Justin Bullock, MD, MPH, a nephrology fellow at the University of Washington, is very open about living with bipolar disorder with his colleagues and patients. He wears a jacket that identifies himself as a “doctor with a disability,” which often opens the door to positive patient conversations. “Patients seem so much more comfortable after they ask me about it,” Bullock said in an interview with Kidney News. “It makes them feel I’m more of a human, less of a robotic doctor.”
He says that feeling like he can be himself at work and open about his mental health makes him a better physician. He uses the intense focus and ability to sometimes operate on less sleep that comes with his condition, and he is also able to better connect with patients with kidney diseases who are often facing enormous health challenges and coping with their own mental health struggles.
During a Kidney Week 2023 presentation, Bullock shared his view that nephrology can leverage clinician mental wellness to serve patients better (1). His advocacy reflects a growing reckoning in medicine with how systems and culture may impair clinician well-being, fueling burnout, attrition, and poor patient care. The US Surgeon General (2) and the National Academy of Medicine (3) have published reports highlighting the need to better support clinician wellness and have provided roadmaps for institutional change. Some training programs and workplaces are already implementing changes at their institutions to streamline administrative burdens, give physicians greater autonomy, and emphasize clinician wellness.
“When physicians feel like they’re working for an organization that has values consistent with their own values, that decreases burnout and increases professional fulfillment,” said Mickey Trockel, MD, Director of Evidence Based Innovation for the Stanford University School of Medicine WellMD Center. “When physicians are working in an environment with policies and procedures that make sense and increase efficiency, they’re less likely to experience burnout as well.”
Preexisting conditions
Burnout, exhaustion, and moral distress were preexisting conditions in the health care workforce when COVID-19 hit, driving many clinicians closer to the breaking point, according to the US Surgeon General's advisory (2). A 2019 National Academy of Medicine report found that 34% to 54% of nurses and physicians and 45% to 60% of medical students and residents reported symptoms of burnout (4). “Physicians are more likely to reduce their hours or leave their place of practice if they are burnt out,” Trockel said.
Burnout and poor work environments contribute to work–personal life conflicts and higher rates of anxiety and depression among clinicians, according to the Surgeon General's report (2). Patient care often suffers, with studies linking burnout, poor clinician well-being, and resulting sleep disturbances with more patient complaints and medical errors that cause patient harm (5, 6).
Nephrologists are not immune to these challenges. A 2020 survey found that 30% of first- and second-year nephrology fellows reported burnout; 28%, emotional exhaustion; and 14%, feelings of depersonalization (7). Women and fellows who reported work–life conflicts or dealing with disruptive behavior from other physicians were more likely to experience burnout. “Nephrology is unique in requiring collaborative efforts with so many other health care professionals,” said the survey's lead author Varun Agrawal, MD, FASN, associate professor of medicine (nephrology) at The Robert Larner, M.D., College of Medicine at the University of Vermont in Burlington. “There are a lot of opportunities for differences of opinion or disagreements in nephrology.”
Approximately one-third of fellows also reported depressive symptoms in the survey. Factors linked with depressive symptoms were lack of social support and strong department leadership and a poor work–life balance. In a 2021 survey, nephrology fellows also frequently reported moral distress—when a physician feels they cannot take the ethically appropriate action (8). Providing dialysis care that they felt was futile or not beneficial to the patient was a source of moral distress for three-quarters of the trainees. Moral distress contributes to burnout; almost 30% reported that they had thought about leaving their fellowships, and 1 in 10 was considering quitting when they completed the survey. In fact, 2022–2023 Accreditation Council for Graduate Medical Education data show that nephrology fellows account for one in five of the internal medicine fellows who withdraw before completing their fellowships (9).
“Burnout and depressive symptoms in nephrology fellows highlight the need for optimal support of mental health and well-being,” Agrawal said. “One may wonder if burnout in nephrology plays any role in fewer residents wanting to get into nephrology, fellows staying in training, or attendings leaving nephrology practice, when compared with other specialties.”
Another survey of 457 nephrologists, published in 2022, found that one in four reported experiencing burnout; 21%, emotional exhaustion at least once a week; 9%, depersonalization at least once a week; and 7%, both emotional exhaustion and depersonalization both weekly or more often (10). Those who reported burnout said their work hours, burdensome electronic medical record requirements, lack of time with family and friends, and clinic workloads were the main drivers. Other contributors described a decreased sense of autonomy, lack of sense of purpose or connection with work, low reimbursements or the financial strain, and lack of focus on patient well-being.
Trockel reflected that the culture of medicine may contribute to burnout. He noted lack of self-compassion—a culture that condemns errors or imperfections rather than supporting growth—and that perpetually deferring self-care affects physicians more than other fields. Additionally, physicians face a greater likelihood of work–life conflict. All of these factors can contribute to burnout or poor mental health. “Doctors are humans, and humans experience depression,” Bullock said.
But the culture of medicine or stigma associated with mental health conditions in the field can be barriers to seeking help, Bullock explained. Physicians often pride themselves on pushing through difficult situations, and physicians are often portrayed in the media as being unaffected by the difficulties they experience, which may discourage help-seeking, he noted. “We’re often praised for being great in some way; it makes people very hesitant to want to ask for help and get help. What turns out to be a small problem can amplify to a bigger problem because there's societal judgment around mental illness, but then there's certainly judgment [in the field of medicine] that's on top of that,” Bullock said.
Culture of care
Fostering cultures that emphasize care for physicians and their well-being can help. Trockel noted that when Stanford began offering a specialized mental health service for residents and fellows over 1 decade ago, approximately 50 to 60 trainees took advantage of the service the first year (11). But last year, 300 used the service. He noted that increased awareness and reduced stigma have led to greater uptake. “The difference in stigma comes from people getting help, then telling their friends, and seeing the fears they had about bad things happening are unfounded,” he said.
One fear that has held some physicians back from seeking mental health is that they may worry it could affect their licensure. However, Trockel explained that most states have updated their licensure requirements to prevent this, and he is not aware of any trainees who have used the service and encountered problems with licensure. Dozens of medical associations are also lobbying for reauthorization of the 2022 Dr. Lorna Breen Health Care Provider Protection Act, which made $103 million available to 44 health care organizations to implement clinician well-being programs and for additional changes to protect physicians who seek mental health help (12). The law honors an emergency department physician who died by suicide during the pandemic.
The 2020 survey results also point to potential factors that may protect nephrologists against burnout or poor mental health (7). For example, this survey of nephrology fellows found that having social support, good work–life balance, and strong program leadership were associated with lower rates of burnout or depressive symptoms. Agrawal and coauthors noted that some fellowship programs are experimenting with new models, such as having “nephro-hospitalists” who focus on handling in-patient consultations for a specific part of the hospital, restructuring how fellows manage night calls, or adding nonteaching clinicians such as nurse practitioners or physician assistants to help support the nephrology service. “Program directors have to come up with novel, creative ways of supporting fellows through the nephrology program and helping them achieve a good balance between their work and personal lives,” he said.
Bullock said that he paid careful attention to how programs treated their fellows when choosing a program. He had selected his fellowship program at the University of Washington because he felt comfortable being open about his bipolar disorder during the application and interview process. He also felt supported by Cary Paine, MD, program director of the Nephrology Fellowship Program at the University of Washington, who became the director of the fellowship program shortly before Bullock's arrival and worked with him to develop a plan for managing any issues related to his condition. “It felt like he cared about ‘Justin’ as a person,” Bullock said. Creating environments in which fellows feel like they can be their authentic selves and are comfortable asking for what they need is essential, he reflected.
Paine said that the program prioritizes fellow and faculty well-being. If someone needs time off, he prioritizes that over staffing. That approach is made possible by institutional and division leadership support, staffing redundancy, and a jeopardy coverage pool, he said. He also noted that it is essential that the division is not overly reliant on the fellows. He said attendings in the program are willing to step in and do not feel fellows’ work is beneath them. “It's important for fellows to be integral to the team, but the system has to be able to operate and not crumble when a fellow is absent,” Paine said.
Bullock said not being able to do things that are important to you is a big driver in burnout in fellows. But feeling that your requests are taken seriously and granted, when possible, helps and makes it easier to accept when the answer is no. “When you feel like your team will go to bat for you, then you’ll go to bat for your team,” he said.
Many resources are available for programs and program directors who want to improve the well-being of faculty and trainees. Trockel highlighted the Surgeon General's report and recommendations (2). The National Institute for Occupational Safety and Health's Impact Wellbeing program, which was developed in coordination with the Dr. Lorna Breen Heroes Foundation, details evidence-based interventions to help institutional leaders build health systems in which health care workers thrive (13). Programs like Stanford's WellMD program (11), which studies and advocates for institutional approaches to improve clinician well-being, and conferences like the American Conference on Physician Health or the International Conference on Physician Health also provide information on best practices and emerging research.
Bullock emphasized that taking these steps is essential to improving patient care: “If we cannot care for the mental and physical health of [ourselves and our colleagues], then I don't believe that it is ever possible to be able to do so effectively for patients.”
References
- 1.↑
Bullock JL. Leveraging provider personal experience with mental illness in the care of people with kidney diseases. American Society of Nephrology, Kidney Week 2023. November 2, 2023. https://www.asn-online.org/education/kidneyweek/2023/program-session-details.aspx?sessId=448444
- 2.↑
US Department of Health and Human Services. Addressing health worker burnout: The Surgeon U.S. General's advisory on building a thriving health workforce. May 23, 2022. Accessed February 26, 2024. https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf
- 3.↑
National Academy of Medicine. National plan for health workforce well-being. October 2022. Accessed February 27, 2024. https://nam.edu/initiatives/clinician-resilience-and-well-being/national-plan-for-health-workforce-well-being/
- 4.↑
National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. The National Academies Press; 2019. https://nap.nationalacademies.org/catalog/25521/taking-action-against-clinician-burnout-a-systems-approach-to-professional
- 5.↑
Trockel J, et al. Assessment of the relationship between an adverse impact of work on physicians’ personal relationships and unsolicited patient complaints. Mayo Clin Proc 2022; 97:1680–1691. doi: 10.1016/j.mayocp.2022.03.005
- 6.↑
Trockel MT, et al. Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. JAMA Netw Open 2020; 3:e2028111. doi: 10.1001/jamanetworkopen.2020.28111
- 7.↑
Agrawal V, et al. Burnout and emotional well-being among nephrology fellows: A national online survey. J Am Soc Nephrol 2020; 31:675–685. doi: 10.1681/ASN.2019070715
- 8.↑
Saeed F, et al. Frequency and severity of moral distress in nephrology fellows: A national survey. Am J Nephrol 2021; 52:487–495. doi: 10.1159/000516575
- 9.↑
Accreditation Council for Graduate Medical Education. Data Resource Book: Academic Year 2022-2023. ACGME; 2023:114. https://www.acgme.org/globalassets/pfassets/publicationsbooks/2022-2023_acgme_databook_document.pdf
- 10.↑
Nair D, et al.; National Kidney Foundation Education Committee. Burnout among nephrologists in the United States: A survey study. Kidney Med 2022; 4:100407. doi: 10.1016/j.xkme.2022.100407
- 12.↑
American College of Emergency Physicians, et al.Letter to Senators Kaine and Young and Representatives Wild, Kiggans, Dingell, and Carter. February 15, 2024. Accessed February 27, 2024. https://cdn.ymaws.com/www.renalmd.org/resource/resmgr/2024/congressional_comms/Lorna_Breen_Health_Care_Prov.pdf
- 13.↑
National Institute for Occupational Safety and Health (NIOSH). Impact Wellbeing. Centers for Disease Control and Prevention. Accessed February 27, 2024. https://www.cdc.gov/niosh/impactwellbeing/default.html
