Approaching Well-Being 2.0: Nephrologists as Humans, Not Heroes

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Physician burnout is a work-related syndrome that is characterized by some combination of exhaustion, indifference, and a sense of reduced effectiveness and is associated with depression, substance abuse, medical error, and increased costs to the health care system.^1,2 Nearly half of practicing physicians met the criteria for burnout in a national study that assessed burnout using the Maslach Burnout Inventory in 2017.³ According to a survey conducted by the Medscape news website that examined burnout by medical specialty, nephrology fell in the middle of the pack in 2020, with 43% of responding nephrologists reporting burnout.⁴ The nephrology literature has seen an uptick in publications on burnout in recent years that emphasize implications of the burnout crisis and propose systemic solutions.5, 6, 7, 8 Notably, nephrologists may be uniquely at risk of burnout. Our patients rank among the most medically complex, often requiring disproportionally more time and resources; our administrative burden is considerable; and our work is highly protocol-driven.⁹ Nephrology leaders have highlighted the corporatization of health care delivery as a potential driver of burnout.¹⁰ Furthermore, nephrology is experiencing a recruitment crisis that both contributes to and may be an unfortunate repercussion of our intense workload.¹¹

In this issue of Kidney Medicine, Nair et al¹² describe the development and administration of a 15-item survey that aimed to assess the prevalence and drivers of burnout among a sample of 457 practicing US nephrologists in 2019. The survey was developed by educational leaders at the National Kidney Foundation and contains a validated, 2-question measure of burnout adapted from the Maslach Burnout Inventory that asked participants to qualify how often they feel burned out from their work as a nephrologist and how often over the past year they had felt callous toward people.¹ Respondents were queried about the top 3 factors that have contributed to their burnout from a list of determinants relevant to nephrology. These determinants map to 3 key aspects of the work environment that affect an individual’s level of well-being: the demands placed on us in the workplace, the support we receive from supervisors and colleagues, and the degree to which we have control over the work environment.¹³

The prevalence of burnout in this sample was 23%. This is considerably lower than that described in the aforementioned surveys, as well as lower than the rate in a 2018 study in which Pawlowicz and Nowicki⁷ reported that 49% of practicing nephrologists in Poland experienced high levels of emotional exhaustion, 52% reported high levels of depersonalization, and 32% reported feeling a high level of reduced personal accomplishment.^3,4 The results of the study by Nair et al¹² are similar to those of a 2018 survey of US nephrology fellows, in which the overall burnout prevalence was 30%.⁸ All 3 of these studies used validated measures of burnout—versions of the Maslach Burnout Inventory—although Pawlowicz and Nowicki⁷ applied a longer instrument with relatively more emphasis on the personal accomplishment component of burnout.¹ Nair et al¹² point to the inability to identify a true response rate as a limitation of their study. Respondents were primarily men, trained in the United States, and practicing in academic settings. This may not accurately reflect the current workforce of practicing nephrologists, and it is difficult to know what we might have seen had they obtained more responses from women, internationally trained nephrologists, and those practicing in nonacademic settings.¹⁴

Nonetheless, nearly a quarter of US practicing nephrologists have recently experienced burnout, and it is worth noting that these data were collected before the coronavirus disease 2019 era. In the years since, this same workforce has been practicing medicine in the midst of a pandemic, which for many of us has generated greater work intensity, an increased burden associated with caring for even more medically complex and critically ill patients, concerns about our safety in the workplace, and relative isolation. Leaders from the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience have acknowledged the threat of a parallel pandemic of deteriorating clinician well-being and warned that we have a brief window of opportunity to get ahead of not only the spread of the virus but also the threat to clinicians’ mental and physical health imposed by the coronavirus disease 2019 pandemic.¹⁵

The primary drivers of burnout most commonly identified in the study by Nair et al¹² included the number of hours worked per week, electronic medical record requirements, the lack of time with family and friends, and clinic workload. Free text responses showed that burnout was driven by the following factors: challenges related to medical complexity, moral distress that comes from an inability to provide patients the care that they deserve due to a lack of resources, lack of autonomy, administrative demands, financial burdens, lifestyle intrusiveness, and concerns about innovation in the field. The comment “it has become hard to do the right thing” succinctly embodies the frustration felt by so many nephrologists over these issues. Of particular concern is an additional emerging theme captured in the qualitative responses that some nephrologists feel undervalued in their work. This seems to occur at all levels—by patients and family members, colleagues, local administrators, and the wider US health care system. Respondents who commented on the positive aspects of their work highlighted the importance of control over their time and feeling appreciated by patients, colleagues, and their employing organizations.

One cannot overestimate the importance of feeling that the work that we do makes a difference. A sense of personal accomplishment, which goes beyond simply feeling that we are competent at our job, is important for us to thrive in the workplace. Because it is less directly tied to negative outcomes, a sense of low personal accomplishment is often underemphasized as a dimension of burnout compared with emotional exhaustion and depersonalization. However, feeling chronically undervalued at work can lead to emotional exhaustion. Conversely, becoming more intentional about the aspects of work that we find meaningful can mitigate the effects of exhaustion, which may ultimately prevent us from experiencing depersonalization. In the study by Nair et al,¹² the quantitative assessment of burnout incorporates questions related to 2 of the 3 components of burnout. Specifically, they ask about both the subjective experience of burnout, which maps to the construct of emotional exhaustion, and the feeling of callousness toward other people, which corresponds to depersonalization; however, they do not specifically ask about having a sense of low personal accomplishment. The inclusion of a qualitative content analysis, a significant strength of this article, highlights the importance of underappreciation at work for some respondents and thus more completely captures the full picture of burnout faced by practicing nephrologists in the United States.

The antidote to a sense of low personal accomplishment is finding meaning at work, and a growing body of literature supports the notion that drawing our awareness to the aspects of work that are most meaningful is linked to a reduction in burnout.16, 17, 18 As humans, we are naturally conditioned to focus on the negative and draining aspects of our life, including our work. To overcome this negativity bias, we should endeavor to notice the things at work that sustain us and bring us gratification and be deliberate in carving out time to do these things. Finding meaning at work, like all drivers of burnout and engagement, should be the shared responsibility of the individual and the system.¹⁹ Health care systems ought to strive to provide a robust mentorship network to support physicians, with an emphasis on matching work to strengths and interests, and should promote an organizational culture that fosters appreciation and acknowledgment of physicians’ performance.

Unfortunately, many health care organizations send the message to their physicians that it is the physicians’ responsibility to become more resilient and to fix their own burnout. When organizations focus on physicians’ personal resilience to the exclusion of addressing organizational factors, our natural response is to be skeptical, or even indignant. In a recently published article, Shanafelt,²⁰ the chief wellness officer at Stanford Medicine, outlined the evolution of the physician well-being movement. He divided this into 3 distinct eras: the Era of Distress (before 2005), in which there was a lack of awareness, or even neglect, of physician distress; Well-Being 1.0 (2005-2017), a period characterized by increasing evidence and awareness that physician well-being is important; and Well-Being 2.0, the future.²⁰ Efforts developed in Well-Being 1.0 were primarily focused on the individual and included things such as the expansion of mental health and peer support and efforts to cultivate resilience. In the process, physicians were given the message that they should take care of themselves, engendering a victim mentality and, for many, resentment. The progression to Well-Being 2.0 has brought a more proactive approach characterized by systems-based interventions to address the root causes of physicians’ distress and to work to prevent it, rather than finger pointing, which has historically occurred bidirectionally between individual physicians and the systems in which they work.

Well-Being 2.0 is a call to action for 2 groups: administrators, to address system issues, and physicians, to recognize the things that are under our control and to work to incorporate mindfulness, self-compassion, boundaries, and self-care into our professional lives. In the ideal future, as Shanafelt²⁰ writes, we are not victims, nor are we heroes. We are humans; we are vulnerable; we thrive most when we find meaning and purpose in our work.