Physician Heal Thyself: How Lessons From a Leper Colony Offer the Solution to Physician Burnout

| 10 June 2013

This week’s blog was inspired by two of our talented senior residents in the Medicine Program at Queen’s University, Dr. Barry Tin Shin Chan (left) and Dr. Nazanin Fallah-Rad (right).

Fallah-Rad, Nazanin

They presented a riveting Grand Rounds on a taboo subject; a disease that afflicts 45% of physicians, leaving them depersonalized, isolated, frustrated and uncertain of their mission. Barry and Naz have distilled their talk into a guest blog. But first, an intro. What is this insidious, prevalent and little-discussed syndrome? The disease is called Physician Burnout. While burnout has no simple cure, awareness of its signs and symptoms (and its existence) can provide partial immunity. The term burnout borrows its origin from a term used to describe end-stage leprosy. Its application to the state of psychological burnout likely stems from Graham Green’s novel, A Burnt-Out Case. In the story, a famous architect, Querry, becomes disillusioned and tired of his fame. Feeling his life has lost its meaning, he goes to a Congolese leper colony. There, the resident doctor diagnoses him to have the psychological equivalent of an end-stage case of leprosy, in which inflammation gives over to mutilation (i.e. a 'burnt-out’ case). The story gives a clue to the cure for physician burnout; as Querry immerses himself in something meaningful (read the book and find out what he chooses) his mind slowly heals and burnout is relieved.

Burnout is recognized in the ICD-10 as "State of vital exhaustion" (Z73.0) under "Problems related to life-management difficulty" (Z73), but not considered a "disorder". A 2012 survey of ~90,000 American Physicians by Shanefelt et al reveals that 45% of our colleagues consider themselves to be affected by burnout. The diagnostic tool is the Maslach Burnout Index and defined in this study as a high scoring on emotional exhaustion, or depersonalization. Traditionally doctors have been taught to deal with the stress of their profession with stolid silence. Stiff upper lip, suck it up and deal with it, carry on! It might be OK to acknowledge fatigue, and frustration to a colleague or spouse, but it is less easy to acknowledge sadness and depression or to admit to an inability to cope or even (gasp) suggest changing professions. Moreover, if you are selected for medicine based on high achievement and marks (grades and glory) you may be disappointed to find you are the servant of your fellow man; not always glamorous, and very demanding. Physicians often try to function as Empaths, like Dr. Deanna Troi, a half Betazoid who is doing her IMU rotation on the Starship Enterprise. Dr. Troi gave me permission to acknowledge that she has suffered from this illness (see Face of the Enemy episode). Like Bill Clinton, the physician Empath can “feel your pain”. However, this contact with human pain and suffering can wear an Empath down, leaving them in need of some quality time on the holodeck. Dr. Troi: intermittent victim of burnout

Patients come to a physician and they tell us their troubles; their families expect our ministration to heal their loved one. They look to us for reassurance about their mortality. It is our mission to relieve their burden. But what of our own burdens, our own families, our own mortality? It is hard to walk amongst the ill without being at times exhausted and overwhelmed. Some days the combination of hospital bureaucracy (complete this course, sign this form, interact with 20 people to achieve a discharge,) workload, sleep deprivation and emotional stress can leave even the strongest Empath depleted. Burnout is not rare, nor does it only affect MDs-nurses and others are equally susceptible. However, burnout it is not something that is not necessarily progressive or persistent. I tend to view burnout like a sports injury, such as a stress fracture. The difference is the foot pain related to a stress fracture, acquired by too much running, is socially acceptable. No shame in being an athlete who has overdone it and needs rest. How about the Empath? Too much work, too much stress and you are exhausted and questioning why you chose this difficult path. The Rx is not so easy. Engagement, in whatever it is that satisfies you, is the cure; it worked for Querry, at least for a while. Spend time with friends, discuss how you feel, exercise, rest, engage in a life-reaffirming hobby. Of course, its important to not confuse burnout with Depression - a common but much more serious mental illness.

Interestingly the treatment for leprosy focuses not only on eradicating the causal bacterium (Mycobacterium leprae) but also on restoring dignity and reengaging people in society…the metaphor is complete! Guest blog by Barry Chan and Naz Physician Burnout: The resident’s perspective

Burnout… “The Elephant in the Room” A term that is not so unfamiliar to most of us. Perhaps it means something different from one to another. After all, it is such a personal experience. Nevertheless, a triad of Exhaustion (physically and emotionally spent), Depersonalization (cynicism, sarcasm), and Inefficacy (low sense of accomplishment) has been described as the essential constructs of burnout. Do we burnout? Even the previous steel-like generation of physicians that were forged by the blazing furnace of unrelenting draconian residency, may succumb to the pervasive rusting caused by the demands of life and work. In a recent study by Tait et al (Arch IM 2012; 172:1377-85), 45% of US attending physicians were burnout – a number that is similar to previous studies with medical student and resident cohorts. Most interestingly though was that there appears to be a very complex relationship between Burnout and Satisfaction with Work-Life Balance. Emergency Medicine, General Internal Medicine, and Neurology had the highest rate of reporting burnout whereas General Surgery and Internal Medicine Subspecialty were less than average. However, when each subspecialty were asked of their satisfaction with work-life balance, General Surgery were the most dissatisfied whereas Emergency Medicine physicians were more satisfied than the average. Unfortunately, the General Internists reported higher than average work-life dissatisfaction (see below).

fig5

A significant source of stress that contributes to the development of burnout is the The Great Divide between core personal values that make us happy and professional values that we aspire for and loathe. In JCO 2006; 25:3020-3026, Shanafelt et al discussed such an experience within oncology and how it should be approached. However, it is applicable to every specialty and other lines of work. Within the article are two short yet introspective questionnaires that ask the physician to honestly identify and reflect on their own personal and professional values. The purpose, as the author candidly wrote, is to have a “frank appraisal of personal and professional factors contributing to burnout for the given individual, [and thereafter] along with deliberate and intentional changes to address these factors.”

But what of the workplace where the half of the war is taking place? We mentioned of “Starting a Movement” to curtail burnout. How do we start? As doctors, we are not the best at taking care of our own well-being… let alone “treating” burnout of others. Perhaps we should start by knowing, recognizing, and preventing burnout. This is what we have been trained to do over the years: to know a condition exist, to diagnose from the intricate plays of risk factors and symptomatology, and to advocate for prevention first by ending the unwarranted, yet persistent, negative stigma of burnout within the medical culture – fostering residency as a more safe and pleasurable environment.