COMMENTARY

What Can Cardiologists Do to Avoid Burnout?

Mamas A. Mamas, BM, BCh, MA, DPhil, FRCP

Disclosures

July 01, 2019

This transcript has been edited for clarity.

Hi, my name is Mamas Mamas. I'm professor of cardiology based at Keele University. And today we're going to talk about a very important topic - that of physician burnout. What do we mean by physician burnout? Well, it's an occupational health and stress-related disorder characterised by three factors:

  • Firstly, physical or emotional exhaustion

  • Secondly, depersonalisation

  • And finally a reduced sense of personal accomplishment

How common is physician burnout? Well, we know the answers for this from a recent Medscape survey published earlier this year, which asked 15,000 doctors from 29 different specialties, and reported a physician burnout rate of 44%, with cardiology being particularly prevalent.

Why is this important? Well, it's important for a number of reasons. Physician burnout can lead to early departure from the career, can lead to impaired physician performance and delivery of health care to patients, and can also lead to frayed relationships with colleagues, family, and patients.

Physician burnout is one of the strongest factors for physician suicide. In the United States, one doctor commits suicide every day, and in the Medscape survey, up to 1 in 6 doctors had reported having suicidal thoughts. This is an important factor in many suicides reported amongst physicians, and only by understanding physician burnout, can we help contribute to reduction of this major problem blighting our healthcare society.

Dr Shelley Zieroth

My first guest is Dr Shelley Zieroth, head of the heart failure transplant programme at St Boniface Hospital in Winnipeg. Dr Zieroth will talk to us about the personal factors that can contribute to physician burnout.

Hi, I am Dr Shelley Zieroth an associate professor at the University of Manitoba and a heart failure cardiologist in Winnipeg Canada, and more importantly a mum.  I would like to thank Professor Mamas and Medscape for the opportunity to discuss the personal factors contributing to burnout.

Burnout occurs as a result of a complex interplay between institutional and personal factors. The personal factors that are frequently identified that contribute to physician burnout can be described using  the acronym ‘PERSONAL’ [1,3,4]:

P Physicians’ sex, and Physicians’ personal factors

ER—Engaging in Random coping strategies

S—Sleep deprivations

O Over-commitment

N Non-physician partner 

A— Age of the physician, and having a child less than 21 years of Age

L— Life imbalance (professional vs. personal)

According to some studies, female physicians are at 30-60 % higher risk of experiencing burnout compared to male physicians[1,2,4,5].

Age is another significant personal factor[3,6,7].  Contrary to what is established for non-physician populations, several studies have demonstrated that younger physicians experience higher levels of burnout compared to older physicians[8–10]. Perhaps physicians with more clinical experience have more thorough understanding of the work dynamics, safeguarding them against burnout.

In addition, physician personality traits including introversion, predispose physicians to burnout[11–13]. Conversely, grit and perseverance have been identified as protective factors against burnout [14–16].

Other factors associated with burnout include having  a younger child, less than 21 years of age, having a partner in a non-medical profession and lack of a social support system[4,17].

In summary, younger age, female sex,  having a non-physician spouse and having the added responsibility of a younger child are important personal factors that predispose physicians to a higher risk of burnout[1,11].  Recognising these personal factors may inform preventative strategies to lower the risk of burnout and could guide strategies to aid the development of wellness and resilience among physicians.

Remember - look for signs - remember the acronym PERSONAL - ask for help and - offer help!

Dr Harriette Van Spall

I'm next joined by Dr Harriette Van Spall from the McMaster University Faculty of Health Sciences, who's also a heart failure physician. Dr Van Spall will talk to us about institutional factors, such as bullying, that can contribute to physician burnout.

The research methodology to investigate institutional and practice level factors associated with burnout are primarily self-reported surveys. In a survey of 1800 American academic physicians, primarily internal medicine specialists, several institutional-level factors were identified as being associated with burnout. Some of these factors included lack of control over workplace scheduling; excessive work hours, which are generally defined as work hours in excess of 60 to 80 hours per week; loss of control over clinical decision-making at the point of care, and unsupportive work environments in which there was limited social cohesion. Other studies have revealed that workplace harassment and bullying are important factors associated with physician burnout, and that workplace wellness programmes can help offset some of the sequelae of burnout.

Career stage can have an impact on burnout. Relative to mid-career physicians who have been in practice for 11 to 20 years, those at the early career stage are at increased risk of burnout, and those who are at the late stage of their careers have the least risk of burnout. In one study, early career physicians had a 1.6 times odds of burnout relative to mid-career physicians, and those who were near the end of their career had about a 0.6 odds of burnout relative to mid-career physicians.

The consequences of physician burnout can be both personal and practice related. At the practice level, physicians who report feeling burned out are more likely to reduce their clinical work hours, and to reduce the number of patients in their clinical practice. Some physicians are more likely to quit medicine altogether, or to retire from their home institution and to find places of work that are more conducive to a work-life balance.

Dr Beth Frates

My next guest is Dr Beth Frates from Harvard Medical School, a bestselling author who has created the path to wellness programme. She's a health and wellness coach. Dr Frates will talk to us about how to improve personal well-being in order to prevent burnout.

Welcome, I'm Dr Beth Frates, here to discuss well-being.

There are three dimensions to well-being: the healthy body, the peaceful mind, and the joyful heart.

For a healthy body you need to focus on exercise, nutrition and sleep. For exercise, the guidelines are to accumulate 150 minutes of moderate intensity physical activity in a week. For nutrition, we're striving for a healthy eating pattern, not a diet, but an eating pattern that follows closely to the Harvard Healthy Plate where half the plate is vegetables and some fruit, a quarter of the plate is whole grains, and the last quarter is a healthy protein. [We should be] striving to eat that type of plate three meals per day. In terms of sleep, the National Sleep Foundation recommends 7 to 8 hours of sound sleep per night for individuals over the age of 18. For a peaceful mind, we need a strong stress-reduction technique that we can use in the moment. Deep breathing is one of those techniques. We can have a long inhalation and a forceful exhalation with a focus on the breath and only the breath for 2 to 3 minutes and that will increase our parasympathetic system and dampen the sympathetic drive or that fight-or-flight response.

In terms of well-being, we need a growth mindset where mishaps and mistakes are opportunities to learn and grow. There's no room for shame, blame and guilt here. We also need to take time out; to take our vacation: not only take our vacation, but unplug during our vacation, so that we're not checking email and texts; we're not checking in with projects and patients. We're resting, rejuvenating, relaxing and re-energising. For a joyful heart we need natural sources of energy, not caffeinating ourselves morning 'till night. Instead, if we have a low at 3pm we can look for a handful of nuts, almonds or walnuts; carrots and celery with hummus, or maybe an apple with almond butter. Some people are energised by a walk or talk with a friend. Whatever energises you that's natural is what we need to use as our go-to.

A sense of well-being goes hand in hand with a sense of purpose. We often had a strong sense of purpose when we went into medical school in the first place, but we often lose that; it fades, maybe even disappears after years of practising medicine. It's time to reconnect with our sense of purpose. Think about the why: why did we go into medicine?, and the what: what gives us joy in medicine?, and do more of that.

Lastly, we need high quality connections, where we can express emotion, negative and positive, in a safe environment. We need these connections at work and at home. The physician lounge used to give us this opportunity, but now, with that fading and disappearing, we need to craft opportunities with colleagues to connect at work and outside work: maybe at lunch, maybe at dinner.

I hope these tips are helpful to you.

So, we've heard about the personal and institutional factors that can contribute to burnout. But what things can professional societies do to help support physicians and help prevent burnout?

Dr Madhav Swaminathan from Duke University and current president of the American Society of Echocardiography will reveal his work and his society's work around supporting physicians to prevent, and to also help treat, physician burnout.

Dr Madhav Swaminathan

Burnout, as we know, has become an omnipresent threat to advancing health care at every level.

It undermines all our efforts at taking better care of our patients. We're a family, a family of healthcare practitioners who are facing unprecedented levels of burnout and exhaustion.

Those caring for patients, regardless of specialty, give a lot to the field they love and suffer the consequences of neglecting themselves in the process.

We think we are a resilient lot: the gruelling years of training, the altruistic nature of our profession, the privilege of taking care of a fellow human being, the ability to alleviate suffering. It's exhausting. You can't pour from an empty cup. Our patients deserve healthy clinicians. Our loved ones do too.

So while our workplace leaders recognise and respond to this crisis, we must ask ourselves, is this sufficient? Beyond our workplace, there are other opportunities to ignite social change.

Membership of professional societies is how we relate to other professionals who share our passion for what we do. We gather frequently at scientific meetings, learn from each other, share experiences, and even follow guidelines and recommendations made by experts in our societies.

Large professional societies have powerful advocacy efforts that impact the way we do our work. It is therefore vitally important that societies understand that they have an important role to play in addressing burnout.

Most of our scientific gatherings focused on promoting science and networking, as they should. But if we don't address the needs of all our members, we aren't really doing our job well.

Are we providing equal access to all our members? For example, we know that young parents, especially mothers, are often at a disadvantage because of the lack of adequate childcare resources, or private lactation rooms. This often leads to their absence from meetings, and the consequent loss of opportunity to learn and network and advance in their careers. Professional societies have an obligation to ensure that all attendees have equal access to all that is offered at these meetings.

More and more scientific conferences, including the American Society of Echocardiography (ASE), offer childcare services and nursing pods to allow our young parents and mothers to get the best experience of the meeting, without compromising on any aspect of their personal lives.

Professional societies also have an important role to play in advocating for best practices through guidelines and recommendations. But advocating for best practices should also consider what is most reasonable to ensure a healthy and happy clinician.

Advocating for healthy environments, sense of purpose, recognition, and belonging are important ways in which societies can support their members in positive ways.

Another area in which societies see a lot of interaction with their members is in the digital environment. Whether the website, or apps, or social media. We at the ASE, for example, are focusing on efforts on providing resources on our website for strategies to address burnout and enhance resilience, such as discussions on wellness using the hashtag #ASECares on Twitter, and including information on our apps so that our members can access these resources at their fingertips all the time.

Burnout remains a complex issue. This isn't going to be solved by blaming our electronic medical records, regulations, leadership, or even modern society. Enhancing resilience and combating burnout will take a multi-pronged approach in which everyone sees it as a collective problem that we can solve only by working together to find solutions to become happier clinicians. And that includes you, me, our health system, and our professional societies.

The Three Rs

So, we have heard in this podcast factors that contribute to physician burnout, both from an individual personal perspective, but also from an institutional perspective.

We've also discussed how institutions or professional societies can help reduce burnout.

And finally, we've also talked about how personal wellness can improve our resilience to burnout.

Remember, the three Rs:

1. Recognise: Recognise the symptoms of burnout.

2. Reverse burnout. So how do we do that? We reverse burnout by seeking professional help to reduce the damage that has been caused by burnout.

3. Develop resilience to burnout by improving our own personal wellness.

I'd like to thank my guests for giving their time up so freely to discuss issues around burnout. And I'd like to thank you for joining me. Remember, if you're feeling burnt out, the important thing is to discuss this - discuss with family, with friends, with professional societies, with colleagues, because it's only then that we can bring it into the open and hopefully reduce physician suicide and [improve] wellness.

Thank you for joining us.

COI: Dr Shelley Zieroth, Dr Harriette Van Spall, Dr Beth Frates, and Dr Madhav Swaminathan have made no relevant disclosures. 

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