Of Hearth and Home: Professional Wellness After Hours

Abstract

Burnout is a prevalent problem in the contemporary practice of medicine. Defined by the Agency for Healthcare Research and Quality as, “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment,” this multifactorial condition has significant implications for the clinicians who suffer it, their patients, and families. Neurologists suffer some of the highest rates of burnout. Burnout research on interventions often focus on the work environment. In this article, we will focus on burnout’s effects on home life and features of home life that can impact resiliency, specifically sleep hygiene.

A career in medicine is uniquely demanding. Across specialties and clinical roles, physical, mental, and temporal boundaries are regularly challenged. In addition to mounting workloads and clerical tasks, the electronic medical record and documentation proliferation have become particularly burdensome and have found their way into clinicians’ homes on portable electronic devices. ¹ Organizational support structures and leadership culture have not successfully addressed these burdens. Burnout research and interventions often focus on the work environment, but in this article, we will focus on burnout’s effects on provider homelife and features of homelife that can impact resiliency, with an emphasis on sleep.

Defined by the Agency for Healthcare Research and Quality as, “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment,” burnout has significant implications for the clinicians who suffer it, their patients, and families. ² According to the American Medical Association burnout affects all medical specialties and all practice settings. Burnout can appropriately be described as epidemic in the US health care system and is a complex, dynamic phenomenon, which unfolds over time. ³ Health care workers have reported mood concerns (stress, depression, anxiety) and sleep disturbances, and over half of health care workers report feeling burned out. ⁴

Neurologists have typically fallen at, or toward, the top of the charts when scrutinizing burnout, negative emotional symptomology, and professional turnover. ⁴ Estimates have been wide-ranging, but in the field of neurology, the presence of depressive symptomology has been often accepted to be seen in at least 55% of professionals, accompanying an estimate of 18% endorsing a regret in their career choice. This phenomenon is not limited to seasoned professionals, either; one study noted 61.6% of neurology residents satisfied measurable criteria for burnout. ⁴ Burnout may be particularly salient for epilepsy providers. Whereas some studies have demonstrated that subspecializing in epilepsy may be a protective against burnout, additional factors frequently associated with neurology work such as hours worked per week, nights on call, outpatient volume, clerical volume are affiliated with greater risk for burnout, and can, perhaps paradoxically, be exacerbated by the complexity and longitudinal nature of epilepsy patient care. ⁵ Furthermore, the long-term relationships built between epilepsy providers and their patients can often induce a clinician’s propensity for self-sacrifice, at the risk of suffering a moral injury where one feels they may not have utilized all their resources to successfully manage the complexity and various lifelong needs of their patients, especially in the presence of intractable and debilitating seizures. ^6,7

The consequences of suffering from burnout symptomology can be diverse and present a significant risk to not only the individual clinician but also to their team, department, their patients, and families. These can range from decreased focus on patient care secondary to increased demands from work stress and tasks, to placing stress on the reliability and cohesion among multidisciplinary team members. These concerns are also further complicated by the blurred line between home and work that is so frequently seen by on-demand providers who, despite not being “on” or in clinic, are perpetually available thanks to the use of pagers, text data, e-mail, and tasks delivered via electronic record systems. ^7,8 The difficulty, or even inability, of providers to separate their personal and professional obligations (eg, “taking their work home with them”) can be extrapolated as a primary driver for neurology physician burnout, as research has illustrated greater support for (and subsequently, satisfaction with) work–life balance and flexibility has been associated with a lower-risk of burnout. ^9,10

Work–home balance is a bidirectional construct. Burnout can contribute to sickness-absence, decreased productivity, and staffing-shortage. Health care workers are either retiring early, going to part-time or leaving the field altogether. ¹¹ As a result, the staffing shortage increases the burden on those who remain. The COVID pandemic has also served as a catalyst to a new work model as it shifted the delivery of care to virtual with telemedicine and remote monitoring, and gave rise to a generation of “travelers.” ¹² While remote working seems very appealing and offers flexibility, boundaries between work and life outside of work can be blurred. ¹³

Drivers of burnout are largely rooted within health care organizations and systems, although physician-level factors also play a role. ¹⁴ While “life satisfaction” is identified as a multivariable construct necessitating a multidirectional approach to management there are intervention strategies, particularly when implemented early, that can prove beneficial. ¹⁵ Given the significant and widespread presence of burnout concerns, it would behoove health care administrations, both nationally and locally, to invest in provider wellness initiatives. Managing weaknesses on a granular level with clinical providers may be the strongest variable in physician retention. To wit: rapid, honest, and visible responses to smaller but specific needs on an individual or division level can effectively demonstrate investment in individual wellness and can serve as institutional protection against attrition. ^15,16 While it does not appear to be “curable,” systemic burnout across the medical profession can be mitigated by a moderate level of both engagement and investment. ^{17 -19} Several interventions beyond financial incentives, however, have been identified as helpful and actionable at larger and smaller scale levels to help reduce the impact of burnout; these can include (but are not limited to) visible organizational acknowledgement, and enabling and cultivating community relationships to empower clinicians at a local level. ⁹

The encouragement and development of department-level wellness committees is a visible first-step which can allow clinicians to identify local difficulties and frustrations, as well as identify and share interventions they have employed on their own (often with resource limitations). This can subsequently be extrapolated to more regional (eg, institution-wide) protocols. An example of an efficacious intervention that facilitated individual clinician home- and self-care strategies was to ask physicians to anonymously identify community-based, culturally competent mental health care providers they had personally used and then to create local database. ⁸ Often, medical centers promote institutional values that allude to, or even outright note, a focus on a culture of wellness, inclusivity, and compassion; it is of paramount importance for these values to apply not just to patients but to the clinical staff as well, such as physicians, nurses, and allied health workers. ¹⁹ At a core level, an investment in an individual provider is a downstream investment in the greater institution; at a broader level, investing in providers is a humanitarian imperative.

While institutional investment is critical for burnout mitigation, provider-level self-care is also necessary. Cultivating self-awareness, reflection on work and home priorities, self-care practices including exercise, adequate sleep, and setting boundaries are important self-management skill sets. It is reasonable to follow the advice of flight attendants who remind passengers to, “secure your own oxygen mask before assisting others.” Sleep practices are particularly overlooked and undervalued behaviors and are critical components of both physical and cognitive health, playing a pivotal role in overall well-being and serving as a cornerstone for achieving excellence in the medical profession and maintaining a work–life balance. Physicians frequently face demanding schedules and high-pressure environments, making sleep even more crucial to maintaining optimal cognitive abilities, decision-making skills, and resilience when navigating the intricacies of patient care.

Unfortunately, sleep insufficiency has become an emerging public health crisis within our nation, impacting two-thirds of teenagers and one-third of adults who fall short of the recommended 8 to 10 hours and 7 to 9 hours of sleep per CDC and the National Sleep Foundation. ^20,21 Sleep is essential for many important bodily functions: During slow-wave sleep, our body restores itself, the immune system boosts to keep us healthy, and it cleanses away neurotoxic proteins through the glymphatic system. ^22,23 During rapid eye movement sleep, our memory consolidates, and it is a critical time for us to process emotions.

This population-level sleep debt is clearly made manifest among physicians. ²⁴ The inherent challenges of sleep among physicians stem from long working hours, irregular shifts, disrupted sleep due to emergency calls, and high-stress work environments. Sleep insufficiency increases the risk of cardiovascular disease, stroke, hypertension, diabetes, and obesity, as well as mental health conditions such as depression and anxiety. ^25,26 The repercussions of sleep deprivation extend beyond individual well-being, reaching into compromised patient safety, health care outcomes, and personal safety, such as drowsy driving, car accidents, and work-related injuries.

Addressing provider sleep challenges necessitates pragmatic solutions. Practical tips for enhancing sleep quality are not merely recommendations; they constitute essential strategies for physicians grappling with demanding schedules. ²⁷ Developing a consistent sleep schedule is a foundational habit. Clinicians often experience irregular working hours, making it essential to establish a consistent sleep schedule. Creating a routine that includes a set bedtime and wake-up time, even on days off, helps regulate the body’s internal clock, promoting better sleep. Optimizing sleep environment further increases sleep efficiency. Providers should prioritize creating a conducive sleep environment—dark, quiet, and cool. Investing in blackout curtains, eye masks, earplugs, can help mitigate disruptions and enhance the quality of sleep. When sleep deprivation is inevitable, “power naps” are useful evidence-based tools. Given the unpredictable nature of emergency calls and long shifts, incorporating strategic power naps can be beneficial. Short naps of 20 to 30 minutes during breaks can provide a quick energy boost and improve alertness without encountering sleep inertia or interfering with the ability to fall asleep at night. ²⁷

Sleep quality and quantity aside, work stressors, and recreational activities can negatively impact falling asleep. Mindfulness and relaxation practices, such as meditation and deep-breathing exercises, can help physicians unwind from the stressors of their work. Integrating these practices into presleep routines or using them during breaks can foster relaxation and mental clarity, promoting better sleep. Exposure to screens before bedtime can disrupt the body’s natural sleep-wake cycle due to the blue light emitted. Physicians should minimize screen time at least an hour before bedtime to facilitate the production of melatonin. Regular physical activity has been linked to improved sleep quality. While fitting in a full workout may be challenging, incorporating short bursts of exercise or stretching throughout the day can contribute to better overall sleep. ²⁷

As previously described, however, individual level interventions are best accompanied by institutional investment. ¹⁹ Hospitals and health care institutions could play a role in promoting better sleep by providing educational programs on sleep hygiene. This includes emphasizing the importance of sleep, offering tips for better sleep, and creating awareness about the impact of sleep on cognitive function and overall health. It is not just about individual choices; it is a collective responsibility for institutions to recognize sleep as a cornerstone of success in the medical profession. Prioritizing sleep is not a luxury; it is a necessity for job satisfaction, retention, reduced burnout, and peak performance among medical professionals.

Burnout is a prevalent problem in the contemporary practice of medicine. This multifactorial condition has significant implications for the clinicians who suffer it, their patients, and families. There is evidence, however, that even basic interventions at the local and regional level can have positive impact on clinician well-being. Self-management strategies, such as a focus on improved sleep hygiene, play a role in burnout mitigation at individual levels. Given dangers of burnout to clinicians, families, patients, and institutions, it is incumbent on the health care system at all levels to not just recognize burnout, but to take practical administrative steps to address it and to educate and empower providers to protect themselves, as well.