The current pandemic has been a catalyst of change in many people. Health guidelines prioritized public safety over other practices, including clinic visits, social activities, worship, and school. Together we waited for the process to pass in our silos, a shared experience in time but not in space. The pandemic also put into the forefront burnout and work fatigue.
If you feel like you are experiencing work fatigue, you are not alone. In a survey conducted in February 2021, more than half of respondents feel burned out, and two-thirds believe that burnout has worsened during the pandemic. There has also been fallout from those working remotely from their homes. A study of 18,935 nurses during the COVID-19 pandemic showed that 34% felt emotionally exhausted, 12.6% had depersonalization, and 15% felt lack of accomplishment- all elements of burnout.
The experience of burnout doesn’t occur from a lack of mental strength, and it doesn’t melt away by taking a vacation. Organizations often are ill-equipped to address these challenges or provide additional support to their workforce. Although we are just beginning to realize the mass exodus of nurses from traditionally paid hospital positions, the lack of staffing has severe ramifications for patient care. Consider New York City, a city with high rates of COVID cases; there was a 400% increase in nurses looking for new jobs last year.
The situation is so dire that the US Bureau of Labor Statistics reported that the inpatient healthcare workforce was down 524,000 jobs since February 2020, the brunt of lost work in nursing and residential care facilities. In particular, for nursing, which has already been short-staffed before COVID, the pandemic seems to have exposed long-standing workforce shortages.
Whether you have contemplated leaving work or count yourself in the numbers, some methods can help to build or rebuild resilience while rekindling the creative flow that all of us would benefit from permitting its flow. Although this article targets healthcare workers, I hope that any reader can derive helpful tips to becoming inspired in one’s career path again.
Table of Contents
The Writing on the Wall: My Burnout Story
The seeds of burnout in my professional life were likely planted early on in my training. To get into a competitive internal medicine residency program, I essentially agreed to repeat my intern year. The year was demanding, and I was frequently sleep-deprived. Fast forward to my career as a doctor, assuming the role of the consultant required me to stay for longer hours and work on weekends.
I agreed to work three long days weekly in a recent position and be available for call two weekends per month. If I missed a phone call or were in an area of poor cell reception for a few hours, I would often hear about it the next day or week. To avoid this, I ultimately agreed to take a pager to reduce the frequent messaging I received on the smartphone and ensure that I would answer the calls right away, including the days that I was not physically in the hospital.
When the COVID-19 pandemic hit, the hospital administration stopped elective procedures, as many other hospitals did. I found that my workload sharply diminished, since many of the patients I saw came in after procedures, often only seeing a few patients each day. While this may seem more manageable, it created a concern about the value I added to the hospital’s patient care. Several clinicians either resigned over the ensuing months or lost their jobs, making me wonder if my time were near.
One day, I experienced tension with one of the hospitalists. I very much enjoyed working with all of the hospitalists, including this provider. We discussed whether a particular procedure that I performed was necessary. I wanted to bring it up for peer troubleshooting and provided articles that supported its role. In fact, after the event, they even asked me to perform the same procedure another patient.
It seemed like too many nerves were hit between us, and the provider asked me to drop any discussion with them about this topic. Two days later, I received a phone call from a recruiter in my specialty. Although they were vague about the location and hospital initially, as they always are, she announced that it was a hospital that I knew well. My hospital was recruiting for my position. I was being nudged out.
After I regained my composure and put my ego aside, I analyzed what had happened. Over the last year, I was working at a different pace, and my presence was not always assumed. Additionally, I could not meet the hospital’s needs for COVID meetings, etc., because of the additional days, my children being at home for school, the lack of in-person meetings, and limitations in progress for therapy in the early months. Additionally, some providers had lost faith in my recommendations, running things by another consultant provider or making plans without involving me. The discussion with my colleague was just the straw that broke the camel’s back.
I realized that I had been showing signs of burnout, and it affected the fruit of my labor. Not to mention, I realized that there was a mismatch in expectations between the providers and what I was able to do. I put my letter of resignation after discovering my job coming up for hire.
I am now working part-time and plan to continue to build this website and work on my books. If you asked me whether leaving work helped reduce the feeling of burnout, I would answer “yes” and “no.” The most developed skill set for many doctors is patient care, and since I need to make a living for my family, I have to return to some work. But at least the flexibility helps. I continue along the journey of discovering a career that fits my passion and that fuels my actions. I work toward strengthening my resilience and grit outside of my comfort zone as I strive into the unknown.
Burnout: Finding the Path to Resilience
Similar to any work environment, when a medical job is not conducive to change, either the physician “exits.” leaving the job or the profession. or they “give voice,” negotiating, protesting, complaining, etc. (Kravitz, 2012). If a physician is discontent and leaves a job, an individual correction of the problem may be necessary, but the disagreeable work environment may continue.
Physician employment is the raison d’etre for Health organizations, in as much as income is generated by physicians inpatient visits, referrals for diagnostic studies, and procedures and surgeries. Physicians likewise have a lot of leverage in negotiating and bargaining their work environments, salaries, and expectations. Some of this includes identifying factors that may be creating stagnation or instigating physician demoralization.
Let’s pause for a moment to deconstruct a job description. As a physician, nurse, or other healthcare workers, your training and experience create value in the services you provide. Employers often underpay healthcare employees for their work. Instead of looking at multiple opportunities and reviewing the workload, salaries, payor mix (the type of insurance the patients have), and call schedule, what if you could construct your job. What type of practice would you make for yourself if you had autonomy and no financial strain?
I could ask a similar question to the general audience: how would you use the time of your life if you followed your calling? The answer is unique for each person and affected by timing and circumstances. For physicians, it would likely be a hybrid of various responsibilities, each balancing out the other. It may be a job that stimulates interest, serves others, and is collegial. It would be a work that someone is excited to wake up and get started.
For me, it would incorporate my interests, a chance to teach students and residents, a variety of work settings and opportunities, and a good pace of patient visits, to allow for more time to develop a physician-patient relationship and do a thorough evaluation. Although these questions come up often for someone who wishes to downshift before retirement, these might be the right questions any physician at any stage wishes to consider for their practice.
The seed of burnout can begin early in the physician’s development, where s/he indoctrinated with medicine’s work ethic and culture. As many as 50% of medical students and residents already reported feeling burnout during their training (Dyrbye, 2014). The field of medicine espouses self-sacrifice, compassion, and altruism, all of which are honorable traits. Often, physicians in training are inculcated with perfectionism, prioritizing work above all, low self-care, and keeping stress inside instead of the messages of humility, professionalism, and self-compassion (Shanafelt, 2019).
More expectations on the physician come from hospital systems that incentivize productivity and income generated over quality care and physician fulfillment. Lacking in medicine is a dialogue within the physician community, sensitive to the issues that fuel burnout. Without a framework, the individual physician often must cope on their own and make survival changes to protect themselves from burnout, sometimes with the not-so-healthy “work hard, play hard mentality.”
Intern year usually begins July 1st, a week or two after graduation from medical school. An intern begins the rigorous training of residency, often filled with long hours and many patients. A typical day combines some didactic hours of morning report and noon conference with the usual duties of patient visits and rounds. The intern usually could leave only after the work was done – even after a call. As an intern, this often means a more extended post-call day since the sleep deprivation slowed down my work efficiency the next day. I would sometimes uncontrollably nap as I was typing or writing notes. I feared making a mistake in the hospital, or getting into a car accident, falling asleep at the wheel after leaving.
In 2003, residency programs implemented new changes after pressure from academic committees such as the American College of Graduate Medical Education (ACGME). The trainee work shift adjustments permitted improved well-being, quality of care, and patient safety. It called for caps on work weeks (80 hours) and consecutive hours worked (16 hours interns, 24 hours residents).
A frequent discussion at the time, especially with older attendings, was the idea of “when I was a resident,” as they described longer days and more night calls. These physicians raised concerns that fewer hours meant more holes and less endurance in training. The criticism did not weigh the costs of increased medical errors, learning gaps from sleep deprivation, and demoralization of not changing the status quo. The indisputable fact is that there will always be holes, no matter how busy a residency program is.
A transformative shift in medicine culture carries the profession’s positive ideals while emphasizing collaborative efforts to increase communication and physician support. Edgar Schein refers to the changes as “managed evolution,” or fine-tuning the culture, adopting new beliefs while discarding others. When a physician can address their needs in the context of a supportive culture, patient care is enhanced.
Physicians can also drive the culture shift in decisions regarding their professional goals. Many may be under the assumption that the current model of care works well enough. Why work toward an ideal work-life balance closer to retirement? I asked myself that question. My answer was to start from a blank slate and work several jobs.
Once I removed the small tasks from my workload, I reframed each day as an opportunity to support my mission and develop my career path rather than look for a job to pays the bills.
Sometimes a person needs to live through something to learn to protect themselves from it. There is wisdom gained from experience. I want to provide the blueprint of fortuitous learning so that physicians, other providers, and healthcare workers may benefit from my experiences, no matter where they are in their careers. There is no silver bullet that targets the nascent development of burnout. For sure, if a physician is developing burnout, it will not go away on its own without an action plan. This action plan requires incorporating resilience tools.
What is resilience? Although there is no one accepted definition, Luthar (2006) defines resilience as “positive adaptation despite adversity.” This fits quite well with medical practice, as much as it does in development. Medical care is a service-related field that can be quite a challenging work-environment. Doctors have among the highest suicide rate of any profession, more than twice the general population. Alcohol abuse is also two-to-three times higher in physicians than the general population.
Resilience is a skillset that prepares a physician for challenges in the career. There is a lot of research that supports that resilience training is beneficial starting in medical school. Several resilience strategies may help buffer the medical student, resident, or physician who has thought long enough about leaving the profession. These include reducing the workload, taking some time to volunteer locally or internationally, changing to a non-clinical career in medicine, or developing other hobbies or a “side-gig.”
Resilience relates to growth even in the setting of adversity or dilemma—a physician who wields resilience buffers themselves from the burnout triggers in medical practice. The rigors of medical training equip the physician with some degree of resilience.
Likely the best resilience programs are physician-directed, both the individual and community, and driven by the health care institutions in which they are employed (Epstein, 2013). Contrary to the enculturation and adaptation that stokes burnout, physicians can learn resilience skills and instrumental roles in directing their future practice. The best options consist of small-group instruction on mindfulness, reflection, and shared experience. These programs effectively decreased depersonalization rates (15.5% less vs. 0.8% control), emotional exhaustion, and overall burnout in a randomized clinical trial. They were sustainable 12 months after the study (West et al., 2020).
In the setting of work stress, physicians may choose to face the situation in front of them and sideline self-care. An over-extended physician may fail to recognize or ignore early signs of burnout – perhaps like I did. Self-awareness of one’s responses to stress through approaches that provide greater mindfulness, such as meditation and organizational skills training, can equip physicians with improved skills to direct their future practice. Self-care support is also paramount, such as exercise, meditation, and relaxation techniques, ensuring proper sleep, and minimizing other distractions (e.g., too much time on the smartphones).
Another essential factor for physician well-being is a positive work environment. The practice of medicine has become an increasingly insular experience, with an increased work demand for electronic medical records and scheduling. Although multiple physicians may be in one practice, their busy schedules can sometimes become obstacles to developing a collegiality and community environment. Physicians in the same group may support each other by blocking time to meet regularly as a community to voice concerns and offer support. Workplace settings could also consider implementing methods to reduce inefficient practices, ensure appropriate staffing, and survey physicians for potential challenges before becoming greater.
Ultimately, it is helpful for the physician to communicate their needs, balance clinical with personal responsibilities, set limits, and prioritize self-care. Medical schools have not routinely taught self-resilience lessons until recently. Attending physicians can learn these skills through training workshops as well.
However, with such a high prevalence of burnout in medical practice, we are reminded that it is a product of a system that too commonly emphasizes what a physician can produce rather than the quality they provide to it. Physician resilience is nurtured in the context of a pro-active health system that bolsters its providers, creates a fertile environment for the community, and encourages collaborative and creative problem-solving to protect its physicians.
Ways to Grow Resilience
Workload Reduction and Increased Autonomy
If burnout can occur from the excessive demands of a busy clinic or hospital job, what would happen to you if you reduced your workload? In some people who are experiencing burnout, no abbreviated schedule can address what they are going through. A reduced plan may not seem immediately attainable for others because of their current program or job arrangement. After all, a high workload is typical among physicians. One study found a correlation between burnout and increased workload; autonomy predicted a lower likelihood (Shirom et al., 2009).
Your Health Forum is a strong supporter of Mindfulness meditation (MM) and other practices. Here are some benefits of practicing MM. Additionally, these practices can be helpful in reducing burnout in medical staff. An analysis of 16 papers on MM and its use on nursing students suggested a positive impact, including stress, anxiety, depression, and burnout.
Mindfulness meditation can increase gray matter in the frontal cortex and other brain parts (ACC and PCC) that correlate with learning, cognition, memory, and empathy. Importantly, these changes can occur within a short time of training. Another way to look at it is that resilience can be developed through training and is likely related to structural brain changes.
Shared Dialogues and Social Support
There is a stigma attached to burnout that often allows nascent issues to go unaddressed until they become too large to go unnoticed. Yet, many hospital administrations are ill-equipped to handle burnout proactively, often finding themselves in high turnover situations when these issues remain unaddressed. Mindful communication through shared dialogue can be helpful to address the root cause of burnout: mismatched expectations and unspoken concerns.
Communication and social support opens up a lot of channels of suppressed emotions and allows healing and problem-solving to replace the isolation that comes with burnout. One beneficial program with a hospital system I worked for was a Commensality group (here is a PDF for a starter toolkit)that met monthly over dinner, supported by the hospital. We talked about work-life issues, burnout prevention and provided support to one another. Here is a YHF article on the benefits of social support.
A study of seventy physicians in NY showed that training programs, amounting to 2 1/2 long sessions, an all-day session, and ten monthly 2 1/2 hour sessions, improved physician well-being, mood, and decreased burnout. There was also a benefit in empathy, something that often suffers in the setting of physician burnout.
Medical Volunteerism and International Volunteer Missions
While volunteer and missionary burnout does occur, sometimes changing the scenery of work can be beneficial for some experiencing these challenges. When a person comes to provide care in a developing country, they realize the rewards of providing care to a community that needs assistance. It can help physicians rediscover the joy of medical care and create a new narrative as they return to their work setting.
As a healthcare worker, your training and experience provide a highly sought-after perspective in a non-clinical position. These jobs include works as a consultant, educator, and supervisor, including writing and editing. It might just be what the doctor ordered (ha!). In a survey of 95 nonclinical faculty who answered the Abbreviated Maslach Burnout Inventory, only 1% of respondents reported high burnout, and 35% percent said a medium amount. These rates of burnout are much lower than clinical providers, which can often be more than half (60%) experiencing burnout.
Burned-out healthcare workers have little energy for hobbies and social activities, let alone ensure that they take care of themselves with proper nourishment, exercise, and sleep. It is incumbent on each person to begin to carve out some time to make each day, both inside and outside of work, memorable.
Please take all of your interests and bring them along with you throughout your life. Many people feel like they can just set aside time to do the things they like most during their retirement. A hobby is not only what helps one achieve satisfaction right now but also provides a greater sense of resilience. Studies support that taking these steps to develop leisure activities can strengthen one’s health and well-being.
I can say that music has truly helped me manage stress and develop creative skills. As much as it is something that I have always loved, playing the guitar truly was a step – and continues to be – out of my comfort zone. It provides me with relaxation, entertainment, and a chance for continued learning.
Summary: Resilience is Possible
Burnout is long-term stress that can manifest as emotional fatigue, depersonalization, and a lost sense of fulfillment.
There are many skills that physicians can develop to protect themselves from burnout and to serve as stewards to support others. The goal is to equip each person with resilience that can not only enhance the care that they provide but also create a more fulfilling experience.
Administrative and Education committees also need to be aware and include resilience programs that address burnout for their workforce. Commensality dinners and mindfulness seminars may be helpful initiatives from these groups. Ultimately, it is essential to frame burnout as a joint endeavor between physicians, practice members, and administration.
References are included as links in the text