Burnout among gastroenterologists: How to manage and prevent it

Introduction

The term ‘burnout’ was coined by the psychologist Herbert Freudenberg. During therapy for drug addicts, he would notice that patients stared at their cigarettes as they burned out.¹ This behaviour encapsulates the meaning of ‘burnout’: a state of mind that is characterised by intense depersonalisation, exhaustion and a decreased sense of personal achievement.² In many ways, burnout may be similar to depression. In fact, it has been argued that if depression is modelled in a continuum, burnout is merely a more moderate form rather than a categorically different condition.² Thus, it is a phenomenon that should be considered as a significant mental-health condition and consequently a major impediment towards a physician’s ability to perform their work.

Professional burnout has a significant impact on the individual as well as on the health-care institution. Physicians’ burnout is associated with broken relationships, alcohol and substance abuse and suicide. It has also been shown to result in poor work performance, lack of engagement in the institution’s mission, a significant decline in patient satisfaction and a higher likelihood of reporting medical errors.³

Burnout among gastroenterologists

Several studies have shown burnout to be widespread amongst physicians but especially amongst gastroenterologists. A representative study of the American Medical Association with more than 7000 participants concluded that 37% of gastroenterologists reported burnout. Although this is lower than the 50% reported by emergency room physicians, it is still substantial and merits deep consideration by our community.⁴ In addition, it has been shown that younger professionals are the most affected.⁵ Literature data suggest that the modern generation of gastroenterologists have been through a system of education characterised by ‘helicopter’ and ‘snow plough’ parenting that has made them less able to handle failure and criticism while being used to having much higher autonomy in their roles compared to previous generations at that age.⁶ As a result, they may be more prone to perceiving a sense of lack of personal achievement – one of the key causes of burnout. In addition, young physicians have a more unpredictable working schedule compared to more senior peers, while it is still very demanding. Finally, a lack of formal training in communication skills has been identified as a major source of burnout for young consultants.⁵ The increased prevalence of burnout amongst trainees and early career gastroenterologists is yet another reason why addressing the issue is critical for the gastroenterological community and the medical community as a whole. However, burnout does not just affect younger gastroenterologists. Although senior physicians who are more established are less likely to experience depersonalisation due to performing more advanced work, the results of surveys on burnout are representative across all levels of seniority.⁴

Managing burnout

The issue of work–life balance is at the centre of the burnout phenomenon. Research in this area has adopted two different theoretical perspectives.^7–9 According to the scarcity argument, each individual has a limited amount of resources to spend (i.e. time, energy), and as such, commitment to one role inevitably undermines the resources available for another task. This view is perfectly in line with the view that people cannot succeed in their professional life without making big sacrifices in their private life.¹⁰ The second theory on work–life interaction suggests that experiences from both work and family domains accumulate and have a positive influence on one another: time and energy dedicated to one role are not necessarily taken from the other, but the individual might take advantage from participating in multiple roles.¹¹ Human life is the intersection and interaction of four major domains: work, home, community and the private self. People who succeed in merging and balancing activities in these areas achieve ‘four-way wins’ that result in improvement in all four domains.¹⁰ While pursuing the ‘four-way wins’, actions taken both by the organisation and by its individual contributors within the professional domain do matter. Organisation-directed interventions are associated with greater reduction in burnout scores than physician-directed interventions.¹²

There are strategies that organisations and individuals can adopt in order to mitigate burnout. The ‘Areas of Worklife’ model identified six key drivers of burnout, including workload, control, reward, community, fairness and values.¹³ Work overload leads to insufficient opportunity to recover and restore balance and to integrate personal life and professional life successfully. As physicians are frequently high achievers, this may result in dissatisfaction about their performance in both domains. These challenges may be even more emphasised for female professionals because of different societal expectations. The option to work less than full time or, perhaps more importantly, providing flexibility in when and how they work may become an increasingly important strategy for long-term retention.¹⁴ Experiencing lack of control at the individual level has also been associated with burnout. On the contrary, adequate leadership behaviour could reduce this imbalance by creating the possibility of influencing decision making and exercising professional autonomy.

Leadership behaviour in general plays a critical role in the well-being of physicians. Leaders are recognised as key providers of workplace support. They can alleviate their followers from stressful situations and value and enhance their potentials.^15–17 Non-supportive leadership behaviour represented by a lack of recognition of individual achievements, a lack of dialogue and unjustified criticism or inadequate expression of criticism causes major psychological stress for 65% of subordinates.^18,19 By rewarding individual achievements through institutional, social or financial means, the physicians’ sense of personal accomplishment at work improves and the chance of burnout decreases. Rewards such as greater flexibility (which can facilitate work–life balance) or protected time to pursue personally meaningful aspects of work (i.e. protected research time) may create more room for professional fulfilment. Importantly, physicians who devote at least 20% of their professional time to activities that are fulfilling are less prone to burnout. This also helps to integrate the values or motivations that originally attracted the physician to their job.^14,20 Additionally, leadership has a crucial role in maintaining fairness and objectivity about decisions and in avoiding those perceived to be unfair or unequal.

Community drivers that can contribute to person–job imbalance and promote burnout include relationships among colleagues that are characterised by a lack of support and trust or unresolved conflicts. Peer support has always been regarded as critical to helping physicians navigate professional challenges. This support can be formal, such as team-building activities, or informal by creating workspaces suitable for interaction.^14,20

Preventing burnout

Physicians who lack the professional support system mentioned above can adopt several strategies to cope with the risk of burnout at the individual level. Problem-focused coping aims at resolving the core problem, as opposed to emotional-focused coping, which aims at managing the negative emotions associated with the stressful situation.²¹ Avoidance and emotion-focused coping are more strongly related to the risk of burnout than problem-focused coping. The ‘Selection, Optimization and Compensation’ method was developed for individuals with diminishing resources (e.g. ageing), although it can be broadly implemented. Using this method, the individual selects goals and priorities, optimizes their means and uses compensatory measures. Self-initiated behaviour to seek resources, advice or challenges (‘job crafting’) has been shown to reduce work-related stress and burnout.

Interestingly, a meta-analysis evaluating the effect of physician-directed and organisation-directed interventions on preventing burnout concluded that the effect of organisation-directed interventions was significantly larger than the effects of physician-directed interventions.²² Organisational strategies that allow acknowledging burnout, promoting leadership that fosters professional development and fulfilment, developing interventions that reduce work-related stress and promoting peer-support and mentorship have been shown to reduce the risk of burnout. In addition, strategies that facilitate work–life integration, offer protected time and provide resources that promote well-being are equally important for preventing physician burnout.²³

Conclusion

Burnout is not only a medical diagnosis but also an occupational problem that can be reduced if recognised early and treated by promoting self-care and balanced work–life integration. Systemic assessment at the departmental level could provide an early signal for timely intervention. Top-down organisational strategies complemented by bottom-up approaches by individuals could lead to a significant reduction in burnout. Peer support and mentoring remain invaluable when facing professional challenges in any medical specialty, including gastroenterology.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.