Physician, Heal Thyself?

Updated: 6 days ago

- The myths of self care and burnout


By Dr Kerrianne Huynh


Kerrianne is a transition fellow working in Melbourne and the current WIN blog editor

 

I remember a particularly challenging day at work.

We had 16 patients.

Before 11am one of them had arrested.

It was 7pm before we finished the round. Not the afternoon round; our first round.



I remember having a sniffle the day before I went to work.

I knew there was no on call; so no one to replace me if I called in sick.

I knew the unit would be busy.

I felt mostly ok.

So I went to work.



I used to work in a really busy unit.

They didn’t protect our teaching time.

I often had to skip lunch.


Three anecdotes from before the pandemic from ICU trainees.


 


Medicine has always been fertile ground for burnout.


Health care workers are more vulnerable to mental health problems than the general population, with women particularly at risk, well before anyone had heard of SARS-CoV-2 [1].


It is serious enough to have caught the attention of the World Health Organisation. In 2019 the WHO included ‘burnout’ in the 11th Revision of the International Classification of Disease (ICD-11); not as a medical condition but as a workplace phenomenon. Burnout is described as a syndrome resulting from chronic workplace stress that has not been successfully managed. It is characterised by the following components: feelings of energy depletion or exhaustion, increased feelings of negativity, cynicism, or a sense of mental distance from one’s job and reduced professional efficacy [2].


It is serious enough to be serially measured. In 2016, the Critical Care Societies Collaborative (CCSC) recognised that burnout is common in those that look after the critically ill [3]. Burnout in intensivists has a prevalence of up to 47%, with some suggestion that it is higher in female intensivists [4, 5]. The CCSC described four risk factors that are associated with burnout: the characteristics of the individual, factors of the organisation, the quality of working relationships, exposure to end-of-life issues and an inadequate support system outside the work environment. The characteristics of the individual and the organisation will not surprise. Individuals prone to self-criticism, combined with sleep deprivation, a poor work-life balance and engagement in unhelpful coping strategies are more prone to burnout. Organisations that are typified by increasing workload, lack of control over the work environment, insufficient rewards, and a general breakdown in the work community predispose to burnout.

Figure 1. Risk factors associated with burnout in the ICU [6].


The consequences? Everything you would expect: dysfunction in the clinician practice, ranging from decreased effectiveness to reduced quality of patient care and increased medical errors [6]. The consequences are not limited to the patients. A 2017 meta-analysis showed that burnout is a significant predictor in cardiovascular disease and a whole host of multisystem disorders up to and including increased mortality – in clinicians [7].


Surely, the most intelligent intervention is implementing strategies that prevent burnout. This brings me to the concept of self-care, a practice that has become quite popular during the pandemic. Self-care has been generally described as a practice of taking action to preserve one’s well-being and happiness; certainly, a priority during a time plagued by loss of employment, travelling restrictions, unpredictable lockdowns, and being separated from our loved ones, in a midst of a disease that has seemingly no cure. Surely burnout occurs on a spectrum with self-care at one end and burnout at the other. Surely, one mechanism that may prevent burnout is greater self-awareness of its symptoms and mechanisms to preserve self-care.


Multiple factors predispose intensive care trainees and their consultants to neglect self-care. The shifts are long and hard. There are regular encounters with traumatic and ethically difficult situations. Intensive care unfortunately means frequent exposure to patients with high morbidity and mortality, as well as the distress and despair of their loved ones. Many feel the need to put others before themselves. Australian and New Zealand trainees generally have a lack of non-clinical time to build portfolios and advance their own education.


This has been exacerbated by the pandemic. Increased patient workloads, long hours in PPE, the sufficiency of PPE supply and adequate fit, inadequate staffing, and fear of being infected and infecting our families all contribute to the anxiety of working in intensive care. An influx of new staff from outside non-critical care services can ironically increase the workload of critical care staff and the risk of medical errors. Yet these new staff, unfamiliar with ICU practice, also represent a population particularly vulnerable to the effects of burnout. A study during Melbourne’s first wave showed there was significant symptoms of moderate to severe depression and anxiety in health care workers. Working in a high exposure environment such as ICU was associated with greater symptoms of PTSD [8].


One’s gender also has an impact on the ability to self-care. The Australian Government’s Workplace Gender Equality Agency found that the pandemic exacerbated existing gender inequality. Women not only comprise the majority of the healthcare workforce, they are also more likely to take on the responsibilities of educating children at home and care for unwell family members, an added physical and psychological burden forming an ‘invisible’ extra ‘shift’ outside the workplace [9, 10]. Furthermore, current vaccination guidelines in Australia do not allow children under the age of five to be vaccinated [11], adding further stress to frontline health workers who are afraid of carrying the virus home to children too young to be vaccinated or yet to be fully vaccinated.


So, what can be done about self-care?


A 2017 article from the Harvard Business Review describes six ways to weave self-care into the workday. These include making sure you have a break, updating your workspace and the ever-elusive ‘recharge and reboot’. A leading medical insurance provider has multiple suggestions for self-care strategies for doctors in training including adopting a mentor and preventing social isolation from your peers [12] and that pursuit of wellness involves having a plan for both physical and mental health [13].


These articles, like many, place the burden of caring for the self on the individual with little or no onus on the workplace. Ignoring the role of the workplace in the successful execution of self-care fails to address a significant reason why burnout happens in the first place. It is incredibly naïve to believe that somehow the personal ‘at risk’ characteristics such as self-criticism, sleep deprivation and poor work-life balance can somehow be separated from the workplace or cannot be engendered and encouraged in an unsustainable work environment.


The World Health Organisation defines self-care quite differently as ‘the ability of individuals, families and communities to promote health, prevent disease, maintain health and to cope with illness and disability with or without the support of a healthcare provider’ [14]. In other words, self-care is not merely even mostly an individual concern. It is a concern of a community.


Currently in the ICU, there are hundreds of protocols for anything from insertion and management of ECMO to management of the brain injured patient with high intracranial pressure. There are protocols regarding the qualifications required before you start inserting central lines without supervision. These are systemic guidelines written with the goal of best practice for the patient but also the safety of the doctor implementing patient care. Surely the same could be implemented for ensuring trainees can perform self-care at work. A recent systematic review and meta-analysis examined self-care interventions to reduce physician burnout. Interestingly, self-care interventions directed by the organisation had greater effect on burnout compared to those directed by the individual physician [15]. The CCSC suggest a broad range of interventions at the level of the individual, the team as well as the work environment [3].


In my experience, trainees are not asking for much. They want to work in a place of physical and psychological safety, be given uninterrupted breaks to ensure they are well fed and watered. They want appropriate breaks between shifts and their training requirements met so that they can advance in their careers. During the peak of the pandemic, there were multiple self-care initiatives initiated at my workplace. Food was provided free for ICU workers 24 hrs a day, a daily stretching initiative commenced, and there was a flexible, mobile workforce that can meet the dynamic needs of the intensive care unit including a proning team. These are amazing initiatives, and we were lucky to have them; unfortunately, the experience of trainees across departments and states in Australia and New Zealand is not uniform. Furthermore, it is not clear how long these resources may be available.


As the pandemic fades from memory, how do we learn from our mistakes? How do avoid the trappings of our profession – overwork, being burnt out, compassion fatigue, turning up to work sick? Can we avoid being a profession of people with higher suicide rates, higher alcohol abuse, higher substance abuse and incidence of depression and anxiety?


The question is, will we be brave enough to continue these initiatives once we get back to business as usual.




For more CICM resources on Well Being:


cicm.org.au/Resources/Member-Health-Well-being



 

References

  1. F. Dutheil et al., "Suicide among physicians and health-care workers: A systematic review and meta-analysis," (in eng), PLoS One, vol. 14, no. 12, p. e0226361, 2019, doi: 10.1371/journal.pone.0226361.

  2. W. H. Organisation, "International Classification of Diseases 11th Revision."

  3. M. Moss, V. S. Good, D. Gozal, R. Kleinpell, and C. N. Sessler, "A Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Health-care Professionals. A Call for Action," American Journal of Respiratory and Critical Care Medicine, vol. 194, no. 1, pp. 106-113, 2016, doi: 10.1164/rccm.201604-0708st.

  4. E. L. Burnham, K. E. A. Burns, M. Moss, and P. M. Dodek, "Burnout in women intensivists: a hidden epidemic?," (in eng), Lancet Respir Med, vol. 7, no. 4, pp. 292-294, Apr 2019, doi: 10.1016/s2213-2600(19)30029-3.

  5. K. E. A. Burns, A. Fox-Robichaud, E. Lorens, and C. M. Martin, "Gender differences in career satisfaction, moral distress, and incivility: a national, cross-sectional survey of Canadian critical care physicians," (in eng), Can J Anaesth, vol. 66, no. 5, pp. 503-511, May 2019, doi: 10.1007/s12630-019-01321-y. Différences hommes/femmes en matière de satisfaction professionnelle, de détresse morale et d’incivilité : un sondage national et transversal des médecins intensivistes canadiens.

  6. M. P. Kerlin, J. McPeake, and M. E. Mikkelsen, "Burnout and Joy in the Profession of Critical Care Medicine," Critical Care, vol. 24, no. 1, 2020, doi: 10.1186/s13054-020-2784-z.

  7. D. A. J. Salvagioni, F. N. Melanda, A. E. Mesas, A. D. González, F. L. Gabani, and S. M. D. Andrade, "Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies," PLOS ONE, vol. 12, no. 10, p. e0185781, 2017, doi: 10.1371/journal.pone.0185781.

  8. H. Dobson et al., "Burnout and psychological distress amongst Australian healthcare workers during the COVID-19 pandemic," Australasian Psychiatry, vol. 29, no. 1, pp. 26-30, 2021, doi: 10.1177/1039856220965045.

  9. W. G. E. Agency. "Gendered impact of COVID-19." Workplace Gender Equality Agency. (accessed 2021).

  10. C. Crimi and A. Carlucci, "Challenges for the female health-care workers during the COVID-19 pandemic: the need for protection beyond the mask," (in eng), Pulmonology, vol. 27, no. 1, pp. 1-3, Jan-Feb 2021, doi: 10.1016/j.pulmoe.2020.09.004.

  11. A. G. Department of Health. "Who can get vaccinated." https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/who-can-get-vaccinated (accessed 2022).

  12. A. Mutual. "Self care strategies for doctors in training." https://www.avant.org.au/member-benefits/doctors-health-and-wellbeing/your-health/physical-and-mental-wellbeing/self-care-strategies-for-doctors-in-training/ (accessed 12th October 2021).

  13. A. Mutual. "Wellness: what does it mean for doctors?" https://www.avant.org.au/member-benefits/doctors-health-and-wellbeing/your-health/physical-and-mental-wellbeing/wellness--what-does-it-mean-for-doctors/ (accessed 12th December, 2021).

  14. W. H. Organisation, "What do we mean by self-care?," 2022. [Online]. Available: https://www.who.int/reproductivehealth/self-care-interventions/definitions/en/

  15. M. Panagioti et al., "Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis," (in eng), JAMA Intern Med, vol. 177, no. 2, pp. 195-205, Feb 1 2017, doi: 10.1001/jamainternmed.2016.7674.

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