Clinician Burnout and Mental Health

Cost, consequences, and culture

Have a long week? I’m sorry to say that the doctor performing your check up likely had it worse.

Last week in the New York Times, and also in a Healthcare Triage video, Aaron Carroll reported on a study comparing the effects of modified residency programs on patient outcomes and physician wellbeing. In 2003, the Accreditation Council for Graduate Medical Education restricted resident hours to 80 hours a week and placed constraints on shift lengths and required time off. This study showed that these limitations did not result in a trade-off between patient care and physician wellness — the old hypothesis being that having residents constantly changing shifts due to “shorter” work days would result in harm to the patient.

Over at Vox, Sarah Kliff writes about the “second victim” problem — when a nurse of physician makes a medical error, beyond the patient’s suffering, the clinician is also faced with emotional and cognitive stress that can have long-term detrimental effects on confidence and clinical judgement. This is only compounded by the fact that the majority of physicians will have a near miss or an error during their career.

The long hours of residency are not the first exposure to the constant stressors of clinical practice, but what’s particularly worrying about the hand-wringing around resident hours is how it works to reinforce the culture that leads to high rates of physician burnout. Almost 50% of all medical students report burnout by their third year, and up to 60% of practicing physicians report experiencing burnout: the sense of emotional exhaustion, depersonalization (treating patients like objects), or very little accomplishment. For patients, this means a lower quality of care — in fact, one study found that reducing burnout in nursing staff by 30% prevented over 6,000 infections and saved nearly $68 million annually. For physicians, this means personal problems like substance abuse, stress-related health issues, and marital/family issues. This has also led to physicians having a suicide rate nearly twice that of the general population. It’s no wonder that the percentage of medical students entering primary care as dwindled over the past 20 years. This in and of itself is expensive — replacing a physician who leaves practice is estimated to cost at least $250,000.

What the second-victim problem illustrates is the ongoing reluctance to report and treat clinicians suffering from burnout, depression, and various mental illnesses. Burnout can lead to medical errors, which in turn cause more stress and can lead to depression or worse. However, many of these errors, and the resulting fallout, go unreported. Only 22% of medical students who had screened positive for depression sought help from mental health services — primarily citing stigma or fear of documentation on their record. The healthcare system reinforces this trend after students become practicing physicians. Doctors with psychiatric disorders face discrimination in medical licensure, hospital privileging, and malpractice insurance. As a result, psychological autopsy reports have shown that most of the physicians who commit suicide had an unreported or undiagnosed mood disorder. It’s telling that since the 1960’s, cancer and heart disease risks related to smoking have dropped 40–60% in physicians and are lower than the general population thanks to doctors heeding their own prevention advice, yet continue to suffer mental illness at higher rates. Preventing these issues means first recognizing the signs of struggling clinicians and removing the stigma in seeking diagnosis and treatment which strains all mental health efforts.

Part of the problem, according to Anthony Suchman of the University of Rochester School of Medicine, is how we’ve organized our, well, organizations. We view organizations as a machine. In this perspective, we design and operate healthcare systems and businesses according to an exacting blueprint. Every person and routine has an exact function, and change can only come from the engineers at the top. If you’ve complained of feeling “like a cog in the wheel,” this is the result of machine structuring.

The reason this thinking is so harmful is that it leads to a loss of control. In trying to maintain control, or the appearance of control, individuals in the machine are constrained and this exacerbates feelings of imposter syndrome and strains relationships, in turn increasing anxiety across the organization. Employees begin to internalize helplessness, passivity, and feelings of incompetence. When accompanied by a daily stream of stressors such as you might find in the medical field, these feelings are linked to low motivation, low self-esteem, substance abuse, depression, and family issues. In short: burnout.

What Suchman suggests instead is shifting our view of organizations from being a machine to a conversation. Instead of a rigid blueprint, we should see organizations as a set of ongoing interactions between people since, in fact, that’s what they are. Suchman argues that this shift in perspective grants legitimacy and autonomy to individuals, leading to what he calls “relationship-centered care.” Conversations are personal, open, and respectful. This is often a central theme in proposed interventions to prevent burnout. Individually-targeted solutions promote clinician wellbeing and resilience by focusing on mindfulness, and giving small groups of physicians protected time in the day to discuss and reflect.

Suchman also discusses the “pathologizing” gaze — since we see organizations as machines, when problems arise we look for deficiencies. This results in a search for blame when mistakes happen, seeding defensiveness and fear. By shifting to organizations as conversations, we also reduce the stigma of seeking help after mistakes. Other groups agree, emphasizing the need for a non-punitive environment in the wake of errors, which gives physicians an opportunity to learn from mistakes and improve in the future.

There is a long way to go before clinician burnout is not a factor in practice. Education to promote wellbeing has to start at the beginning of training, not as a catch-up measure once on the job. We still don’t know to what degree clinician mental illness goes unreported, and the relationship between physician-patients and their doctors has its own problems. Perhaps most challenging, but most promising, is changing the prevailing practice of thinking of the organization as a machine (see above my use of “system”) to be a more flexible, rewarding, and less punitive culture.