Cultivating Cultural Humility to Address the Healthcare Burnout Epidemic–Why It Matters

Abstract

Physician burnout is a major problem that has long been facing our healthcare system. The COVID-19 pandemic has unfortunately deepened this problem and shed the light on the multiple structural shortcomings of our healthcare system that need immediate attention. Demoralization is one of the core features of “physician burnout,” which results from a breakdown of genuine physician-patient interaction. A healthcare system that embraces cultural humility, where we find ourselves rewarded for supporting, uplifting, and respecting our patients’ diverse voices could pave the way for battling burnout. Unlike cultural competency, which suggests that one should know everything about another’s culture (an unfeasible task), cultural humility is a continuum of self-reflection and critique that aims to foster a deep connection between the physician and patient; a connection that sits at the core of the humanistic and multicultural experience of medicine.

Now is an incredibly challenging time to be a physician. While fighting a global pandemic would bring expected challenges, practicing medicine in our current era has never been more disheartening, where current data suggest that 1 in 5 physicians are planning to leave medicine altogether in 2 years. ¹ Physicians have long decried the prioritization of medical documentation for billing and malpractice coverage over genuine human interaction. With the Black Lives Matter (BLM) movement and increasing awareness of the health inequities faced by Black and minority communities, physicians became more collectively aware of structural racism in medicine. And now, adding to all of this, COVID-19 sheds new light on the politicization of public health measures, rampant public misinformation, and overstretched healthcare staffing within a healthcare system that was already broken. This is demoralizing.

Demoralization is one of the core features of “physician burnout,” which results from a breakdown of genuine physician-patient interaction. Physician burnout is a concept that emerged in the late 1960s ² and expanded overtime to describe the emotional and psychological job-related stress in any health practice environment. ³ Foundational work by Maslach et al in the 1980s ⁴ described burnout as a combination of emotional exhaustion, depersonalization, and low personal accomplishment that stems from the chronic stress of medical practice.

In a dehumanized healthcare system, repeated episodes of depersonalization can lead to loss of compassion. Without compassion and empathy, physicians can fall in the trap of having a distant feeling towards patients, treating them as objects rather than human beings and becoming more callous towards them which may lead to cynicism or sarcasm, also described as “compassion fatigue”. While historically emotional exhaustion has been held to be the dominant domain of burnout, depersonalization was found to align more strongly with most negative consequences of burnout. ⁵ As physicians lose sight of their patients as unique individuals, they fail to attend to the unique needs of their diverse patients. This cycle lends to a multiplier effect that deepens the very inequities created by the healthcare system. It is therefore not surprising when physician burnout leads to low job satisfaction, decreased work productivity, increased medical errors, early retirement, poor quality of patient care, lower patient satisfaction, and healthcare system failure. ⁶ This highlights the ongoing need for better characterizing this global crisis and coming up with the effective tools to fight it, which is likely beyond the scope of wellness modules and mindfulness training. ⁷

This is where cultural humility can be the answer. Cultural humility is a practice that embraces 3 key ideas; lifelong learning and self-reflection, mitigating power imbalances and institutional accountability. Therefore, it is more than an unimpactful checklist to meet ends in a physician’s strained schedule, but a tool to build a workforce of culturally humble providers; individuals who, in their nature and every interaction, seek to connect with patients as individuals. It is a concept that is meant to build a continuum of practices to transform clinical practice and allow physicians to address the biases within themselves and the healthcare system that lead to human disconnect and hence burnout. Unlike cultural competency, which suggests that one should know everything about another’s culture (an unfeasible task), cultural humility is a continuum of self-reflection and critique that aims to foster a deep connection between 2 individuals. ⁸

The 5 Rs of cultural humility were described as a framework for implementing this concept in clinical encounters and at the organizational level. The 5 Rs refer to: Reflection, Respect, Regard, Relevance, and Resiliency. In a stepwise self-interrogation technique, each of these tenets can be respectively reflected in a question: what did I learn from that encounter? Did I treat everyone in the encounter respectfully? Did unconscious bias drive this encounter? How was cultural humility relevant in this interaction and finally, how was my personal resilience affected by this interaction? As physicians introspectively answer these questions, they find themselves self-reflecting, better connecting with their patients, identifying their own biases and ultimately enhancing their resilience as they embody cultural humility in their interactions. Therefore, as we encourage efficient and mindful physician-patient rapport at the personal and the organizational level, we could potentially mitigate physician burnout and cultivate a sense of satisfaction and well being for our patients. ⁹

Throughout the COVID-19 pandemic, a feeling of personal connection between physicians and patients has been lost with limited patient and family interactions due to fewer visitors, higher number of patients to be seen, and extra work placed on providers. Depersonalization led to disappointing and demoralizing encounters that have been repeatedly reported by physicians on various forums. Nevertheless, during that moment on the backdrop of BLM movement in the United States and a globally polarized political atmosphere in general, we witnessed a near universal uptick in Diversity, Equity, and Inclusion initiatives (DEI). Research suggests that achieving DEI not only benefits physicians themselves, but also the patients to whom they provide care and may in fact improve clinical outcomes. ¹⁰ In the light of this data, we argue that DEI efforts could be one the steps that can help shift towards an organizational climate that embraces cultural diversity and humility. Hence, as we continue the efforts towards embracing diversity in patients and their providers, we are in fact enriching a culture of cultural humility.

To that end, a healthcare system that embraces cultural humility is where we find ourselves represented with our diverse backgrounds and in turn rewarded for supporting, uplifting, and respecting our patients’ diverse voices. This environment could pave the way for battling burnout ¹¹ while honoring the unique “cultural experience” of medicine.

ORCID iD

May F Elbanna https://orcid.org/0000-0002-9745-9066