Burnout in the clinical environment can be described as a psychophysical condition that develops when the professional demands on an individual persistently exceed the available professional and personal resources. Burnout has traditionally been characterized by three domains: emotional exhaustion (EE), depersonalization, and decreased sense of personal efficacy (Annu Rev Psychol 2001;52:397-422). There are strong theoretical models supported by decades of published evidence that explain the factors affecting the occurrence (and mitigation) of clinician burnout – perhaps the most complete overall summary can be found in the 2019 National Academy of Medicine consensus report Taking Action Against Clinician Burnout (A Systems Approach to Professional Well-Being. 2019).
While variability can be seen depending on each clinician's unique professional and personal circumstances, organizational characteristics (e.g., culture, leadership behaviors, work norms, and characteristics of the practice environment) most typically explain unit- or hospital-level patterns. Health care professionals expect to and do work hard (i.e., long, challenging work weeks). Even in the most supportive work environments, excessive work and associated fatigue will increase EE. Furthermore, EE increases with increased work demands (i.e., intensity, stress, emotional demands of caring for patients, and duration) and will be greater for similar work schedules in an unsupportive work environment relative to a supportive one. Depersonalization is best characterized by cynicism about work and one's work life. Although all dimensions of burnout are concerning, based on our research and review of the literature, increased depersonalization is the most ominous sign of progressive burnout for both the individual (e.g., from burnout symptoms to burnout syndrome) and the organization, as exemplified by decreased work quality and loss of workforce effort through presenteeism, absenteeism, reduction in productivity, and decreased retention (early retirement, changing jobs) (Mayo Clin Proc 2016;91:422-31; Mayo Clin Proc 2017;92:1625-35). Although decreased perception of efficacy has not traditionally been as prominent a factor in clinician burnout, it is seen more commonly in clinicians in training and may be a larger factor in front-line clinicians' experience of burnout in response to COVID patient care (Med Educ 2020;54:116-24).
“Now more than ever, we must all become engaged both locally and nationally by advocating for clinician safety and well-being as a top organizational priority.”
Although studies are only now appearing in the literature, the already significant level of clinician burnout pre-COVID may have increased with the onslaught of COVID in 2019-2020, along with increased incidence of anxiety, depression, and PTSD (Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. 2019; Healthcare (Basel) 2020;8:421; Curr Opin Psychiatry 2021;34:413-9). This was primarily associated with increased work demands (in locations seeing large numbers of COVID patients), the uncertainty of how best to care for these patients, and the systemic shortages of personal protective equipment (PPE) (JAMA 2020;323:2133-4). This broad framing, however, may be an oversimplification where the changes in clinician burnout have been quite variable based on occupation (e.g., physician, nurse, respiratory therapist, or pharmacist), specialty, geography, whether or not deployed outside typical area of expertise, and the magnitude of local surges. This is not surprising – although clinician burnout is an international problem, it manifests locally and is profoundly influenced by unique situational and organizational factors, going down to the level of the hospital, unit, and/or clinic. Although most clinicians have experienced massive stress as a result of COVID, the support and resources provided in the local work environment can mitigate or magnify the impact (Mayo Clin Proc 2020;95:698-708). For example, the behaviors of work unit leaders, provision of adequate PPE, staffing, training, scope-extending work, and resources may reduce health care professional stress and anxiety (Ann Intern Med September 2021). Further, the uncertainty, stress, and anxiety nearly every individual felt related to the initial surges in COVID played an important role in clinicians' personal and professional lives (e.g., worries about getting infected themselves and infecting their families) and influenced their burnout response. That said, many clinicians, at least those working in more supportive clinical environments with visible and effective leaders (e.g., transparency, accessibility, prioritization of staff well-being, positive messaging, etc.), reported finding more meaning and purpose in their work. The above description appears supported by two interesting nascent clinical workforce trends from the initial COVID era (i.e., the initial surges of 2020) – an increased loss of experienced clinicians, especially nurses (probably in part due to increased burnout in less supportive organizations), and an increased interest of young people in entering health care professions (JAMA Netw Open 2021;4:e2121435; BMC Health Serv Res 2018;18:851). During this time, the health care industry in general and front-line clinicians specifically were considered heroes – a framing with both positive and negative dimensions (JAMA 2021;326:127-8; Mayo Clin Proc 2021;96:2682-93).
Contrast this situation with our more recent experiences in summer and fall 2021. There is less uncertainty about how to treat COVID patients, fewer supply shortages (especially of PPE) in developed countries, and many organizations have mobilized efforts to better care for their clinicians. (We would be remiss if we didn't mention the residual vaccine hesitancy of a minority of non-physician health care workers, which may be another source of stress for their vaccinated colleagues and organizations). Now, for many organizations, the biggest issue is not that of having enough beds, but finding enough clinicians, especially nurses, to provide care for the more recent surge in COVID patients, the vast majority of whom are voluntarily unvaccinated.
Under these very different conditions (from 2020), what we increasingly hear from many clinicians and especially our ICU colleagues is exhaustion, burnout, and expressions of frustration, anger, despair, and moral distress as they care for unvaccinated patients who are overwhelming system capacity. Most of the current COVID hospitalizations and deaths were preventable (i.e., if these patients had been vaccinated). The work is long and exhausting as aggressive treatment of severe COVID is intense and frequently futile. Some patients dying of COVID deny with their last breath that they even have COVID. Further, the politicization of COVID has led a minority of the American population to view the health care industry and its clinicians as “the enemy” as we advocate for vaccination and other evidence-based public health measures.
It is too early to have empirical data on the effects of this second phase of the COVID pandemic on clinician burnout, but based on an understanding of the conceptual framework, here are our predictions: 1) We will see substantially greater increases in all three burnout domains, but especially emotional exhaustion and DP (cynicism), when compared to the first era (or the pre-COVID baseline); and 2) There will continue to be appreciable variability by region, local conditions, and specialty. One would expect that intensivist and hospital-based physicians and nurses working with high COVID patient censuses in low-resource/support organizations will manifest the most burnout, degraded well-being, and mental distress. Alarmingly, a major societal consequence of this new phase of COVID-induced clinician burnout will be further reductions in the available clinician workforce, which may create staffing shortages for years to come (and increase the risk of burnout for the remaining clinicians practicing in understaffed clinical care settings).
How should we respond to this crisis? At the organizational level, leaders must make worker health and safety (both physical and psychological health and well-being) their new top priority. As Matthew Weinger, MD, described in his 2020 Ellison C. Pierce Patient Safety Memorial Lecture (APSF Newsletter 2021;1:23-4), organizations that care about and take care of their workers deliver better overall performance (i.e., both safer and higher-quality care), probably due to happier, more engaged personnel who work more effectively with less burnout (asamonitor.pub/3q1ui96; Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. 2019). A recent article provides an excellent framework for practical steps health care organizations could take to address the crisis of clinician burnout and degraded well-being (Ann Intern Med September 2021). At the societal level, physicians must take more responsibility (and accountability) as public health leaders. It is very important for clinicians to strongly advocate for a scientific approach to public health and the treatment of COVID. We must emphasize those measures that will really make a difference (e.g., vaccination, evidence-based treatment regimens) and eschew those of little to no incremental benefit (e.g., masking when outdoors while assuming appropriate distancing). Finally, for individual physicians and our professional organizations, in addition to advocacy, we must endeavor to take better care of ourselves and of each other. We all went into medicine because we wanted to make a difference. Thus, degraded clinical well-being and burnout are an existential threat to safe delivery of health care. Now more than ever, we must all become engaged both locally and nationally by advocating for clinician safety and well-being as a top organizational priority.
Disclosure: Dr. Shanafelt is co-inventor of the Well-Being Index instruments (Physician Well-Being Index).