Extinguishing burnout for pediatric oncology physicians
This is based on a presentation by Michael Terao, MD, St. Jude Hematology/Oncology Clinical Fellow.
Long hours and patient caseload pressures have always been part of the physician lifestyle. But when constant work stress tilts us into the syndrome known as burnout, it becomes a costly and destructive problem. Burnout is common among clinicians on the front lines of healthcare—emergency, primary care and internal medicine—but those specializing in childhood cancer are not immune. How do you prevent or treat burnout? Research points to interventions at both institutional and personal levels, ranging from leadership training to more functional computer applications.
Ignoring signs of burnout in ourselves puts patients at risk. Whenever you fly, think about the cabin crew’s pre-flight safety briefing:
“Place the oxygen mask on yourself first before helping small children.”
Against all parental instincts, we’re told to safeguard ourselves before helping the child sitting next to us. But if we can’t breathe—if we aren’t taking care of ourselves—of what good are physicians to the children under their care?
Before explaining the risks of burnout among physicians, please know that St. Jude Children’s Research Hospital addresses this issue through an initiative of the Resilience Center, which focuses on the importance of caring for oneself and developing healthy ways to deal with stress, burnout, and compassion fatigue.
Is burnout a real diagnosis?
“Burnout” sounds more like slang than a clinical term, but psychologists have been documenting and treating it as a specific syndrome for decades, including pioneering work by Christina Maslach at UC Berkeley. Dr. Maslach’s definition of burnout is “a syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who work with people in some capacity.”
And that is exactly what we do, working every day to help patients and their families beat the odds in the face of a catastrophic diagnosis. Let’s break down that description along the three core symptoms:
- Emotional exhaustion: As their emotional resources are depleted, physicians feel they are no longer able to “give of themselves” at a psychological level. This is where you are going through the motions and not emotionally involved with your patients. Data shows that this is linked with physician turnover.
- Depersonalization: The doctor experiences negative or cynical attitudes or feelings about patients and other people at work. They start to view patients as items on a chart, as though they are saying to themselves, “that's leukemia; that's a solid tumor; that's my next hematology patient,” as opposed to thinking of the patient in terms like “here is Sarah, from Alabama, who loves to play outside with her dogs; she’s afraid of spiders, but not the dark—unless the dark has spiders in it.”
- Reduced personal accomplishment: This is self-disappointment with performance, a tendency to evaluate oneself negatively, particularly regarding progress with patients.
There are many different opinions about how widespread burnout is, but research data shows that the rate among pediatric oncologists is around 40%.
Does it really matter if we're burned out?
Do clinicians need to just tough it out and keep doing what they're doing? Our culture holds up the virtue of self-sacrifice in the service of others, but what about self-neglect? Research data indicates that burnout does matter because it is connected to clinical productivity, the quality of patient care and even patient recovery times.
One large hospital surveyed its doctors about burnout symptoms and then surveyed those doctors’ patients about their experiences. Higher levels of physicians’ self-diagnoses of depersonalization were associated with both lower patient satisfaction and increased recovery time. (Note that “associated with” means burnout was not clearly the cause of those patients’ experiences.) Other surveys in emergency medicine and surgery, found that doctors who self-report medical errors or sub-optimal care also tend to self-report signs of burnout.
Burnout is expensive for hospitals
Aside from its human toll, physician burnout also costs the healthcare system a lot of money. Undiagnosed or untreated burnout will eventually lead to doctors leaving (or losing) their jobs, and the cost of replacing a physician can cost between two and three times the position’s annual salary. One estimate, from a Stanford University study, estimated the per-physician cost at $250,000 to almost $1 million.
What causes physician burnout?
Pressures that lead to physician burnout include problems with job demands (e.g. hours worked), work-life balance, sluggish computer software, leadership styles, and physicians’ lack of empowerment to improve their own workflow.
Did “sluggish computer software” surprise you? This refers to electronic health record (EHR) or electronic medical record (EMR) systems that function as digital patient charts and order forms, documenting or scheduling every examination, lab test and prescription.
Harvard’s T.H. Chan School of Public Health published a high-profile report in 2019 on remedies for physician burnout. The report’s authors called for more resilience programs as well as counseling services that are accessible and stigma-free for physicians. But the bulk of the report hammers away on the impact of the EHR systems mandated by insurance payers and regulatory authorities.
“For many physicians, EHRs impose a frustrating and non-intuitive workflow,” the Harvard report states, “and detracts from, rather than reinforces, the goals of good patient care.” Simple tasks, like requesting a prescription refill, requires navigating a galaxy of windows and menus that trigger unhelpful or disruptive alert pop-ups. Physicians routinely spend two hours on EHR reporting for each hour they interact with patients.
A 2016 Mayo Clinic study found that, while entering orders on EHR software was associated with the higher risk of burnout, use of the EHR without order entry—only for checking records—did not increase the rate of burnout.
Preventing emotional exhaustion, depersonalization and self-disappointment
Self-awareness training programs, which can include meditation, mindfulness and physical exercise, were moderately effective at reducing burnout, but only for physicians who actually had the time to devote to such a program (e.g., two hours per week for meditation).
Organizational change appears to be a more sustainable preventative for physician burnout. In a randomized study of primary care clinics, researchers examined various institutional interventions, such as special meetings where doctors could vent about what's bothering them, reducing clerical burdens, and pairing a dedicated medical assistant to each clinician to improve workflow. Doctors who experienced these organizational enhancements had significantly larger decreases in burnout, compared to physicians who only participated in mindfulness, exercise and communication skills programs.
What about the frustrating order-entry processes in the EHR systems? The Harvard report recommends that third-party software providers should be permitted to develop plug-in apps that can operate within any EHR system, much like Apple IoS and Google Android operating systems. This would enable hospitals and physicians to customize their interfaces and workflows to fit clinical needs.
Another Mayo Clinic study found connections between burnout and the scores physicians gave their immediate supervisors in leadership evaluations. Burnout rates were lower where physicians feel their supervisors empower them to do their jobs, show interest in their opinions, treat them with respect, encourage them to suggest ideas for improvement, and other forms of encouragement.