Learning Objectives: After reading this case, students will be able to:
- Identify at least two symptoms of burnout that often affect healthcare professionals.
- Describe how burnout can lead to patient harm.
- Identify at least three ways to prevent burnout among health care professionals.
Description: Ana is a second-year resident in a demanding internal medicine residency program. She is generally regarded as one of the most talented residents and has just been elected to the chief resident position for the next year. For several months, however, she has been feeling a significant amount of burnout. Ana’s mood has become low, her energy level has dropped, and she is having difficulty getting out of bed in the morning. She is in the middle of a very demanding ICU (Intensive Care Unit) rotation, during which she is on call every third night, so at first she thinks that it might just be sleep deprivation causing the problem. But she continues to feel increasingly unwell both physically and emotionally. To make matters worse, Ana’s mother was recently diagnosed with breast cancer…
Ana is a second-year resident in a demanding internal medicine residency program. She is generally regarded as one of the most talented residents and has just been elected to the chief resident position for the next year. For several months, however, she has been feeling a significant amount of burnout. Ana’s mood has become low, her energy level has dropped and she is having difficulty getting out of bed in the morning. She is in the middle of a very demanding ICU (Intensive Care Unit) rotation, during which she is on call every third night, so at first she thinks that it might just be sleep deprivation causing the problem. But she continues to feel increasingly unwell both physically and emotionally.
To make matters worse, Ana’s mother was recently diagnosed with breast cancer. Her mother lives over a thousand miles away, and it’s impossible to visit her, since Ana only has one day per week off from work. Her mother reassures her, saying, “Don’t worry about me – keep working.” Nevertheless, Ana can’t stop thinking about her mother and is having a hard time focusing on medicine. She has to force herself to complete tasks and she stops doing the extra reading on medical cases that she usually enjoys. She is feeling overwhelmed and increasingly hopeless about life and, in spite of her many past successes, she is starting to regard herself as a complete failure.
Ana also feels that she is not able to care for her patients as well as she used to in previous rotations. The other day when a patient was admitted with recurrent fainting episodes, she took a brief history from the patient and did not do a thorough job asking about family history, missing the fact that both the patient and other family members had histories of blood clots. As a result, she did not think to work the patient up for a pulmonary embolus (blood clots to the lungs) even though he had had some shortness of breath on admission, which is a common presenting symptom of this dangerous condition. If a colleague had not thought about this possibility and suggested the requisite testing, the patient’s life might have been in danger. Ana feels that she did not spend enough time talking to the patient; she also feels that if she were doing her usual amount of reading of the medical literature, she would have been better prepared.
Ana is worried because she was briefly diagnosed with clinical depression as a teenager, and her symptoms are beginning to resemble what she felt back then. She knows, however, that she cannot drop out of rotation; there is no one who can take her place in her ICU, and her not being there would force the other residents to be on call every other night, giving them an intolerable work load. Even if it were possible to find a substitute for the rotation, she does not have any vacation time left and she can’t progress to the third year if she takes off any more time.
Ana is afraid to tell anyone how she feels because she knows that people in the program will start to regard her as a “weak” resident if she complains. Besides, all the other residents are working just as hard and don’t seem to be having any problem. She will not even discuss the situation with her family at home because she does not want to disappoint them. She is feeling completely trapped and wonders why she went into the medical field in the first place; she would do anything at this point to escape it.
What would you do if you were Ana? Is there anyone in your organization to whom you could go if you felt you needed help?
Have you ever experienced burnout at work? What role did workplace culture play in the situation?
How might a health care organization prevent and screen for problems such as burnout, stress, and depression in the workplace?
What would you do if one of your colleagues wasn’t performing well and you were worried about the care that his or her patients were getting? What if the person were senior to you?
How do you maintain a balance between the demands of your work and your own personal sense of well-being?
Perhaps the most significant issue behind this case is the prevailing culture of medicine, which does not always emphasize wellness for its professionals. Within this culture, many tend to place a strong emphasis on industriousness and self-sacrifice. What is often lacking, however, is the ability and willingness to engage in self-reflection, the skills to seek help when needed, and the application of the principles of compassionate care toward oneself. Many in the medical field also seek to avoid appearing weak or vulnerable. Ana’s unwillingness to ask for time off or talk to any of her colleagues reflects the culture around her and, unfortunately, makes it that much more difficult to deal with her clinical depression.
Most health care workers may never develop clinical depression or a substance abuse problem. Many, however, do experience significant work-related stress, which may contribute to burnout – described as “a silent anguish of the healers.”[i] The symptoms of burnout may include “emotional exhaustion, cynicism, perceived clinical ineffectiveness, and a sense of depersonalization in relationship with coworkers, patients, or both.”[ii] A study of physician satisfaction between 1986 and 1997 showed that in every aspect of their professional lives (satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality), there was a decline in physician satisfaction,[iii] even though the awareness of physician burnout was actually increasing.
The workplace culture of self-sacrifice and self-denial that may lead to burnout is seemingly admirable, but it may paradoxically compromise our work and the quality of care that we provide to our patients. When physicians experience the symptoms of burnout, more errors may be likely. These errors, in turn, may contribute to worsening of burnout. ;[iv] One study, for example, found that patient care (self-reported by internal medicine residents as “suboptimal patient care practice”) suffered significantly when healthcare providers experienced burnout. [v]
The best way to prevent burnout may be to consciously and actively promote wellness for healthcare professionals – not just while they are in school or residency training, but throughout the career path. It has been shown that the physicians’ wellness reaps its benefits in better care of patients. [vi] Spickard et al. suggest some ways that organizations can promote wellness (the responsibility, of course, lies with the healthcare professionals themselves as well as with their organizations):
Provider health committees (with equal stature as other key committees)
Mentor programs for junior providers
Confidential support groups facilitated by an outside professional
Continuing medical education programs relating to wellness
Involvement of medical professionals in the design of their own practice environments
Flexible scheduling allowing time for personal and family needs
Availability of leaves of absence to pursue personal interests
[i] Neuwirth ZE. The silent anguish of the healers. Newsweek. 1999;134:79.
[iii] Murray, A., Montgomery, J. E., Chang, H., Rogers, W. H., Inui, T., & Safran, D. G. (2001). Doctor discontent: A comparison of physician satisfaction in different delivery system settings—1986 and 1997. Journal of General Internal Medicine, 16,
452– 459. http://www3.interscience.wiley.com/cgi-bin/fulltext/118978736/HTMLSTART
(accessed May 6, 2009).
[iv] Crane M. Why burned-out doctors get sued more often. Med Econ. 1998;75:210-218.
[v] Shanafelt, T. D., Bradley, K. A., Wipf, J. E., & Back, A. L. (2002). Burnout and self-reported patient care in an internal medicine residency program. Annals of Internal Medicine, 136,
358 –367. http://www.annals.org/cgi/content/abstract/136/5/358?ijkey=a2deea705364cf572f9dfed45eae2bdbc66968db&keytype2=tf_ipsecsha
(accessed May 6, 2009).