Burnout

I looked at the clock. It showed 2:58 am. The ED hadn’t paged in 30 minutes. No calls from the floor either in at least 15. It was now or never. I hurried over to the refrigerator and threw my microwave dinner in to heat. Two minutes later, I heard the beep. My stomach was growling; I realized I hadn’t eaten anything in about 12 hours. Then, I realize the beeping wasn’t the microwave at all. BRAIN ATTACK arriving with ETA of 5 minutes…. I looked at the microwave and then the door and then back at the microwave. Shall I try to take a few bites before I run down to the ED? Do I bring it with me? Then, the pager goes off again, outside caller trying to reach an on-call doc. Forget it. I grabbed my laptop and ran to the ED to meet the incoming patient. No food, no water. I dial the outside line, “Neurology Emergency Line, this is the on-call doctor…” and my pager goes off a third time as I head down the steps…

Burnout (Noun): 1. The reduction of a fuel or substance to nothing through use or combustion. 2. Physical or mental collapse caused by overwork or stress.1

In healthcare, burnout is more frequent than we care to realize, especially when we are in training to become doctors, nurses and other healthcare professionals. It’s characterized by emotional exhaustion, cynicism and decreased sense of personal accomplishment. Sound familiar? We have all experienced stress, lack of autonomy, and even, dare I say it, symptoms of depression. What we might not realize is that not only is burnout higher in physicians than in many other professions, it’s also particularly high in neurology. The specialty, in some surveys, ranks as high as third among all specialties and greater than 50% of practicing neurologists cite at least one symptom of burnout; the national average is 45.8%2. It would be good news, if the new, baby-faced, yet to be jaded residents, who just recently earned the title of ‘doctor’, were walking the halls with yards of optimism and infectious good will. Unfortunately, recent data suggest their burnout rates are even higher than that of the attending physicians – 76% of recently surveyed internal medicine residents had signs of burnout. 2

When we truly reflect on this epidemic of ‘burnout,’ we must not only come to recognize signs and symptoms just as we do with medical diagnoses, but we must come to understand the causality, the true effects of burnout. When physicians are exhausted, they begin to lack interest in their work, and enthusiasm dwindles. When less emotionally tied to their outcomes, room for error begins to break through. There is risk for depersonalization, or losing the individuality each patient encompasses; we run the risk of losing what we have been taught to cherish most, the art of personalized medicine, with each patient presenting a unique opportunity to understand the clinical picture and improve and cherish the uniqueness. With all of this comes less satisfaction, a loss of the sense of personal accomplishment each time we diagnose someone correctly or hear a patient say, “thank you.” There’s a stampede of relocation, increased work hours and worse yet, increasing numbers of medical errors, depression and suicide. The twinkle in the eye of the young resident is gone and the glory they found in having the opportunity to serve others has become a burden.

Surprising to some may be the recent claim of the American Academy of Neurology (AAN) Workforce Task Force, which predicts a shortage of neurologists in the future. 3 How might burnout occurring now and risk for burnout among future neurologists play a role in this number? The special Task Force appointed by the AAN is researching the prevalence of burnout with a second group focusing on mitigation and prevention. 4 Words such as these harken me back to my work with emergency management and disaster response. A well-known paradigm that addresses four phases of emergency management, 5 and an application here, in our own hair-raising reality of increased burnout and decreasing idealistic medical professionals, seems valid. After all, by identifying risks and those at risk, aiding in their recovery and preventing future struggles, there may be hope to decrease rates of burnout in our specialty.

Graphic of the cyclical process of burnout: Preparedness, response, recovery and mitigation.

Though risks for burnout are not well understood and will remain a point deserving further research for quite some time, plans to mitigate and prevent burnout do exist and are evolving for the better. A recent editorial in Neurology by Neil A. Busis, MD makes a dramatic and likely well-overdue claim, “to revitalize neurology we need to address physician burnout. 5” As mentioned, we have a goal of personalized medicine for our patients, but that goal ignores a key component of providing top care—the provider. How can we ensure that physicians, and specifically, neurologists, remain healthy, happy, engaged and committed, which will hopefully result in physician satisfaction, quality patient care and thus inspire students to pursue neurology as their specialty of choice?

Given the recent recognition of burnout as a risk to medical professionals, many suggestions are currently flooding the literature hoping to not only understand this better, but to face it head on. This includes availability of counseling, increasing autonomy, increasing team approaches to provision of care, changing the culture of medicine to increase recognition for jobs well done and continuing to validate the commitment physicians make to their patients and to their colleagues and institutions. 2 Mentoring has been identified as a possible conceptual model for change as well as decreasing the burden of rules that place limitations on patient care. 6 It is hypothesized that the opportunities for personal growth must abound and the timely tasks of insurance debates must cease. Only through a recovery process, which would include identification of these areas of change, can we mitigate and prevent burnout.

Burnout is not limited to physicians, nurses and healthcare professionals. We must recognize it not only in ourselves and in our colleagues, but among the caregivers of our patients as well. The reality of many of the neurologic diagnoses we give day in and day out is that patients and their caregivers are signed up for new, lifelong journeys. Some of those journeys will be straight on a smooth road, always paved and without construction, and others will be long, with bumps and detours and patches of highway that seem never-ending. It is these individual journeys of caregivers – the range of emotions, the physical strain, the mental rollercoaster—that result in burnout leading to depression and other health problems. 7 It is important to address risks of burnout with these caregivers early on, to have checks and balances in place to work to prevent it, and provide resources for support and management. We must make it our role as the health care provider to educate our patients and their caregivers on resources available to them including aids, support groups, new ways to address guilt, and not only accept help, but learn how to ask for it.

But again, identifying those at risk must include the physician. Trained to care for others, the physician must not lose sight of his or her own health and fulfillment. Burnout has recently become part of the conversation, but we must ensure the continued focus on identification of risks, development of strategies for intervention, establishment of resources to help those struggling and focus on prevention. Then perhaps, burnout rates will decline, errors will be prevented, physician health will be promoted and our patients as well as our specialty will benefit.

Self-actualization (Noun) 1. To realize one’s full potential. 2. The need to be good, fully alive and find meaning in life.

It was 7:15 a.m. 45 more minutes and my shift was over. Dictations are complete. Sign out has been given. I open my granola bar and reflect on my night. Two brain attacks. One patient received TPA. Another patient with myasthenia was started on IVIG and her respiratory status was stable. I was exhausted, but deep down, knew I had made a difference tonight. And then, my pager begins to beep. I look down, and this time, I smile. Brain attack, ETA 5 minutes. Another opportunity to learn. And, as I head down the stairs this time, I feel an extra skip to my step. I have the best job in the world…

Selected resources for further discussion

Resources for caregivers


Mary Elizabeth Kovacik Eicher, MD
Neurology Resident
PHONE: 717-531-3828
RESIDENCY: Neurology, Penn State Milton S. Hershey Medical Center, Hershey, Pa.
MEDICAL SCHOOL: Pennsylvania State University College of Medicine, Hershey, Pa.


References:

  1. Oxford University Dictionary. Oxford University Press, Accessed December 5, 2015.
  2. Sigsbee B, Bernat, JL. Physician burnout: a neurologic crisis. Neurology. 2014;83:2302-2306.
  3. Freeman WD, Vatz KA, Griggs RC, Pedley T. The Workforce Task Force report: clinical implications for neurology. Neurology 2013; 81:479-486.
  4. Cascino TL. President’s column: improving the well-being of neurologists. AAN News 2015;29(10):3,27.
  5. Coetzee C, Van Niekerk, D. Tracking the evolution of the disaster management cycle: A general system theory approach. Jàmbá: Journal of Disaster Risk Studies. 2012; 4(1), Art. #54, 9 pages http://dx.doi. org/10.4102/jamba.v4i1.54
  6. Busis NA. To revitalize neurology we need to address physician burnout. Neurology. 2014;83:2202-2203.
  7. Richmond C. Help for the caring. 2015. Neurology Now. Oct/Nov:54-57.

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