 
|
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Journal of the New Zealand Medical Association,
29-April-2011, Vol 124 No 1333
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Professional burnout—a regulatory
perspective
Ron Paterson, John Adams
Definition, causes
and prevalence
Burnout is usually defined as a “syndrome of emotional
exhaustion, depersonalisation and a sense of low personal accomplishment that
leads to decreased effectiveness at
work.”1 It is well described by
psychiatrist Glen Gabbard as “erosion of the soul”, marked by
“a sense of joyless striving.”2
Burnout may result from chronic work stress. Stress is both
a physical and emotional syndrome. It occurs when the demands on someone are
greater than their capacity to respond and is mediated by both factors in the
external work environment, and internal qualities in the
person.3 A downward spiral is frequently set
up, because performance drops when stress mounts.
Felton suggests that employees are vulnerable to burnout
when they have little input into how to do a job, are never caught up with work
demands, would like to leave but fear doing so, or are experiencing major
changes in their workplace.4 An Israeli study
of 890 specialists concluded that “[p]erceived overload, long known to be
the most potent predictor of burnout, should be considered as a prime culprit in
that it probably leads to both elevated levels of burnout and reduced levels of
quality of care.”5
Wallace and colleagues list familiar stressors specific to
medicine.6 Workload and fatigue, dealing with
emotionally-charged situations associated with suffering, fear, failures and
death, difficult interactions with patients, families, and other medical
personnel, excessive cognitive demands, increased patient-care demands,
remuneration issues, growing bureaucracy, increased accountability, conflict
between the needs of the organisation and patients, and a decline in physician
autonomy are all suggested as having a role in producing stress and consequent
burnout.
Factors in doctors’ personalities also create
vulnerabilities. Compulsiveness can be a very helpful attribute in many areas of
medicine, but it causes doctors difficulty in saying ‘no’ to
additional work, leads to ‘burying’ resultant frustration and anger,
makes many doctors put off satisfaction in their lives, and is associated with
perfectionism and fear of failure, which pushes doctors to keep going despite
feeling personally compromised. Gabbard has characterised this as the triad of
doubt, guilt and an exaggerated sense of
responsibility.7
Many studies document the prevalence of health problems in
health professionals, including a major UK Department of Health Report in 2010,
“Invisible Patients”.8 It noted the
higher rates of depression, anxiety and substance misuse in health
professionals, the problem of “presenteeism” (staff who turn up for
work when they are unwell), and the fear of stigma that often stops health
workers seeking professional help. There is no reason to think that the problems
would be any less in New Zealand; indeed, being part of a smaller community with
fewer degrees of separation, it is likely to be even harder to seek anonymous
help for health problems.
Burnout appears common among practising doctors, with rates
ranging from 25% to 60%.9 A 1999 New Zealand
postal survey of a random sample of 500 doctors found that 61% reported
suffering moderate to severe stress, but only 11% had regular health
assessments, and 29% did not have a doctor.10
In our experience doctors as a group often neglect their own health, are not
good at nurturing their family and social supports, and have few outlets for
divesting themselves of the significant emotional load they carry from their
work. Each area of medicine has its own strains. We also observe that, as a
profession, doctors are relatively poor at giving mutual support and
constructive feedback to each other, or seeking help.
Burnout is not a problem confined to senior doctors and can
begin to develop early in the medical career. In a survey of 2682 medical
students in 7 US medical schools, 53% of respondents met criteria for
professional burnout. Students with burnout were less likely to hold altruistic
views regarding physicians’ responsibility to
society.11 In a prospective cohort study of 110
medical students from the University of Sydney, rates of burnout increased from
28% (in the final year of medical school) to 61% (18 months later in the trainee
intern year).12
Adverse effects on quality of careDoctors in the process of burning out will depersonalise or
withdraw from patients, leading to a “vicious cycle where physician
withdrawal may lead patients to express discontent, thereby creating further
physician stress and ... a tendency for the physician to withdraw further during
the medical encounter.”13 Burnout and
“compassion fatigue” are a particular problem in specialties that
involve intense emotional demands and staff shortages.
A number of published studies indicate that the risks of
medical errors and suboptimal patient care are higher for burnt out physicians.
A recent study of 1311 German surgeons showed that “burnt out male
surgeons are significantly more likely to rate their quality of care as
suboptimal.”14
The relationship between depression, burnout and errors is
complex. In an interesting prospective cohort study of 123 paediatric residents
in the United States, 24 (20%) met the criteria for depression and 92 (74%) met
the criteria for burnout. Depressed residents (96% of whom also reported
burnout) made significantly more errors than their non-depressed peers; however,
burnout on its own did not seem to correlate with an increased rate of medical
errors.15
Patients are often well aware that doctors are
overworked— they experience the results firsthand. A breast cancer
survivor, whose breast prosthesis was punctured by a surgeon who mistook it for
a fluid collection, complained to HDC. In her letter of complaint, she wrote:
“Surgeons should not be overworked to the point of mistakes. I hope those
involved have been able to learn from this and can thus prevent a mistake which
could result in loss of life.” Her statement highlights another point:
most patients are very conscious of the demands on busy health professionals,
and may be reticent to speak up about concerns that should be brought to a
doctor’s attention.
Stress from mistakes and complaintsFirth-Cozens notes that stressors, the personal
characteristics of the doctor (including their psychological make-up, coping
ability and competence), and the degree of impairment of the doctor, all impact
on doctors’ performance.16 One stressor
that is well documented is the impact of a mistake or complaint on the doctor.
Albert Wu has called the doctor who makes a mistake
“the second victim” of medical
error.17 He writes:
...In the absence of
[support and] mechanisms for healing, physicians find dysfunctional ways to
protect themselves. They often respond to their own mistakes with anger and
projection of blame, and may act defensively or callously and blame or scold the
patient or other members of the healthcare team. Distress escalates in the face
of a malpractice suit. In the long run some physicians are deeply wounded, lose
their nerve, burnout, or seek solace in alcohol or drugs.
In research published recently in the Archives of Surgery, 1
in 16 (of a sample of 7905) American surgeons reported suicidal ideation in
the previous year. Suicidal ideation was
markedly increased among surgeons who perceived they had made a major medical
error in the previous three months. Also alarming was the finding that 60% of
surgeons with recent suicidal ideation reported that they were reluctant to seek
professional help due to concern that it could affect their medical
licence.18
One might expect that rates of burnout attributable to the
impact of mistakes and complaints to be lower in New Zealand. As noted by the
Chief Medical Editor of HemOnc Today, “It would be interesting to
compare the burnout rate of oncologists in ... countries [with] universal health
care ... and minimal malpractice
litigation.”2
The effective absence of medical malpractice litigation in
New Zealand, due to our “no fault” accident compensation scheme
covering “treatment injury”, and the strong focus on resolution and
remediation from HDC and the Medical Council, might be expected to dilute the
stress on doctors from mistakes and complaints. In our experience many doctors
report significant stress during HDC and Council processes. Most are
conscientious people and struggle with the thought that they have not performed
well. A serious incident or complaint may well tip a stressed and overworked
doctor into burnout.
Preventing and
alleviating burnout
To help prevent burnout, and to alleviate it when it occurs,
we see the need for changes in three areas.
Culture change—The first is culture
change. All doctors make mistakes and every doctor is likely to face complaints
in the course of their work. This needs to be more openly acknowledged within
the medical profession.
In recent years, we have observed a less punitive
environment and a much greater willingness on the part of individual doctors to
admit, in front of their peers, having been involved in a serious incident or
the subject of a complaint. We see this as a healthy development. A more open
and realistic environment should in turn make doctors more willing to seek help.
In the words of former BMJ editor Richard Smith, “We need to move
from a culture that encourages doctors to hide distress and difficulties to one
where we share them and ask for
help.”19
Waitemata physician Pat Alley, who has done much good work
in this area, comments that “for a profession that has no shortage of
Colleges, the medical profession is surprisingly uncollegial to its members who
are in difficulty, and colleagues sadly often look the other way when a doctor
becomes unwell from burnout” (personal correspondence, 28 January 2011).
As noted earlier, burnout is not confined to middle-aged
physicians. In our view senior doctors have a special responsibility towards
medical students and trainees to speak more openly about their own challenges,
support mechanisms, and life choices, to help the next generation of doctors see
through the myth that “the harder we work, the more patients we have, and
the more tired we are, the better physicians we are”. Students, trainee
interns and junior doctors need to be taught about ways to respond to mistakes,
complaints and the everyday stresses of medical work.
Support services—Secondly, employers
and colleges need to do a much better job of supporting doctors facing stress of
any sort, including from the impact of mistakes and complaints. It stands to
reason that early intervention might help prevent a slide into more significant
difficulties with an increasing risk of error. Reducing environmental work
stressors and identifying, supporting and treating doctors under stress is a
crucial quality issue for our health service.
Some support services are available. The Doctors Health
Advisory Service, based in Wellington, offers a free, confidential 24-hour
support service. The Medical Protection Society and the Medical Assurance
Society fund a counselling service for doctors suffering from work-related
stress.20
An interesting initiative is offered by the Royal
Australasian College of Surgeons, under its Surgeons Support Group programme.
This involves training volunteer Fellows of the College in the skills necessary
to help surgical colleagues involved in stressful medico-legal processes, such
as complaints and inquiries. However, the initiative relies on the stressed
doctor knowing that the service exists, and having the courage to contact it. In
2003, Bruce and colleagues called for a peer-support system for physicians,
after a sample of 50 physicians in the Waikato and Bay of Plenty reported
relatively high levels of burnout.21 Clearly,
there is a role for Colleges to do more.
Employers also need to do more. Some district health boards
and primary care organisations in New Zealand do a good job in identifying and
supporting clinicians at risk of burnout or distress from a significant incident
or complaint. But in many cases an individual doctor bears the burden alone. We
agree with Pat Alley that “DHBs should be devoting far more resource than
they do to managing burnout in all health professionals” (personal
correspondence, 28 January 2011).
Responsive regulators—Thirdly,
regulators need to handle complaints and inquiries promptly and sensitively.
Practitioners understandably dread receiving an envelope from HDC or the Medical
Council. Both organisations should aim to ensure that correspondence and
interviews are professional but not officious; that parties are kept regularly
updated; and that a determination is reached as quickly as possible.
There is a statutory duty on any health practitioner who has
reason to believe that a doctor is “unable to perform the functions
required for the practice of his or her profession because of some mental or
physical condition,” to notify the Medical
Council.22 Such referrals are handled by
Council’s Health Committee, which has many years of experience with ill
doctors. All referrals are handled sensitively and with appropriate
confidentiality, yet many doctors still view referral to the Committee as a
disciplinary measure.
The Health Committee makes sure that necessary assessments
are performed, helps put treatment in place and monitors progress closely. In
addition, through voluntary undertakings with the doctor and contact with
employers and colleagues, the committee can help modify the work environment. As
at 30 June 2010, 210 doctors being were monitored by the Health Committee. Of
the 63 new referrals in the previous year, 36 were for psychiatric difficulties,
6 for alcohol abuse and 2 for drug abuse.
Regulators need to walk a fine line in handling cases
involving sick doctors. This is a challenge both for the Medical Council and
HDC. Both agencies have a public protective role, and there may be pressure from
the media, and from individual patients and families, to take a punitive
approach. The Council and HDC recognise the systemic factors that contribute to
burnout and, through their processes and decisions, seek to highlight the
responsibility of district health boards and other employers to provide
appropriate support.
Where a burnt out doctor turns to alcohol or other drugs for
relief, and harms a patient while under the influence, there will inevitably be
disciplinary consequences. But in other cases where a doctor accepts personal
responsibility, says sorry, and is willing to seek professional help, it is in
everyone’s interest that a rehabilitative approach is taken. Both Council
and HDC have been supportive of the rehabilitation of sick and burnt out
doctors.
ConclusionAs a society, and as a profession, we are rather conflicted
in our attitudes about sick and burnt out health professionals. All too often we
admire the individual who soldiers on, uncomplaining, with a heavy workload and
never seems to get sick.
However, such attitudes help produce an environment that
contributes to a significant, though largely hidden, quality issue in our health
service. As Wallace notes, “... [W]hen physicians are unwell, the
performance of the health-care system can be sub optimum. The corollary is that
physician wellness might not only benefit the individual physician, but also be
vital to the delivery of high-quality health
care.”6
There needs to be a culture change within the health
professions, so that practitioners feel able to seek help. Colleagues must also
recognise their ethical responsibility to take action if a health or competence
problem is not being adequately addressed.
Professional burnout carries hidden costs: for individual
health professionals, their colleagues, their patients and their families. In
additional to these physical and emotional costs, it is a financial burden on
the health system as a whole. We hope our paper will highlight an important
issue and give impetus to steps to prevent, recognise and treat burnout of
doctors in New Zealand.
Competing interests: None.
Author information:
Ron Paterson, Former Health and Disability Commissioner, Professor of
Law, Faculty of Law, University of Auckland, Auckland; John Adams, Chair,
Medical Council of New Zealand and Dean, Dunedin School of Medicine, University
of Otago, Dunedin
Acknowledgement:
This article is based on papers we delivered at the University of Otago
Inaugural International Cancer Symposium in Wellington on 15 February
2011.
Correspondence:
Ron Paterson. Email: r.paterson@auckland.ac.nz
References:
|
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|