This article was first published by MJA Insight+
IT IS well known that burnout is endemic in the medical profession. Undoubtedly the problem has worsened since the beginning of the COVID-19 pandemic, exacerbated by the traumatic stress typically associated with pandemics along with the multitude of workplace stressors such as fear of illness, lack of adequate personal protective equipment, changing rules and expectations, transitioning to telehealth and loss of work or income.
Some clinicians may be experiencing it for the first time in their careers. I’ve certainly been struggling with it and been seeing more clients than ever before with burnout. Since the outbreak of the pandemic, I have facilitated multiple peer support groups of burnt-out GPs, was invited to talk about issues relating to clinician self-care in a recent Black Dog Institute webinar and was invited to present (via Zoom) to the Australian and New Zealand Mental Health Association regarding preventing burnout, and have started to present at GP lunchtime meetings on the same issue.
Burnout is a complex issue and there are different ways of understanding it. As UNSW Scientia Professor Gordon Parker notes:
“Burnout has become a shorthand for a range of negative experiences, yet relatively little is known about what causes it, how it differs from other psychological conditions, and how to effectively treat it.”
The 11th Revision of the International Classification of Diseases (ICD-11) defines burnout as a syndrome “resulting from chronic workplace stress that has not been successfully managed” and is typically characterised by exhaustion, cynicism and feeling nothing you do makes a difference. As such, it is not recognised as a medical or mental health condition in the traditional sense, although research by the Black Dog Institute shows issues such as anxiety and depression may be associated with it.
The ICD-11 definition provides a very useful description of burnout, but it is not specific enough to inform interventions from beyond generic stress management strategies. I have also found that one-size-fits-all approaches such as mindfulness, meditation, relaxation exercises or other self-care activities have a role, but they don’t address the complexity of moving parts contributing to burnout or necessarily deal with its impacts on an individual.
So while we are waiting for more evidence about the comparative effectiveness of individual strategies, my immersion in discussing burnout with many doctors has resulted in me reframing burnout and leading me to develop a practical framework that blends principles of chronic disease management (such as asthma) with a cognitive behaviour therapy case-formulation approach that looks at:
- the problem;
- predisposing factors;
- precipitating factors;
- perpetuating factors;
- protective factors.
The advantage of taking a formulation or conceptualisation approach (in contrast to thinking about burnout as a diagnosis) is that it is simultaneously descriptive, explanatory and predictive for an individual.
The problem: what does burnout look like and how does it arise?
Burnout is a complex issue and can be a bit of a masquerader. Although some people come to me and explicitly say they are burnt out, many don’t recognise this at all. Rather they present with wanting help with issues such as:
- career decisions – whether they should change roles, specialties, leave health care altogether;
- feeling like an impostor or lacking confidence in times of transition;
- procrastination and motivation – particularly in terms of exam or interview preparation.
It’s only once we start talking that burnout reveals itself as an underlying factor and I start to hear conversation reflective of the three classic dimensions highlighted by ICD-11. Other clues I’m noticing that signal burnout may include a tendency towards frustration, irritation and anger in the face of relatively small issues that would (in normal times) pass by unnoticed.
It’s useful to think about these emotional and behavioural responses in terms of the classic Yerkes-Dodson inverted U stress curves which are a theoretical approach to describing the relationship between stress (physiological arousal) and performance.
Stress is good for us when it enhances our performance. If we had no stress, we wouldn’t get anything done. We often feel at our best when our skill set is well matched to a particular challenge and enter into flow. However, in the pandemic, we are all pushed out of this optimal performance zone on a chronic basis into a stretch zone, meaning we are spending too much time in heightened physiological arousal driven by cortisol and other stress hormones. This is entirely functional for short term events, such as exams, interviews or performing a cardiopulmonary resuscitation. However, if we hang out there too long, then we lose cognitive capacity and ability for emotional regulation and can easily tip over the edge into overwhelm and burnout.
Given the sheer amount of disruption in work and life, the uncertainties and associated fears that have come along with the pandemic, it is not surprising that any of us are spending too much time in the stretch zone. The consequences can be catastrophic. At a personal level, burnout can have a negative impact on relationships and trigger depression or anxiety, substance misuse, addictions or even suicide. At a professional level, burnout is associated with a risk of increased errors, complaints, reduced productivity, increased sick days, and leaving the job altogether, which can have an impact on patients and the system as a whole.
It seems that certain personality styles may increase an individual’s vulnerability to burnout. Perfectionism and other personality traits such as conscientiousness (meaning you are highly organised, reliable and self-disciplined) and neuroticism (a tendency for anxiety, tension, moodiness) are weak predictors of burnout. Of course, these types of behaviour are highly valued in health, so maybe there’s some baseline vulnerability for us all. Similarly, it seems theoretically likely that a past history of related conditions such as depression, anxiety and trauma would increase the risk of burnout.
Precipitating factors are the external triggers and situations that can spark burnout – a bit like putting a match to a log of wood – or, to continue the asthma example, like exposure to pollen.
There is so much about the health system during the pandemic that is complex, unstable and stress inducing. I’m sure I don’t need to outline these, you know them only too well. Much of this is a recipe for overwhelm and burnout. Similar to asthma triggers such as pollen or cold weather, they can be avoided if possible, or we can modify our response to them, but at an individual level, their existence cannot be changed.
In terms of burnout, I think of perpetuating factors as those that broadly involve the way we react to external situations. These, unlike precipitating factors, we do have control over and includes factors such as maladaptive coping styles including unhealthy eating, substance misuse (alcohol or other drugs) or isolating yourself from friends and family and other sources of support.
Perpetuating factors also include a having a pessimistic explanatory style with regard to external circumstances or events. This means having a habitual way of explaining external events as personal (my fault), permanent (it will always be like this, nothing will ever change) and pervasive (this affects everything, nothing is good).
It’s easy to see how these very common responses serve to keep adding fuel and oxygen to the fire. While optimistic explanatory styles can be learned, it does take effort and practice.
Even more powerful than having a pessimistic explanatory style are the hidden beliefs, assumptions and “shoulds” that control us without us knowing, like the way strings control puppets. These reflect the hidden curriculum and unstated cultural expectations and serve to keep us frozen in particular patterns of behaviour such as the inability to say no (even when it is possible to do so), turning up to work when you are sick, and feeling like you can never let anybody down (except yourself, your family and friends). Unless these assumptions are addressed, it is very difficult to take time for a self-care routine.
Using asthma as analogy is a really useful way to think about protective factors. In asthma, the broad principles of management are:
- ensure the patient understands the condition and how it is managed;
- identify triggers and reduce or avoid exposure to them if possible;
- reduce reactivity to triggers with preventers;
- manage symptoms with relievers that arise despite preventive steps;
- ongoing monitoring.
Let’s take these one at a time and compare them to burnout:
In terms of burnout, this means raising self-awareness about burnout and what it looks like for each individual. Without awareness, change cannot happen. As I noted above, many doctors (and I do include myself in that) do not seem to recognise burnout in themselves until it is bad. So, a bit like understanding that cough may indicate asthma, the first step in managing burnout is getting to know yourself and your habitual response to stress better.
Identification and avoidance of triggers
It is probably impossible to avoid the multitude of system and environmental triggers to burnout – especially during a pandemic. However, that doesn’t mean there is nothing you can do about your own wellbeing. No matter how bad a given situation is, as Viktor Frankl says in his classic book Man’s Search for Meaning:
“…everything can be taken from a [person] but one thing: the last of human freedoms – to choose one’s attitude in any given set of circumstances, to choose one’s own way.”
So while system reform and organisational interventions are most certainly necessary to combat the burnout epidemic in healthcare, in the meantime, even as you may advocate and implement positive change, it is an empowering attitude to take steps to look after yourself and ensure you have the tools and training to keep yourself safe as best you can – and the wisdom to know when to leave the situation altogether.
Reducing reactivity to triggers
Given the inevitability of ongoing exposure to systemic triggers to burnout, it’s important to work towards becoming less reactive to them. In general, this involves managing your physiology via reducing sympathetic arousal and increasing parasympathetic arousal.
There are a multitude of strategies available and widely publicised including: exercise, sleep, eating well, meditation and relaxation exercises, seeking support from friends and family, gratitude journaling, prayer, self-compassion, managing self-talk with cognitive behavioural therapy, and more.
In the absence of compelling research regarding the relative utility of these interventions, the choice is somewhat personal. I operate on the principle that we probably need a whole-person approach and a blend of physiological and psychological and spiritual activities to really get stress reactivity under control in a sustainable way. There are many self-help websites and apps to help you manage these strategies; likewise, there are grassroots organisations emerging providing such as Hand’n’Hand.
As well as building in habitual strategies to reduce reactivity to stress, it is good to learn some techniques derived from the above strategies for managing yourself in the moment. These could include taking mindful moments, a minute of slow breathing, or reframing negative self-talk.
Self-help is fantastic and, like asthma, the more a person is engaged and empowered in their own health, the better overall control there will be. But even with excellent self-management, there comes a time where professional support is necessary. Burnout is no different, and there should be no shame in seeking support for managing this.
I think about professional support for burnout on a spectrum from symptom management to capacity building for managing uncertainty and stress-inducing situations. The right type of support depends on the individual situation and comfort and preference of the individual.
Symptom management approaches are commonly known and practised by psychiatrists, psychologists and GPs. However, for many people it is equally important to be building capacity, which is more the domain of coaching or professional supervision.
Like keeping an eye on peak flow, monitoring yourself for your personal signals of burnout is important. Despite the best asthma management plans, asthma attacks can still happen. So too with burnout. Given the ongoing nature of external triggers and precipitating factors, it may be that burnout is not 100% avoidable. No matter how good you are at stress management, or how resilient you are, there are some circumstances and situations (such as a pandemic) in which recognising, preventing and responding to burnout becomes a lifestyle choice that we must take as seriously as managing asthma or other chronic diseases.
Dr Jocelyn Lowinger has an Honours degree in Medicine (1994) and a Master of Science in Coaching Psychology. A former GP, Dr Lowinger coaches doctors and other health professionals in proactive professional development including helping them develop leadership skills, confidence and well-being. Visit http://www.coachgp.com.au