Before the COVID pandemic, the medical community in general, and physicians in particular, were dealing with and continue to deal with a pandemic of its own: Burnout. In 2019, burnout was categorized as a disease by the WHO. It is characterized as:
“…a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”
There are 3 dimensions of burnout:
If someone is suffering from any of these dimensions, they are considered burned out. Unlike depression or other mental health diagnoses, burnout is mostly an occupational phenomenon. This is particularly important when examining the effects of COVID on burnout. If any of the factors that lead to burnout is impacted in a negative way, then the impact on burnout is transferrable to the physician. In simple terms:
If A (Causes) leads to B (Burnout), and C (COVID) increases the magnitude of A, then the outcome, B, is also increased.
So let me divide the rest of this blog into three parts: A, B, and C.
Review of the literature identifies several factors that contribute to burnout. When Christina Maslach developed the Maslach Burnout Inventory, she described the three main causes of burnout:
From: Maslach C, Zimbardo PG. Burnout: The Cost of Caring. 2003. Malor Books. Lost Altos, CA.
According to a Medscape survey, the translation of these categories in medicine in terms of measurable and identifiable factors have been proven/shown in numerous studies; they include the following:
According to the AMA and research conducted by Medscape, the following risk factors impact burnout:
From: Shanafelt, T et al. Impact of Organizational Leadership on Physician Burnout and Satisfaction. Mayo Clinic Proceedings. 4/2015 90(4): p. 432-440 4. Swensen, S., et al.
The expression goes: “People quit their bosses, not their jobs.” We know now that poor leadership makes for higher burnout.
According to psychologists Herbert Freudenberger and Gail North (Jan. 2019), burnout goes through a 12-stage model:
How these 12 stages manifest are effectively summarized in one of several landmark studies by Tait Shanafelt.
Adapted from: Balch CM, Freischlag JA, Shanafelt TD. Stress and Burnout Among Surgeons: Understanding and Managing the Syndrome and Avoiding the Adverse Consequences. Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575.
When COVID hit the healthcare industry, it impacted all of the causes listed above in the following way:
COVID also increased moral injury. “Moral injury refers to an injury to an individual's moral conscience and values resulting from an act of perceived moral transgression, which produces profound emotional guilt and shame, and in some cases also a sense of betrayal, anger, and profound ‘moral disorientation.’”
Physicians have had to practice medicine below the normal standards of care; they were allowed to do so. Whereas it might have been the safer approach, it impacted them in a negative way because they were providing subpar care, and that caused them to be morally injured. According to psychologists, moral injury intersects with PTSD in certain aspects, as diagrammed below.
The literature has shown that COVID has:
Dealing with one pandemic was problematic for the healthcare industry. Adding COVID to it is really stressing physicians. More physicians are thinking of leaving the profession, and fewer are thinking of entering it in the first place. While most of the focus has been to protect this workforce from COVID, the chaotic scenes from the beginning of the pandemic, the toll it is taking and has taken and will continue to take, the plethora of its signs and symptoms, the uncertainties facing it now, and the unknowns of the future remind us of the more deadly burnout pandemic. On average, one physician commits suicide on a daily basis. The last thing burnout needs is something to make it worse.
This sacred profession is under attack. Thankfully, there is a tremendous increase in awareness and the future looks brighter now than it ever did. For that and so much more, many thanks, prayers, and love are shared with each and every physician. Thank you for all that you do. This world is a much better place because of your dedication, resilience, tenacity, love of human life, and your unrelenting promise to help others.