“Physician, heal thyself!” has never been a compliment. The Jewish proverb goes back to ancient times, when it implied either doubt of a doctor’s skill, or that those closest to the physician, his family and neighbours, should be cared for before strangers.
Nowadays, it’s generally taken to mean you shouldn’t criticize others for faults you have yourself. Either way, it must ring cruelly in the ears of doctors suffering from burnout, who know better than most that healing oneself is far from easy.
Burnout, defined as “a state of mental exhaustion, depersonalization and a decreased sense of personal accomplishment,” is brought on by long hours, overwork, high levels of stress and disrupted personal life.
But what causes it is not the challenge. What to do about it is what most people want to know, and perhaps the one advantage to the burnout epidemic is the range of ideas for avoiding it necessity has generated. In the first part of this two-part article, we promised you ways to tackle burnout. Let’s look at them now, starting with another article on the Boldly website — From one doctor to another: here’s what you can do about burnout.
The article, by Duncan Rozario chief of surgery at Oakville Trafalgar Memorial Hospital, recommends self-care — from exercise and meditation to playing a Tibetan singing bowl (choice of instrument is presumably up to you). But Rozario gets more concrete, quickly: block off the time you need for yourself in your schedule — you and everyone else need to see that it’s as real an obligation as a patient appointment or meeting. Another piece of advice: learn to say no. And on the professional front, Rozario recommends getting involved in the planning and administration of your organization. It’s the best way to get some control over the decisions and practices that can burn people out.
Despite the range of factors that contribute to burnout, many approaches to mitigating it focus on individual physicians developing greater resilience — a wrong-headed, blame-the-victim attitude, according to an article by psychology professor Alan Card of the University of California at San Diego’s School of Medicine. Working with people in great need is inherently stressful, and can cause physicians what Card calls “unavoidable suffering.” But there is also “avoidable suffering,” caused by working conditions, administrative demands and unrealistic expectations.
“Resilience training makes perfect sense as part of a response to unavoidable suffering,” Card says, adding “Resilience training does nothing to solve the underlying causes of avoidable suffering, and may even cause harm: First by giving the illusion of a simple solution, it may pre-empt the hard work required to address systems failures. And second, it may send the message to affected doctors that they are the problem, that they need to do better at absorbing negative conditions.”
Research seems to back the notion that individual efforts have a limited effect on burnout. In a systematic review, “Controlled Interventions to Reduce Burnout in Physicians,” Maria Panagioti and colleagues analyzed 20 interventions and found only small, though significant, impact from any of them — and those that focused on individual efforts (such as training in mindfulness-based stress reduction techniques, and programs to improve self-confidence and communication skills) were less effective than those directed by organizations (which are less common).
The authors conclude, since organizational interventions (mainly involving changing shifts and reducing workload) were more effective, burnout “is rooted in the organizational coherence of the healthcare system…[and] is less likely to be effectively minimized by solely intervening at the individual level.” They also echo Card’s warning about blaming the victim, saying doctors might either see having to treat their own burnout as one more responsibility, “or blame themselves for being less ‘resilient.’”
But — perhaps because so many physicians are looking for ways to prevent or alleviate burnout — there’s no shortage of journal articles on how to do just that. In “Physician Burnout: the Hidden Health Care Crisis”, Brian Lacy et Johanna Chan offer five principles for treating physician burnout:
- Learn to balance personal and professional goals
- Shape your career and identify stressors
- Nurture wellness strategies
- Become engaged or re-engage
- Build resilience
Balance, they say, requires control over your schedule, and not always agreeing to see one more patient. Shaping your career is done by identifying what drains you, focusing on what energizes you and deciding how to modify work accordingly. Nurturing wellness is about self-care: know what relaxes and soothes you and make time for it every day — exercise and time for family and friends are all known to reduce burnout, or the risk of it. Getting (re)engaged in work probably depends on the first three — when you feel better about yourself, you’ll be open to rediscovering what excited you about your job in the first place. Finally, Brian Lacy et Johanna Chan refer to Panagioti’s study to recommend building individual resilience.
Helen Meldrum, associate professor of psychology at Bentley University, interviewed 14 “exemplary” physicians, who had won the American Medical Association’s 2007 Pride in the Professions award, about their strategies for avoiding burnout. She distilled what they told her into five points:
- Set limits through self-regulation. This takes discipline and self-awareness — the model doctors watch for when stress builds, and take steps to dissipate it. They know their limits and accept them.
- Spend time with family and friends. Many of the physicians count spending time with their families as important for fighting burnout, as is camaraderie at work.
- Exercise. About half the model doctors regularly work out, hike, dance, and take active holidays.
- Relax. The other half either play or listen to music, or both, or pursue hobbies, go fishing, or let go of everything for a good night’s sleep.
- Laugh. They make jokes and see the funny side.
“These ideas are not novel,” Meldrum says, “but it is important to note that people with such crowded days and critical work use them.”
In their systematic review, Pangioti and colleagues found that when organizations actually did take steps to fight burnout, multi-faceted approaches were the most effective. “Those that combined several elements, such as structural changes, fostering communication between members of the health care team and cultivating a sense of teamwork and job control tended to be the most effective in reducing burnout. However, such intense organization-directed interventions were rare and were not evaluated widely.”
In a 2017 paper, “An Organizational Framework to Reduce Professional Burnout and Bring Back Joy in Practice”, Stephen Swenson and Tait Shanafelt say that reducing professional burnout is “an important opportunity…to create value for patients because of its deleterious effects on safety, quality, access and patient experience.” Their framework recommends six actions. They are:
- Design organizational systems to address human need
- Develop leaders with participative management competency
- Build social community
- Remove sources of frustration and inefficiency
- Reduce preventable patient harm and support second victims
- Bolster individual wellness
Is any of this going to be easy? Was med school easy? Was creating a health system easy? Preventing and managing burnout is part of that same continuum — applying good minds and organizational commitment to a problem that is hurting people (in this case, doctors) and keeping them from living healthy, happy lives that benefit others (patients). It’s more than worth the effort — it's essential for the future of health care.
This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule. Feel passionate about physician-led innovation? Please connect with us at firstname.lastname@example.org.