By Jane Sullivan, Ph.D.
Epidemic is the term currently used to describe the increased incidence of both burnout and post-traumatic stress disorder (PTSD) in emergency physicians. It’s difficult to know if calls to action to address this epidemic have been responded to with any successful intervention. So perhaps the statistics will continue to be astounding:
- 300 to 400 physicians commit suicide a year
- 52 percent of emergency physicians report being burnt out
- 60 percent of midcareer doctors have been involved in lawsuits
- 10 to 15 percent of all doctors have issues with substance abuse during their careers
- 80 percent of physicians state that they believe that the medical profession is on the decline
The Symptoms of PTSDThe symptoms of PTSD are usually quite demonstrable — flashbacks, nightmares, startle responses that can last for months and can become debilitating. Treatment options exist for those medical providers suffering from PTSD, and most organizations are sympathetic to and supportive of providing help.
BurnoutRecognizing burnout may be more elusive. The term “burnout” suggests that one was on fire at some point, but now the fire is gone. Christine Maslach, who has done significant work on burnout, defines it as, “an erosion of the soul caused by a deterioration of ones values, dignity, spirit and will.”
The Symptoms of BurnoutThe symptoms of burnout are varied and refer to a change in a person’s behavior and personality. They include:
- Loss of a sense of personal satisfaction, accomplishment and meaning
- Isolation from friends and family
- Increase in cynicism and sarcasm (patients become stereotyped)
- Appetite changes – weight gain, weight loss
- Loss of interest in favorite activities
- Robotic actions
- Fatigued before the day begins
- Increased alcohol and/or drug use
- Change in demeanor
- Overreaction to minor incidents
- Angry outbursts
- Increased rate of divorce
- Loss of empathy
- Disengagement from patients, profession and other providers
The factors contributing to burnout are numerous and somewhat predictable. They include:
- Societal and patient expectations for medical “perfection” (no mistakes)
- Personal physician expectation of “perfection” (personal cost of mistake)
- Too much output, not enough input
- Pressure to see more patients
- Medical malpractice creates defensive medicine
- Focus on the negative
- Repeat narcotic-seeking patients, drunk patients in the ED
- Emergency physicians becoming “social workers”
- Loss of autonomy
- Increased scrutiny, e.g., physicians judged by quality measures, documentation, chart reviews, peer reviews
- Standardized medicine
- Repetition of patients who may appear to be willfully self-destructive or neglectful, with expectations that doctors will “fix them” (“Same stuff, different day”)
- Decreasing public respect for the medical profession
- Increasing reliance on technology by patients
- The impact of night shifts on sleep patterns
- Disillusionment in medicine, whereby idealism becomes disappointment and dissatisfaction
- “Destination sickness”; You’ve “arrived,” but now what?
- Decreasing trust between doctor and patient and increased distance
- Adversarial relationship with administration
- Years of ongoing litigation, which generates guilt and, worse, profound shame
- Shame for failing to live up to one’s image
- Repetitive grief with no space to grieve
- Constant stress, fear of making a mistake
Given the impact of burnout on physician behavior, higher medical errors, suicide and lower quality of care, it would seem imperative to understand the causes of burnout and generate concrete actions to address the “epidemic.” However, there are barriers and challenges that exist in addressing both PTSD and burnout which impacts mobilizing treatment interventions.
First, medical organizations and administrators whose focus is on the financial bottom line may believe that it’s more cost effective to replace a “hurting” physician than invest in supporting that physician. Individual physicians, who view themselves as heroic and strong, may have difficulty admitting to their own pain and need for help. Peers who witness other doctors with the symptoms of PTSD or burnout are reluctant to talk with their fellow providers about what they are witnessing, perhaps because of a concern about what the reaction may be. In addition, there may be fear of acknowledging a potentially debilitating distress because of the medical licensing board’s question: “Have you ever had a medical condition or been treated for a problem that could hinder or impair your ability to provide patient care?”
Identifying and Treating Burnout and PTSDAlthough some organizations do attempt to assess how their physicians are doing by surveying clinicians, such surveys typically have only about a 40 percent response rate. It will, therefore, take vigilance on the part of peers, fellow practitioners and medical directors (who may themselves be burning out) to be observant of physician behavior and attitudes. Engaged physicians maybe the ideal, but identifying and supporting those physicians struggling with PTSD and burnout needs to be a more immediate goal.
Treatment of both burnout and PTSD is the responsibility of all involved. There are many support systems available to help individual physicians in their struggles, such as the American Medical Association and The HappyMD.com.
As Nietzsche said, “Physician, heal thyself: then wilt thou also heal thy patient.”
Peer groups provide safe, non-judgmental environments to address issues of mistakes, guilt, shame, disengagement, anger and all of those emotions that impact physicians’ attitudes and behaviors. Knowing one is not alone can be very helpful. Staff meetings could include some of these topics for general discussion. Hospital administrations can advertise their commitment to not only helping identify those physicians struggling with the cost of their profession, but also their investment in support activities. In fact, several large hospital systems have hired professionals trained in physician health and well-being to provide care, both proactively and reactively.
If burnout and PTSD in healthcare is indeed at epidemic levels, it will take mobilizing all of the resources necessary to respond adequately. The cost is too high to continue to ignore this issue.