52 CLINICAL FOCUS
52 CLINICAL FOCUS
14 JULY 2023 ausdoc . com . au
Therapy Update
Burnout in medicine
Often misunderstood , burnout can have deep and lasting effects , but support for doctors is becoming easier to access .
First published online on 1 July 2023
Mental health
Dr Amy Imms is a medical practitioner in Tasmania , with a special interest in burnout , particularly in health professionals .
BURNOUT has increasingly appeared in the literature and media over the last five years , and particularly since the pandemic . 1 More workplaces are recognising the impact of burnout , and are interested in staff wellbeing , although this commitment may now be declining . 1
Public awareness is increasing , and with it , people are more likely to open up about the struggle to manage the mounting pressures of work and life , and to seek an elusive solution .
The concept of burnout has appeared in literature in various forms for thousands of years . However , it wasn ’ t first described formally until 1974 , when psychologist Herbert Freudenberger coined the term ‘ burnout ’ to describe the experience among healthcare workers of loss of motivation , a growing sense of emotional depletion , and cynicism . 2
The World Health Organization ( WHO ) recently included it in the 11th revision of the International Classification of Diseases ( ICD-11 ) as an “ occupational phenomenon ”, described as “ a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed ”. 3
Some suggest the concept should apply more broadly than as a strictly workplace phenomenon , and include roles such as caring , studying , volunteering and parenting . 4
A particularly colourful definition describes burnout as the accumulation of hundreds or thousands of tiny disappointments , each one hardly noticeable on its own . 2 This description resonates with many who have experienced burnout .
Burnout particularly affects those who work in people-oriented professions , including healthcare professionals , teachers and emergency service workers . 5
Such professionals tend to approach their work in a selfless and self-sacrificial manner , frequently work long hours , and go ‘ above and beyond ’ to provide good care . 5
Over time , it has been recognised that burnout has become more widespread and affects all sectors to some degree .
Incidence among doctors
Burnout rates in doctors may be as high as 80.5 %. 6 , 7 Among GPs , 73 % have experienced feelings of burnout in the past 12 months . 8 Junior doctors have particularly high rates of burnout , although the phenomenon can occur at any time throughout a medical career . 9
In recent years , doctor burnout has increased due to the demands of the COVID- 19 pandemic , floods , bushfires and Australia ’ s ageing population . 8 , 10 This convergence of events has led to increasing complexity of patient needs and consultations , difficulty accessing leave entitlements , and exam disruption and postponement , on top of the usual demands of the role .
Furthermore , many doctors are reducing their clinical work hours and intend to retire earlier due to burnout , which in turn exacerbates workforce shortages . 8 , 11
Causes
Burnout results from complex interactions between workplace , individual and circumstantial factors . 12
Six key components of the workplace environment contribute : workload , control , reward , community , fairness and values . 13 When there is a mismatch between an individual and their employer in these areas , the individual is more likely to burn out .
Doctors experience widespread mismatches in all six areas , which makes it unsurprising that burnout rates are high in the medical profession .
Workloads for doctors are generally very high , often with limited opportunity to take adequate breaks , significant unpaid overtime , rising administrative tasks , taking on additional tasks and responsibilities due to staffing shortages , physically and emotionally draining work , limited support , and insufficient time to adequately recover between episodes of work . 8 , 9 , 12
This is exacerbated by the emotional nature of the work , which tends to affect doctors beyond their formal working hours , making their rest time less effective . Inadequate organisational support makes this workload and emotional toll unsustainable long term , without risking a significant impact on wellbeing . 13
Doctors often have limited control over their work , with competing demands that make it difficult to set priorities or influence their workload to match their capacity . 13 There can be significant role ambiguity , in which there isn ’ t clarity on precise expectations , or the official expectations are different to what is required day to day . 13
A sense of reward is vital to sustain motivation and prevent burnout . 13 Adequate financial reward is of practical economic importance , as well as a reflection of contribution and appreciation . Other rewards include emotional reward , social recognition , prestige , respect , and pride from family and friends .
Emotional reward from interactions with patients and colleagues diminishes as doctors become overworked and exhausted , especially in understaffed systems . In such settings , doctors often say they feel their remuneration doesn ’ t reflect the intensity and quantity of their work . 8
Workplace and social support are important in preventing burnout . 13 These are lacking for many doctors , particularly when they have moved from overseas , rotate interstate or to rural locations , participate in shiftwork , or have heavy workloads , including attaining additional qualifications and exam study . Workplace support can be inadequate due to under-staffing , bullying , microaggressions , suboptimal clinical support from senior staff , and limited sense of community with colleagues .
In stressful work environments , staff look to organisational leaders for optimism and fairness . 13 Fairness is a sign of a strong community . In medical settings , it ’ s particularly important to consider fairness in distribution of rewards , opportunities and recognition , 13 including rostering , leave requests , clinical learning opportunities , rotation allocation and payment of overtime .
Values are the principles and standards that bring someone to their specific career or job . 5 Burnout increases when an employee is required , as part of their job , to be involved with actions that conflict with their personal values .
Diagnosis
Burnout poses significant diagnostic challenges , often leading to misdiagnosis and ineffective management . Limited awareness leads to under-recognition , as symptoms are dismissed as minor or acceptable , or are incorrectly attributed to depression or anxiety . This leads to inadequate or inappropriate treatment , or to the burnt-out doctor feeling invalidated , which reduces the likelihood of seeking further support .
Some contend that burnout is a form of depression , although most researchers acknowledge it is a distinct entity . 5 Features of burnout do overlap with those of depression and anxiety . These include low energy , reduced motivation , low mood , isolation , cynicism , procrastination , irritability and feelings of exhaustion . 12 However , burnout is considered to be more job- or role-related and situation-specific . 5
Recent data have found no prominent cluster of depressive symptoms among burnout participants . 4 Depression can co-exist with burnout or can develop as a consequence . 4
Burnout also frequently results in physical symptoms such as headaches , gastrointestinal upset , muscle tension and hypertension . 5 These overlap with many organic illnesses , highlighting the importance of correct diagnosis .
Diagnosis has predominantly been based on the Maslach Burnout Inventory ( MBI ), a diagnostic tool that has largely influenced the ICD-11 classification of burnout . 14 The MBI identifies three core features of burnout ( see box 1 ).
Several other diagnostic tools have been developed over the years , and many argue that the MBI doesn ’ t adequately detect
NEED TO KNOW
Burnout is distinct from depression , and management requires consideration of both individual and workplace factors .
Burnout is not a sign of low resilience , failure or inadequacy . It is a sign that the demands placed on the individual have been persistently greater than the resources available to them to meet them .
Doctors are at high risk of burnout during their junior training years , when studying for exams , and at major transition points which require increased responsibility .
To sustain wellbeing , doctors must have their own trusted GP to turn to . When burnout is present , this is essential for diagnosis , and assessment of severity and safety .
Sustained recovery is optimised by regular professional support , alteration of workplace factors over which the individual has a level of influence , setting healthy boundaries , engaging in social networks , and addressing individual factors , including stress responses and perfectionism .
Box 1 . Three core features of burnout
1 . Overwhelming exhaustion 2 . Feelings of cynicism and detachment from the job 3 . A sense of ineffectiveness and lack of accomplishment . 5
the core symptoms . The Sydney Burnout Measure is an alternative assessment tool , based on research indicating that burnout symptoms are more complex , variable and frequently include impaired cognitive functioning , which isn ’ t encompassed in the MBI definition . 4 Difficulties with cognition may include impaired memory , concentration and attention . 4
Impact and prognosis
Burnout affects all areas of work and life . It can impact career progression and work engagement ; it can increase the risk of mistakes ; it can lead to poor communication , aggression , social withdrawal , relationship difficulties or breakdown , substance misuse , and suicide . 5 Burnt-out doctors often reduce their work hours , leave their job , move into a non-clinical or less stressful area of medicine , or transition into an entirely different field of work . 5
The prognosis of burnout is variable due to the complexities of individual circumstances and the presence of comorbid mental illness .
Recovery time is variable depending on burnout severity , treatment engagement , and ability to alter causative factors . If no significant changes are made in work or life , burnout tends to worsen , not resolve spontaneously with time . 15 ‘ Recovery ’ is not a permanent cure , but rather reflects a return to the individual ’ s usual level of energy , hope , engagement with work , connection to others , and feeling that life is sustainable .
Optimal recovery also involves the