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 Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 1-10

Understanding physician burnout syndrome: Antithesis of physician well-being


Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Web Publication12-Jun-2019

Correspondence Address:
Prof. Dr. Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Yenepoya (Deemed to be) University, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_75_19

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How to cite this article:
Shelley BP. Understanding physician burnout syndrome: Antithesis of physician well-being. Arch Med Health Sci 2019;7:1-10

How to cite this URL:
Shelley BP. Understanding physician burnout syndrome: Antithesis of physician well-being. Arch Med Health Sci [serial online] 2019 [cited 2019 Aug 21];7:1-10. Available from: http://www.amhsjournal.org/text.asp?2019/7/1/1/260025



Be who you are and say what you feel because those who mind don't matter and those who matter don't mind.

– Dr. Seuss

The stoical scheme of supplying our wants by lopping off our desires, is like cutting off our feet, when we want shoes.

– Jonathan Swift, Thoughts on Various Subjects (1711)


  A Personal Narrative Reflection Top


After 10 years of experience abroad in academia, honing two postdoctoral fellowships and research experience, I relocated to India almost a decade ago. Reminiscing upon my epicenter of working experience in India, being in my sixth decade of life, and after being in this profession for about four decades, I have found myself racing along, seeing neurological patients 50 hours a week, and keeping a student-centric schedule of teaching, my own writing and research, and balancing a positive work–life culture. Looking back at my doctorhood experience during the last decade or so, I do now reminisce upon all the unexpected stresses and conflicts I had to face. I know myself to be an erudite bedside physician, an educator, a mentor, personified as an “exemplary” physician, a recipient of Doctor's Day award, an effective clinician neurologist emboldened with virtues of compassion, altruism, empathy, professionalism, and relation-centered care. I would state that I was doing an excellent work of selfless service, teaching in classrooms and the clinical bedside, and passionately pursued all avenues for career and professional development. Over the last few years, my insight increasingly mirrored upon me that I have insidiously been transforming to “new avatar” where my good humor was getting progressively tarnished. Astonishingly and ironically, I experienced a progressive loss of idealism and energy and a “compassion fatigue.” In fact, I seemed to be “burning out” but never did realize this as a defined phenomenon or medical diagnosis. All I knew was that I was experiencing a work-related “maladaptive phenomenon” characterized by the erosion of my soul-full professionalism, cynicism, and a sense of depersonalization (DP). In short, I was not happy, lost my emotional resilience and the experience felt akin to “an erosion of my human soul and work–life balance,” and a struggle analogous to the Greek mythological character Sisyphus. I attempted to introspect what happened to the passion and enthusiasm I had as a compassionate-empathetic physician who had unflinching commitment to quality care and patient satisfaction.

I was only bewildered with this new “avatar” metamorphosis of my professional persona and was trying to grapple why “the feeling physician” in me was vanishing away, or rather is dying. As luck would have it, it is around this “rough-and-tough patch” that I was fortunate to stumble and read an enlightening article titled, “Physician, Heal Thyself,” in the Annals of Internal Medicine 2019 by Dr. Neal J. Thomas of Penn State Pediatric Critical Care Medicine, Pennsylvania, United States (US). This had a semblance to the ancient proverb “First, Heal Thyself,” which actually is from the Bible Luke 4:23. Dr. Neal's reflective piece of writing poignantly gave a narrative on being a conscientious doctor where “work and duty got in the way of his life.” Before he turned fifty, he developed a critical left anterior descending coronary artery block and cardiac arrest. Ironically, when I read this article, I recollected my similar tryst with imminent death in 2008 and my miraculous escape from Type 2 Wellens' syndrome (widowmaker syndrome) probably due to the tremendous and overburdened patient load, poor streamlining of clinical workflow, and new job stress adjustment just as I relocated to India from Cambridge, United Kingdom.

The morale from this narrative is quite simple. First, there is a notion that physicians are “superhuman” and that normal human limitations do not necessarily apply to us. The public do not realize that physicians are “person (human) first, doctor second” and that we are not invincible and are indeed vulnerable and fallible. Physicians are caregivers. They take care of others and often put others' needs first. If a super-specialist, like me, sees 60 patients a day, 6 days a week, 48 weeks a year for almost a decade, will this be sustainable? Sustainability depends as much on how people renew and recover energy as on how they expend it. It is “chronic stress without recovery” that depletes energy reserves, leading to burnout. The public do not comprehend that “doctors” have a generic name too… “Human” and I would unwittingly state that no one at a public level, organizational-systems level, and/or hospitalist/managerial level acknowledges and positively promotes a workplace culture of “Physician Well-being.” Second, the “Oath of Physicians” underscores their pledge “I solemnly pledge to dedicate my life to the service of humanity, the health and well-being of my patient will be my first consideration” or stated simply “putting patients first before oneself.” Perhaps altruistic and humanistic physicians in our art of doctoring, notwithstanding the pressures of our hugely demanding profession, and in pursuit of idealism, we unknowingly and unwisely neglect our own health. I regret that “we do not practice what we preach to patients” about lifestyle and behavioral modification for a “healthy physician lifestyle,” “physician well-being,” and our very own “emotional well-being.” An insightful book, I read during my “metamorphosis of burnout” that truly did portray the “inner emotional side” of physicians and other medical health-care professionals, was “What Doctors Feel – How Emotions Affect the Practice of Medicine” by Dr. Danielle Ofri of the New York University School of Medicine. This editorial delves beneath the conventional stereotype of the cerebral side of medicine and reiterates the emotional layering, especially its negative influences in the therapeutic doctor–patient encounter that ultimately threatens the quality of medical care. The thrust of this editorial is to learn to recognize and navigate the emotional vocabulary of what I am suffering from, namely “physician burnout syndrome” (BOS) which is the antithesis of “physician well-being.” The takeaway for a “Physician Career Satisfaction,” I would stress, is to “work smarter, not harder” and “work to live with joyfulness and fulfillment, not live to work.” Essentially, we as physicians, medical students, residents, and allied health-care professionals need to ponder on “self-care,” change our “work culture of medicine,” and strategize and advocate for campaigns, seminars, conferences for “physician wellness-centric cultures” so as to have a positive balanced, well-integrated and fulfilling work–life culture. We need to create “self-awareness” and promote “self-care strategies,” improve “physician wellness,” and mitigate BOS by charting out multileveled “anti-burnout strategies.” By “physician well-being,” I mean not only physical wellness but also encompassing pluralistic domains of intellectual, spiritual, social, occupational, and a fulfilling joyful work culture. I stress that the concept of physician well-being is to be viewed as a “multidimensional wellness model” and must go beyond merely the absence of burnout and professional dissatisfaction. We need to understand that physicians are prone to BOS, depression, suicide, and other detrimental consequences. To take care of patients well, physicians must take care of themselves which is reflected in the two insightful and poignant quotes I cite: “To excessively devote our lives to the practice of medicine while we neglect other aspects of living may be tantamount to never having lived at all” (Joseph D. Wassersug, MD) and “Being kind to others begins with being kind to ourselves” (Kelsey Crowe and Emily McDowell).


  Physician “burnout Syndrome: The Antithesis of Physician Well-Being Top


“And that's the thing: You don't understand burnout unless you've been burned out. And it's something you can't even explain. It's just doing something you have absolutely no passion for.”

– Elena Delle Donne, Olympic Gold-Medalist in Women's Basketball

Physician well-being and burnout, although viewed as flipsides of the same coin, are indeed multicoated and complex constructs.[1],[2],[3],[4],[5] My recent insidious transformation into this new “avatar” of a “wounded healer” and “distressed physician” fortunately ignited my emotive self-reflective soul searching spirit to “diagnose” my “dis-ease.” As I read the article titled, “Physician, Heal Thyself,” in the Annals of Internal Medicine 2019, I learned about the problem of physician burnout, and I came to recognize that I was not alone. It is indeed a pervasive global health-care crisis reaching epidemic proportions in many parts of the affluent world. I learned that burnout is not some psychological abnormality too embarrassing to speak about in public.

The term burnout was first coined in the 1970s by Herbert Freudenberg, a practicing American psychologist, as a “state of mental exhaustion caused by one's professional life.” Burnout first emerged as a social problem, not as a scholarly construct. The concept was developed further by the academic researcher and social psychologist Dr. Christina Maslach. Burnout syndrome, a maladaptive work-related syndrome, was later defined as the triad of emotional exhaustion (EE), DP, and a loss of PA. Burnout, by yet another definition, is a physical or mental collapse caused by overwork or stress. The psychiatric definition is an exceptionally mediated job-related dysphoric and dysfunctional state in an individual without major psychopathology. To put in another perspective, I would state that burnout occurs when our mental, physical, or spiritual energy accounts have a low balance over time, coupled with low emotional resilience on a continuum of chronic allostatic load. This pervasive sense of physician distress is characterized by a conglomeration of symptoms such as loss of enthusiasm for work (”I'm not sure how much longer I can keep going like this”), feeling overworked and overextended, a loss of sense of purpose of dedication to serving the interest of the patient, mental inertia for a meaningful connect with and care for patients, becoming unfeeling, disenchanted and unempathetic in our response to our patients (compassion fatigue), reduced effectiveness (reduced efficacy, poor clinical decisions leading to suboptimal patient care), and feelings of cynicism coupled with a low sense of PA.

Having understood the construct of physician BOS, how can we measure it? In its conventional concept, the leading standard for burnout diagnosis is the Maslach burnout inventory (MBI), developed by Dr. Christina Maslach et al. at the University of San Francisco in the 1970s. The MBI is an introspective psychological inventory consisting of 22 items pertaining to occupational burnout that incorporates a 9-item EE scale, 5-item DP scale, 8-item PA, 5-item cynicism scale, and a 6-item professional efficacy scale. Dr. Christina, in her words, did describe burnout as “an erosion of the soul caused by a deterioration of one's values, dignity, spirit, and will.

Why does BOS matter? It is a mistake to assume that burnout is merely an emotional response to long hours or a challenging job. Sadly, BOS does impact career satisfaction and physician well-being, but more importantly, it has a deleterious and profound impact on patient care too. The pervasive “energy drain” at various levels of the brain–mind interface and its consequent moral distress, sadly, is a forerunner to several negative consequences which reinforces the supremacy of “physician wellness.” To my mind, the cause for concern among physicians succumbing to BOS lies in a pervasive sense of “professional dissatisfaction,” absenteeism, impaired professionalism, disruptive behavior, and disengagement. Instead, as a ripple effect, the tragedy lies in the personal consequences of depression and suicidal thoughts and behaviors, substance abuse, broken relationships, higher work–life conflicts, and various other adverse health outcomes. Burnout does cause somatic symptoms such as interpersonal problems, insomnia, irritability, prolonged fatigue, headaches, chronification of pain, musculoskeletal disorders, gastrointestinal issues, and respiratory problems and, in addition, has been linked to a higher incidence of cardiovascular disease. Moreover, BOS has been causally linked to dyslipidemia with higher levels of low-density lipoprotein, lower high-density lipoprotein levels, hypertriglyceridemia; type 2 diabetes mellitus, obesity, immune system depletion, metabolic syndrome, and to a smaller extent, the electrocardiographic aberrations. In fact, burnout does leave its mark on the brain. The biometric markers of burnout do cause brain dysregulation, disrupt the neuroendocrine system, and disrupt prefrontal processing and attentional control, in addition to functional magnetic resonance imaging morphofunctional aberrations in the brain's functional connectivity associated with regional reductions in brain tissue volumes. Thus, burnout is undoubtedly a major cause of concern for the physical and psychological well-being of medical professionals. It is quintessential to be cognizant of another facet and detrimental downstream consequence of BOS that will include the poor quality of patient care and patient safety, higher risks for medical errors, lower patient satisfaction, decreased access to care due to physicians reducing work hours or leaving clinical positions, and increased health-care costs.

Since I do fulfill the standard assessment of BOS by the MBI, the panoply of questions that vexes my mind is many. What are the magnitude and global scenario of BOS? Is it an epidemic that is still under-recognized? What are the plausible drivers of BOS? After diagnosing BOS, what are the anti-burnout strategies that can be implemented? What is the antithesis of BOS? Can we stamp out BOS by charting out a “preemptive and preventive” roadmap? Let me attempt to seek answers to my reflective questions. BOS is not a myth. Burnout is an underappreciated “hidden” problem in a general global perspective. However, it is a looming crisis well documented in the US and Canada (Cahoon SL, 2003; Lee FJ et al., 2008; Boudreau RA et al., 2007), but various reports do reaffirm its common prevalence in Europe, Latin America (Suñer-Soler R et al., 2014), and many other countries including China (Xiao Y et al., 2014, Lo D et al., 2018), Yemen (Al-Dubai SA and Rampal KG, 2010), Saudi Arabia (Alsaawi A et al., 2014), Africa (Rossouw L et al., 2013; Rajan and Engelbrecht, 2018), and Arab countries (Elbarazi I et al., 2017).

It is truly mind-boggling that one-third to a half of the physicians are estimated to experience BOS around the world. Nearly two-thirds of American physicians report feeling burned out, depressed, or both. One in three stated that these burnout feelings negatively affect their work. At the end of the line, suicide is the most tragic outcome. It is estimated that one doctor dies by suicide every day in the United States, the highest rate of any profession and double that of the general population. Burnout symptoms in the United States affect 30% to 68% of physicians overall, exceeding the levels of any other professional group. It is also interesting to note burnout is nearly twice as prevalent among physicians as US workers in other fields after controlling for work hours and other factors. The Medscape Emergency Medicine Lifestyle Report 2016 reported that 55% of the US emergency-care physicians experienced burnout in 2016 and 52% experienced burnout in 2015 (Peckham C). Shanafelt et al., in a 2012 nation-wide study with 7288 physicians in the US, found that physicians experience more burnout than other US workers and that those physicians working in specialties at the front line of care seem to be at greatest risk. Furthermore, yet another pivotal study, the 2018 Survey of America's Physicians Practice Patterns and Perspectives, found that 78% of respondents experienced feelings of professional burnout. The National Physician Burnout, Depression and Suicide Report, 2019 revealed that more than 15,000 physicians across 29 specialties reported 44% burnout, low mood in 11%, and clinical depression in 4%. The answer to the question, “Do you plan to seek help for burnout?” was a negative one in this study. Help-seeking for burnout was not ideal with an unprofessional stigma, and many felt that reporting BOS would have serious repercussions for their career. This research also showed the number of physician suicides to be 28–40 per 100,100, which is actually more than twice that of the general US population.

Similar trends on burnout among practicing doctors are also reported from Europe (Lee YY et al., 2015; Soler JK et al., 2008). The European General Practice Research Network study surveyed burnout in European family doctors in 2008. This study depicted the real-world statistics. On the MBI, 43% scored high on EE, 35% on DP, 32% scored poorly on professional accomplishment, whereas 12% reported burnout level in all three indices of MBI. Studies from Cape Town, South Africa (Rossouw L et al., 2013), showed that EE of 53% and DP of 64% were experienced by doctors working in the Cape Town Metropolitan Municipality community health-care clinics and district hospitals of the Western Cape. A study (Rajan and Engelbrecht, 2018) also did reaffirm moderate-to-high risk of burnout among emergency physicians from public-sector hospitals in Gauteng, South Africa.

Is BOS a problem faced by medical and health-care professionals in India? It is disappointing to know that there are hardly six studies on this “work-related phenomenon.” However, the narrative in India is surprisingly not too different from the western scenario. These studies do echo a high prevalence of burnout in Indian medical practitioners, which is similar to the results of studies done on burnout among the medical practitioners in other countries. A study in Mumbai (Langade D et al., 2016) did survey 500 doctors using the abbreviated MBI and Burnout Clinical Subtype Questionnaire-12 scales reported that approximately 45% of the respondents scored high on EE, whereas 66% did score high on DP. A similar study reported 50% of burnout among medical students in West Bengal (Bera T et al., 2013). High level of EE, DP, and lower personal achievement scores were also observed among critical care and intensive care professionals in India (Guntupalli KK et al., 2014; Amte R et al., 2015). There is only a single study (Sarma PG, 2018) that ascertained burnout among psychiatrists in Hyderabad (India). This study reported a prevalence of 32% burnout among the psychiatrists. Another study (Grover S et al., 2018) from the premier PGIMER, Chandigarh, demonstrated that a significantly higher proportion of doctors in Indian setting experience stress (80%), depression (30%), and burnout (90% prevalence for some degree of burnout) using multiple scales such as patient health questionnaire-9 (for depression), Cohen's perceived stress scale, and the MBI.

To sum up on the magnitude and landscape of BOS, I have now learned that burnout is not a personal problem or to call it as just a “nervous breakdown,” instead of a public health crisis that modern medicine is now facing as an “epidemic of burnout.” Although the practice of medicine can be incredibly meaningful and personally fulfilling, it is also demanding and stressful. It is now evident that burnout is a major issue, albeit an underappreciated “silent” crisis among physicians world over with potentially devastating consequences. Physicians who experience some or all of the behavioral repertoire of BOS are at odds with their professionalism and do not voice their distress since the organization and their patients that they care have a one-dimensional belief that such behaviors at work are unprofessional. Physicians tend to avoid reporting burnout or even discussing the issue within the workplace as there is a perceived stigma of failure, career repercussions, and other negative consequences. I would reiterate that burnout is everywhere, but you cannot fight an enemy unless you recognize it and we cannot “sweep burnout under the carpet,” instead demands an urgent need to foster a greater unbiased understanding and awareness of BOS. The ramifications of burnout present an under-recognized crisis in the health-care system that carries the consequences of personal, professional, institutional, and societal costs.


  The Neurologists and Burnout Syndrome Top


There is no profession without stress and tension, which differs from profession to profession and person to person. However, it is well documented that physicians are at increased risk for a number of negative consequences related to the high stress and demanding nature of their jobs. Being a neurologist, and knowing the essentiality of a time-intensive systematic, hierarchical, algorithmic approach, and pattern recognition skills for the bedside clinical neurologic diagnostic formulation, I did wonder if there would be differences in the prevalence rates of BOS when the various medical specialties are compared? The National Physician Burnout, Depression and Suicide Report, 2019, referred to earlier, did provide me with the answer I was looking out for.

This study in the United States did substantiate that “specialty-wise burnout” ranked top among Urology and Neurology. Emergency Medicine physicians, Internal Medicine, Family Medicine, Diabetes and Endocrinology, and Plastic Surgery were the other most burned-out specialties. Other specialties prone to moderate burnout were Critical Care, Oncology, and Cardiology. The least burned-out specialties in this study were Dermatology, Ophthalmology, Otolaryngology, Nephrology, and Public Health and Preventive Medicine. In this study, some of the physician comments were noteworthy in understanding BOS as well as the plausible factors. A neurologist commented, “I have lost enthusiasm for patient care,” another neurologist commented, “I dread coming to work. I find myself being short when dealing with staff and patients,” while cardiologist lamented, “Burnout has made me plan for an earlier, more austere retirement,” and few nephrologists exclaimed, “It's getting worse every year. Data collection is more important than patient care to everyone except the physician practicing it” and “I am not the problem, the medical system is the one that needs a change in work culture.”

Being a neurologist myself, I had the foresight that burnout could be indeed quite high in my specialty. Undoubtedly, my collective wisdom was re-affirmed by studies in the US. It is estimated that neurologists in the US suffer a higher rate of burnout and career dissatisfaction than any other medical specialists.[6] Indeed, six out of 10 neurologists report at least one symptom of burnout. A higher risk of burnout in neurologists and neurology residents have also come into light from other parts of the world such as Iraq (Al-Janabi O et al., 2019) and Japan (Aiba I et al., 2019). Burnout was reported by the Japanese Society of Neurology to be more common among female Japanese neurologists. Among all female neurologists, 46.1% experienced EE, 43.9% felt they had low PA, and 7.3% perceived DP. Overall, 63.7% (397 of 623) female neurologists experienced at least one burnout symptom.

There is an absolute dearth of neurologist burnout studies in India. The usual suspects as culpable factors for “neurologist burnout” include higher administrative burden, lower autonomy, and perceived meaningfulness of work, clerical burden, un-useful electronic health record (EHR) documentation which effectively reduces direct patient examination time, EHR documentation that did not translate to improved patient outcomes, too many administrative tasks, excessive workload (hours and patient volume), inadequate support staff, higher volume of work on weekends and evenings, too little effective “team-based” support staff, and a lack of diversity in professional activities beyond clinical work.

Does a unique personality explain why neurologists experience job dissatisfaction that seemingly exceeds that of many other medical specialties? By my own career-long observations, I offer an untested hypothesis. To my mind, the other potential specific factors explicated in higher risk of neurologist being more prone for burnout are due to the demands for a detailed history and examination coupled with personality factors of conscientiousness; with neurologists who display a more compassionate attitude, potentially increasing the risk for EE and compassion fatigue, making it difficult to operate under imperatives to increase patient encounters. This negative sentiment was evident in a neurologist's statement “Patients with complex neurological conditions need a lot time. I am expected to see follow-ups in 15 minutes. It is taking a toll on my health because I don't have time exercise or cook healthy foods. It is taking a toll on my family.” I fervently believe that individual dispositions and personality attributes of an effective clinical neurologist (such as perfectionism, curious, meticulousness, detail-oriented obsessive traits, conscientiousness, committed, compassionate, high empathy, effective listening/communication skills to hear all the tiny details, and time spent to narrow down possible diagnoses) do trigger burnout. I would reiterate that we, as neurologists, cannot just rush in without dedicated focused time for Holmesian reasoning in an attempt to substitute clinical rationalism and logico-deductive analysis.

Clinical Neurology is quite challenging with a high load on cognitive diagnostic heuristics, thinking styles, and demand for intellectual curiosity in addition to a focused time consuming neurological examination. The unique predisposition for a neurology specialty-specific burnout was echoed by Dr. Gregory Cascino in his Presidential Plenary Address at the 2017 AAN Annual Meeting. Dr. Casino, Professor of Neuroscience, at the Mayo Clinic College of Medicine and the Enterprise Director of Epilepsy at Mayo Clinic, Rochester, US, argued that unique personality traits shared by neurologists be responsible for their increasing job dissatisfaction. Although there appears to be no formal study of the neurologist's personality type, a Myers–Briggs personality inventory administered to nearly 100 neurologists at Johns Hopkins (Griffin JW, 2006) revealed that they were “highly analytical, organized and somewhat introverted intellectuals.” The neurologist among all other specialists is the quintessential “last physician-scientist” generating hypotheses at the bedside while eliciting the patient's history and then testing the hypotheses, at least with respect to lesion localization, with a targeted time-consuming examination of the patient.

In the US, neurology seems to be the only medical specialty that has both one of the highest rates of burnout and the poorest work–life balance. Having authored a review article on “Preventing “neurophobia: Remodeling neurology education for 21st-century medical students through effective pedagogical strategies for neurophilia” I was taken aback as I visualized a “double threat.” One would be the malady of “neurophobia” in neurology education. The finding of the highest rates of BOS in neurology specialty would have a tremendous and adverse impact on medical students not only to nurture interest in neurosciences but most crucially to facilitate the next generation of medical students to pursue career options in neurology. Although there is a dearth of studies on BOS among medical residents, physicians, and specialty-wise burnout in India, curing neurophobia, and strategic research in the direction for advocacy and programs to prevent and mitigate neurologist burnout and promote their well-being and engagement does become absolutely essential. This is only too relevant in India since we are facing a silent neurologic epidemic of epilepsy, stroke, dementia, and traumatic brain injuries in addition to the “triple-burden” disorders of communicable, noncommunicable, and nutritional disorders. The Indian scenario is further compromised by the looming shortage of neurology workforce.


  Physician Wellness and Self-Care Top


“We need to protect the workforce that protects our patients.”

– Tim Brigham, Senior Vice President, Education, ACGME, United States

“Self-care is so important. When you take time to replenish your spirit, it allows you to serve others from the overflow. You cannot pour from an empty vessel. Take care of yourself first. Self-care is not selfish.”

– Eleanor Brown

My personal motto and advocacy would be-”Self-care isn't selfish. It is the balance of things. Self-care is something that needs your awareness of yourself. Caring for the physician and his well-being, in order to regenerate his power of caring, enabling him to care for others.” At the end of the day, to the surprise of many, I would state that physician BOS and suicide is a real problem. BOS is an “under-recognized, underreported, underappreciated threat” or a “hidden healthcare crisis” in our medical profession and is invisible to the general public in many parts of the world. Painstakingly, being a “feeling physician,” I ask these questions now. Physician-centric wellness: isn't it a high time for a paradigm shift? Does this matter? Isn't it time to heal the healer? Physicians are not invincible, are they? Should we make it happen and be the advocates for such a meaningful change to endorse the concept of “Physician heal thyself?” Healers, after all, are human first; also need healing, don't they? Do patients recognize that we are first a person, that our generic name is “human person” then a “physician by profession” and whether patients are conscientious or have attitudinal awareness on physician wellness and burnout? How do patients perceive physician wellness and its links to patient care?

Before I venture into “physician well-being,” let me direct the reader to Hippocratic Oath adopted by the World Medical Association (WMA) in 1948. This physicians' pledge is monumental to maintain professionalism, preserve the goal of our profession as a moral enterprise grounded in a covenant of trust, caring, and exemplify always the fundamental ethics of the physician's mandatory beneficence. The physician's pledge underscores the sentiments “I solemnly pledge to dedicate my life to the service of humanity; the health and well-being of my patient will be my first consideration.” Being in the doctorhood profession for almost four decades, I have had the perception and worry that the Hippocratic Oath was solely riveted to a philosophy of a “self-sacrifice.” Hence, I pose this question to the readers “Does the Hippocratic Oath promote burnout?” To reflect my intuitive perception of the fallout of “physician burnout” as encoded in Hippocratic Oath, i.e., “putting patients first before oneself,” I would like to allude to an interesting study published on March 28, 2017, by Medscape Business of Medicine that studied 2600 physicians. The findings showed a mixed trend in their feelings about the danger of burnout by putting patients first as required by their oath: 20% had equivocal answers, 34%were in the affirmative, whereas 45% were not in favor that the Hippocratic Oath was the culprit for physician burnout.

To see the light at the end of the tunnel, it is certainly reassuring and a welcome change in the Hippocratic Oath from a mindset of “self-sacrifice” to the words echoed in the updated version of the 2017 Revised Declaration of Geneva: “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.” I strongly welcome this new change in the culture of medicine, i.e., “Caring for oneself to care for others.” I would reiterate that Revised Declaration of Geneva of the Physician's Oath critically acknowledged the growing awareness of burnout phenomenon among physicians amid increasing workload burdens and occupational stress. It also did underscore the potential adverse effects these factors could have on physicians, their health, and their ability to provide the best quality care possible. The medical profession, in fact, consistently “hovers near the top of occupations with the highest risk of death by suicide.”

Many of us were called to medicine because of a deep need to be needed. Those of us trained in the old days lived by the mantras: “My time is not my own” and “Patients' needs come first.” Is this question wrong? To take care of patients well, physicians must take care of themselves! Since modern medicine in the 21st century is witnessing a rapidly changing climate of academic medicine and corporate medical enterprise, I would unhesitatingly reiterate that “Self-care is not to be attributed as selfish” since we are “ first human, then doctor” and there need a renewed change in the culture of academic medicine to accept the irrevocable identity that “Doctors are human beings before we are doctors” and therefore “Practicing Self-care Doesn't Mean You're Being Selfish.” Therefore, this new perspective of the Physician's Oath has paved the way forward to change the culture of medicine reinforcing “heal thyself concept.” This will primly enforce self-care and caring for oneself. The WMA statement on physician's well-being and self-care has catapulted “physician wellness” as a global collaboration. This undoubtedly is the crucial key to the inner life of the physician, professional fulfillment, career satisfaction, and a positive work–life integration, all of which would translate to quality patient care and satisfaction.


  Physician Well-Being: Changing The Culture of Medicine Top


Physician wellness is an important topic that has received increasing attention over recent years.[7],[8] I would underscore that physician wellness is not about the absence of disease (BOS), but it is all about maximizing the quality of our life, achieving an equipoise on the work–life balance and career–family ladder of life, and in accordance with “work to live, don't live to work” to achieve physician happiness, satisfaction, and a balanced lifestyle. Such a 360° perspective of “physician's life beyond work” has been innovatively studied by the 2018 and 2019 Medscape Physician Lifestyle and Happiness Reports. Therefore, a bold change has been set in motion in the US by the Collaborative for Healing and Renewal in Medicine, American Medical Association (AMA), and the Association of American Medical Colleges by creating a “health systems and organizational systems-based charter as a shared responsibility for physician well-being.” Here, a group of medical educators, academic leaders, and wellness research experts endorsed the concept of energized, engaged, and resilient physician workforce conducive to achieve national health goals. The “Charter on Physician Well-being” explicates the principles and key commitments as a framework have been laid down to limit physician burnout and promote well-being.[9]

In the US, Dr. Tait Shanafelt, Dr. Colin West, and Dr. Lotte Dyrbye to name a few are physician burnout researchers who have been at the forefront of this area of “Physician wellness” promotion and have published numerous articles on the prevalence of physician burnout. Dr. Shanafelt argues that organizations and hospitals should stop blaming the individual physician. Dr. West, a physician-researcher at Mayo Clinic and senior author of the “Charter on Physician Well-being,” advocates that physicians should not be alone in managing burnout. He vehemently emphasizes that burnout and physician distress should become a responsibility shared between individuals and the organizations in which they practice by creating a supportive milieu through a higher quality of professionalism, communication training, emotional intelligence, and relationship management and all other levels of engagement that would ultimately minimize the stigma and promote a holistic and positive workplace culture. This would form the fundamental strategy for a high-performing health-care organization.


  Balanced Approach to Burnout Syndrome Prevention Top


Physicians, like all health professionals, are humans with human needs. I would, therefore, state that until we promulgate role models who exemplify physical and mental well-being (rather than complete self-sacrifice), our profession will continue to be plagued by burnout, depression, and suicide. I reiterate that the secret of the care of the physician is in caring for the Physician's well-being. A “one size fits all” approach will not mitigate burnout problem. Multimodal strategies akin to the “Canary and the Coalmine” analogy, where burnout prevention or rescue should address the health of the canary as well as the condition of the coal mine, so as to help create a resilient physician (at an individual level) well supported by a conducive professional environment (at a systems and organizational level). There must be a change in the culture of medicine to implement advocacy for physician wellness since burnout in physicians is endemic, and in most cases, physicians are “suffering in silence.”

Burnout occurs when our mental, physical, or spiritual energy accounts have a low balance over time. To prevent burnout, it is imperative to decrease our energy expenditures by ameliorating our stress levels and increase our energy deposits by finding strategies to promote a personal recharge and create more balance in our work–life axis. I would stress upon three domains which would quintessential for the reduction of burnout and promotion of professional fulfillment, namely personal resilience, efficiency of practice, and a culture of well-being. The culture of wellness must include a universal concept of leadership, values alignment, voice and input, appreciation, peer support, flexibility, meaning, and community and collegiality. I would state that merely acknowledging the problem of burnout and its implications is not enough. Instead, we need to explicate the panoply of drivers of burnout, to chart a holistic, comprehensive, and systems-level “anti-burnout” strategies. Improving physicians' wellness and implementing self-care strategies are a multifactorial process utilizing multiple domains of wellness, namely physical, intellectual, emotional, spiritual, social, and occupational, which will then allow individuals to reflect on current life balance and self-care.

Reflecting on the various systematic reviews and meta-analysis of the currently available studies, the intervention for physician burnout does reiterate a balanced, holistic approach to burnout prevention and physician wellness that should incorporate a broad range of therapeutic tools.[10],[11],[12] This strategy rests on two fundamental pillars, namely (i) physician “self-care” intervention programs and (ii) organization-directed interventions. Self-awareness is defined as a clinician's ability to combine self-knowledge and a dual awareness of both his or her own subjective experience and the needs of the patient. Greater self-awareness among clinicians may lead to greater job engagement, enhanced self-care, and improved patient care and satisfaction. Thus, individual interventions must include emotional self-awareness, emotional management abilities, coping skills training, resilience skills, and interpersonal skills to increase social support, cognitive-behavioral approaches such as relaxation techniques, time management, focused breathing, yoga practices, self-reflection, mindfulness-based meditation therapy, recreational activities and hobbies, pursuing reflective writing, fostering narrative medicine (to enhance self-awareness), and spiritual development. In conclusion, I would underscore that physician burnout and wellness interventions must be comprehensive and developed at both the individual and institutional levels, in a balance between service responsibilities and personal training that ultimately ensures positive work–life integration.

The world lead researcher in physician wellness and burnout from Mayo Clinic, Dr. Tait Shanafelt does not attribute “blameworthiness” solely to be upon the individual physician. Instead, he, a “physician's physician” and currently the Director of the Stanford Well MD Center, Chief Wellness Officer for Stanford Medicine, does perceive burnout to be an organizational and practice environment “systems” problem. Instead of always “blaming the individual physician,” Dr. Shanafelt addresses the issue of burnout and the “culture of wellness” to be a “shared responsibility” of both the individuals and health-care organizations. He advocates for a system-level and organizational -level strategies to reduce burnout and promote engagement.[13]

With the increasing health awareness, personalized health checkup, and senior citizen packages, preventive health care, screening, and wellness packages in the corporate world do indeed reflect an emerging trend of people taking charge of their own health and of those close to them. In tandem with this concept, there are several conferences on various disorders, but isn't it high time to have a “Conference of Physician health/Clinician Well-Being,” “Conference on Physician wellness and Distress,” and “Conference on Physician Burnout and Suicide?” Shouldn't we advocate for a “national physician health awareness day,” a “national physician wellness day” or a “physician suicide awareness day” emblematic of “under-recognized” issues of a “wounded healer” syndrome in the doctor's world?

Each year, one million Americans lose their doctors to suicide. Robyn Symon, a film director in the US, has produced a movie titled “Do No Harm” as a first film to documentary with the motive to “bring to the open” the toxic medical culture depicting the consequences of pressure-filled and stress-inducing demands of medical education, training, and practice. Indeed a documentary exposing the epidemic of physician suicide and burnout. However, are there any specific “healthcare/wellness health packages that target physician health and/or wellness? Are there any annual wellness checkup, awareness, and preventive strategy packages for occupational hazards for the physicians? I would vehemently state that various professional bodies to which physician are affiliated should mandatorily pave a meaningful change to thrust the idea of “physician wellness” does matter. This may be orchestrated by organizing National and International Conferences on Physician Health and/or CME focusing on physician wellness awareness, research, support systems, physician wellness programs, and innovative strategies to prevent physician burnout. Don't we need wellness-centric cultures in medical institutions and medical profession? One such step is The International Conference on Physician Health (2018), which is a collaborative meeting by the AMA, Canadian Medical Association, and British Medical Association on Physician Wellness strategies and mitigating BOS.


  Burnout Syndrome – “putting on Your Own Oxygen Mask first-Before Helping Others” Top


As an allegory, every time as passengers boarding a plane, many of us will be able to recall the safety briefing routinely broadcast at the start of every flight. Part of that briefing goes: “In the unlikely event of an emergency, oxygen masks will drop from the panel above you. Put on your oxygen mask first before assisting others.” The practical and critical reason is that if you don't get your own oxygen first, you will not be able to help others. In the unlikely event of an in-flight emergency, you need to help yourself before helping others. In accordance with thermodynamic law of human energy is “you can't give what you have not got.” You must “put your mask on first” and manage your energy accounts or your ability to care for others will be compromised. Similarly, physicians need to be reminded that they can't help others if they do not first address risks to their own well-being. If we do not look after ourselves, then we will be no good at looking after our patients. We must remember to put on our own oxygen masks first. This illustrates the importance of self-care and by taking this empathetic posture toward ourselves empowers us to have greater empathy for others. Such advocacy will certainly ameliorate the EE, cynicism, inefficiency at work, and burnout. This is indeed a part of a therapeutic beneficence, a vital piece of human fellowship, and compassionate humanism in medical practice. I quote Prof. Rita Charon, Professor of Clinical Medicine, and Director of the Program in Narrative Medicine at the Columbia University College of Physicians and Surgeons “When we stop caring about our patients and begin to feel irritable and overburdened, this is a signal to replenish ourselves, to nurture our capacity to care deeply.” I underscore the need that we must embrace the critical importance of Self-Care. Hence, what is your self-care plan? Take Care, my fellow physicians!


  Is Burnout Syndrome and Vital Exhaustion Variants of Depression? Top


Before I conclude, let me address an ongoing debate and the complex relationship between psychological concepts of vital exhaustion (VE), BOS, and depression. There has been much “vagueness and ambiguity” around the “mental” concept of burnout. It is also interesting to note the burnout was embedded in a blurry cultural lexicon and initially explained as a “state of VE.” VE is a mental state characterized by unusual fatigue, demoralization, hopelessness, and increased irritability. Therefore, VE does conceptually share several features with depression, thus giving rise to conflicting evidence as to their independence. Although VE and burnout have considerable overlap with depression, it is useful to view depression as psychopathology with very specific diagnostic construct, while VE and BOS are conceptually a psychological construct based on arbitrary “cut-offs” in the items of the Maastricht Questionnaire and MBI. Some proponents do speculate that VE/BOS as likely to reflect a “classical” depressive process unfolding in reaction to irresolvable stress, or a “subclinical form of depression.” Certain symptoms that are considered to be typical for burnout also have a substantial problematic overlap with depression (burnout depression overlap syndrome). In such studies, more than 80% of individuals with high burnout scores meet criteria for provisional diagnoses of depression. Perhaps, an unambiguous concept would be that some characteristics of burnout are very specific, that is, in burnout most of the problems are work-related. In depression, negative thoughts and feelings are not only about work but also about all areas of life beyond the workplace. In problematic overlap scenarios, BOS/VE may be tenable as a phenomenon in those who do not fulfill the diagnostic criteria of “major depressive disorder” and/or persistent depressive disorder (dysthymia). Does BOS and depression lie on a continuum as a dimensional phenomenon or does depression constitute a plausible confounder in BOS and VE research? However, I would state that more rigorous and methodological research in addition to robust statistical analyses is needed, and until then, the jury is still out on this, and yet to be investigated.

On a futuristic and promising note, the World Health Organization, in the last week of May this year, has legitimized the “BOS” as an “occupational, work-related phenomenon” under International Classification of Diseases (ICD). However, burnout from work is now a “syndrome” in the 11th Edition of ICD. This is a step up from the previous edition, ICD-10, which simply had an entry for burnout coded as Z 73.0 in general, as “Problems related to life-management difficulty,” not specifically for work. Now in the ICD-11 BOS is listed as “QD85 Burn-out” under “problems associated with employment or unemployment,” which in turn is listed under “factors influencing health status or contact with health services.”

In conclusion, I cannot afford to adopt an “ostrich-like attitude.” Will I be not right to ask these questions? Shouldn't our organization and hospital administration have a mission statement that pledges toward Physician Wellness and Satisfaction and have a “Physician Wellness Committee” or a “Doctors Wellness Group?” Should not the organization pledge commitment for a “change in culture” that inculcates both physician and patient satisfaction? My first instinct was that I needed to put the issue of physician burnout and clinician well-being on the front burner, as a major under-recognized threat to the physician workforce, and also a factor that jeopardizes quality health indicators. I will vehemently reiterate that medical schools and educators are arming medical students with unparalleled knowledge and immense skill as “front line soldiers” to battle, conquer, and stamp out disease. It is also quintessential to create awareness and recognize BOS, advocate not only a “burnout prevention strategy,” instead implement a preemptive “Physician Wellness Curriculum” in medical schools.

In my opinion, the onus is on us, the physician fraternity, to be critically self-reflective of our own brokenness, recognize and foster comprehensive multilevel anti-burn out strategies. Healing our own vulnerabilities and self-care should not be misconstrued as selfish. In an imperfect real world, physician “self-care” concept is not turning a blind eye to another person's suffering. We all need to fight this occupational hazard, to find a holistic meaning that will evolve toward greater cohesion, solidarity, and shared responsibility in not only sensitizing the burnout problem. All professional bodies, especially the Indian Medical Association, need to promote national burnout research to estimate the prevalence rates, create awareness, sensitize healthcare professionals, and ultimately develop recommendations, advocate policy changes, and implement innovative interventions to address potential drivers of burnout. Our medical profession must identify the root causes of burnout, and more importantly, there is an absolute need to revitalize our specialties and develop a “Physician Wellness Program” to put the joy and professional fulfillment back in practice of medicine and in the art of doctoring. Therefore, we must advocate and foster solidarity for “breaking the silence on physician BOS” and put the case forward for “Investment in Physician Well-being.” Let us have a “culture change” that tantamounts to rekindling professional fulfillment, resurrecting the joy in practice of medicine, and enhancing physician satisfaction, thereby ensuring high-quality care for our patients. Physician burnout and its tremendous consequences cannot merely be “brushed under the rug.”


  Physician Burnout Quotes Top


What do you Owe Your Patients?

“As physicians, we owe our patients two things – only two things. Our time and our skill. We do not owe our patients our lives.

Doctors must take some time off from their daily work to get some rest, to travel, to participate in their family affairs, be an active member of their community, etc.

To excessively devote our lives to the practice of medicine while we neglect other aspects of living may be tantamount to never having lived at all.”

– Dr. Jospeh D. Wassersug, MD

“Burnout also leads to a large swath of physicians who aren't as empathetic toward their patients as they could be.”

– Danielle Ofri, MD. What Doctors Feel: How Emotions Affect the Practice of Medicine



 
  References Top

1.
Wallace JE, Lemaire JB, Ghali WA. Physician wellness: A missing quality indicator. Lancet 2009;374:1714-21.  Back to cited text no. 1
    
2.
Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med 2003;114:513-9.  Back to cited text no. 2
    
3.
Shanafelt TD, West CP, Sloan JA, Novotny PJ, Poland GA, Menaker R, et al. Career fit and burnout among academic faculty. Arch Intern Med 2009;169:990-5.  Back to cited text no. 3
    
4.
Krall EJ. Ten commandments of physician wellness. Clin Med Res 2014;12:6-9.  Back to cited text no. 4
    
5.
Squiers JJ, Lobdell KW, Fann JI, DiMaio JM. Physician burnout: Are we treating the symptoms instead of the disease? Ann Thorac Surg 2017;104:1117-22.  Back to cited text no. 5
    
6.
Busis NA, Shanafelt TD, Keran CM, Levin KH, Schwarz HB, Molano JR, et al. Burnout, career satisfaction, and well-being among US neurologists in 2016. Neurology 2017;88:797-808.  Back to cited text no. 6
    
7.
Lall MD, Gaeta TJ, Chung AS, Dehon E, Malcolm W, Ross A, et al. Assessment of physician well-being, part one: Burnout and other negative states. West J Emerg Med 2019;20:278-90.  Back to cited text no. 7
    
8.
Lall MD, Gaeta TJ, Chung AS, Chinai SA, Garg M, Hussain A, et al. Assessment of physician well-being, part two: Beyond burnout. West J Emerg Med 2019;20:291-304.  Back to cited text no. 8
    
9.
Thomas LR, Ripp JA, West CP. Charter on physician well-being. JAMA 2018;319:1541-2.  Back to cited text no. 9
    
10.
Dyrbye LN, Shanafelt TD, Sinsky CA, Cipriano PF, Bhatt J, Ommaya A, et al. Burnout Among Health Care Professionals – A Call to Explore and Address this Under Recognized Threat to Safe, High-Quality Care, NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2017. Available from: https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care. [Last accessed on 2019 Apr 07].  Back to cited text no. 10
    
11.
Wiederhold BK, Cipresso P, Pizzioli D, Wiederhold M, Riva G. Intervention for physician burnout: A systematic review. Open Med (Wars) 2018;13:253-63.  Back to cited text no. 11
    
12.
Shapiro DE, Duquette C, Abbott LM, Babineau T, Pearl A, Haidet P, et al. Beyond burnout: A physician wellness hierarchy designed to prioritize interventions at the systems level. Am J Med 2019;132:556-63.  Back to cited text no. 12
    
13.
Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-46.  Back to cited text no. 13
    




 

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