Burnout Education: Are We Playing with Fire?

As a critical-care physician in the coronavirus disease (COVID-19) ICU, I (T.N.A.) dreaded each ICU shift in which I was surrounded by 40 intubated patients with monitors alarming constantly with impossibly low oxygen saturations and families wailing on Zoom as they watched their loved ones die alone. As my colleagues and I cared for COVID-19 patients and managed significant pandemic-related stressors at home, we experienced feelings of anger, frustration, numbness, and grief, as well as physical symptoms including debilitating fatigue and changes in eating patterns. The stigma of psychiatric illness and a misunderstanding of the spectrum of mental health problems that can develop during extreme stress led many of us to defer psychiatric assessment in favor of self-assessment of burnout. In some cases, the assumption of burnout was erroneous and led to substantial delays in obtaining evaluation and treatment for potentially life-threatening psychiatric illness. Frontline healthcare workers (HCWs) deserve better.

Educational programming has made physicians of various disciplines aware of physician burnout (1); however, despite research that shows that psychiatric disorders (many preexisting) are found in as many as half of individuals experiencing extreme stressors such as disasters, physicians are far less willing or able to consider the possibility of a psychiatric disorder than they are to conclude that their distress represents burnout (2, 3). Educational programs for ICU workers not differentiating burnout from full-fledged psychiatric disorders are essentially playing with fire; real harm can result, including a lack of recognition and treatment of psychiatric illness among HCWs. This article outlines the categories of ICU-related mental health problems among HCWs and proposes interventions.

Differentiating Distress from Psychiatric Illness

Distress is a constellation of symptoms and emotions that do not reach the diagnostic criteria for psychiatric illness (3, 4). Distress is not a psychiatric disorder, and diagnostic criteria for it have not been established (4). Distress may occur in HCWs during normal ICU operations given the emotional and stressful nature of ICU work and is nearly universal during an intense stressor such as a pandemic (4). Distress has numerous manifestations, varying from negative emotions to established syndromes such as burnout, moral distress, and compassion fatigue (Table 1) (1, 3). Manifestations of distress may overlap with those of psychiatric illness, and diagnostic assessment by a psychiatrist is necessary to distinguish the two (5).

Table 1.

Distress Syndromes in Healthcare Workers

Condition	Definition
Burnout	Burnout is a form of psychological distress in response to chronic emotional and interpersonal stressors. It typically includes three dimensions: overwhelming exhaustion, cynicism or detachment, and inefficiency or a sense of nonaccomplishment (7).
Moral distress	Moral distress (also termed “moral injury”) includes negative emotions or symptoms that develop when healthcare workers find themselves in a moral dilemma (7). Moral dilemmas for healthcare workers revolve around their inability to treat patients in a manner that is ethically acceptable to them (7).
Compassion fatigue	Compassion fatigue is the final endpoint of a progressive and cumulative process involving intense patient contact and exposure to stress, culminating in indifference to others’ suffering (12). Compassion discomfort is the first step on the ladder toward compassion fatigue (12).

A proportion of HCWs during a pandemic, and some ICU workers during times of normal operations, will experience psychopathology above and beyond emotional distress (4, 6). The psychiatric disorders that most commonly develop during prolonged and intensive stress are major depressive disorder and generalized anxiety disorder (6). The stress of a disaster may also contribute to the continuation or exacerbation of preexisting substance-use disorders (4, 6). A formal assessment by a psychiatrist is necessary to diagnose psychiatric illness, and treatment of psychiatric illness may consist of medications and/or psychotherapy (5). Failure to recognize and treat psychiatric illness can have life-threatening consequences (5).

Existing Educational Initiatives on the Breadth of ICU-related Mental Health Problems

Existing burnout education programs, including those on the American College of Physicians website and in the call to action for physician burnout issued by the Critical Care Societies Collaborative (7, 8), do not provide training on the warning signs of psychiatric disorders or suggest the need for psychiatric evaluation to address potential psychiatric disorders in addition to burnout. Although no research has determined the numbers of individuals with an erroneous self-assessment of burnout who are actually experiencing a psychiatric disorder, failure to identify psychiatric disorders can lead to morbidity and mortality, including suicide (3, 5, 9).

Proposed Educational Initiatives

Educational programming has been demonstrated to increase awareness and decrease the stigma of psychiatric disease (10). Although HCWs cannot diagnose their own psychiatric illness, they can learn some warning signs that may warrant formal psychiatric assessment. Suicidal thoughts may occur with distress such as burnout, and suicidal thoughts warrant careful psychiatric evaluation (4, 5). Reduced functioning can occur as a normative response to stress alone or as a manifestation of psychiatric illness, and thus a formal psychiatric assessment is appropriate for individuals with significant functional impairment (6). Further, individuals whose symptoms do not improve with time off and supportive interventions for distress warrant diagnostic assessment for psychiatric illness (6).

We recognize that adding yet another training program to an already burdensome administrative load may not be feasible and may not be necessary if a few elements are added to existing training. Wellness programs and burnout training are common in healthcare organizations and can be enhanced by embedding education regarding psychiatric illness, especially addressing the culture of psychiatric stigma within existing programs. Further, divisional conferences, departmental grand rounds, or town hall meetings are excellent educational opportunities for this important issue.

Proposed Institutional Interventions for Distress and Psychiatric Disease

In addition to providing training on psychiatric disorders, institutions can assist with needed access to psychiatric treatment among frontline HCWs by operationalizing psychiatry staff to meet increasing demand during intense stressors and by offering screening surveys for psychiatric disease (3, 6). Positive screening survey findings can suggest a risk for psychiatric illness but are not diagnostic and thus must be followed with a full psychiatric assessment (3, 11).

Institutions may also help HCWs to manage distress. Distress can be managed with supportive care, including clear risk communication, personal check-ins, supportive counseling, and psychological first aid (6). Psychosocial interventions for burnout include a supportive ICU culture, adequate time away from work, proper job training, and psychoeducation (7). Moral distress can be addressed by education on moral dilemmas to help HCWs identify system factors that contribute to their distress and by promoting institution-wide discussions about ethical dilemmas in health care (7). Psychosocial interventions for compassion fatigue may include broadening the pool of ICU workers during periods of high demand for ICU services and instituting surveillance for and management of compassion discomfort and fatigue. When no improvement is seen with these interventions for distress, psychiatric evaluation is an appropriate step. Institutions may also facilitate qualitative research to explore the experience of ICU workers with psychiatric disease.

Conclusions

Failure to address the breadth of mental health problems in ICU workers is essentially playing with fire. By providing appropriate education and screening for psychopathology, institutions can encourage frontline HCWs with high levels of distress nonresponsive to psychosocial interventions to seek psychiatric care. Critical-care physicians, in turn, must be willing to accept psychiatric care, which is enabled by the destigmatization of psychiatric illness. Educational efforts may help HCWs with psychopathology to move from erroneous self-assessment of normative distress such as burnout to reach out for diagnosis and treatment. Our lives may hang in the balance.