Increasing clinical demands, regulatory issues, and documentation requirements have contributed to physicians’ burnout over the past decade, and the COVID-19 pandemic has created additional strain, speakers said during Kidney Week 2020 Reimagined. Now more than ever, they said, clinicians need to practice self-compassion, forge connections, and find ways to alleviate stress.
About 44% of physicians had already experienced at least one manifestation of burnout (1), said Tait Shanafelt, MD, chief wellness officer for Stanford Medicine and associate dean for the Stanford School of Medicine. Then the pandemic changed all aspects of physicians’ personal and professional lives. Traditional sources of physicians’ distress, including challenges with work-life integration and feelings of decreased control over work, have now been joined by concerns about being exposed to the SARS-CoV-2 virus or bringing it home to family members, Shanafelt said. People are feeling isolated and disconnected from their support networks and extended family.
Nephrology itself is a high-burnout field, said Karen Warburton, MD, FASN, FACP, a transplantation nephrologist and associate director of the Clinician Wellness Program at the University of Virginia School of Medicine.
In a Medscape survey (2) ranking burnout by specialty, nephrology ranked third behind urology and neurology, with 49% of those surveyed reporting burnout, Warburton said. Several factors contribute to these feelings, she said. The clinical workload is intense, with nephrologists working long hours treating complex patients. Nephrologists also have considerable administrative burdens, especially in dialysis care. Many work in a highly protocol-driven environment and feel beholden to regulatory agencies. There are numerous quality metrics and requirements for public reporting, and nephrologists may lack control and flexibility at work. On top of that, the specialty is in the midst of a fellowship recruitment crisis.
“Many of us grew up in families where ‘work hard’ or ‘work now, play later’ were either a spoken or an unspoken value,” Warburton said. “These values often drive us to work to the point of burnout without being aware that we’re even doing this.”
There also are personality traits that contribute to burnout (3), she said, such as feelings of doubt or guilt or an exaggerated sense of responsibility. “This leads us to blame ourselves for things that are out of our control,” she said. Physicians also tend to be independent to a fault and have difficulty saying no or asking for help. Additionally, many are perfectionists. Pessimism can cause physicians to give more weight to negative experiences over neutral or positive ones. Family stressors and work–home interference also can contribute to burnout.
Physicians may not be able to change some of these factors, Warburton said, “but we can be mindful of them and how they impact how we look at things and the choices we make.”
Strategies to reduce burnout
There are strategies that both organizations and individuals can adopt to reduce burnout, the speakers said. During the pandemic, employers can listen and create feedback channels that enable physicians and other healthcare workers to share what they need (4, 5), Shanafelt said. They can provide support for tangible needs like child care, and they can relax some career milestones, like extending the promotion clock while workers care for their families. They can provide emotional support for employees, especially those who quarantine, and they can recognize that people deal with stress differently and encourage people to work together.
In the longer term, they can commit to mitigating burnout through actions like establishing leaders to drive improvement. They can develop strategies and infrastructures to change the work environment and measure their initiatives to assess progress.
On the personal side, physicians can be most effective by focusing their energy on things they can control, Warburton said. Problem-focused coping skills include actions like better time management, delegating tasks or saying no, and developing a mentorship network, even if it is virtual. Seek adequate administrative support, she said, and find meaning at work.
Finding meaning at work can be healing, Warburton said. Studies by Shanafelt and others have shown this can contribute to lower burnout, higher well-being, and a better quality of life. Physicians should consider what they most enjoy about work so they can better cope with activities that may be less enjoyable. A Mayo Clinic study (6) found that those spending less than 20% of their time on activities they found most meaningful had higher rates of burnout, Warburton noted. Making sure they spend at least 20% of their time doing rewarding work can get physicians through the rest of the week, she said.
There also are emotion-focused coping skills clinicians can use to better handle things outside of their control, Warburton said. This includes accepting things they cannot change and allowing for mindfulness and self-care. Many people have narrow views of self-care, thinking that it’s limited to going to yoga or coloring, she said, but there are many ways to practice self-care, such as spending time with family and friends, exercising, or taking a few minutes in the day for guided meditation.
Embracing a culture of positivity also can help, Warburton said. Write down three things you are grateful for each day, take time to write thank-you notes or emails, and post thank-you letters from patients and families in work areas for all to see.
Finally, she said, practice self-compassion.
“This practice is one of the most important parts of achieving well-being and can be really hard for us,” Warburton said. “Self-compassion is not about ignoring our mistakes or shortcomings, or ruminating on them, but rather using them to grow….It’s about recognizing that life is hard and we’re doing our best, and beating ourselves up or shifting the blame to others doesn’t help anyone.”
Self-compassion is critically important during this challenging time, Shanafelt said. Prioritize taking care of yourself and calibrating your stress level (7).
Embracing the mindset of “good enough”
“We have to embrace the mindset of good enough right now,” Shanafelt said. “There are things in the world that we can’t fix….We can’t replace everything [children] are not getting at school and in relationships, and we need to just accept that, do the best we can, recognize that this season will pass, and not hold ourselves to unrealistic expectations.”
There are predictable chapters to experiencing a disaster (8). The healthcare community went through initial stress and was inspired by the heroism of colleagues. Now we’re in a long chapter of “post-honeymoon disillusionment,” he said.
“It can take more than a year to go through recovery, even in short emotional disasters, and recovery is nonlinear,” he said. “We often make progress, then take steps back. Be patient with yourself, your colleagues, and your organization as we go through this seesaw.”
References
- 1.↑
Shanafelt TD , et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clin Proc 2019; 94:1681–1694. doi: 10.1016/j.mayocp.2018.10.023
- 2.↑
National physician burnout & suicide report 2020. The generational divide. Medscape. https://www.medscape.com/sites/public/lifestyle/2020. Accessed Nov. 1, 2020.
- 3.↑
Spickard A , et al. Mid-career burnout in generalist and specialist physicians. JAMA 2002; 288:1447–1450. doi: 10.1001/jama.288.12.1447
- 4.↑
Shanafelt T , et al. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020; 323:2133–2134. doi: 10.1001/jama.2020.5893
- 5.↑
Shanafelt TD , et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc 2016; 91:422–431. doi: 10.1016/j.mayocp.2016.02.001
- 6.↑
Shanafelt, TD , et al. Healing the professional culture of medicine. Mayo Clin Proc 2019; 94:1556. doi: 10.1016/j.mayocp.2019.03.026
- 7.↑
Shanafelt TD , et al. Career fit and burnout among academic faculty. Arch Intern Med 2009; 169:990–995. doi: 10.1001/archinternmed.2009.70
- 8.↑
Phases of disaster, from DeWolfe DJ. Training Manual for Mental Health and Human Service Workers in Major Disasters (2nd ed., HHS Publication No. ADM 90-538). Substance Abuse and Mental Health Services Administration (SAMHSA). https://www.samhsa.gov/dtac/recovering-disasters/phases-disaster. Accessed Nov. 1, 2020.
