In “Stumbling Into the Next Stage of Your Pandemic Life,” psychotherapist Lindsey Antin describes the complicated psychology of “returning” (asamonitor.pub/3lv1nYo). For some people, returning means coming out of quarantine and going back to their work or practice in person. That doesn't apply to us. Anesthesiologists have been on the front lines of this pandemic for its entirety. The sprint we started 18 months ago has become a marathon. And not just any marathon, but a marathon seemingly occurring “right next to a nuclear reactor” (asamonitor.pub/3DwOcww).
“COVID-19 has exposed and widened significant shortcomings in our health care system, including how it cares for its workforce. At the same time, the pandemic marathon has given us an opportunity to reflect on what is most important for sustaining our health care workers and how to create supportive practice environments that value health and well-being for all.”
The result has been an uneasy mixture of positive and negative emotions. Gratitude, enhanced meaning and purpose, community cohesion, hope for the future, and confidence in our resilience have co-existed with cumulative grief, exhaustion, fear, uncertainty, anger, and moral distress (BMJ 2021;373:n1543; asamonitor.pub/3AxNRYu; J Appl Soc Psychol June 2021; Front Psychol 2021;12:648112). What does it mean for us to return?
COVID-19 has exposed and widened significant shortcomings in our health care system, including how it cares for its workforce. At the same time, the pandemic marathon has given us an opportunity to reflect on what is most important for sustaining our health care workers and how to create supportive practice environments that value health and well-being for all. The pandemic has exposed and exacerbated pre-existing troubles. It is time to address them.
Burnout, and its root causes, existed prior to the pandemic
Burnout is a term popularized in the 1970s and 1980s by social science researchers, including Dr. Christina Maslach, Professor of Psychology at the Healthy Workplaces Center at the University of California, Berkeley. Burnout is a syndrome related to prolonged response to chronic stressors on the job. It is characterized by exhaustion, cynicism, detachment, and a lack of personal accomplishment from work.
Research over the past decade has shown that physicians experience burnout at a higher rate than the general population (Mayo Clin Proc 2019;94:1681-94). Physician burnout is linked to detrimental effects on patient care, including increased medical errors, more frequent professional misconduct, reduced quality of care, and decreased patient satisfaction (J Gen Intern Med 2020;35:1465-76; Mayo Clin Proc 2018;93:1571-80; J Gen Intern Med 2017;32:475-82).
Burnout has impactful, and potentially tragic, consequences for the physician as well. It is associated with disrupted relationships, increased incidence of accidents and traumatic injuries, depression, anxiety, substance use disorders, and suicide (J Am Coll Cardiol 2019;73:521-4; J Gen Intern Med 2014;29:155-61; Am J Addict 2015;24:30-8; Arch Surg 2011;146:54-62). Burnout has been coined the “Billion Dollar Problem,” as the financial impact of physician burnout has been estimated between $4 and $5 billion dollars per year (JAMA Intern Med 2017;177:1826-32).
Crucial to understanding and mitigating burnout is recognition of its drivers. As described by Maslach, burnout is the result of demand overload, lack of control, insufficient reward or valuation, socially toxic workplaces, perceived lack of fairness, and value conflicts (asamonitor.pub/3lwbnAU). Tait Shanafelt, MD, Professor of Medicine and Chief Wellness Officer at Stanford Medicine, expanded the model of the physician burnout-engagement continuum to include workload and job demands, control and flexibility, work-life integration, social support and community at work, meaning in work, organizational culture and values, and efficiency and resources (Mayo Clin Proc 2017;92:129-46). Optimization of these drivers leads to more engagement. Misalignment leads to more burnout.
“Even before the COVID-19 pandemic, healthcare workers faced elevated rates of burnout, depression, anxiety, post-traumatic stress disorder (PTSD), and suicide. Now more than ever we must support the well-being of our healthcare workforce” – Lorna Breen Heroes' Foundation (asamonitor.pub/2YGfZvj).
Prior to the pandemic, health care workers were suffering. In the largest study to date on burnout in anesthesiologists, Afonso et al. collected data from ASA members just at the start of the pandemic in March 2020 (Anesthesiology 2021;134:683-96). They found that 13.8% met criteria for burnout syndrome, defined as high scores in all three domains of the Maslach Burnout Inventory (MBI): exhaustion, depersonalization, and lack of professional accomplishment. Perceived lack of support at work (OR 10, 95% CI 5.4-18.3) and perceived lack of support at home (OR 2.1, 95% CI 1.7-2.7) were most strongly associated with burnout syndrome. The authors found that 59% of anesthesiologist participants had high scores on emotional exhaustion and/or depersonalization, which many surveys declare as “burnout” (although this study aptly refers to this as “high risk of burnout”). Perceived lack of support at work (OR 6.7, 95% CI 5.3-8.5), working 40+ hours per week (OR 2.22, 95% CI 1.80-2.75), LGBTQIA status (OR 2.21, 95% CI 1.35-3.63), and perceived staff shortages (OR 2.06, 95% CI 1.76-2.42) were most strongly associated with a high risk of burnout.
The pandemic's long-term impact on mental health that has been added to the above burdens must be addressed.
The early, acute stressors of the pandemic revealed a three-fold increased prevalence of anxiety and depression symptoms and two-fold increase of suicidal ideation in the U.S. adult population (JAMA Netw Open 2021;4:e2037665; JAMA Netw Open 2020;3:e2019686). The prevalence of these symptoms in the general public has remained elevated in the latter stages of the pandemic (JAMA Netw Open 2021;4:e2037665). These stressors are exacerbated in health care workers. The mental health consequences of COVID stressors on health care workers include symptoms of depression, anxiety, insomnia, and PTSD, particularly in those with frontline exposure to COVID-19 (Brain Behav Immun 2020;88:901-7; J Pain Symptom Manage 2020;60:e60-e65; Psychiatry Res 2020;292:113312; J Community Health 2020;45:1168-77; BMJ Open 2020;10:e042752; Int J Emerg Med 2020;13:40; Biol Psychiatry 2021;107:110247; Front Psychiatry 2021;12:594340).
Historically, the professional culture of medicine has mirrored that of the rest of society in stigmatizing people with mental health issues (Acad Med 2021;96:635-40). Concerns regarding privacy, licensure status, disability, malpractice insurance, hospital privileges, and judgment from colleagues lead to delays in seeking treatment. As a result, many physicians experiencing burnout, or illnesses such as depression, PTSD, or anxiety, suffer in silence (Mayo Clin Proc 2017;92:1486-93; Acad Med 2021;96:635-40).
Return to a better normal
The new normal has to be better. One silver lining in this tragedy is that these issues have become so severe that it is widely acknowledged that change is required. In response, we must increase access to and promote utilization of mental health treatment programs, as well as focus on creating provider support in the workplace. Successful physician well-being initiatives begin with action and investment by leaders and organizations (Mayo Clinic Strategies to reduce burnout: 12 Actions to Create the Ideal Workplace. 2021).
In this issue, we will examine burnout as an occupational risk and ongoing phenomenon. Our contributors include Drs. Amy Vinson and Jina Sinskey, chair and co-chair of the ASA Committee on Physician Well-Being; Drs. Anita Honkanen and Jody Leng, Well-Being Directors at Stanford University; Robert Pearl, MD, former CEO of The Permanente Medical Group; and Josh Lumbley, MD, MBOE, FASA, Chief Quality Officer of NorthStar Anesthesia.
Discovering alignment, particularly during this challenging time, requires us to remember our deepest intrinsic motivator to practice medicine – the relief of suffering. Compassion, the recognition of suffering and the desire to alleviate it, drives what we do as physicians and as anesthesiologists. It is compassion that brings meaning to our professional lives. When we find meaning, we also find purpose. Particularly now, we must extend this compassion to each other and to ourselves. We must appreciate one another. We need to lift each other up in times of need.
If you are suffering, please find the support and help you deserve. Thank you for the care you have given to others. Now is the time, physician, to heal thyself.