- Email: [email protected]
Burnout and resilience in anaesthesia and intensive care medicine
BJA Education, 0 (0): 1–7 (2017) doi: 10.1093/bjaed/mkx020 Matrix reference 1H02, 2H01, 3J02
Burnout and resilience in anaesthesia and intensive care medicine Adrian View-Kim Wong BSc MBBS MRCP FRCA FFICM EDIC1,* and Olusegun Olusanya BSc BM MRCP FRCA2 1
Consultant in Intensive Care Medicine and Anaesthesia, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK and 2North Hampshire Hospital, Basingstoke, UK
*To whom correspondence should be addressed. Adult Intensive Care Unit, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK. Tel: 01865 220621; Fax: 01865 222979; E-mail: [email protected]
Key points • Burnout is a syndrome characterized by deper-
sonalization, emotional exhaustion, and loss of sense of achievement. • The incidence of burnout among medical profes-
sionals appears to be rising, although improved awareness and diagnostic capabilities may be partly responsible. • Burnout is associated with significant morbidity
and mortality. The management of burnout syndrome involves a multidisciplinary approach, and a biopsychosocial model may be helpful. • Preventing burnout is feasible. Proactive, multi-
modal techniques beginning early in medical education, engaging the individual and community can be effective, albeit with limited evidence. • Tools are available for practising clinicians to im-
prove well-being, increase resilience, and reduce risk of burnout.
The term ‘burnout’ describes the collection of symptoms and signs, both physical and psychological, experienced by individuals due to their work. It is defined as the condition where professionals ‘lose all concerns, all emotional feeling for the people
they work with, and come to treat them in a detached or even dehumanised way’.1 Individuals often feel a sense of emotional exhaustion, indifference, depersonalization, and a lack of desire for personal achievement. Stress is related to, but is not the same as burnout (Table 1). Stress occurs when the individual’s ability to cope and deal with demands is exceeded. In controlled amounts, stress allows an individual to improve his/her performance, while burnout is an intrinsic response to continued excessive stress without time or space for recovery. Often mentioned and described with burnout, resilience is defined in the Oxford Dictionary as ‘the capacity to recover quickly from difficulties’. A true clinical definition of resilience is lacking, although it has considerable overlap with the concepts of wellness and well-being. Rather than simply being the absence of burnout, it is considered a state of being able to thrive in the presence of challenges.2 Like burnout, resilience is a complex interplay between the individual, environment, and culture.
Prevalence among health care professionals Although burnout can affect workers from any field, health care professionals are particularly at risk. With the ever-increasing workload and demands placed on the modern health care system, there is growing concern about burnout among health care professionals due to its potential to negatively affect the workforce and also patient care. Doctors reported substantially higher rates of psychological distress and attempted suicide compared with both the general population and other professionals.3
Editorial decision: April 6, 2017. Accepted: April 6, 2017 C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. V
For Permissions, please email: [email protected]
1
Burnout and resilience in anaesthesia and intensive care medicine
Within health care, there are wide variations in the published prevalence of burnout within different specialties and health care groups. Anaesthesia and intensive care medicine are characterized by their high demands (physical and emotional) and stress levels. Both specialties deal with long working hours in high-risk, complex working environments involving multidisciplinary teams. It is therefore unsurprising that the incidence of burnout and self-harm/suicide is high. Prevalence rates of burnout from surveys of European anaesthetists are variable, ranging between 6% and 18%.4,5 The rates are higher for both critical care physicians and nurses. Embriaco and colleagues found that almost 50% of critical care physicians had high levels of burnout symptoms.6,7 A recent survey from the USA suggests a prevalence of 55% among critical care physicians, the highest in surveyed medical specialties.8 The concept of resilience as a quality for selection is still in its infancy in medicine. No data are available on the number of ‘truly resilient’ doctors.
Risk factors Various factors (individual, environmental, and organizational) contribute to the risk of developing burnout (Fig. 1).
Individual factors Age While some studies have suggested an increased risk with age,9 more recent data from the UK Practitioner Health Programme suggests the opposite.10 This is consistent with works from both Europe and USA, where age less than 55 years was an independent risk factor for burnout. A confounding factor may be the fact that younger workers have had less professional experience and thus less time to develop effective strategies for dealing with occupational stress. Sex Females report higher burnout rates than men. Female doctors with young children and good social support, however, have a lower risk of developing burnout.11 Social support/network Social isolation at both work and home increases the risk of burnout. Coping strategies The availability and type of coping strategies utilized also have a role. ‘Positive’ strategies, such as exercise, meditation, and a strong social network, are protective. ‘Negative’ strategies, such as the use of alcohol and illicit substances, are associated with a higher burnout risk.
Table 1 Stress vs burnout Stress
Burnout
Characterized by overengagement Emotions are overactive Produces urgency and hyperactivity Loss of energy Leads to anxiety disorders Primary damage is physical
Characterized by disengagement Emotions are blunted Produces helplessness and hopelessness Loss of motivation, ideals, and hope Leads to detachment and depression Primary damage is emotional
Personal characteristics
Personality Personality traits, which are considered to be stable and difficult to change, are important in burnout and psychological distress. Individuals with certain personality types may choose highstress occupations, so doctors who choose to pursue a career in anaesthesia might have personality traits suited for the specific stressful demands of the specialty. People who score high on neuroticism tend to have an increased susceptibility to their environment, a tendency to be anxious and insecure with a highperformance drive. This predisposes them towards developing burnout.
ICU environment
Organizational factors
Moral distress Perceived delivery of inappropriate care Compassion fatigue
Burnout
Post traumatic stress disorder & other psychological symptoms
Fig 1 Causes and consequences of burnout.16
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Decreased patient satisfaction and quality of care
Increased rate of job turnover
Burnout and resilience in anaesthesia and intensive care medicine
Personality testing may be used in selection of trainees/residents to reduce burnout in future anaesthetists. Hence, strategies to address these problems can be focused on reinforcing the coping strategies of the individual. Educational programmes could be individualized to personal competence and resilience and to professional knowledge and skills.
Sense of low personal accomplishment This is when the individual feels he/she no longer achieves anything remarkable and is wasting his/her time. A feeling of failure and insufficiency indicates diminishing trust in one’s abilities.
Effects Organizational/work-related factors Work–life imbalance Spending more time at work leads to disproportionately less time for personal interests, family, and recovery. Lack of control An inability to influence decisions that affect one’s job, e.g. schedule, assignments or workload, and the lack of resources needed to perform at a satisfactory level can also contribute to burnout. Unclear job expectations Poorly defined roles and objectives are likely to result in discomfort at the workplace. Workplace/colleague culture and dysfunction Despite increased awareness and measures to deal with bullying within the NHS, it still exists and poses a significant challenge to the well-being of all health care professionals. The way an organization addresses events with poor outcomes can contribute to the stresses of the individuals involved.
Symptoms and signs The myriad of physical and psychological symptoms and signs makes diagnosing burnout a challenge. This problem is further compounded by an affected individual’s reluctance to seek help for fear of the negative connotations associated with burnout. Burned-out physicians may be angry, irritable, or impatient. They may seem to treat patients as objects or to be simply emotionally depleted. They may be frequently absent or seem unable to leave work. The clinical symptoms and signs of burnout are often nonspecific and can include depression, irritability, insomnia, tiredness, and anger. The hallmark of burnout is the triad of: • emotional exhaustion; • depersonalization; and • sense of low personal accomplishment.
Maslach and Jackson1 initially regarded emotional exhaustion as a reaction to interpersonal demands, depersonalization as a coping strategy, and sense of reduced personal accomplishment as a consequence of non-adaptive coping. Emotional exhaustion Emotional exhaustion is a chronic state of physical and emotional depletion that results from excessive job and/or personal demands and continuous stress. It describes a feeling of being emotionally overextended by one’s work, manifested by both physical fatigue and a sense of being psychologically ‘drained’. Depersonalization This consists of unfeeling and impersonal attitudes and reactions towards others, particularly people with whom one deals regularly. This behaviour therefore creates distance between oneself and those who cause discomfort.
Burnout affects negatively on the individual and can result in reduced quality of patient care, costs related to absenteeism, and high turnover of staff. The individual Burnout has a considerable overlap with mental illness, in particular depression and anxiety disorders. This can lead to considerable psychological and physical morbidity. In the USA, it is estimated that 400 physicians commit suicide each year, with burnout thought to contribute to a significant proportion based on a 1977 study by Sargent and colleagues. It is a predictor for developing depression, absenteeism, substance abuse, and a decline in working ability. Physical symptoms may include non-cardiac chest pain, palpitations, shortness of breath, bowel upset, dizziness, and headaches. Burnout has been associated with an increased risk of myocardial infarction and coronary heart disease. It has also been related to reduced fibrinolytic capacity, decreased capacity to cope with stress, and hypothalamic–pituitary–adrenal (HPA) axis hypoactivity.12 Those experiencing burnout may be more vulnerable to emotional and/or uncontrolled eating with a risk of obesity and its associated health problems. Trainees who burnout are unlikely to continue their chosen career and join the consultant workforce which is not cost-effective for the health care system. The patient The body of medical literature on burnout has demonstrated significant professional repercussions including decreased patient satisfaction, increased medical errors and litigation, and the personal consequences of substance abuse and depression. Patients cared for by burned-out physicians are less compliant, less satisfied with their care, and may even experience an increased time to full recovery.13 The institution Burnout has institutional costs; the cost of supporting or replacing a burned-out physician is significant. Additionally, less quantifiable costs occur when the loss of a colleague disrupts care teams and work communities. In the longer term, a work environment that is rife with burned-out physicians and health care professionals will not be a positive environment to work in and may struggle to attract the high-quality professionals required to deliver excellent patient care.
Diagnosis There is some controversy surrounding the diagnosis of burnout. It is not considered a formal psychiatric diagnosis in the latest edition of the Diagnostic and Statistical Manual of Health Disorders (DSM-V). The most widely used tool used to diagnose burnout is the Maslach Burnout Inventory (MBI);14 this questionnaire consists of 22 items, where the responders are asked to indicate the frequency with which they experience certain feelings with regard to their work. Other tools used include the
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Table 2 List of resources Support4Doctors Support4Doctors provides access to a wide range of specialist advice and support for doctors and their families. http://www.support4doctors.org/ Practitioner Health Programme (London based) The NHS Practitioner Health Programme is an award-winning, free, and confidential NHS service for doctors and dentists with issues relating to a mental or physical health concern or addiction problem, where these might affect their work. http://php.nhs.uk/ BMA support pages Doctors for Doctors—Confidential, nationwide counselling service for doctors and medical students, provided by BACP-registered counsellors, available 24/7. http://www.bma.org.uk/support-at-work/doctors-well-being/about-doctors-for-doctors Phone: 0330 123 1245 Doctor Advisors—The Doctor Advisor Service runs alongside BMA Counselling giving doctors and medical students in distress the choice of speaking in confidence to another doctor. Phone: 0330 123 1245—ask to speak to a Doctor Advisor Doctors Support Service—Confidential phone and face-to-face support for doctors facing GMC fitness to practice hearings. http://www.bma.org.uk/support-at-work/doctors-well-being/doctor-support-service Doctors Support Network Self-help group for doctors with mental health concerns, including stress, burnout, mood, and eating disorders, with regular meetings around the UK, a newsletter and an email forum. Address: Doctors Support Network, PO Box 360, Stevenage SG19AS, UK Tel. 0870 321 0642 DSN England E-mail: [email protected] DSN Scotland E-mail: [email protected] The Sick Doctors’ Trust An early intervention programme for addiction, which facilitates treatment in appropriate centres, arranges funding for inpatient treatment, and provides advocacy and representation when required. Tel: 0370 444 5163 (24 h) London Deanery Coaching and Mentoring A confidential coaching and mentoring service for London’s trainee dentists and doctors and health care professionals in Bands 5–8. http://mentoring.londondeanery.ac.uk/ E-mail: [email protected] The Couch (doctors.net) This service is available to doctors registered with doctors.net. There is a forum for mutual support and advice, with the option of anonymous posting, and a long list of doctors around the UK happy to help colleagues in distress. http://www.doctors.net.uk Psychiatrists’ Support Service, Royal College of Psychiatrists A confidential support and advice telephone helpline for Members or Associates of the College. Tel: 0207 245 0412 E-mail: [email protected] Royal College of Obstetricians and Gynaecologists Mentoring Scheme Aimed at obstetricians and gynaecologists who have been experiencing difficulties in relation to their work. Tel: 020 7772 6369 Email: [email protected] Association of Anaesthetists support pages http://www.aagbi.org/professionals/welfare/welfare-schemes Royal College of Surgeons Confidential Support and Advice Services for Surgeons (CSAS) This is a confidential telephone service providing a listening ear for surgeons, with further links to appropriate sources of advice and support. Tel: 020 7869 6030 Email: [email protected] Tea and Empathy- an online peer-to-peer support group. https://www.facebook.com/groups/1215686978446877/ Twitter: @tea_empathyNHS
Copenhagen Burnout Inventory and the Oldenburg Burnout Inventory; however, the MBI remains the most widely used and validated.
Dealing with burnout—the 3Rs: recognition, reversal, resilience Recognition Maintenance of wellness and treatment of burnout both require a carefully considered, biopsychosocial approach. It is the authors’ opinion that the management of burnout is not entirely up to the individual. This idea of the ‘resilient
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superhuman doctor’ who can cope with and handle everything independently is associated with an increased risk of burnout, mental illness, and suicide.13 Anyone who is experiencing severe symptoms should receive expert help. All doctors should be registered with a general practitioner who will provide a knowledgeable base from which to seek further help. Occupational Health departments are also an excellent initial port of call and handle all enquiries confidentially. There is no legal obligation for a struggling doctor to inform the General Medical Council. It is important for individuals to screen themselves, and people they care about, for symptoms of burnout. UK
Burnout and resilience in anaesthesia and intensive care medicine
Table 3 Summary of interventions Intervention
Aim
Example
ICU organization
Optimize intensivists’ work schedule Improve work environment
Weekend respite, Shift models Improved design, natural lighting, well-designed relaxation spaces, comfortable on-call rooms Changing theatre lists, ‘buddy’ systems Planned sabbaticals, varied job plans Meeting team members socially, ‘fun’ events, Schwartz rounds
Change team composition Team building and job rotation Improving work connectedness and psychological safety Improving sense of value at work Individual—practical
Individual—personal
Educational programme Communication skills Relaxation exercise Mindfulness Physical exercise Hobbies Personality and coping Social support Counselling
Practitioner Health Programme has developed a useful screening questionnaire reproduced below (with permission): 1. Has anyone close to you asked you to Cut down your work? 2. In recent months have you become Angry or resentful about your work or about patients? 3. Do you feel Guilty that you are not spending enough time with your friends, family, or even on yourself? 4. Do you find yourself becoming increasingly Emotional, for example, crying, getting angry, shouting, or feeling tense for no obvious reason? A free online self-test questionnaire, based on the Oldenburgh Burnout Inventory, can also be accessed through the BMA website.15 Reversal The authors appreciate the difficulties and stigma surrounding this delicate topic. For those seeking professional assistance, a list of helpful resources is available in Table 2. Strategies to prevent and treat burnout can be grouped into personal and environmental (intensive care unit/hospital) strategies.
Recognizing excellence—‘employee of the month’ schemes, excellence meetings Well-being seminars Non-violent communication, empathic listening Yoga, Tai Chi Mindfulness-based stress-reduction courses, online courses, apps Running, joining a gym Art, music, reading Emotional intelligence training Arranging regular meet up with friends, joining new groups, prioritizing family time Formal psychotherapy, informal through a mentor/friend
Some interventions overlap between personal and environment, for instance; cognitive–behavioural therapy can be offered at the workplace but requires participation of the individual. A recent review assessing these strategies suggested that system-wide strategies may be more effective and long-lasting than individual strategies. However, this review was limited by the heterogeneity of the current evidence base. Also, it is recognized that workplaces themselves are incredibly diverse, and solutions need to be tailored to the individual’s environment.17
Resilience Compared with the studies on burnout, which date back to the 1970s, our understanding of the opposite of this, i.e. the factors that keep people buoyant even in the face of dire misfortune, is in its infancy. As opposed to being a personality trait, recent research suggests that certain skills (which can be taught and practised to an extent) can contribute to an individual’s resilience. Some simple recommendations include: • Expressing gratitude to people—this generates positive emo-
Personal strategies Focusing on the health care practitioner, these rely on the individual to recognize their symptoms, seek help, and pursue strategies to allow them to manage the symptoms and their consequences. These include spiritual practices, exercise, meditation, and hobbies outside work.16
Environmental strategies These focus on the working environment and are multifaceted. Involving unit leaders, hospital administrators, and reaching as far as government policymakers, these interventions can be vast and far-reaching. They range from rostering extra staff, allowing adequate rest between shifts, improving workplace communication, and support groups to adjustments in training and credentialing, and improving laws and regulations.16 Table 3 gives further examples of such interventions.
tions, engages us with others/our workplace, develops relationships, and gives us a sense of accomplishment. • Spending time developing our bonds with friends and family. • Recording a diary of achievements. • Spending time getting to know oneself. This may involve meditation, coaching, frank discussions with friends and colleagues, and online resources such as personality testing. Identifying one’s strengths and weaknesses in a nonjudgemental fashion may allow one to refine and develop a higher sense of purpose. A recent systematic review18 identified studies looking at resilience training in doctors and found modest benefits.19,20 These strategies are merely a guide. There are other potential strategies not mentioned here which individuals may find helpful. Again, we must emphasize that each individual has his or her own internal and external point of optimum balance.
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Burnout and resilience in anaesthesia and intensive care medicine
A careful, considered, multi-angled approach to well-being, involving the individual practitioner and their support network (e.g. family, friends, social or religious groups, work colleagues, and employer) can lead to a state of sustained vitality. It is also important for employers, administrators, funding agencies, professional societies, academic institutions, patient advocacy groups, and policymakers to pay attention to this ‘silent epidemic’ and institute change.
There is also help available for those experiencing symptoms and in distress, both locally and nationally. In future, many of these strategies will be built into our medical training and will be natural parts of a functioning work environment. It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.—Darwin
Declaration of interest A personal story of burnout from one of the authors My wife, a paediatric ST4, started to show some (in retrospect) telltale signs of burnout in 2012. She became very tired, irritable, and lost a lot of her confidence following an unsuccessful attempt at her MRCPCH clinical examination. Unfortunately, this went unrecognized by all around her, myself included, and culminated in a full mental breakdown in 2013. Since then, we’ve had to make several changes. 1. A sabbatical—we’ve both taken time out of our busy careers. 2. More exercise. 3. Spending more time with family. 4. Reconnecting with hobbies. She rediscovered her love of baking and has since started her own baking business. 5. Medications for mood and sleep. 6. A full reappraisal of our lives, our relationship, and what is important to us. Full-blown burnout with its physical and psychological sequelae is incredibly challenging. It’s our hope in writing this article and sharing our story that others can learn and hopefully prevent this from ever happening to them or someone they care for.
O.O. is a founding member of the online, free Tea and Empathy support group.
References 1. 2.
3.
4.
5.
A real life example—supporting a burnt out colleague One of the authors was contacted by a friend from medical school. She had recently taken some time off work and was feeling tired, low in mood, and generally exhausted. She’d recently been through some major life changes. She was finding work tiresome and was ‘losing the point of it all’. The first thing I did was listen. This was clearly very difficult for her to talk about, and she hadn’t really confided in anyone before. The second thing I did was let her know she was far from alone. What she was experiencing was a real phenomenon, and not just some form of personal weakness that she needed to ‘snap out of’. I was able to direct her towards some resources—her local occupational health department, a local psychotherapy service, and a professional careers coach. I kept in contact as much as I could. A few months later, she felt better and was finding joy in work again.
6.
7.
8.
9.
10.
11.
Conclusions Burnout is a life-altering syndrome characterized by depersonalization, emotional exhaustion, and a loss of sense of achievement. Left unchecked, it can lead to reduced productivity, work absences, and at worst mental illness and suicide. The stresses and prolonged hours in anaesthesia and intensive care make us particularly vulnerable. Many strategies can be employed to mitigate its effect. Maintaining a strong social network, being physically active, practising mindfulness, continual learning, and maintaining a sense of value all promote resilience. Workplace strategies, such as sabbaticals and work control, may be more effective than individual strategies, or at least synergistic.
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12. 13.
14.
15.
Maslach C, Jackson S. The measurement of experienced burnout. J Occup Behav 1981; 2: 99–113 Balme E, Gerada C, Page L. Doctors need to be supported, not trained in resilience. BMJ Careers 2015. Available from: http://careers.bmj.com/careers/advice/Doctors_need_to_be_ supported,_not_trained_in_resilience (accessed 19 April 2017) Shanafelt TD, Hasan O, Dyrbye LN et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90: 1600–13 Van Der Wal R, Bucx M, Hendriks J et al. Psychological distress, burnout and personality traits in Dutch anaesthesiologists: a survey. Eur J Anaesthesiol 2016; 33: 179–86 Milenovic M, Matejic B, Vasic V et al. High rate of burnout among anaesthesiologists in Belgrade teaching hospitals: results of a cross-sectional survey. Eur J Anaesthesiol 2016; 33: 187–94 Embriaco N, Papazian L, Kentish-Barnes N et al. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care 2007; 13: 482–8 Embriaco N, Azoulay E, Barrau K et al. High levels of burnout in intensivists. Prevalence and associated factors. Am J Resp Crit Care Med 2007; 175: 686–96 Medscape critical care lifestyle report 2016: bias and burnout. Available from: http://www.medscape.com/features/sli deshow/lifestyle/2016/critical-care (accessed 19 April 2017) Ramirez AJ, Graham J, Richards MA et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995; 71: 1263–9 Gerada C. How to improve junior doctors’ morale and wellbeing. BMJ Careers 2016. Available from: http://careers.bmj. com/careers/advice/How_to_improve_junior_doctors%E2% 80%99_morale_and_wellbeing (accessed 19 April 2017) McMurray JE, Linzer M, Konrad TR et al. The work lives of women physicians: results from the physician work life study. J Gen Intern Med 2000; 15: 372–80 Landsbergis PA, Schnall PL, Belkic KL et al. Work stressors and cardiovascular disease. Work 2001; 17: 191–208 Drummond D. Stop Physician Burnout: What To Do When Working Harder Isn’t Working. Collinsville, MS: Heritage Press Publications, 2014 Maslach C, Jackson S, Leiter MP, eds. Maslach Burnout Inventory Manual, 3rd Edn. Palo Alto, CA: Consulting Psychologists Press, 1996 Doctors for doctors: burnout questionnaire. Available from: https://web2.bma.org.uk/drs4drsburn.nsf/quest?OpenForm (accessed 19 April 2017)
Burnout and resilience in anaesthesia and intensive care medicine
16. Moss M, Good V, Gozal D et al. A critical care societies collaborative statement: burnout syndrome in critical care healthcare professionals. A call for action. Am J Respir Crit Care Med 2016; 194: 106–13 17. Public Health England. Interventions to Prevent Burnout in High Risk Individuals: Evidence Review. Available from: https:// www.gov.uk/government/uploads/system/uploads/attach ment_data/file/506777/25022016_Burnout_Rapid_Review_ 2015709.pdf (accessed 19 April 2017) 18. Marine A, Ruotsalainen J, Serra C et al. Preventing occupational stress in healthcare workers. Cochrane Database Sys Rev 2006; 4: CD002892
19. Gander F, Proyer RT, Ruch W. Positive psychology interventions addressing pleasure, engagement, meaning, positive relationships, and accomplishment increase wellbeing and ameliorate depressive symptoms: a randomized, placebo-controlled online study. Front Psychol 2016; 7: 686–78 20. West CP, Dyrbye LN, Rabatin JT et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 2014; 174: 527–33
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Burnout and resilience in anaesthesia and intensive care medicine Adrian View-Kim Wong BSc MBBS MRCP FRCA FFICM EDIC1,* and Olusegun Olusanya BSc BM MRCP FRCA2 1
Consultant in Intensive Care Medicine and Anaesthesia, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK and 2North Hampshire Hospital, Basingstoke, UK
*To whom correspondence should be addressed. Adult Intensive Care Unit, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK. Tel: 01865 220621; Fax: 01865 222979; E-mail: [email protected]
Key points • Burnout is a syndrome characterized by deper-
sonalization, emotional exhaustion, and loss of sense of achievement. • The incidence of burnout among medical profes-
sionals appears to be rising, although improved awareness and diagnostic capabilities may be partly responsible. • Burnout is associated with significant morbidity
and mortality. The management of burnout syndrome involves a multidisciplinary approach, and a biopsychosocial model may be helpful. • Preventing burnout is feasible. Proactive, multi-
modal techniques beginning early in medical education, engaging the individual and community can be effective, albeit with limited evidence. • Tools are available for practising clinicians to im-
prove well-being, increase resilience, and reduce risk of burnout.
The term ‘burnout’ describes the collection of symptoms and signs, both physical and psychological, experienced by individuals due to their work. It is defined as the condition where professionals ‘lose all concerns, all emotional feeling for the people
they work with, and come to treat them in a detached or even dehumanised way’.1 Individuals often feel a sense of emotional exhaustion, indifference, depersonalization, and a lack of desire for personal achievement. Stress is related to, but is not the same as burnout (Table 1). Stress occurs when the individual’s ability to cope and deal with demands is exceeded. In controlled amounts, stress allows an individual to improve his/her performance, while burnout is an intrinsic response to continued excessive stress without time or space for recovery. Often mentioned and described with burnout, resilience is defined in the Oxford Dictionary as ‘the capacity to recover quickly from difficulties’. A true clinical definition of resilience is lacking, although it has considerable overlap with the concepts of wellness and well-being. Rather than simply being the absence of burnout, it is considered a state of being able to thrive in the presence of challenges.2 Like burnout, resilience is a complex interplay between the individual, environment, and culture.
Prevalence among health care professionals Although burnout can affect workers from any field, health care professionals are particularly at risk. With the ever-increasing workload and demands placed on the modern health care system, there is growing concern about burnout among health care professionals due to its potential to negatively affect the workforce and also patient care. Doctors reported substantially higher rates of psychological distress and attempted suicide compared with both the general population and other professionals.3
Editorial decision: April 6, 2017. Accepted: April 6, 2017 C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. V
For Permissions, please email: [email protected]
1
Burnout and resilience in anaesthesia and intensive care medicine
Within health care, there are wide variations in the published prevalence of burnout within different specialties and health care groups. Anaesthesia and intensive care medicine are characterized by their high demands (physical and emotional) and stress levels. Both specialties deal with long working hours in high-risk, complex working environments involving multidisciplinary teams. It is therefore unsurprising that the incidence of burnout and self-harm/suicide is high. Prevalence rates of burnout from surveys of European anaesthetists are variable, ranging between 6% and 18%.4,5 The rates are higher for both critical care physicians and nurses. Embriaco and colleagues found that almost 50% of critical care physicians had high levels of burnout symptoms.6,7 A recent survey from the USA suggests a prevalence of 55% among critical care physicians, the highest in surveyed medical specialties.8 The concept of resilience as a quality for selection is still in its infancy in medicine. No data are available on the number of ‘truly resilient’ doctors.
Risk factors Various factors (individual, environmental, and organizational) contribute to the risk of developing burnout (Fig. 1).
Individual factors Age While some studies have suggested an increased risk with age,9 more recent data from the UK Practitioner Health Programme suggests the opposite.10 This is consistent with works from both Europe and USA, where age less than 55 years was an independent risk factor for burnout. A confounding factor may be the fact that younger workers have had less professional experience and thus less time to develop effective strategies for dealing with occupational stress. Sex Females report higher burnout rates than men. Female doctors with young children and good social support, however, have a lower risk of developing burnout.11 Social support/network Social isolation at both work and home increases the risk of burnout. Coping strategies The availability and type of coping strategies utilized also have a role. ‘Positive’ strategies, such as exercise, meditation, and a strong social network, are protective. ‘Negative’ strategies, such as the use of alcohol and illicit substances, are associated with a higher burnout risk.
Table 1 Stress vs burnout Stress
Burnout
Characterized by overengagement Emotions are overactive Produces urgency and hyperactivity Loss of energy Leads to anxiety disorders Primary damage is physical
Characterized by disengagement Emotions are blunted Produces helplessness and hopelessness Loss of motivation, ideals, and hope Leads to detachment and depression Primary damage is emotional
Personal characteristics
Personality Personality traits, which are considered to be stable and difficult to change, are important in burnout and psychological distress. Individuals with certain personality types may choose highstress occupations, so doctors who choose to pursue a career in anaesthesia might have personality traits suited for the specific stressful demands of the specialty. People who score high on neuroticism tend to have an increased susceptibility to their environment, a tendency to be anxious and insecure with a highperformance drive. This predisposes them towards developing burnout.
ICU environment
Organizational factors
Moral distress Perceived delivery of inappropriate care Compassion fatigue
Burnout
Post traumatic stress disorder & other psychological symptoms
Fig 1 Causes and consequences of burnout.16
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Decreased patient satisfaction and quality of care
Increased rate of job turnover
Burnout and resilience in anaesthesia and intensive care medicine
Personality testing may be used in selection of trainees/residents to reduce burnout in future anaesthetists. Hence, strategies to address these problems can be focused on reinforcing the coping strategies of the individual. Educational programmes could be individualized to personal competence and resilience and to professional knowledge and skills.
Sense of low personal accomplishment This is when the individual feels he/she no longer achieves anything remarkable and is wasting his/her time. A feeling of failure and insufficiency indicates diminishing trust in one’s abilities.
Effects Organizational/work-related factors Work–life imbalance Spending more time at work leads to disproportionately less time for personal interests, family, and recovery. Lack of control An inability to influence decisions that affect one’s job, e.g. schedule, assignments or workload, and the lack of resources needed to perform at a satisfactory level can also contribute to burnout. Unclear job expectations Poorly defined roles and objectives are likely to result in discomfort at the workplace. Workplace/colleague culture and dysfunction Despite increased awareness and measures to deal with bullying within the NHS, it still exists and poses a significant challenge to the well-being of all health care professionals. The way an organization addresses events with poor outcomes can contribute to the stresses of the individuals involved.
Symptoms and signs The myriad of physical and psychological symptoms and signs makes diagnosing burnout a challenge. This problem is further compounded by an affected individual’s reluctance to seek help for fear of the negative connotations associated with burnout. Burned-out physicians may be angry, irritable, or impatient. They may seem to treat patients as objects or to be simply emotionally depleted. They may be frequently absent or seem unable to leave work. The clinical symptoms and signs of burnout are often nonspecific and can include depression, irritability, insomnia, tiredness, and anger. The hallmark of burnout is the triad of: • emotional exhaustion; • depersonalization; and • sense of low personal accomplishment.
Maslach and Jackson1 initially regarded emotional exhaustion as a reaction to interpersonal demands, depersonalization as a coping strategy, and sense of reduced personal accomplishment as a consequence of non-adaptive coping. Emotional exhaustion Emotional exhaustion is a chronic state of physical and emotional depletion that results from excessive job and/or personal demands and continuous stress. It describes a feeling of being emotionally overextended by one’s work, manifested by both physical fatigue and a sense of being psychologically ‘drained’. Depersonalization This consists of unfeeling and impersonal attitudes and reactions towards others, particularly people with whom one deals regularly. This behaviour therefore creates distance between oneself and those who cause discomfort.
Burnout affects negatively on the individual and can result in reduced quality of patient care, costs related to absenteeism, and high turnover of staff. The individual Burnout has a considerable overlap with mental illness, in particular depression and anxiety disorders. This can lead to considerable psychological and physical morbidity. In the USA, it is estimated that 400 physicians commit suicide each year, with burnout thought to contribute to a significant proportion based on a 1977 study by Sargent and colleagues. It is a predictor for developing depression, absenteeism, substance abuse, and a decline in working ability. Physical symptoms may include non-cardiac chest pain, palpitations, shortness of breath, bowel upset, dizziness, and headaches. Burnout has been associated with an increased risk of myocardial infarction and coronary heart disease. It has also been related to reduced fibrinolytic capacity, decreased capacity to cope with stress, and hypothalamic–pituitary–adrenal (HPA) axis hypoactivity.12 Those experiencing burnout may be more vulnerable to emotional and/or uncontrolled eating with a risk of obesity and its associated health problems. Trainees who burnout are unlikely to continue their chosen career and join the consultant workforce which is not cost-effective for the health care system. The patient The body of medical literature on burnout has demonstrated significant professional repercussions including decreased patient satisfaction, increased medical errors and litigation, and the personal consequences of substance abuse and depression. Patients cared for by burned-out physicians are less compliant, less satisfied with their care, and may even experience an increased time to full recovery.13 The institution Burnout has institutional costs; the cost of supporting or replacing a burned-out physician is significant. Additionally, less quantifiable costs occur when the loss of a colleague disrupts care teams and work communities. In the longer term, a work environment that is rife with burned-out physicians and health care professionals will not be a positive environment to work in and may struggle to attract the high-quality professionals required to deliver excellent patient care.
Diagnosis There is some controversy surrounding the diagnosis of burnout. It is not considered a formal psychiatric diagnosis in the latest edition of the Diagnostic and Statistical Manual of Health Disorders (DSM-V). The most widely used tool used to diagnose burnout is the Maslach Burnout Inventory (MBI);14 this questionnaire consists of 22 items, where the responders are asked to indicate the frequency with which they experience certain feelings with regard to their work. Other tools used include the
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Table 2 List of resources Support4Doctors Support4Doctors provides access to a wide range of specialist advice and support for doctors and their families. http://www.support4doctors.org/ Practitioner Health Programme (London based) The NHS Practitioner Health Programme is an award-winning, free, and confidential NHS service for doctors and dentists with issues relating to a mental or physical health concern or addiction problem, where these might affect their work. http://php.nhs.uk/ BMA support pages Doctors for Doctors—Confidential, nationwide counselling service for doctors and medical students, provided by BACP-registered counsellors, available 24/7. http://www.bma.org.uk/support-at-work/doctors-well-being/about-doctors-for-doctors Phone: 0330 123 1245 Doctor Advisors—The Doctor Advisor Service runs alongside BMA Counselling giving doctors and medical students in distress the choice of speaking in confidence to another doctor. Phone: 0330 123 1245—ask to speak to a Doctor Advisor Doctors Support Service—Confidential phone and face-to-face support for doctors facing GMC fitness to practice hearings. http://www.bma.org.uk/support-at-work/doctors-well-being/doctor-support-service Doctors Support Network Self-help group for doctors with mental health concerns, including stress, burnout, mood, and eating disorders, with regular meetings around the UK, a newsletter and an email forum. Address: Doctors Support Network, PO Box 360, Stevenage SG19AS, UK Tel. 0870 321 0642 DSN England E-mail: [email protected] DSN Scotland E-mail: [email protected] The Sick Doctors’ Trust An early intervention programme for addiction, which facilitates treatment in appropriate centres, arranges funding for inpatient treatment, and provides advocacy and representation when required. Tel: 0370 444 5163 (24 h) London Deanery Coaching and Mentoring A confidential coaching and mentoring service for London’s trainee dentists and doctors and health care professionals in Bands 5–8. http://mentoring.londondeanery.ac.uk/ E-mail: [email protected] The Couch (doctors.net) This service is available to doctors registered with doctors.net. There is a forum for mutual support and advice, with the option of anonymous posting, and a long list of doctors around the UK happy to help colleagues in distress. http://www.doctors.net.uk Psychiatrists’ Support Service, Royal College of Psychiatrists A confidential support and advice telephone helpline for Members or Associates of the College. Tel: 0207 245 0412 E-mail: [email protected] Royal College of Obstetricians and Gynaecologists Mentoring Scheme Aimed at obstetricians and gynaecologists who have been experiencing difficulties in relation to their work. Tel: 020 7772 6369 Email: [email protected] Association of Anaesthetists support pages http://www.aagbi.org/professionals/welfare/welfare-schemes Royal College of Surgeons Confidential Support and Advice Services for Surgeons (CSAS) This is a confidential telephone service providing a listening ear for surgeons, with further links to appropriate sources of advice and support. Tel: 020 7869 6030 Email: [email protected] Tea and Empathy- an online peer-to-peer support group. https://www.facebook.com/groups/1215686978446877/ Twitter: @tea_empathyNHS
Copenhagen Burnout Inventory and the Oldenburg Burnout Inventory; however, the MBI remains the most widely used and validated.
Dealing with burnout—the 3Rs: recognition, reversal, resilience Recognition Maintenance of wellness and treatment of burnout both require a carefully considered, biopsychosocial approach. It is the authors’ opinion that the management of burnout is not entirely up to the individual. This idea of the ‘resilient
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superhuman doctor’ who can cope with and handle everything independently is associated with an increased risk of burnout, mental illness, and suicide.13 Anyone who is experiencing severe symptoms should receive expert help. All doctors should be registered with a general practitioner who will provide a knowledgeable base from which to seek further help. Occupational Health departments are also an excellent initial port of call and handle all enquiries confidentially. There is no legal obligation for a struggling doctor to inform the General Medical Council. It is important for individuals to screen themselves, and people they care about, for symptoms of burnout. UK
Burnout and resilience in anaesthesia and intensive care medicine
Table 3 Summary of interventions Intervention
Aim
Example
ICU organization
Optimize intensivists’ work schedule Improve work environment
Weekend respite, Shift models Improved design, natural lighting, well-designed relaxation spaces, comfortable on-call rooms Changing theatre lists, ‘buddy’ systems Planned sabbaticals, varied job plans Meeting team members socially, ‘fun’ events, Schwartz rounds
Change team composition Team building and job rotation Improving work connectedness and psychological safety Improving sense of value at work Individual—practical
Individual—personal
Educational programme Communication skills Relaxation exercise Mindfulness Physical exercise Hobbies Personality and coping Social support Counselling
Practitioner Health Programme has developed a useful screening questionnaire reproduced below (with permission): 1. Has anyone close to you asked you to Cut down your work? 2. In recent months have you become Angry or resentful about your work or about patients? 3. Do you feel Guilty that you are not spending enough time with your friends, family, or even on yourself? 4. Do you find yourself becoming increasingly Emotional, for example, crying, getting angry, shouting, or feeling tense for no obvious reason? A free online self-test questionnaire, based on the Oldenburgh Burnout Inventory, can also be accessed through the BMA website.15 Reversal The authors appreciate the difficulties and stigma surrounding this delicate topic. For those seeking professional assistance, a list of helpful resources is available in Table 2. Strategies to prevent and treat burnout can be grouped into personal and environmental (intensive care unit/hospital) strategies.
Recognizing excellence—‘employee of the month’ schemes, excellence meetings Well-being seminars Non-violent communication, empathic listening Yoga, Tai Chi Mindfulness-based stress-reduction courses, online courses, apps Running, joining a gym Art, music, reading Emotional intelligence training Arranging regular meet up with friends, joining new groups, prioritizing family time Formal psychotherapy, informal through a mentor/friend
Some interventions overlap between personal and environment, for instance; cognitive–behavioural therapy can be offered at the workplace but requires participation of the individual. A recent review assessing these strategies suggested that system-wide strategies may be more effective and long-lasting than individual strategies. However, this review was limited by the heterogeneity of the current evidence base. Also, it is recognized that workplaces themselves are incredibly diverse, and solutions need to be tailored to the individual’s environment.17
Resilience Compared with the studies on burnout, which date back to the 1970s, our understanding of the opposite of this, i.e. the factors that keep people buoyant even in the face of dire misfortune, is in its infancy. As opposed to being a personality trait, recent research suggests that certain skills (which can be taught and practised to an extent) can contribute to an individual’s resilience. Some simple recommendations include: • Expressing gratitude to people—this generates positive emo-
Personal strategies Focusing on the health care practitioner, these rely on the individual to recognize their symptoms, seek help, and pursue strategies to allow them to manage the symptoms and their consequences. These include spiritual practices, exercise, meditation, and hobbies outside work.16
Environmental strategies These focus on the working environment and are multifaceted. Involving unit leaders, hospital administrators, and reaching as far as government policymakers, these interventions can be vast and far-reaching. They range from rostering extra staff, allowing adequate rest between shifts, improving workplace communication, and support groups to adjustments in training and credentialing, and improving laws and regulations.16 Table 3 gives further examples of such interventions.
tions, engages us with others/our workplace, develops relationships, and gives us a sense of accomplishment. • Spending time developing our bonds with friends and family. • Recording a diary of achievements. • Spending time getting to know oneself. This may involve meditation, coaching, frank discussions with friends and colleagues, and online resources such as personality testing. Identifying one’s strengths and weaknesses in a nonjudgemental fashion may allow one to refine and develop a higher sense of purpose. A recent systematic review18 identified studies looking at resilience training in doctors and found modest benefits.19,20 These strategies are merely a guide. There are other potential strategies not mentioned here which individuals may find helpful. Again, we must emphasize that each individual has his or her own internal and external point of optimum balance.
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A careful, considered, multi-angled approach to well-being, involving the individual practitioner and their support network (e.g. family, friends, social or religious groups, work colleagues, and employer) can lead to a state of sustained vitality. It is also important for employers, administrators, funding agencies, professional societies, academic institutions, patient advocacy groups, and policymakers to pay attention to this ‘silent epidemic’ and institute change.
There is also help available for those experiencing symptoms and in distress, both locally and nationally. In future, many of these strategies will be built into our medical training and will be natural parts of a functioning work environment. It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.—Darwin
Declaration of interest A personal story of burnout from one of the authors My wife, a paediatric ST4, started to show some (in retrospect) telltale signs of burnout in 2012. She became very tired, irritable, and lost a lot of her confidence following an unsuccessful attempt at her MRCPCH clinical examination. Unfortunately, this went unrecognized by all around her, myself included, and culminated in a full mental breakdown in 2013. Since then, we’ve had to make several changes. 1. A sabbatical—we’ve both taken time out of our busy careers. 2. More exercise. 3. Spending more time with family. 4. Reconnecting with hobbies. She rediscovered her love of baking and has since started her own baking business. 5. Medications for mood and sleep. 6. A full reappraisal of our lives, our relationship, and what is important to us. Full-blown burnout with its physical and psychological sequelae is incredibly challenging. It’s our hope in writing this article and sharing our story that others can learn and hopefully prevent this from ever happening to them or someone they care for.
O.O. is a founding member of the online, free Tea and Empathy support group.
References 1. 2.
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A real life example—supporting a burnt out colleague One of the authors was contacted by a friend from medical school. She had recently taken some time off work and was feeling tired, low in mood, and generally exhausted. She’d recently been through some major life changes. She was finding work tiresome and was ‘losing the point of it all’. The first thing I did was listen. This was clearly very difficult for her to talk about, and she hadn’t really confided in anyone before. The second thing I did was let her know she was far from alone. What she was experiencing was a real phenomenon, and not just some form of personal weakness that she needed to ‘snap out of’. I was able to direct her towards some resources—her local occupational health department, a local psychotherapy service, and a professional careers coach. I kept in contact as much as I could. A few months later, she felt better and was finding joy in work again.
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Conclusions Burnout is a life-altering syndrome characterized by depersonalization, emotional exhaustion, and a loss of sense of achievement. Left unchecked, it can lead to reduced productivity, work absences, and at worst mental illness and suicide. The stresses and prolonged hours in anaesthesia and intensive care make us particularly vulnerable. Many strategies can be employed to mitigate its effect. Maintaining a strong social network, being physically active, practising mindfulness, continual learning, and maintaining a sense of value all promote resilience. Workplace strategies, such as sabbaticals and work control, may be more effective than individual strategies, or at least synergistic.
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