Workplace mental health was often hidden in the past due to the stigma of mental illness and fear of discrimination from the employer. Personal life was thought to be separate from work life. Although this issue certainly remains, there are various societal trends that have resulted in employees expecting greater involvement by their employers into their mental health and well-being. These trends include an increased awareness that mental health influences employee productivity, the importance of recruiting and retaining the best talent in a knowledge economy, and constant connectivity, which blurs the line between personal and professional time.1
Burnout is an example of a work-related mental health phenomena that is generating a great amount of interest in health care. The World Health Organization conceptualizes burnout in the International Statistical Classification of Diseases and Related Health Problems, 11th revision, as “a syndrome resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion, increased mental distance from one's job, or feelings of negativism or cynicism related to one's job, and reduced professional efficacy.”2 It is not classified as an illness but it is considered under the chapter “Factors Influencing Health Status or Contact with Health Services.”2 Numerous factors contribute to physicians being at high risk for burnout. Indeed, a recent national study showed that 43.9% of physicians reported at least 1 of 3 symptoms of burnout in 2017.3 This was actually a decrease from the 54.4% who reported one symptom of burnout in 2014. However, this number continues to exceed the general population.3
Burnout has been associated with numerous negative personal and professional consequences to physicians, patients, and health care organizations.4,5 From a health care organization and business perspective, physician burnout is costing organizations $4.6 billion in physician turnover and reduced clinical hours alone or $7,600 per employed physician annually.6,7 An increasing number of physicians are practicing in an employed model of care so the importance of burnout is likely to grow.8 Although addressing both individual and system-level drivers of burnout is important,5 organization level interventions seem to have a greater effect in reducing physician burnout.9
A recommended integrated approach to workplace mental health could be applied to the burnout problem. This integrated approach recommends three steps: (1) “protect mental health by reducing work-related risk factors; (2) promote mental health by developing the positive aspects of work as well as worker strengths and positive capacities; and (3) address mental health problems among working people regardless of cause.”10
This integrated approach follows the primary, secondary, and tertiary prevention approach, which must target both the individual employee as well as organizational-level factors. Primary prevention aims to reduce job stressors by identifying and modifying the job environment. Secondary prevention is “worker-directed and ameliorative” and aims to provide employees with the appropriate skills to cope in stressful conditions and build resilience.10,11 Tertiary prevention is “reactive” and involves treating employees already affected by a mental health condition, and includes rehabilitation and supporting the employee's return to work.11 Primary, secondary, and tertiary interventions are complementary, and a comprehensive approach that encompasses all three levels is most likely going to be needed to manage physician burn-out.10
Given burnout results from chronic workplace stress and the solutions to burnout involve interventions for the individual physician and for organizational drivers of burnout, the occupational and organizational psychiatrist has numerous opportunities to play a key role in the multifactorial solutions that will likely be required to finally improve the physician burnout epidemic. Occupational and organization psychiatry (OOP), also called workplace, industrial, or corporate mental health, is a subspecialty of psychiatry that focuses on the link between mental health and work.1,12 It is a field that is still underrepresented in psychiatry residency training and the number of skilled practitioners remains quite low.12,13 Schouten13 states that “OOP can be divided into issues related to the functioning and health of the larger organization (organizational) and issues related to individual work-related mental health concerns (occupational).” He notes the distinction is not always clear as the overlap between the two groups is complex. The occupational and organizational psychiatrist often works in a consultation model and there are many different capacities and roles in which the practitioner may assist individual employees or organizations.1,14,15
Organizations such as the Center for Workplace Mental Health of the American Psychiatric Association Foundation, the Academy of Organizational and Occupational Psychiatry, and the American College of Occupational and Environmental Medicine, which has formed a new Behavioral Health Section, are involved in providing employees, employers, and payors best practice information to improve the overall mental health of employees and the workplace environment. These organizations also can help develop the occupational skills and knowledge required for clinicians to develop the expertise needed to serve as an occupational and organizational psychiatrist.
In this issue of Psychiatric Annals, the articles describe four interventions where occupational, organizational, and forensic psychiatry can be used to help improve the well-being of the individual physician and the overall health care organization. These interventions are examples of primary, secondary, and tertiary interventions and highlight the integrated approach to achieving workplace mental health. In the first article, “Organizational Approaches to Burnout,” Dr. Gregory Couser and myself describe a consultation model that an organizational psychiatrist could take to help modify the organizational and work-unit drivers of burnout. The article highlights the importance of leadership, culture, workplace efficiency, measurement, and provides specific evidence-based organizational interventions that have been shown to improve well-being. In the second article, “Workplace Violence in Health Care: An Overview and Practical Approach for Prevention,” Dr. Michael Schmidt and colleagues review the critical area of workplace violence in health care settings, particularly violence in behavioral health settings. Mental health workers are at particular risk of violence at work and this rupture in psychological safety can be devastating to everyone involved in the care of our patients.16 Without psychological safety, well-being for the clinician will prove to be illusive. The authors provide an excellent framework for organizational consultation with an illustrative case of the psychiatric emergency department to show how these principles can be used to decrease the risk of violence. In the next article, “The Forensic Evaluation and Rehabilitation of the Impaired Physician,” Dr. Daniel H. Angres and colleagues demonstrate the important role of occupational, forensic, and addiction psychiatry in identifying the causes of physician impairment and the process to restoring functioning. This tertiary intervention highlights how the role of the clinician is not only to improve the well-being of the impaired physician, but also to critically preserve the wellness culture of the entire team that interacts with the impaired physician. In the final article, “Enhancing Physician Wellness Through Coaching: An Occupational Psychiatry Tool,” Dr. Elaine E. Schulte and colleagues describe the use of coaching and the coach approach in helping individual physicians and trainees improve well-being and maximize their strengths. They invite occupational psychiatrists to consider adding this tool to their toolbox as there is increasing focus on coaching in academic medical centers to help with faculty development, leadership development, improved quality of life, and burnout reduction.17,18 I hope readers find these articles informative on how occupational and organizational psychiatry can be useful in achieving physician well-being. However, I especially hope the articles expand our notion as to what constitutes an intervention that falls into the category of “improving wellness.” Although secondary prevention interventions, such as training physicians in mindfulness and self-care habits, are useful, a more comprehensive menu of interventions including primary, secondary, and tertiary prevention interventions will be needed to transform the health care practice environment so that physicians can deliver health care and practice medicine in a sustainable, joyful way.
- Sperry L. An overview of organizational and occupational psychiatry. Hosp Community Psychiatry. 1994;45(8):814–817. https://doi.org/10.1176/ps.45.8.814 PMID:7982699
- World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. https://www.who.int/mental_health/evidence/burn-out/en/. Accessed October 9, 2019.
- Shanafelt TD, West CP, Sinsky C, 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(9):1681–1694. https://doi.org/10.1016/j.mayocp.2018.10.023 PMID: doi:10.1016/j.mayocp.2018.10.023 [CrossRef]30803733
- Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714–1721. https://doi.org/10.1016/S0140-6736(09)61424-0 PMID: doi:10.1016/S0140-6736(09)61424-0 [CrossRef]19914516
- Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129–146. https://doi.org/10.1016/j.mayocp.2016.10.004 PMID: doi:10.1016/j.mayocp.2016.10.004 [CrossRef]
- Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. 2019;170(11):784–790. https://doi.org/10.7326/M18-1422 PMID: doi:10.7326/M18-1422 [CrossRef]31132791
- Shanafelt T, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826–1832. https://doi.org/10.1001/jamainternmed.2017.4340 PMID: doi:10.1001/jamainternmed.2017.4340 [CrossRef]28973070
- Kane CK. Policy Research Perspectives. Updated data on physician practice arrangements: for the first time, fewer physicians are owners than employees. https://www.ama-assn.org/system/files/2019-07/prp-fewer-owners-benchmark-survey-2018.pdf. Accessed October 9, 2019.
- West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272–2281. https://doi.org/10.1016/S0140-6736(16)31279-X PMID: doi:10.1016/S0140-6736(16)31279-X [CrossRef]27692469
- LaMontagne AD, Martin A, Page KM, et al. Workplace mental health: developing an integrated intervention approach. BMC Psychiatry. 2014;14(1):131. https://doi.org/10.1186/1471-244X-14-131 PMID: doi:10.1186/1471-244X-14-131 [CrossRef]248844254024273
- Memish K, Martin A, Bartlett L, Dawkins S, Sanderson K. Workplace mental health: an international review of guidelines. Prev Med. 2017;101:213–222. https://doi.org/10.1016/j.ypmed.2017.03.017 PMID: doi:10.1016/j.ypmed.2017.03.017 [CrossRef]28347696
- Sperry L. Residency education, work-related issues, and organizational and occupational psychiatry. Acad Psychiatry. 1995;19(1):44–45. https://doi.org/10.1007/BF03341417 PMID: doi:10.1007/BF03341417 [CrossRef]27517270
- Schouten RJ. What is organizational and occupational psychiatry?Psychiatr Times. 2004;21(7).
- Kahn J. Organizational and occupational psychiatry: overview and examples. Psychiatr Ann. 2006;36(11):747–753.
- Schouten R. Psychiatric consultation in problem employee situations. Psychiatr Clin North Am. 2012;35(4):901–913. https://doi.org/10.1016/j.psc.2012.08.010 PMID: doi:10.1016/j.psc.2012.08.010 [CrossRef]23107569
- Tattoli L, Bosco C, Grattagliano I, Di Vella G. The risk of assault against mental health professionals: a fatal case report and literature review. Forensic Sci Med Pathol. 2019;15(2):276–280. https://doi.org/10.1007/s12024-019-00105-6 PMID: doi:10.1007/s12024-019-00105-6 [CrossRef]31028573
- Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a professional coaching intervention on the well-being and distress of physicians: a pilot randomized clinical trial. JAMA Intern Med. 2019;179(10):1406–1414. https://doi.org/10.1001/jamainternmed.2019.2425 PMID: doi:10.1001/jamainternmed.2019.2425 [CrossRef]
- Gazelle G, Liebschutz JM, Riess H. Physician burnout: coaching a way out. J Gen Intern Med. 2015;30(4):508–513. https://doi.org/10.1007/s11606-014-3144-y PMID: doi:10.1007/s11606-014-3144-y [CrossRef]4371007