Module 1 – Avoiding Burnout, Enhancing Resilience

Module 1 – Why do Doctors Struggle with Resilience and Burnout?

by Dr Suzy Jordache

Over the last decade, interest and research into physician wellbeing has exploded exponentially. Studies show that physician burnout is linked to the risk of making mistakes, failing to communicate effectively, listen or empathise with patients – all of which increase medicolegal risk.

At Premium Medical Protection we are keen to explore issues that affect you and your medicolegal risk and we believe that this is a key area of concern for many.

Aims

1. To explore the definition, prevalence and impact of burnout in doctors.
2. To acknowledge and explore the importance of context and personal ideals noted across the medical profession as risk factors for burnout.

Learning outcomes

To understand burnout as a well recognised occupational phenomenon with a solid evidence base, as well as introducing you to research findings from which you can adopt or enhance your own resilience strategies.

Introduction

Over the last decade the interest and research into physician burnout 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.

This has been further highlighted during the COVID-19 pandemic with studies amongst frontline workers in China and the BMA survey in May 2020 demonstrating that anxiety, depression and stress are – unsurprisingly – currently high in our profession.

What is burnout?

In the 1990s, Christina Maslach, a Californian psychologist, described the burnout syndrome, in the “Maslach Burnout Inventory” as a triad of “emotional exhaustion, depersonalisation and reduced personal accomplishment”.

According to IMO U (2017), up to 54% of UK doctors scored highly on burnout scores.

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.”

The review paper by Louise Hall in 2016 (Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review) concluded that there is an association between wellbeing, burnout and patient safety.

Physician wellbeing: the three-legged stool

The paper by Bryan Bohman et al, Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness, and Personal Resilience (2017), suggests that we consider doctor wellbeing as a three-legged stool. All three legs of the stool must be thought through if long term stability in practising medicine is to be achieved. The three legs proposed are:

• Practice efficiency
• Culture of wellness
• Personal resilience

“Improvement efforts should focus on all three domains to achieve best results”.

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 – culture of wellness. If wellbeing is prioritised in the workplace, all doctors are more likely to flourish at work.
3. The third leg – 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 an individual to prioritise wellbeing.

Why are doctors so vulnerable to burnout?

Dr Patricia Watson explains, in the Schwartz Center for Compassionate Healthcare webinar, Caring for Yourself & Others During the COVID-19 Pandemic: Managing Healthcare Workers’ Stress (March 2020), some of the psychological theories behind why doctors are vulnerable to burnout.

She states that in her experience “most people who work in settings where they might potentially have high levels of stress, are typically guided by ideals and values that guide their entry into that job and that guide the daily decisions that they make”. She links these ideals with vulnerability.

Double-edged sword of values and ideals

Ideals and values such as selflessness, loyalty, stoicism, moral code and excellence can introduce vulnerabilities such as presenteeism, moral injury, perfectionism and defensiveness. Individuals and systems must acknowledge and strive to guard against these pitfalls to minimise burnout. Healthy ideals and values can turn into unhealthy patterns of behaviour that create the perfect environment for burnout – the double-edged sword. See Table 1.

Table 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

Summary

• Healthcare systems are often poorly designed to mitigate against inherent vulnerabilities in their medical workforce.
• Doctors often lack the self-awareness and confidence to avoid the pitfalls of presenteeism, moral injury, perfectionism and defensiveness.
• Doctors who are stressed or suffering burnout often do not know it and do not seek help.

Support

The GMC Doctor support service, BMA Wellbeing and support services, NHS Practitioner Health and others, provide excellent resources and face-to-face confidential help. However, there is a widely recognised stigma amongst doctors around admitting the need for self-care and asking for help. This can have tragic consequences.

PMP hopes that this first module in the series of Avoiding Burnout, Enhancing Resilience webinar series has provided you with new insights, food for thought, and some great ideas to work on to build your own protective resilience strategies.

This topic is explored further in the second module, where we will take some time to look in-depth at the three-legged stool analogy and at organisational strategies to enhance practice efficiency and the culture of wellness. Module three explores how to enhance personal resilience.