workplace burnout, and simply aren't sure how to deal with it. There are too many options, and too many jobs in medicine for anyone to be stuck in an environment that is intolerable. Hopefully as we move towards recognition of burnout as a widespread and important issue we can help physicians develop the personal tools to cope with difficult situations as they arise, and workplaces that support this process.

Self-care is not a soft subject and should not be treated as such. Doctors can't provide good care to patients when they themselves are unwell. We all have a duty to bring our best selves to our work and to our lives, and this involves giving self-care more than the short change it currently receives.


Xavier Emmanuelle said...

Thank you for this. Really. It validates a lot of what I felt this year when I started to burn out. I'm only in undergrad, but I had to take some time to step back and take a look at my priorities. I had never sen anyone in medicine admit to needing time to reflect and re-evaluate, so a part of me thought that it was a sign of weakness. I'm glad to hear that someone who is finished all the training and such does it as well.

Dr. J. said...

Unfortunately the majority of people in medicine will read this and think it's total bunk because the prevailing view in medicine is that doctors don't need time to reflect and that it is a sign of weakness. Many doctors still believe that it is a sign of great (moral) strength to simply suck it up and keep on keeping on....the unfortunate aspect of this sort of thinking is that these negative experiences don't bottle well and often leak out at inopertune moments and with unintended consequences.
Significant curtural shift needs to occur before this sort of thinking will be widely accepted.
Dr. J.

Midwife with a Knife said...

What a timely post. Lots to think about. Where I was a resident, we had monthly, schedualed debriefings. Because our job so often involves delivering dead babies, dealing with bad outcomes, and we did all of the pediatric sexual assault evals, these abnormal events really are normal for what we do.