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Burnout
Burnout arises in response to stress. We are often called to provide palliative care in very stressful situations. As discussed previously, I train palliative care students to ask themselves the question, “Who is the patient and where is the suffering?” Stress is a form of suffering and, like nasty microbes, is highly contagious. Patients, family members, other clinicians, and we ourselves may become infected and experience burnout. We may all become patients. So, what to do about it?
Burnout can never be completely eliminated. However, I believe that having a better understanding of burnout and developing a plan to manage it can go a long way in ameliorating its toxic effects.
Palliative Care Note
What is your plan for burnout? No plan is probably not a great plan.
Understanding Burnout
Common Stressors in Health Care
Time-Pressure Stress
If you ask clinicians what bugs them the most in practice, they often respond that they just do not have enough time.1 No doubt about it, time-pressure stress is a problem, whether one is flipping burgers at McDonald’s or trying to see too many consults. However, time-pressure stress often masks deeper conflicts.
Role-Conflict Stress
Role-conflict stress arises when there is a tension among a person’s roles, responsibilities, or values.2 The most obvious such stress for clinicians is a tension between professional and personal roles and responsibilities, as we have seen most poignantly in the pandemic. Clinicians felt a professional obligation to provide care, all the while worrying that they may expose family and loved ones to the virus. Clinicians may also experience stress in trying to balance clinical responsibilities with bureaucratic ones, such as charting or billing.
Value-Related Stress
Similarly, clinicians, families, and patients may also experience a form of role stress related to values.3 Value-related stress may arise when one is caught between conflicting roles in terms of values or obligations. For a family member this may occur when being asked to serve as a proxy for a loved one, based on the prior wishes of the patient (surrogate decision making). And yet such wishes may conflict with one’s own feelings, values, or sense of obligation toward that loved one. Clinicians may experience something similar if and when they feel obligated to say or behave in a particular way professionally that conflicts with their personal beliefs about the situation. An example might be if an oncologist felt obligated to recommend a certain course of therapy that he or she would not choose for himself or herself.
Moral Distress
Role-conflict stress, especially as related to values, often has a strong component of moral distress. Moral distress is usually not as simple as a weighing of relative benefits and burdens in an aseptic ethical sense. People experiencing moral distress feel trapped in a position wherein they cannot help but do something that will cause harm. Put another way, they may feel it is impossible to get to the “good” without doing some “bad.” This is a horrible feeling. I remember many cases in my early training where this occurred. I once asked a woman, whom I believed was dying, if she truly wanted invasive ICU care. She nodded “yes,” and so we provided it. We were doing “good” in abiding by her wishes, but every time I inserted a line and she moaned, I knew I was hurting her. I was causing harm, unquestionably doing “bad.”
I know I am not alone in this experience. Every physician and nurse I know has experienced something like this. Nurses may experience distress when given an order by a physician that, while technically within “standards of care,” they believe will not help a patient and may actually cause harm. They are being true to their obligation to follow physician orders but are acting contrary to their conscience and experience.
To a large degree my becoming a palliative medicine physician was motivated by a desire to find a field with less of this type of moral distress. While we are not immune to moral distress, I do think we experience less of it than clinicians in many other disciplines.4 However, moral distress is frequently a subtext in palliative care consultations, experienced by patients, families, or clinicians. As such we may experience a degree of moral distress “by proxy.” That is, we may be drawn into the moral distress of others.
Burnout bears striking similarities to post-traumatic stress disorder (PTSD), as I learned working with veterans struggling with PTSD. Veterans with whom I worked coming back from Iraq and Afghanistan often described feeling trapped in dangerous situations where they didn’t know who was friend or foe. Sometimes they ended up making a mistake. As one vet said to me, “Doc, I went to protect our country. I ended up blowing up a family that I thought was the Taliban. I wanted to get out, but how?” Mercifully, I have been spared such a terrible experience in my life. But I could relate in feeling trapped as a physician in providing care of little if any benefit. I worry about the current generation of clinicians experiencing the pandemic, feeling trapped at times in providing life-prolonging care to those they believe to be dying. PTSD differs from burnout in that a serious threat to one’s own safety and well-being is experienced. Clinicians on the front lines of the pandemic seem at high risk for both.
Underlying Components of Stress
Lack of Control
Bureaucracy
If you ask physicians what they least like about the practice of medicine, they most often cite some bureaucratic aspect of medical practice, such as using electronic health records. A 2017 Medscape report found that the number-one cause of burnout attributed by physicians was bureaucracy (followed by time pressure, “feeling like a cog,” and electronic health records).1 By “bureaucracy” they mean all the rules, regulations, and tasks that are requisite parts of modern medical practice. “Bureaucracy” almost certainly is not why they became physicians, and yet they often find themselves “trapped” in working at bureaucratic tasks. This also gives rise to role conflict (healer versus bureaucrat roles) and at times in moral distress, if and when bureaucratic requirements impinge on clinical care. An example of this might be if palliative care physicians feel pressure to discharge patients from hospice if they “no longer meet criteria,” even though they believe hospice care will best serve them.
Imposed Relationships
In everyday life many of our interactions are brief and transactional—buying groceries, for example. If we find a person disagreeable, we can often find a way of avoiding him or her. However, clinical practice, especially as relates to chronic and terminal illness, is often interpersonally intense. We are often forced into emotionally challenging encounters with patients, families, and other clinicians that are unpleasant and unavoidable. Our professional obligation is to serve regardless of how disagreeable the encounter is. I recall working with a psychology trainee in palliative care. She was discussing a difficult interaction with a patient. I asked her if she liked the patient. She seemed somewhat shocked by the question. She struggled to form the words, “Not really.” I was impressed that she almost did not allow herself to acknowledge her dislike of the patient, although her demeanor had strongly suggested this. She was trapped in having to work with this man but, worse, not being able to acknowledge to herself her own feelings. I sympathized with her—he was a disagreeable fellow and affirmed that it was perfectly OK to dislike him. Indeed, she likely would serve him better (and feel better about it) if she could acknowledge her dislike to herself and just get on with it.
Loss of Meaning
Human beings are able to tolerate incredibly difficult circumstances—if they can find meaning in them. In the current pandemic, emergency room and ICU clinicians find meaning if or when a patient is successfully weaned from a ventilator and discharged. They rightfully cheer. At the same time, it is so difficult when patients have resuscitation attempted or go onto ventilators, only to succumb. Many have understandably spoken about how disheartening this is.
Palliative care specialists may differ somewhat from other clinicians in that we have generally come to accept the fact that not everything or everyone is curable—that we are indeed mortal. Palliative care specialists, while also cheering cure and long, healthy lives, where possible, work to find their meaning in the quality of life people experience, however long or short. I often think of the U.S. Army motto, “Be all that you can be,” which sums up my view of palliative care. Put another way, in practicing palliative care I’m trying to help people be as “healthy” as they can be, regardless of the severity of their illness—helping them “heal” even into dying.
“How can you do that difficult work?” How many times have I been asked that! All newcomers to the field need to find their own response, but mine is typically something like, “Other clinicians often have to make people feel worse before they can get better. That’s really tough! I have the luxury of being able to just focus on how to make things better. I’m really lucky.”
Palliative care clinicians are not immune to a sense of loss of meaning. Our efforts to improve quality of life may not always succeed or be appreciated and we can never fully avoid the winds of bureaucracy. While we are indeed “lucky” to have found our way to this specialty, by the very nature of our work, we are exposed to massive suffering. Our one chance of getting through it all is to find refuge in the deeper meaning and value of our work.
Uncertainty
In hard times people both fear and want certainty. Patients and families push clinicians, especially physicians, to find certainty, even where no certainty is to be found. It may be difficult for the lay public and even some clinicians to understand the degree of stress this may cause. Much care involves inherently dichotomous choices. One does a test or not. The result is interpreted as “positive” or “negative.” A treatment is offered, or it is not. The surgeon must decide whether to cut or not. It is hard on patients and families when we get it wrong, but it is also incredibly hard on clinicians. While I do not know of research proving it, I suspect physicians are at particular risk of “uncertainty”-related stress.
Stress Responses: Maslach’s Three Domains of Burnout
Christine Maslach, the grandmother of burnout research, has tried to sum up the effect of stress in promoting burnout in terms of three domains—emotional exhaustion, depersonalization, and ineffectiveness.5 I take some issue with the specific wording she used, but I find these domains useful in organizing typical responses to burnout-related stress.
Emotional exhaustion refers to psychic tiredness and is distinguished from physical exhaustion, to which overworked clinicians are also prone. While termed emotional exhaustion, often cognitive and spiritual components are involved. Loss of meaning usually has cognitive and spiritual (why?) aspects to it.
Depersonalization refers to a sense of isolation. (Note: This is different from the psychiatric use of the word, which refers to an uncommon psychological state in which the person feels he or she is not real or is separate from reality.) Burned-out individuals typically experience burnout as if they alone are struggling against it. This sense of isolation, a term I prefer, is both an intrinsic component of burnout and an adaptive response to an unpleasant situation. If one’s energy is low, it makes sense to try to shut down a bit, isolate, and preserve what precious energy remains. This “shutting down” may include physical isolation but typically goes beyond this to a limiting or filtering of “input” (exposure to cognitive and emotional input from others) and “output” (one’s interactions and work). As a short-term strategy, isolation actually makes good sense and may be an adaptive response—if one is able to restore one’s energy. However, over time isolation begets greater isolation, creating a vicious cycle that is harmful. Given how critical it is for palliative care specialists to attend to others and empathically share, such isolation is very detrimental to good palliative care practice.
The third domain, ineffectiveness, points to the net outcome of burnout—a person who subjectively and eventually objectively is less productive becomes less effective in his or her work. If and when a person becomes less effective, this too creates a vicious cycle—validating any self-doubts one might have, increasing the potential for conflict in the workplace, and making it harder for the individual to find meaning in work.
In summary, in response to chronic stress, individuals experiencing burnout typically undergo a form of psychic exhaustion. In trying to protect themselves against this, they psychically limit input and output, resulting in isolation, which may cause them to become ineffective and further disheartened, a vicious cycle that may devolve into clinical depression.
The discussion above has focused on stressors and responses in the individual. It is all too easy to view burnout solely as the individual’s problem, as something pathologic. This would be a serious misunderstanding. Maslach spoke directly to this: “We should be trying to identify and analyze the critical components of ‘bad’ situations in which many good people function. Imagine investigating the personality of cucumbers to discover why they had turned into sour pickles without analyzing the vinegar barrels in which they had been submerged.”5pp14–15 It is better, I think, to view burnout as a normal response to a toxic situation, which can become pathologic if not addressed. The above discussion suggests that work environments that do not support employees when they experience stresses related to “toxins” like bureaucracy or role or moral distress (or, worse, add to such stress) contribute to the vinegar in the barrel.*
In their book Banishing Burnout, Leiter and Maslach suggest a different way of looking at the problem.6 They identify six “interaction strategies” (points of interaction) between organizations and individuals: workload, control, reward, community, fairness, and values. We tend to speak of burnout as an all-or-nothing phenomenon; like a light bulb, it either burns or is burned out. However, the authors stress that burnout exists along a spectrum, like a rheostat, and that people may be relatively more or less burned out across these six domains in which organizations and individuals interact. I have found this helpful in teaching classes on burnout; I ask students to rate themselves on these six domains. What I have learned is that often there is significant variance in self-rating among the domains. A student may be doing quite well on two to three of them, so-so on a couple, and really struggling on one or two. I believe this self-analysis serves as a useful first step in creating a plan.
Palliative Care Note
Score yourself (1 to 5) on the six domains of interaction with your health care system: workload, control, reward, community, fairness, and values. Which are especially problematic ones that you might address, and which are sources of strength to be bolstered?
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