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Avoiding Burnout, Enhancing Resilience

By Dr Suzy Jordache

Over the last decade, interest and research into physician wellbeing has exploded exponentially. Hundreds of studies, articles and opinion pieces have been published. Studies have repeatedly shown that practising medicine is linked to high levels of stress, burnout, compassion fatigue, moral distress, depression, anxiety and suicide.

The issue has come into even sharper focus as a result of the COVID-19 pandemic, with concern for healthcare staff wellbeing rising to the top of the individual, organisational and even national agenda for perhaps the first time.

Medical organisations representing doctors have long recognised the link between occupational wellbeing and medicolegal risk. Burnout in particular, has been the subject of many studies. It is now clear that high scores on burnout scales are linked to the risk of making mistakes, failing to listen or empathise adequately and being less likely to work through decisions safely with patients – all of which increase medicolegal risk.

Burnout is described as a triad of emotional exhaustion, depersonalisation (or cynicism) and a decreased sense of personal accomplishment. The WHO, in the publication “11th Revision of the International Classification of Diseases (ICD-11)”, 2019, recognised burnout as an “occupational phenomenon”. In the “ICD -11 for Mortality and Morbidity Statistics” (Version: 09/2020), the WHO describe burnout as “a syndrome resulting from chronic workplace stress that has not been successfully managed”.

Dr Leonid Eidelman, in his inaugural speech as the President of the World Medical Association in 2018, summarised the impact of burnout beautifully:

“Physician burnout negatively influences the quality of care and shortens the lifetime a physician is able to practise medicine”

Why do doctors struggle with resilience and burnout?

Burnout is known to be high amongst doctors, nurses, teachers, police and prison officers. Pro-social occupations seem to carry an increased risk. This group of individuals is typically guided by ideals and values that direct their entry into these professions and guide the daily decisions they make. Many experts now recognise that these ideals introduce potential vulnerability (diagram 1). Please refer to the webinar by Watson P, “Schwartz Center for Compassionate Healthcare”, March 24 2020.

Diagram 1: Double-edged sword of values and ideals
Strength Guiding ideal Vulnerability
Patients and work come first Selflessness Fail to sleep, drink, eat and rest appropriately; presenteeism
Strong commitment to people, projects, places Loyalty Guilt and strong reactions when losses or errors occur
Toughness/grit; endure hardships without complaint Stoicism Failure to recognise the need for self-care; stigma around self-care
Follow an internal moral compass to choose ‘right’ over ‘wrong’ Moral code Feel frustrated and betrayed when others fail to follow the same code
Strive to become the best and most effective professional possible Excellence Feel ashamed of, or deny/minimise imperfections

Many have suggested that avoiding burnout and enhancing resilience requires first and foremost that organisations and systems recognise and endeavour to understand the causes. Not least of which are the challenging ideals and values that doctors have inculcated through training and practise. This leads to a need for organisations to protect their doctors, essentially from themselves.

The importance of organisational strategies to minimise physician burnout

Bryan Bohman et al, in their 2017 paper, “Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness, and Personal Resilience”, offer the analogy of a three-legged stool. They suggest all three legs of the stool must be thought through if long term stability and wellbeing whilst practising medicine is to be achieved. The three legs or areas outlined, are practice efficiency, the culture of wellness in the workplace, and personal resilience (diagram 2).

Diagram 2: Physician wellbeing; the three-legged stool

1. The first leg – ‘practice efficiency’ is critical. We know that doctors working in calm, efficient environments tend to maintain their resilience, despite considerable fluctuations in demand and personal circumstances.

2. The second leg – represents the ‘culture of wellness’. If wellbeing is prioritised in the workplace, all doctors are more likely to flourish at work. A paper, “Burnout in Healthcare: The Case for Organisational Change”, published by Professor Montgomery and colleagues in 2019, discusses the six areas of work that guide interventions in the workplace to maximise resilience.

Diagram 3: The ‘Six Areas of Work’ model

Examples of evidence-based strategies aimed at improving staff experience in these areas include:

  • “Getting Rid of Stupid Stuff”: “GROSS” projects championed by the American Medical Association, an amusing title. However, evidence suggests that it is exactly this kind of initiative that can transform practice efficiency dramatically.
  • “Joy in Work programme”: championed by the Institute for Healthcare Improvement (IHI) a simple yet effective structured programme using careful conversations to ask staff, “What matters to you?” This teases out a range of issues from all six areas of work that can lead to small and large shifts in efficiency and wellness culture.
  • “Schwartz Rounds”: a group reflective practice forum that provides an opportunity for staff from all disciplines to reflect on the emotional aspects of their work. This initiative can dramatically increase a sense of community and can realign values safely.
  • “GREAT-ix reporting”: this is an initiative that can improve recognition and reward in the workplace. The system is designed to enhance patient safety and learning through excellence. Staff can submit a “GREAT-ix” report and their colleague then receives a formal thank you letter.

3. The third leg – of the stool, ‘personal resilience’, is important too. However, without the other two legs of the stool safely in place, even the most resilient individuals will eventually fall over. Unfortunately, inefficiencies, excessive workloads and other negative stressors have become normalised in many healthcare contexts. It often requires considerable courage from individuals to prioritise their own wellbeing.

Enhancing personal resilience: How do I keep myself safe?

  • 1. Develop safe habits:
    • Prioritise sleep and build in regular breaks at work
      Manage fatigue throughout the working day. Building in 10-minute breaks or even brief ‘Power Pauses’ every two hours can transform performance and enjoyment at work.
    • Keep hydrated and fuelled throughout the day
      Plan and take in your own healthy food and drinks.
    • Take time off when unfit
      Many doctors present or go to work when physically sick, emotionally unwell and exhausted. There is good evidence that repeated presenteeism and burnout are intricately linked. Failing to build in cover to enable doctors to take time off when needed is a systemic failure that must be addressed. Please refer to the 2015 webinar by Dr Charlotte Chambers, “Superheroes don’t take sick leave”.
  • 2. Maintain strong boundaries around safe workloads:
    • Say ‘no’ for safety
      Some clinicians have become extremely proficient in ‘saying no’ to extra clinics, more patients and additional duties. The wording that seems to work best in healthcare is around safety. For example, “Thank you so much for thinking of me. However, it would be unsafe for me to take on this extra project at this time”. Safety is hard to argue against.
    • Learn to successfully delegate where safe and possible
      Doctors strive for excellence and can become relentlessly self-critical with a tendency to micromanage and a reluctance to delegate. The balance between what is described as healthy perfectionism and a more neurotic tendency can be difficult. Tasks that one individual finds tedious and unpleasant may be enjoyed and valued by another. The art of delegation involves choosing someone willing and able, investing time in a careful and detailed explanation, offering light-touch support, remembering to acknowledge, appreciate and celebrate when a task is successfully completed.
  • 3. Reconnect with meaning, purpose and passion

    Many doctors find it useful to ask themselves two questions, as discussed in the study “Association Between Physician Burnout and Identification With Medicine as a Calling” by Jager A J et al, in 2017:

    • Why am I doing this work?
    • Am I doing enough of what I am uniquely good at and passionate about?

    Evidence suggests that to maintain resilience, it is important to spend at least 20% of work effort on activity that is personally meaningful. This will be different for everyone. Examples include research, education, management or sub-specialisation. It is said that an individual can cope with whatever is required up to 80% of the time without much enjoyment if their passion can flow throughout the rest of the working day or week.

In summary

Avoiding burnout and enhancing resilience requires individuals and organisations to recognise and mitigate against the inherent vulnerability doctors bring to their work through their strong values and ideals. Organisations must actively promote practice efficiency, a culture of wellness and doctors themselves must strive to commit to self-care as a priority. All three legs of the ‘wellbeing stool’ must be strong enough to ensure a physician can practise safely across a lifetime.

This article is accompanied by a series of three webinars that explore this topic in more depth. The webinars will be available on our website in the coming weeks.

Many experts and agencies are in place to support doctors facing concerns regarding their own wellbeing or that of a colleague, such as the GMC Doctor support service, BMA Wellbeing and support services, NHS Practitioner Health, which provide excellent resources and face-to-face confidential help.

If you have any queries or concerns surrounding the issues raised in this article, please do not hesitate to call the PMP medicolegal helpline. The helpline is open 24/7, contact details can be found on your policy documents or customer card.

Information correct at time of publication June 2021
This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. Because the facts applicable to your situation may vary, please contact your solicitor, legal advisor or other professional advisors if you have any questions related to your legal or medical obligations or rights, applicable law, contract interpretation, or other legal questions. © 2021 Premium Medical Protection Ltd. All rights reserved.
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