Healthcare Professional Burnout and Links to Depression
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When Dr. Lorna Breen, an ER doc in Manhattan, died by suicide in April 2020, it opened up a public discussion about the burdens faced by healthcare professionals especially during the COVID-19 pandemic. Yet healthcare provider burnout has been on the rise for years.
In fact, a review article in the Cureus Journal of Medical Science points to research done prior to the pandemic, which indicates that in the U.S., healthcare providers have been reporting symptoms of burnout:
- 51% of physicians
- 33% of hospital nurses
- 78% of surgical residents
- 44% of medical students worldwide
While burnout is not classified as a psychiatric disorder in the DSM-5, the Cureas Journal article cites one study that indicates that “over 90% of participants assessed as ‘burned out’ by the Maslach Burnout Inventory (MBI) also met diagnostic criteria for depression” and cites another study that claims “depressed and ‘burned out’ participants displayed similar attentional and behavioral alterations.”
The alarming number of cases of healthcare professional burnout and depression makes it clear that to safeguard clinicians, their families, and society, we need to implement meaningful, long-term solutions that address both the causes and the effects of this growing problem.
A Slippery Slope: Burnout, Depression, Suicide
The term burnout was used in the 1970s by clinical psychologist Herbert Freudenberger to describe exhausted free clinic volunteers who manifested multiple somatic and emotional symptoms while working in the East Village of New York City, which was drug-ridden at the time. A definition of workplace burnout was clarified by social psychologist Christina Maslach to include three components: “emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment.”
The relationship between burnout and depression has been under debate in the research community, according to an article in the Journal of Health Psychology. However, the authors of the study concluded “burnout and depression might actually match the same pathological realm.”
The Journal of Health Psychology study’s objective “was to examine whether burnout was distinguishable from depression at a symptom level, a level of analysis that is of prime importance for medical practice.”
Of the nine major depressive episode (MDE) symptoms – depressed mood, anhedonia, appetite-weight change, sleep change, psychomotor disturbance, fatigue, self-blame, cognitive impairment and suicide ideation – presented in the study, self-reported scores were similar across the depression and burnout groups for each symptom except self-blame.
“It turned out that burnout and MDE were associated with a similar amount of depressive symptoms both when considering overall depression ratings and when scrutinizing ratings related to eight of the nine MDE diagnostic criteria,” stated the authors. “Indeed, by sharing eight of the nine MDE defining features, burnout reveals a prominent depressive core, remembering that a MDE diagnosis can be produced in the presence of only five of the nine MDE diagnostic criteria.”
A research study in The Western Journal of Emergency Medicine reports that depression and burnout are likely causes for the more than 400 physician suicides reported each year.
“Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of EPs [emergency physicians],” write the study’s authors. “Burned-out physicians are unlikely to seek professional treatment and may attempt to deal with substance abuse, depression and suicidal thoughts alone.”
Driving Forces Behind Healthcare Professional Burnout and Depression
A review published in Behavioral Sciences (Basel, Switzerland) cites burnout among healthcare providers as a level of emotional exhaustion that makes them “feel drained and ‘used up’,” which can lead to “negative, cynical, hostile attitudes and detached feelings toward patients, known as depersonalization.”
Burnout presents with a diminished sense of personal accomplishment, the review reports, which “implies negative self-appraisal, feelings of incompetence, and inefficiency in daily work.”
What is driving this emotional exhaustion, depersonalization, and diminished sense of personal accomplishment that seem to plague such a large swath of the healthcare professional population?
In an article published by Family Practice Management, Dike Drummond, MD, shares a few potential causes of burnout that he heard most often during 1,500 hours of one-on-one coaching experience with burned-out physicians:
- The Day-to-Day Grind. Even on good days, dealing with sick or injured people and their families can be a huge energy drain. The inescapable stress, Dr. Drummond explains, is born from the classic combination of a lot of responsibility without a lot of control.
- Non-Patient Aspects. Beyond patient care, being a physician comes with a set of stressors unique to the job. For example, Dr. Drummond suggests that unique stresses include “your personal call rotation, your compensation formula, the local health care politics associated with the hospital(s) and provider group(s), the personality clashes in your department or clinic, your leadership, your personal work team, and many, many more.”
- Life Outside Your Job. Recharging when “off the clock” can be difficult for physicians. Residency trains you to believe that it is a weakness to prioritize your personal needs (i.e., physical, emotional and/or spiritual) over work. Additionally, your home life can also cause added stress, as everyone faces normal, everyday non-work pressures and conflicts.
- Medical Education Conditioning. Four character traits that make you a great physician can also set you up for burnout. Drummond defines them as being a workaholic, a superhero, a perfectionist, and a lone ranger. To add to that, Drummond writes that “physicians absorb two prime directives” which are likely to lead to burnout:
- “Put the patient first” makes it difficult for the physician to shift to putting his or herself first when not with patients
- “Never show weakness” makes it difficult to ask for help when stress has reached a tipping point.
- Your Immediate Supervisor. Drummond writes that “your work satisfaction and stress levels are powerfully affected by the leadership skills of your immediate supervisor.”
How Healthcare Professional Burnout is a Societal Problem
Burnout and depression among healthcare professionals is a problem on many levels: it negatively impacts the individual, their families, staff and patients, healthcare organizations, the healthcare system, and society as a whole. According to Dr. Drummond, burnout is directly linked to:
- “Lower patient satisfaction and care quality,
- Higher medical error rates and malpractice risk,
- Higher physician and staff turnover,
- Physician alcohol and drug abuse and addiction,
- Physician suicide.”
In a recent report, A Crisis in Health Care: A Call to Action on Physician Burnout, published by the Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society and Massachusetts Health and Hospital Association, the authors write that physician burnout is a public health crisis, which is consistent with reporting from major medical journals and in general media.
“A primary impact of burnout is on physicians’ mental health, but it is clear that one can’t have a high performing health care system if physicians working within it are not well,” write the report’s authors. “Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public.”
The study reports that burnout should not be the responsibility of the individual physicians.
“Physician burnout is a public health crisis that urgently demands action by health care institutions, governing bodies, and regulatory authorities,” write the authors. “If left unaddressed, the worsening crisis threatens to undermine the very provision of care, as well as eroding the mental health of physicians across the country.”
To address the issue, the authors present three possible solutions:
- “Support proactive mental health treatment and support for physicians experiencing burnout and related challenges.” The authors suggest it is important for physician institutions to support, encourage, and remove obstacles to facilitate treatment for healthcare professionals dealing with burnout and/or depression. “Improved access to appropriate mental health care will benefit all physicians and medical students,” write the authors.
- “Improved EHR [electronic health record] standards with strong focus on usability and open APIs [application programming interfaces].” The demands of the EHR have added hours of extra work and frustration for most healthcare professionals. The burden of documentation overload is a documented problem. The report’s authors emphasize that the burden of documentation on physicians must be reduced.
- “Appoint executive-level chief wellness officers at every major health care organization.” The better the leadership, the less stress for the physician. Chief Wellness Officers should serve as “champion[s] and organizational focal point[s]” and address the “symptoms and root causes of burnout across their institutions.”
Response to COVID-19’s Impact on the Mental Health of Healthcare Professionals
The impact of the COVID-19 pandemic on front line workers’ mental health magnifies the need to address burnout, depression, and suicide among healthcare professionals. According to the National Academy of Medicine (NAM), the pandemic is “presenting clinicians with even greater workplace hardships and moral dilemmas that are very likely to exacerbate existing levels of burnout and related mental health problems.”
An article in The New England Journal of Medicine relates caring for the healthcare professionals on the front lines of the COVID-19 pandemic to the efforts taken to care for the 9/11 first responders, whose suffering extended beyond the crisis moment of the event.
The article further states that, “Just as the country rallied to care for September 11 first responders who suffered long-term health effects, we must take responsibility for the mental and emotional well-being of clinician first responders to COVID-19 – now and in the long run.”.
In addition to calling attention to needing to protect the well-being of clinicians, NAM offers a long list of resources to support healthcare workers during and post pandemic. These resources are provided by a variety of sources, ranging from global health organizations to U.S. government agencies, associations and organizations, healthcare providers and schools of health professions, peer-reviewed journals, textbooks, and trade press.
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