Maintaining professionalism in the face of burnout

‘We found that, regardless of their experiences of depersonalisation, doctors were able to maintain a sufficient level of professionalism so that their patients (and the external observers) were unable to detect any effects on their consulting skills.’¹

This recent study by Orton et al found that 46% of UK GPs reported emotional exhaustion, 42% reported depersonalisation, and 34% reported low levels of personal accomplishment.¹

This debate and analysis will focus on what professionalism means with regard to wellbeing and burnout. Some suggestions will be made about how this issue could be tackled within the GP profession.

What is professionalism?

Becoming a full member of a profession is a hard-won achievement, bringing high expectations from everyone including the person themselves. Being professional implies high-quality work and an impeccable ethical standard. It implies calm expertise where the professional person is in control of both the situation and their own emotions. It implies that the client, patient, or customer can trust that these high standards will be met at all times, and won’t usually see the personal experience of the professional person.

Does it also imply that the professional person:

• Never makes mistakes?

• Exercises perfect judgement?

• Has limitless stamina?

• Rarely or never needs help?

• Doesn’t allow exhaustion, ill-health, or personal circumstances to impinge on performance?

• Rarely or never lets colleagues know how they feel?

• Never gets emotionally out of control?

• Is never found out if any of the above are not met?

Professionalism can mean a form of institutionalised perfectionism. Professional codes of conduct state the highest aims and standards, and strive for excellence in all respects. No one would expect anything less.

For individuals, however, a perfectionist outlook can be linked to depression and burnout, and ironically, can be instrumental in leading to lower productivity and poorer performance.²

The impact of burnout

The three elements of burnout, based on the work of Maslach and Leiter³ (the foundation of the Maslach Burnout Inventory), are emotional exhaustion, depersonalisation, and low levels of personal accomplishment. This means that professionals experiencing burnout feel that they can no longer give themselves psychologically to their work; feel negative and cynical about their clients (patients); and no longer evaluate their own work positively. Frustration, anger, exhaustion, and no longer feeling any enjoyment or reward from work are all possible burnout experiences.³

Depersonalisation is a particular worry in relation to those in the caring professions. In the context of the measurements in the survey, this refers to a negative and cynical attitude towards clients (or patients). This is different from a psychiatric definition of depersonalisation that instead points to a person’s alienation from themselves and the world, with an associated loss of identity.

It is easy to see how burnout can not only be a deeply unpleasant personal experience but can also spill over into relationships within and outside of work. It can leave professional people feeling a great mismatch between the high ideals they are qualified for and committed to, and the reality of their day-to-day experience.

It puts the organisations employing people with burnout at real risk of having to manage serious errors, underperformance, or sudden absence. The pressure to be professional can also lead people to hide concerns or mistakes in their work too, which increases risk. The shame associated with mistakes can be an overpoweringly strong motivation to hide what happened.⁴ All of this can affect reputations, patient outcomes, and wellbeing.

Are professionalism and wellbeing mutually exclusive?

Doctors are well documented to be reluctant to seek medical advice for themselves.^5,6 The high professional standards set, however, would seem to encourage the active dismissal of any personal concerns about wellbeing and health, whether physical or mental. If professionalism means being perfect in some way, there is little room for human frailty. Therefore, it can follow that issues of wellbeing are ignored or suppressed. Acknowledging them may threaten the professional identity that has been so painstakingly achieved.

Another question that arises is whether the lengthy and arduous training that GPs undertake acts as a rite of passage, involving exceptional stamina and maybe leading to an unsympathetic attitude between senior and more junior colleagues. This attitude may be a manifestation of depersonalisation between colleagues, and thus be compounding the problem of burnout throughout organisations.

It should also be noted that perhaps the Maslach Burnout Inventory³ should be treated with caution in a medical context. A degree of depersonalisation may be necessary, for instance, to avoid being overwhelmed by patients’ needs. However, over half of the GPs surveyed¹ did not demonstrate depersonalised feelings, which suggests it is not inevitable as a coping strategy for the job itself. The variation in depersonalisation rates between GP sex and type of practice, for example, demonstrates that there are ways of being a GP and not scoring highly on the Maslach Burnout Inventory.

Building wellbeing into the concept of professionalism

It is interesting to note that the survey by Orton et al¹ showed that the incidence of burnout was higher in group practices than in single-handed practices. This would suggest that there is a very real organisational perspective to be taken on this issue, in addition to any personal actions that doctors may take in relation to their own wellbeing.

The concept of professionalism in any field implies high personal responsibility. Formally, this means taking responsibility to meet the General Medical Council’s requirements⁷ to be registered with an independent GP. However, it seems likely that doctors usually only consult other doctors (as a patient) when they consider their own healthcare issues to be serious and probably treatable. Consulting their own GP about stress or burnout may not meet these criteria, and in addition may feel like a shameful admission of not being able to cope.^4,6 It is likely that any such consultation would only happen as a last resort.

This can mean that the problems leading up to full-scale burnout build up behind the scenes as a taboo subject. Almost by definition, such feelings are likely to be hidden behind the professional face, unnoticed by patients, and unrevealed to colleagues.

In a group practice, there may be no established or emotionally safe way of communicating what is going on behind that face, or finding out how others feel, without risking professional humiliation. This could lead to a sense of even greater isolation than ironically may be experienced by doctors working single-handedly.

Perhaps being a professional involves more than a reluctant consultation with a fellow doctor when burnout has already taken hold. In the same way that airlines emphasise that passengers should put their own oxygen mask on before attempting to help others in an emergency, professional status should encompass a similar duty to nurture good physical and mental health, and resilience, as a priority before and in order to, help others. This professional responsibility should include organisational responsibility to maintain mechanisms for supporting the professionals working there. An airline has to train its staff, build teams, and equip its planes to deal with emergencies as well as advising passengers.

What can be done?

There are no quick and easy fixes. Even following the Boorman report⁸ and recommendations, the Orton et al survey¹ would suggest that the problem of wellbeing hasn’t gone away. This issue requires courage to examine what may be happening to our GPs, and a willingness to explore what it means to be professional.

Some starting suggestions are as follows:

• Talk about it: somehow. Nothing can be done about burnout unless it is acknowledged and can therefore be explored. This is likely to be very sensitive and probably emotional territory.⁴ Establish ground rules for the conversation that prioritise privacy and safety.

• Manage expectations: if there were instant solutions this would be relatively easy. Sometimes there is a fear of opening, what feels like, a can of worms. However, the energy and risks inherent in keeping a firm lid on the can are considerable.

• Articulate what it means to you to be professional. Does it add up to a harsh perfectionist rod to beat yourself with? If so, perhaps some cognitive behavioural therapy-style techniques, or compassion-based therapy,⁹ can help to redefine this in a more workable and sustainable manner. It is not about losing sight of high ideals, but understanding and using them in a context that allows for professionals to be human (albeit ambitious, capable, and high-achieving).

• Engagement: one of the biggest ways of dealing with burnout from an organisational perspective argued by Maslach and Leiter³ is to increase engagement with the job and the practice, which is typically lost with burnout. Amabile and Kramer¹⁰ argue that engagement is best increased by small wins in the work place. By this they mean the day-to-day tiny achievements that add up to make work feel rewarding and worthwhile. It requires people to notice those achievements; to acknowledge them in themselves and other people; to celebrate; to say thank you; and to take an interest. These things are often the opposite of what starts to happen in stressed organisations, when individuals are increasingly isolated, blamed, and ignored by each other.

• Use current systems: rather than inventing new ones. For instance, it may be possible to build support and open discussion about burnout risks, prevention, and treatment into continuing professional development (CPD) requirements. The trend towards more CPD being online or distance learning may lead professionals into an ever more isolated place despite the perceived time saving benefits. In the US, some of the continuing education requirements are met by attending meetings possibly with partners or families coming along, to give a sense of a ‘working holiday’. This can help to legitimise taking some time away from the day-to-day routine for doctors who feel that they cannot afford the time or money to take time off. The model may not work in the same way in the UK but there may be other ways to build the issue into CPD.

• The power of role models: in all professional organisations, the senior and most influential staff tend to set the tone for the working life style. This gets passed on from generation to generation. It has a powerful effect on how wellbeing is dealt with.

• Learn from those with effective strategies: identify others who are not burning out and find out what their strategies are. For example, the Orton et al report¹ suggests that females are less susceptible to burnout than their male counterparts. There could be many reasons for this, but perhaps it suggests that female GPs are well placed to lead the way on addressing burnout in the profession.

• Experiment: to find ways of introducing small changes that can have big effects; for example, agree with colleagues to share a lunch break once a week; set up mentoring arrangements; set up action learning groups to address common problems in a working week; maybe test some elements of working practice from other organisations that appeal. All of these can introduce a very necessary sense of control, however small, as well as provide opportunities for the small daily achievements that can increase engagement and enjoyment of work. Framed as experiments, they are not a lifetime commitment, but offer the chance to see what works and to adapt ongoing practice.

Conclusion

Preventing burnout and nurturing wellbeing and resilience could be seen as an integral part of being professional. For some people and organisations this could be a profound shift of mindset.

Rather than wellbeing being either taken for granted, or difficulties with wellbeing being dealt with as a hidden weakness or necessary evil of the job, improving wellbeing could bring the increasingly complex and uncertain issue of how to maintain good mental health over a long, productive, and challenging working life to the fore.

It may be argued that the whole population looks to doctors to bring this issue of burnout and stress into the open; to act as role models for patients who may also be struggling with work-related stress and burnout. If this is the case, perhaps it is central to an understanding of what it means to ‘be professional’ to acknowledge the worries and challenges that are inherent in a modern professional job. Only then can we find ways of supporting each other, redesigning systems, and taking personal responsibility to take mental health (not just mental illness) seriously on a day-to-day basis.

Provenance

Commissioned; peer reviewed.