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Tackling Physician Burnout and Moral Injury

January 8, 2020

Across the United States, burnout and suicide rates for physicians have reached record highs, claiming the life of a doctor a day. What can be done to protect and improve the wellbeing of the people who care for everyone else?

Most doctors enter their profession knowing that it is demanding, but believing that it is also rewarding and meaningful work. “Demanding” may be putting it mildly, however. Health care providers sleep less than people in any other profession. Physician stress, depression and anxiety levels are on the rise, with more than half of clinicians reporting symptoms that qualify as emotional, physical and mental burnout. And sadly, between 300 and 400 physicians per year are lost to suicide.

But why do some physicians develop burnout, moral injury and long-term mental health conditions, while others don’t? Why is America losing a doctor every day to suicide? And what can be done about it?

Seeing the Problem

The health care system surrounding today’s clinicians encompasses much more than just providing care. Clinical work is part of a much larger picture that often includes electronic medical record management, office and insurance paperwork, highly complex regulatory requirements, satisfaction reviews, quality improvement and cost reduction responsibilities, continuing education, and multidisciplinary collaboration for complex patients. Clinicians are asked to accomplish more and more, often with no extra time or resources provided.

“These are individuals who are in medicine because they want to help people, so this constant battle is demoralizing, guilt-inducing and makes them feel they aren’t in control of their professional lives. They lose the joy of practicing medicine.” — Brandon Kozar, PsyD, MBA

“Clinicians are increasingly torn by competing priorities, and they report they are constantly making trade-off decisions: having to choose between getting their administrative duties completed and providing more or better patient care,” says Brandon Kozar, PsyD, MBA, director of leadership coaching and development at Nationwide Children’s Hospital. “These are individuals who are in medicine because they want to help people, so this constant battle is demoralizing, guilt-inducing and makes them feel they aren’t in control of their professional lives. They lose the joy of practicing medicine.”

Resourcefulness and hard work cannot solve this dilemma, and their resiliency plummets. Over time, clinicians who feel that these forced trade-offs infringe on their ethical duties — that they are unable to uphold their entrenched moral desire to put patients’ wellbeing first — experience “moral injury,” a significant predictor of other serious mental health concerns, such as clinical depression, substance abuse, anxiety and suicidal ideation.

Burnout — a more common phenomenon, where emotional and physical exhaustion result from constant exposure to stressors and a decreased ability to cope with daily duties — and moral injury have important implications beyond the wellbeing of the affected individual clinicians. These problems may negatively impact patient care and outcomes. When doctors are exhausted mentally, emotionally and physically, they cannot provide optimal care. They become more likely to make mistakes. Substance abuse, sleep deprivation, anger control issues, relationship troubles and other problems arise, further increasing the risk to physicians and their patients.

Unfortunately, physicians and other health care workers often feel they have nowhere to turn for relief.

Understanding the Problem

Historically, clinicians have been known for a dogged commitment to their patients and their work, often at their own expense. Acknowledging emotions and troubles, admitting to being overwhelmed, and seeking help have been tantamount to inadequacy or unprofessionalism, and thus have carried a stigma.

Even in recent years, clinicians with depression or substance use disorders have faced loss of licensure, increased supervision, restriction of hospital privileges, and loss of privacy — making admission of difficulties a potential threat to their livelihood and status. And in part because of the profession’s reticence on the idea of mental health concerns affecting their own, suicide among physicians is believed to be underreported by pathologists trying to protect their deceased colleagues’ reputations.

To further complicate matters, many hospital program and department leaders are clinicians themselves, rather than business experts trained in human resource management and administrative processes. Running a business unit with significant fiduciary, regulatory and supervisory responsibilities may come naturally to some clinical directors, but others struggle to create environments that both support morale and enable engaged productivity. Emotional intelligence — the ability to recognize and empathetically respond to the emotions of the people around you — is perhaps under-appreciated in the selection of leadership, and clinicians and other staff pay the price.

“Some departments have greater rates of burnout and poor mental health than others, and the differences are not best predicted by workload,” says Dr. Kozar, referencing literature on emotional intelligence and clinical staff performance. “Instead, just the perception of being socially supported by peers, superiors or the organization dramatically influences how health care providers cope. Positive and supportive work environments that foster a sense of support and collegiality result in more productive work, more accurate differential diagnoses and less burnout.”

This goes beyond creating a feel-good culture to fostering an environment that systematically embraces a genuine concern for clinicians and other employees both in the adoption of workplace expectations and in the everyday manner of interpersonal interactions.

"... just the perception of being socially supported by peers, superiors or the organization dramatically influences how health care providers cope. Positive and supportive work environments that foster a sense of support and collegiality result in more productive work, more accurate differential diagnoses and less burnout.” — Brandon Kozar, PsyD, MBA

Fixing the Problem

There is no cut-and-dry solution to the problem of overwhelmed and under-supported physicians. But that has not stopped many institutions from trying to take an active step toward identifying burnout and distress, helping physicians in need, and preventing the problem in the first place.

At Nationwide Children’s, for instance, Dr. Kozar’s existence on staff is a primary example of the hospital’s intentional decision to protect its people. His role was created partly in response to the hospital’s Zero Hero program, designed to eliminate preventable harm, such as overtired staff and emotionally depleted clinicians. In addition, it was an attempt to formalize programs and a cultural shift toward de-stigmatizing mental health concerns, supporting employees and equipping them with resources and outlets to address their needs.

Dr. Kozar directs the hospital’s YOU Matter program, which offers emotional and mental health support to both clinical and non-clinical staff faced with work-related and potentially traumatic stressors, such as a patient death. The program has several components, including a peer support initiative, a critical response team, on-site Master’s-level clinical counselors exclusively for staff (focused in high-acuity settings such as the emergency department and intensive care units), and hospital rounds focused on discussing psychosocial impacts of participants’ work. In addition, hospital employees are eligible for confidential counseling sessions at no cost.

“The trick is to avoid framing all stress as evil. Stress actually can have many benefits both professionally and personally, and it isn’t realistic to totally eliminate it. Distress, however, is overwhelming and negative and needs to be reduced.” — Brandon Kozar, PsyD, MBA

“It might be due to the increasing visibility of mental health needs in society at large, but I think clinicians are becoming more accepting of the need to speak up and speak out about salient issues of burnout,” says Dr. Kozar. “The trick is to avoid framing all stress as evil. Stress actually can have many benefits both professionally and personally, and it isn’t realistic to totally eliminate it. Distress, however, is overwhelming and negative and needs to be reduced.”

Further efforts at Nationwide Children’s have included the implementation of business coaching for clinical department leaders to help them run better-organized programs and alleviate burnout. Stress management training for staff — in which the distinction between good and bad stress is emphasized — also reinforces the hospital’s culture of confronting the issue and treating each other with compassion. Staff trained as peer support personnel are taught to pay attention to the work experiences of their colleagues and to reach out to others on a regular basis.

“Human beings are social creatures — we do better when we work and operate in an environment where we are cared for,” says Dr. Kozar. “Instead of an environment where there’s nothing but a time crunched, task-oriented day where clinicians are drawn in every direction with no time to look out for each other, we’re focusing on building deliberate and strategic social support systems that can cultivate resiliency.”

How to Protect Clinician Wellbeing

The widespread problems of burnout and moral injury will not disappear overnight, but Dr. Kozar is confident that personal and institutional steps to counteract these problems can equip clinicians with the support and competencies they need in order to maintain resilience and protect their psyches.

“These are high-performing individuals,” Dr. Kozar says. “When you teach them to do something, they can implement it very effectively. You just have to make sure that you’re not training them to quash problems in one area only for them to pop up in another. The approach has to be comprehensive, which means it’s oriented at the institution’s programs and personal resiliency, not just workload.”

As many as a dozen hospitals per year come to Nationwide Children’s to learn about and implement programs similar to those managed by Dr. Kozar.

His recommended steps for physicians to take to prevent and address burnout and moral injury include:

  1. Recognize as early as possible the signs of compassion fatigue (the “empathy well” has run dry), moral injury (value conflicts between what you are doing and what you believe is the right thing to do), and burnout (loss of pleasure, increasing cynicism, mental/emotional exhaustion).
  2. Seek help early: Use your employee assistance program and/or seek counsel from a trusted colleague or supervisor.
  3. Focus on what you can control (“I can’t change the medical health system, but I can control and improve this…”).
  4. Promote and engage in social support (this is the single greatest protective factor against burnout and a primary source of life satisfaction).
  5. Continue to cultivate resilience by focusing on your interpretation or framing of events and not just the events themselves. Remember: A + B = C (Activating event + Belief about that event = Consequence: How I feel and therefore behave).

Dr. Kozar also suggests some opportunities for institutions to protect their employees from the potentially devastating problems of burnout and moral injury:

  1. Recognize that burnout and the need to support and care for staff is a critical investment for their wellbeing as well as that of patients.
  2. Assign a senior executive sponsor to support, fund and advocate for staff support programs –these initiatives deserve more than just staff-driven “culture club”-level support.
  3. Train chiefs of medicine and other leaders on the 3Rs: How to Recognize, Respond and Refer physicians struggling with socioemotional issues.
  4. Promote the purpose and joy of medicine: Have regular events in which physicians are exposed to past patients and families whom they have helped. Allow them the experience of someone expressing their gratitude and appreciation for what they did.
  5. Remember to “Acknowledge the pain yet promote the gain.”
  6. Teach leaders how to promote and support intrinsic motivation in staff: Autonomy, Mastery, and Purpose.
  7. Hire leaders with above-average emotional intelligence. Poor or ineffective leadership is one of the main drivers of work-related burnout and dissatisfaction. As the saying goes, “Most people don’t leave their jobs, they leave their bosses” — so make sure the “bosses” are good not just at medicine, but at personnel management.

 

References:

  1. Kumar S. Burnout and doctors: Prevalence, prevention and intervention. Healthcare, 2016 Sep;4(3):37.
  2. Andrew LB. “Physician Suicide.” 01 Aug 2018. Medscape. https://emedicine.medscape.com/article/806779-overview#a1. Accessed 08 Nov 2019.
  3. “Physician Burnout.” Content last reviewed July 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html. Accessed 08 Nov 2019.
  4. Miller EG, Mull CC. A call to restore your calling: Self-care of the emergency physician in the face of life-changing stress—Part 4 of 6: Physician helplessness and moral injury. Pediatr Emer Care, 2019;35:811–813.

Photo credit: Nationwide Children’s