Definition, causes and prevalence
Burnout is usually defined as a “syndrome of emotional exhaustion, depersonalisation and a sense of low personal accomplishment that leads to decreased effectiveness at work.”1It is well described by psychiatrist Glen Gabbard as “erosion of the soul”, marked by “a sense of joyless striving.”2
Burnout may result from chronic work stress. Stress is both a physical and emotional syndrome. It occurs when the demands on someone are greater than their capacity to respond and is mediated by both factors in the external work environment, and internal qualities in the person.3 A downward spiral is frequently set up, because performance drops when stress mounts.
Felton suggests that employees are vulnerable to burnout when they have little input into how to do a job, are never caught up with work demands, would like to leave but fear doing so, or are experiencing major changes in their workplace.4 An Israeli study of 890 specialists concluded that “[p]erceived overload, long known to be the most potent predictor of burnout, should be considered as a prime culprit in that it probably leads to both elevated levels of burnout and reduced levels of quality of care.”5
Wallace and colleagues list familiar stressors specific to medicine.6 Workload and fatigue, dealing with emotionally-charged situations associated with suffering, fear, failures and death, difficult interactions with patients, families, and other medical personnel, excessive cognitive demands, increased patient-care demands, remuneration issues, growing bureaucracy, increased accountability, conflict between the needs of the organisation and patients, and a decline in physician autonomy are all suggested as having a role in producing stress and consequent burnout.
Factors in doctors’ personalities also create vulnerabilities. Compulsiveness can be a very helpful attribute in many areas of medicine, but it causes doctors difficulty in saying ‘no’ to additional work, leads to ‘burying’ resultant frustration and anger, makes many doctors put off satisfaction in their lives, and is associated with perfectionism and fear of failure, which pushes doctors to keep going despite feeling personally compromised. Gabbard has characterised this as the triad of doubt, guilt and an exaggerated sense of responsibility.7
Many studies document the prevalence of health problems in health professionals, including a major UK Department of Health Report in 2010, “Invisible Patients”.8 It noted the higher rates of depression, anxiety and substance misuse in health professionals, the problem of “presenteeism” (staff who turn up for work when they are unwell), and the fear of stigma that often stops health workers seeking professional help. There is no reason to think that the problems would be any less in New Zealand; indeed, being part of a smaller community with fewer degrees of separation, it is likely to be even harder to seek anonymous help for health problems.
Burnout appears common among practising doctors, with rates ranging from 25% to 60%.9 A 1999 New Zealand postal survey of a random sample of 500 doctors found that 61% reported suffering moderate to severe stress, but only 11% had regular health assessments, and 29% did not have a doctor.10 In our experience doctors as a group often neglect their own health, are not good at nurturing their family and social supports, and have few outlets for divesting themselves of the significant emotional load they carry from their work. Each area of medicine has its own strains. We also observe that, as a profession, doctors are relatively poor at giving mutual support and constructive feedback to each other, or seeking help.
Burnout is not a problem confined to senior doctors and can begin to develop early in the medical career. In a survey of 2682 medical students in 7 US medical schools, 53% of respondents met criteria for professional burnout. Students with burnout were less likely to hold altruistic views regarding physicians’ responsibility to society.11 In a prospective cohort study of 110 medical students from the University of Sydney, rates of burnout increased from 28% (in the final year of medical school) to 61% (18 months later in the trainee intern year).12
Doctors in the process of burning out will depersonalise or withdraw from patients, leading to a “vicious cycle where physician withdrawal may lead patients to express discontent, thereby creating further physician stress and ... a tendency for the physician to withdraw further during the medical encounter.”13 Burnout and “compassion fatigue” are a particular problem in specialties that involve intense emotional demands and staff shortages.
A number of published studies indicate that the risks of medical errors and suboptimal patient care are higher for burnt out physicians. A recent study of 1311 German surgeons showed that “burnt out male surgeons are significantly more likely to rate their quality of care as suboptimal.”14
The relationship between depression, burnout and errors is complex. In an interesting prospective cohort study of 123 paediatric residents in the United States, 24 (20%) met the criteria for depression and 92 (74%) met the criteria for burnout. Depressed residents (96% of whom also reported burnout) made significantly more errors than their non-depressed peers; however, burnout on its own did not seem to correlate with an increased rate of medical errors.15
Patients are often well aware that doctors are overworked— they experience the results firsthand. A breast cancer survivor, whose breast prosthesis was punctured by a surgeon who mistook it for a fluid collection, complained to HDC. In her letter of complaint, she wrote: “Surgeons should not be overworked to the point of mistakes. I hope those involved have been able to learn from this and can thus prevent a mistake which could result in loss of life.” Her statement highlights another point: most patients are very conscious of the demands on busy health professionals, and may be reticent to speak up about concerns that should be brought to a doctor’s attention.
Firth-Cozens notes that stressors, the personal characteristics of the doctor (including their psychological make-up, coping ability and competence), and the degree of impairment of the doctor, all impact on doctors’ performance.16 One stressor that is well documented is the impact of a mistake or complaint on the doctor.
Albert Wu has called the doctor who makes a mistake “the second victim” of medical error.17 He writes:
In research published recently in the Archives of Surgery, 1 in 16 (of a sample of 7905) American surgeons reported suicidal ideation in theprevious year. Suicidal ideation was markedly increased among surgeons who perceived they had made a major medical error in the previous three months. Also alarming was the finding that 60% of surgeons with recent suicidal ideation reported that they were reluctant to seek professional help due to concern that it could affect their medical licence.18
One might expect that rates of burnout attributable to the impact of mistakes and complaints to be lower in New Zealand. As noted by the Chief Medical Editor of HemOnc Today, “It would be interesting to compare the burnout rate of oncologists in ... countries [with] universal health care ... and minimal malpractice litigation.”2
The effective absence of medical malpractice litigation in New Zealand, due to our “no fault” accident compensation scheme covering “treatment injury”, and the strong focus on resolution and remediation from HDC and the Medical Council, might be expected to dilute the stress on doctors from mistakes and complaints. In our experience many doctors report significant stress during HDC and Council processes. Most are conscientious people and struggle with the thought that they have not performed well. A serious incident or complaint may well tip a stressed and overworked doctor into burnout.
Preventing and alleviating burnout
To help prevent burnout, and to alleviate it when it occurs, we see the need for changes in three areas.
Culture change—The first is culture change. All doctors make mistakes and every doctor is likely to face complaints in the course of their work. This needs to be more openly acknowledged within the medical profession.
In recent years, we have observed a less punitive environment and a much greater willingness on the part of individual doctors to admit, in front of their peers, having been involved in a serious incident or the subject of a complaint. We see this as a healthy development. A more open and realistic environment should in turn make doctors more willing to seek help. In the words of former BMJ editor Richard Smith, “We need to move from a culture that encourages doctors to hide distress and difficulties to one where we share them and ask for help.”19
Waitemata physician Pat Alley, who has done much good work in this area, comments that “for a profession that has no shortage of Colleges, the medical profession is surprisingly uncollegial to its members who are in difficulty, and colleagues sadly often look the other way when a doctor becomes unwell from burnout” (personal correspondence, 28 January 2011).
As noted earlier, burnout is not confined to middle-aged physicians. In our view senior doctors have a special responsibility towards medical students and trainees to speak more openly about their own challenges, support mechanisms, and life choices, to help the next generation of doctors see through the myth that “the harder we work, the more patients we have, and the more tired we are, the better physicians we are”. Students, trainee interns and junior doctors need to be taught about ways to respond to mistakes, complaints and the everyday stresses of medical work.
Support services—Secondly, employers and colleges need to do a much better job of supporting doctors facing stress of any sort, including from the impact of mistakes and complaints. It stands to reason that early intervention might help prevent a slide into more significant difficulties with an increasing risk of error. Reducing environmental work stressors and identifying, supporting and treating doctors under stress is a crucial quality issue for our health service.
Some support services are available. The Doctors Health Advisory Service, based in Wellington, offers a free, confidential 24-hour support service. The Medical Protection Society and the Medical Assurance Society fund a counselling service for doctors suffering from work-related stress.20
An interesting initiative is offered by the Royal Australasian College of Surgeons, under its Surgeons Support Group programme. This involves training volunteer Fellows of the College in the skills necessary to help surgical colleagues involved in stressful medico-legal processes, such as complaints and inquiries. However, the initiative relies on the stressed doctor knowing that the service exists, and having the courage to contact it. In 2003, Bruce and colleagues called for a peer-support system for physicians, after a sample of 50 physicians in the Waikato and Bay of Plenty reported relatively high levels of burnout.21 Clearly, there is a role for Colleges to do more.
Employers also need to do more. Some district health boards and primary care organisations in New Zealand do a good job in identifying and supporting clinicians at risk of burnout or distress from a significant incident or complaint. But in many cases an individual doctor bears the burden alone. We agree with Pat Alley that “DHBs should be devoting far more resource than they do to managing burnout in all health professionals” (personal correspondence, 28 January 2011).
Responsive regulators—Thirdly, regulators need to handle complaints and inquiries promptly and sensitively. Practitioners understandably dread receiving an envelope from HDC or the Medical Council. Both organisations should aim to ensure that correspondence and interviews are professional but not officious; that parties are kept regularly updated; and that a determination is reached as quickly as possible.
There is a statutory duty on any health practitioner who has reason to believe that a doctor is “unable to perform the functions required for the practice of his or her profession because of some mental or physical condition,” to notify the Medical Council.22 Such referrals are handled by Council’s Health Committee, which has many years of experience with ill doctors. All referrals are handled sensitively and with appropriate confidentiality, yet many doctors still view referral to the Committee as a disciplinary measure.
The Health Committee makes sure that necessary assessments are performed, helps put treatment in place and monitors progress closely. In addition, through voluntary undertakings with the doctor and contact with employers and colleagues, the committee can help modify the work environment. As at 30 June 2010, 210 doctors being were monitored by the Health Committee. Of the 63 new referrals in the previous year, 36 were for psychiatric difficulties, 6 for alcohol abuse and 2 for drug abuse.
Regulators need to walk a fine line in handling cases involving sick doctors. This is a challenge both for the Medical Council and HDC. Both agencies have a public protective role, and there may be pressure from the media, and from individual patients and families, to take a punitive approach. The Council and HDC recognise the systemic factors that contribute to burnout and, through their processes and decisions, seek to highlight the responsibility of district health boards and other employers to provide appropriate support.
Where a burnt out doctor turns to alcohol or other drugs for relief, and harms a patient while under the influence, there will inevitably be disciplinary consequences. But in other cases where a doctor accepts personal responsibility, says sorry, and is willing to seek professional help, it is in everyone’s interest that a rehabilitative approach is taken. Both Council and HDC have been supportive of the rehabilitation of sick and burnt out doctors.
As a society, and as a profession, we are rather conflicted in our attitudes about sick and burnt out health professionals. All too often we admire the individual who soldiers on, uncomplaining, with a heavy workload and never seems to get sick.
However, such attitudes help produce an environment that contributes to a significant, though largely hidden, quality issue in our health service. As Wallace notes, “... [W]hen physicians are unwell, the performance of the health-care system can be sub optimum. The corollary is that physician wellness might not only benefit the individual physician, but also be vital to the delivery of high-quality health care.”6
There needs to be a culture change within the health professions, so that practitioners feel able to seek help. Colleagues must also recognise their ethical responsibility to take action if a health or competence problem is not being adequately addressed.
Professional burnout carries hidden costs: for individual health professionals, their colleagues, their patients and their families. In additional to these physical and emotional costs, it is a financial burden on the health system as a whole. We hope our paper will highlight an important issue and give impetus to steps to prevent, recognise and treat burnout of doctors in New Zealand.