Burnout: its meaning and how to deal with it?

In the previous letter, we looked at compassion fatigue. It is difficult to be certain whether compassion fatigue leads to burnout and is its first symptom or they are two different entities. Burnout has been reported from all professions so it is likely that compassion fatigue may be seen in professions that deal with stressful settings, especially with animals and human beings.

Of course, stress is a normal human response to situations or events that are pressuring where the person facing them has very little or limited control. Stress can be caused by over-engagement, overactive emotions, urgency and hyperactivity that lead to low energy and lower interest and may contribute to feelings of anxiety (Stevens 2016) ¹ .

Freudenberger ² used the term ‘burnout’ to describe a set of experiences and symptoms that occurred in the context of stress and high ideals among professionals in helping fields who felt drained, exhausted, tired, listless and unable to cope. Having experienced these symptoms himself because of his failure to produce positive results where expected, he recognised perfectionism as a cause along with long hours. Maslach and Schaufeli developed the concept further by developing a widely used questionnaire in measuring burnout. ³ Burnout needs to be differentiated from stress, which can lead to over-engagement, overactive emotions, hyperactivity or withdrawal with low energy and reduced interest and anxiety. On the other hand, burnout leads to disengagement, blunted emotions, helplessness and hopelessness with feeling trapped, causing detachment and depression. These three conditions of compassion fatigue, burnout and depression may influence each other, and the challenge remains whether they are on a continuum. A key symptom of burnout that often gets ignored is the loss of empathy and having poor interactions with correct colleagues, patients and their care-partners.

Burnout is a pervasive and debilitating state that can occur in any profession. Three key components of burnout are physical, mental and emotional exhaustion caused by emotionally demanding situations that go on for a considerable period. ⁴ Exhaustion, depersonalisation along with a sense of personal accomplishment result from feeling over-extended, lack of time to recover, pressured environment, and so forth. Consequently, relationships get affected. The individual feeling burnout may note a diminishing or missing sense of accomplishment.

It is inevitable that rates of burnout will vary across medical specialties depending upon the degree of pressure they are under.^5–9 In a series of annual surveys of trainees, General Medical Council (GMC) has reported roughly one in five trainees report burnout whereas over half acknowledge that their work is emotionally exhausting.^10,11 Whether such increases are due to the impact of the pandemic, or medicine becoming more complex, or patients being more aware and demanding needs teasing out in structured research. A lack of control over workload, lack of latitude in making decisions, monotonous and chaotic work, mundane work interspersed with high pressured tasks, lack of positive feedback, isolation, lack of team working and other organisational factors can contribute to feelings of burnout. Organisational factors such as rota gaps, understaffing, relationship difficulties, academic pressures, blame culture, lack of time to provide care, hierarchical pressures, a lack of basic amenities, changing public expectations are also contributing factors. In addition, being a perfectionist, pressures of examinations and related stress can contribute to feeling vulnerable. It is also likely that trainees are more likely to experience these symptoms as often they are under maximum pressure but have very little power to change things.

Burnout is said to have three stages: stress arousal (with difficulty in concentrating, memory lapses, irritability, and physical symptoms of anxiety such as poor sleep, panic disorders, loss of libido, etc.), development of maladaptive strategies (such as avoidance, social withdrawal, not responding to phone calls, excess time off, being late, not completing expected tasks as expected) and exhaustion (associated with higher levels of suicidal ideation, apathy, poor decision making and depression). Individuals experiencing burnout may take longer to make decisions, show clinic rage or have emotional outbursts, and so forth. Inevitably, this may lead to increased medical errors, increased staff turnover and poor patient satisfaction, and so forth. Early periods of training, ¹² being female,^12,13 being older and in staff grade posts ¹² are important factors. ABMA ¹¹ survey found that nearly one-third of older doctors were either self-medicating or using alcohol to deal with their symptoms.

Surprisingly, high rates of burnout have been reported in medical students in a series of international studies by Molodynski et al. ¹⁴ Worryingly, in some settings, many students used cannabis and alcohol to cope with their symptoms. Five areas of difficulties were identified by these authors, including academic, relationship, financial and clinical factors. In many settings, students felt isolated and not part of a team with levels of support and supervision varying widely. Not surprisingly, these feelings of abandonment contributed to poor mental health and wellbeing.

Prevention and management

An important aspect of managing burnout is to look at how it can be prevented. Burnout is often seen as a professional risk and yet people under stress often do not like to or even want to talk about it because it is seen as a sign of personal weakness and an inability to cope. Underlying stigma can stop people from recognising and dealing with it. The concept of burnout can raise concerns at individual and institutional levels.

Policymakers

Preventive strategies must start at national policymaking levels with proper research and training. Clear definitions need to be agreed across professions.

Institutions

Institutions must allocate sufficient funds for providing settings that are good for the well-being of its staff. Services need to be stigma-free, widely advertised and easily accessible and fit for purpose. Institutions need to recognise and prioritise health and wellbeing issues among doctors. Access to places to rest, healthy food and opportunities to unwind must be encouraged. Regular time off to rest and recover can be very helpful. To help develop resilience at individual and team level, proper training for working in teams may be required. Wellness programmes and wellness leaders may help. Services provided must be confidential, trustworthy with prevention of bullying and harassment. Coaching and mentoring will help.

Personal

Resilience at an individual level must be encouraged and nurtured. Resilience is about the institutional and organismal ability to recover but at an individual level it is about plasticity in coping. Resilience is multi-dimensional, complex and dynamic. Anzia ¹⁵ highlights that there are key ethical obligations in doctors ensuring that they look after their own health and wellbeing so that they can continue to provide good-quality patient care. At an individual level, various factors influencing resilience are facing one’s fears, having adequate and appropriate social support, good role models, physical well-being, emotional flexibility and having a purpose and meaning in life. ¹⁶ The purpose in medicine often gets conflated and lost between personal and professional demands. Worley and Stonnington ¹⁷ offer a model for combating burnout in psychiatrists, which can be modified for use across specialties. They suggest simple techniques such as learning to say no, dealing with volumes of emails, prioritising, delegating and other strategies that can help build resilience. Different groups will require different strategies. ¹⁸

As an individual, accessing occupational health physicians (if available) or primary care physicians as first port of call will help in catching signs of burnout early. Access has to be timely and prompt rather than waiting for weeks.

Individuals must identify and prioritise activities that are helpful in producing a sense of wellbeing and relaxation. These are very individual and will include a number of options but the key is to make time for rest, sleep, exercise, social networking, nutritious food, and so forth. Work–life balance is important. ¹⁹ This allows one to switch off and re-charge. Breaks and holidays and doing different things can help change cognitions, attitudes and responses in a positive direction.

As a consultant or independent practitioner, the right career portfolio is important. This allows a mix of components such as clinical, research, policy, public health, and so forth, and it is helpful to change something in one’s career portfolio every five to seven years. This may include switching to a different clinical service within the same specialty, learning new skills, adding teaching, research or politics or policy work. Understanding one's own strengths and weaknesses, learning to develop self-compassion and create support systems are important steps in preventing burnout. It is important to recognise that doctors are human beings too and going through these experiences will make them better doctors.

We need to look out for colleagues who may be struggling and recognise the pressures they may be facing. Making ourselves available to listen to their stories and concerns, supporting, helping and pointing them in the right direction is important.

By ensuring good physical health and improving it along with proper rest and relaxation can help improve mental health and wellbeing and thereby help avoid burnout.

Declarations

Competing Interests

None declared.

Funding

None declared.

Ethics approval

Not applicable.

Guarantor

DB.

Contributorship

Sole author.

Provenance

Commissioned; editorial review.