By Adam Staten, GP.
There appears to be widespread discontent amongst doctors. There are recruitment and retention crises in many specialties, large scale emigration, early retirement, not to mention the unprecedented junior doctor strikes of 2016 in England. Underlying much of this unrest is an epidemic of doctor ‘burnout’.
Burnout is a result of prolonged periods of unsustainable stress and it is characterised by three key features; mental and physical exhaustion, a low sense of personal accomplishment, and a sense of depersonalisation that can lead us to treat our patients in callous and disinterested ways. There is much overlap between the ‘burnout syndrome’ and depression or anxiety and some consider it simply to be a less stigma-laden label to give professionals who have become depressed as a result of their work.
Stages of Burnout
There are three stages of burnout. The first is stress arousal during which time the sufferer experiences poor concentration, irritability and anxiety. After this comes the period of energy conservation when the burnout sufferer develops ineffective coping strategies to shield themselves from stress which can include procrastination, work non-attendance, and drug and alcohol misuse. None of these strategies deal with the problem and all of them tend to contribute to a vicious cycle of escalating stress. Finally comes exhaustion which is associated feelings of depression, including suicidality, and the possibility of drug or alcohol dependence. Progression through the stages is not inevitable, but it is probable unless the issue is recognised and dealt with effectively.
Burnout is extremely widespread with some studies finding that up to 70% of young doctors exhibit some signs of burnout and the problem is even well recognised amongst medical students.1 The Practitioner Health Programme in London was set up to help doctors with mental health problems and, over the last decade, it has helped doctors from all specialties but has found that those working in Paediatrics, Emergency Medicine, and General Practice are over-represented amongst their patients. And, worryingly, between 2009 and 2011 the median age of presentation to the Practitioner Health Programme dropped from 50 to 29.
The nature of our work puts us all at risk of burnout and feelings of burnout, whether prolonged or short lived, mild or severe, should to some extent be seen as an inevitable amongst doctors. We tend to treat burnout as a problem suffered by individuals but the data suggests we should really be treating it as a systemic threat. Indeed, some medical schools in the US are already building awareness of work related mental health problems, and how to avoid them, into their curricula. 2
Why do we succumb?
The reasons behind the inexorably rising rates of burnout are complex and vary from doctor to doctor and from specialty to specialty but can be broadly considered to fall into three categories.
- Firstly there are stresses inherent in our work. Our work is intellectually, emotionally, and sometimes physically demanding, and we frequently deal with people who are frightened, unhappy or angry, and who may make us feel frightened, unhappy or angry. Added to this are the problems associated with a population that is increasing in size, age, and multi-morbidity, with rising patient demand and rising patient expectation
- The second category of stressors are those put on us from outside such as resource limitation, the burden of inspection, the burden of assessment and examination, relentless negative media coverage, and seemingly endless political interference and organisational re-structuring.
- The last category of stressors are those inherent to our own personalities. Personality traits that put people at greater risk of burnout include perfectionism, competitiveness, and a heightened sense of responsibility and these are traits that are actively selected for upon entry to medical school. Many of us were born to be at risk of burnout and were then selected to do a job that would only increase that risk.
Some coping strategies
We can’t stop the population ageing, growing or getting sick without a pretty significant divergence from our moral compass, but we can try to cope with the stresses that this places upon us by continually seeking ways to work smarter, more efficiently, and by harnessing technology to make our lives easier.
Sometimes the system feels too big to change but we can influence it, and subvert the political machinations that can sometimes make our lives so much more difficult, by enthusiastically engaging with the bodies that can lobby the government to make changes. Also any negative media that denigrates medical professionals for eye catching headlines can be rebutted by effective use of social media. This happened during the junior doctors’ strikes when the mainstream media ran campaigns such as ‘Moet Medics’ but the noise on social media revealed widespread public support for the strikes that helped legitimise the protest.
Changing ourselves is more difficult but an awareness of the traits that make us more vulnerable to burnout helps. Coping strategies that work include humour, talking things through with colleagues, and making plans to tackle problems. Coping strategies that don’t include simply ploughing on until the work is done, ignoring the problem, or turning to drink. Techniques such as mindfulness may sound wishy-washy but have a growing evidence base amongst doctors and there are a plethora of mindfulness apps that can teach you exercises that can be done in a couple of minutes. These have been shown to reduce the risk of burnout in doctors. 3,4
Above all, we should be aware of the risk of burnout and aware that individual burnout poses a threat to the existence of the whole system.
- Ishak W et al. Burnout in medical students: a systematic review. Clin Teach.2013 Aug;10(4):242-5. doi: 10.1111/tct.12014.
- Brown GE, Bharwani A, Patel KD, and Lemaire JB. An orientation to wellness for new faculty of medicine members: meeting a need in faculty development. Int J Med Educ. England; 2016;7:255-60
- Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA. 2008 Sep 17; 300(11):1350-2
- Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009 Sep 23;302(12):1284-93