An unavoidable side-effect of caring

Doctors’ Mental Health

With 58% of doctors now suffering from some form of anxiety or depression – and 46% saying their condition has worsened since last March – we are serialising sections of a new book edited by Dr Clare Gerada. This month: Burnout in doctors

Burnout is now a public health crisis. It is the single most prevalent psychological complaint found in those who work in the caring professions, with doctors, nurses and counsellors all at high risk. 

It is formally defined and subjectively experienced as a state of physical, emotional and mental exhaustion caused by long-term involvement in demanding situations. 

People lose their joy and zest for work. It becomes mundane, routine and a burden. Burnout strikes those who have been most idealistic, enthusiastic and engaged.

Compassion fatigue

Burnout is thought to be distinct from depression, but I think of them as part of the same process. There is a considerable overlap between symptoms – in particular around hopelessness, poor self-esteem, sleep disturbance – and it might be more acceptable to call oneself ‘burnt-out’ than ‘depressed’. 

Compassion fatigue is also closely linked to burnout and again the two could be considered to be part and parcel of the same thing.

Burnout is a psychological and behavioural syndrome where emotional exhaustion is a major feature. It was first described in 1974 by psychologist Herbert Freudenberger in his work looking at why those working with drug addicts experienced a gradual depletion in energy and loss of motivation and commitment.

While linked, stress and burnout are not the same. Stress is a general term referring to temporary adaptation – with positive as well as negative connotations – accompanied by physical and mental symptoms. In contrast, burnout is the final stage in a breakdown of the person’s ability to adapt, which results from the long-term imbalance between demands and resources. 

Studying burnout

Despite thousands of studies, the exact prevalence of burnout is hard to pin down. It is probably as hard to measure as nostalgia, stoic­ism, fear, hate or love.

We cannot answer basic questions such as who gets it, who is more at risk, how much of it is there, let alone what interventions work in reducing it. Even the impact of burnout is not clearly known. 

Of course, the cause is known: chronic, unremitting emotionally stressful jobs. But this does not really help in studying it. 

Burnout has been described as the ‘painful realisation that we have failed to make the world a better place, to help the needy, to have a real impact in the organisation, that all of our efforts are for nothing’. 

For me, this feels a much better, more honest and a less clinical definition to describe that hopeless feeling, when you know – hopefully temporarily – that you cannot go on caring for others and when you realise you cannot make a difference to your patients’ lives or to the system you work in.

Losing compassion

I have had experience of losing interest in the well-being of my patients, of becoming bored and, worse still, of losing my compassion for them. Exhausted from juggling work and two young children, I felt an overwhelming desire to resign, to pack it all in and leave medicine completely. 

It came to a head after a particularly busy and stressful morning surgery. I felt washed out, didn’t want to return for the evening clinic and resented patients having more of my time than my own family. 

Many were my regulars; patients with longstanding, intractable problems and I felt disillusioned. What could I do to help them? I couldn’t find them jobs or rehousing. I couldn’t repair their broken relationships. 

Hard to quantify

I couldn’t fix their lives. Medicine had lost its spark. I knew I needed a break from clinical practice. These emotions are so much harder to quantify than the multiple questions in burnout questionnaires and studies would imply.

Although the intensity, duration  and consequences of burnout may vary between different individuals and across time in the same person, it always has the combination of the three components: physical, emotional and mental exhaustion. 

Almost all research studies into burnout rely on self-report and largely poorly constructed cross-sectional surveys. I worry that, by constantly measuring burnout, we might be perpetuating the problem rather than finding solutions. 

We might also risk exaggerating the level of distress through contagion of misery. Furthermore, by measuring individual burnout we risk shifting the focus away from where it truly resides, the organisation.

Common feeling

What can be gleaned from these studies is that:

Burnout is common.

Prevalence reduces with better designed and larger studies.

It is probably more prevalent in younger versus older doctors, though this is not entirely clear.

It is probably more prevalent and more intense in those specialities working with patients who present with undifferentiated problems – general practice, accident and emergency – or where workload is harder to control, such as general medicine.

Rates tend to be lower in those specialities that have less on-call commitments and are more containable in terms of hours and workload – and are more highly remunerated – such as plastic surgery and dermatology.

It is probably increasing in the medical workforce.

In the main, those who are most at risk of burnout share three characteristics. The first is that their work is emotionally demanding. The second, that the individual has certain personality characteristics that draws them to ‘public’ service as a career and, finally, these individuals share a ‘patient- centred’ approach to their work. All three are equally important.

Emotionally demanding

Looking at the emotionally demanding nature of our work, in public service professions, people are exposed to emotionally demanding situations over a long period of time. Doctors have to deal with pain, helplessness, despair, death and accept the limits of science.

It is important to keep reminding myself, being a doctor is not easy. Even after 40 years, I am amazed at the trust patients give me, how they open up unconditionally and believe that I can ‘sort them out’. This is hard, emotional work. 

This is not the same as saying the job is ‘stressful’. All jobs are stressful and many of us thrive on stress – and remember the opposite of no stress is boredom. It is the emotional aspect of our work that makes us most at risk of burnout. 

Working long hours, seeing many patients in a single session, having no time between patients, working double shifts in highly emotionally charged or uncertain areas of medicine such as cancer care, general practice magnifies the risk because they act to increase our exposure to this emotional toil. 

Personality characteristics

The second characteristic common in professional groups with burnout is that individuals share a common set of personality characteristics, attitudes and values that has drawn them to their role and which makes them more at risk. 

We become doctors because we think we can make a difference to people’s lives and are willing to sacrifice parts of ourselves to do this. 

The third factor is that of having a patient- or person-centred approach to one’s work. This means making others one’s first concern – as in the GMC’s Good Medical Practice. Most relationships are reciprocal, but the therapeutic relationship is not: the professional gives, the patient receives. This asymmetry is a source of stress. 

On top of these three factors, we each bring our own vulnerabilities derived from our unique experiences, supports and personalities. 

Burnout is present in younger and older doctors, men and women, those in training and those who have achieved final accreditation status, those who work in hospital or general practice.

Addressing burnout

I do not believe we can prevent burnout; rather, we have to manage it, recognise it, minimise it and deal with it when it occurs. Anyone working so close to human suffering will, at some point in their career, develop some aspects of it. 

What is important is recognising when:

 We can go on no longer;

 Negative attitudes turn to loss of compassion;

 Our sense of futility becomes a feeling of hopelessness and helplessness;

 Our work loses its sparkle day in, day out;

 We need to remove ourselves from the stressor.

The best place to start is in the workplace and in particular reduce the pressured environment in which staff work. 

Environments where excessive workload, long work hours, fatigue, intense emotional interactions, restricted autonomy and where constant structural and organisational changes become the norm, lead to increased risk of burnout.

Workplace stressors

At a population level, the most important interventions should be at addressing the workplace stressors, including work pressure, resources – time, people and money – and creating the opportunities for team-working. 

On a larger scale, it means amending external factors, such as regulatory requirements, political influences and media pressures, which all contribute to chronic workplace distress. 

Treating burnout as a public health crisis might mean we use the same prevention strategies as with any other threat to the public’s health. These would include:

Primary prevention – preventing the problem arising in the first place. This largely needs to involve modifying the working environment in which doctors work, especially reducing direct patient contact. 

What is needed is not to provide doctors with more resilience training but instead to address the environment in which they work. Just as mine owners have a responsibility to ensure a safe working mine for miners, so too do those who employ doctors have a responsibility to create a physical and psychological safe place to work. 

A dangerous coal mine is not made less so by teaching miners how to relax. The leading drivers for burnout include excessive workload, chronic work stress and a lack of control over one’s day-to-day work. 

It is a problem of the healthcare organisation as a whole, rooted in issues related to the working environment and organisational culture.

Secondary prevention aimed at reducing the impact of environmental or individual stressors. This might include addressing resilience, providing time out for doctors, improving the systems in the organisation to release time to think, providing group work, improving rest periods and so on.

Tertiary prevention aimed at those with burnout. This is about improving the quality of life and reducing the impact of burnout on the individual. It means providing easy access to confidential services, a culture where it is ‘OK’ to admit you have had enough and opportunities to take time out.

No measure to prevent burnout will be effective unless attention is paid to enhancing a positive work environment. Thus strategies directed at individuals will be of limited benefit.

I have created a short, easy mnemonic to help me remember what I need to do:

B – Balance my work and play times;

U – Understand my limitations – I am not a superhero;

R – Recognise, prevent and treat burnout in myself and my teams;

N – Nurture the next generation – bring the fun back into work;

T – Teamwork – rest, play and reflect together.

Finally, burnout can be a trigger for change and personal growth. The experience of burnout always involves pain and suffering, but it can then force someone, as it did for me, to examine priorities, learn and be more aware of one’s vulnerabilities. 

I was lucky – my sympathetic and progressive partnership and opportunities outside the consulting room meant I could take time out, return when ready and restructure my working life to refresh my psychological self. 

I modified my working practices, especially decreasing the time spent on face-to-face clinical work. 

My experience of burnout led to growth, change and further challenges that sustained me for the years to come.

Dr Clare Gerada (right) is medical director of the Practitioner Health Programme, London, and a former RCGP chairman