Psychiatric Annals

CME Article 

Burnout and Suicide Among Physicians During Times of Stress

Nidal Moukaddam, MD, PhD; Kimberly Parks, MD; Hai Le, MD; Lubna Khawaja, MD; Asim A. Shah, MD

Abstract

Burnout is a significant problem for health care professionals. Burnout, which consists of exhaustion, detachment/cynicism, and reduced sense of personal efficacy, can render the practice of medicine untenable and lead to job turnover, medical errors, and instability in the medical system. Moreover, burnout can develop into depression and lead to suicide. The burnout rate for practicing physicians in the United States was already high before the coronavirus 2019 pandemic, and the pandemic has exacerbated the factors underlying burnout by increasing isolation, workload, and uncertainty, as well as a potential clash of organizational decisions with personal safety. Achieving effective strategies to combat burnout and protecting physicians and health care workers from depression and suicide should be a priority for all systems. Early detection and referral to treatment as well as de-stigmatization of treatment are crucial. Additionally, expanding the conversation about the role of structural and organizational changes in promoting wellness is essential, as effective and consistent leadership can help tremendously when combined with individual efforts toward work-life balance. [Psychiatr Ann. 2020;50(12):536–541.]

Abstract

Burnout is a significant problem for health care professionals. Burnout, which consists of exhaustion, detachment/cynicism, and reduced sense of personal efficacy, can render the practice of medicine untenable and lead to job turnover, medical errors, and instability in the medical system. Moreover, burnout can develop into depression and lead to suicide. The burnout rate for practicing physicians in the United States was already high before the coronavirus 2019 pandemic, and the pandemic has exacerbated the factors underlying burnout by increasing isolation, workload, and uncertainty, as well as a potential clash of organizational decisions with personal safety. Achieving effective strategies to combat burnout and protecting physicians and health care workers from depression and suicide should be a priority for all systems. Early detection and referral to treatment as well as de-stigmatization of treatment are crucial. Additionally, expanding the conversation about the role of structural and organizational changes in promoting wellness is essential, as effective and consistent leadership can help tremendously when combined with individual efforts toward work-life balance. [Psychiatr Ann. 2020;50(12):536–541.]

The term “burnout” in regard to physicians was coined by Freudenberger in 1974,1 and further refined conceptually in 1981 by Maslach and Jackson2 as “a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do ‘people work’ of some kind.” Burnout consists of three subscales: emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment. In 2019, it was classified as an occupational phenomenon, with its own code in the International Classification of Diseases and Related Health Problems, eleventh edition (ICD-11)3 (Figure 1).

Components of burnout according to the World Health Organization.31

Figure 1.

Components of burnout according to the World Health Organization.31

The last decade has seen much needed publicizing of the issue of physician burnout, with surveys indicating that 44% of physicians meet burnout criteria.4 Disturbingly, burnout starts in medical school and continues through residency and fellowship training. National or multi-institutional studies have found that 35% to 45% of medical students had high emotional exhaustion, 26% to 38% had high depersonalization, and 45% to 56% had symptoms suggestive of burnout.4 The prevalence of high emotional exhaustion continues in residency, with higher prevalence of depersonalization (32%–38%) and overall burnout (60%).5

Outside the field of health care, assessment of stress and related burnout belongs to the field of occupational stress disorders. Burnout is an occupational stress disorder stemming from the imbalance between the rewards and fulfilment offered by the job, and the cognitive and physical demands of said job. For physicians, about 80% of burnout can be linked to unfavorable work environment in which physicians work and only 20% to personal factors.6 The coronavirus 2019 (COVID-19) pandemic has exacerbated this imbalance drastically (Figure 2).

Factors contributing to burnout and exacerbated by the coronavirus 2019 pandemic.

Figure 2.

Factors contributing to burnout and exacerbated by the coronavirus 2019 pandemic.

Prior to the COVID-19 pandemic, burnout among physicians was already high. The rate of burnout among physicians was also higher than that of other professions.6 The lack of national data on physician burnout prior to 2011 makes it difficult to have a bird's eye view of this important issue, but recent estimates suggest the rate has been trending upward, with more than one-half of practicing physicians in the United States having one or more burnout symptoms. The higher rate of burnout among physicians in the past decade is likely not a coincidental finding, as medical practice has gone through dramatic changes from individual to system level during the same period. The implementation of electronic health records and new reimbursement models, lead both directly and indirectly to to a variety of factors contributing to higher rates of physician burnout. These include financial pressure, productivity pressure, increased workload, clerical burden, decreased autonomy, “click burnout,” dehumanization in medical practice, and erosion of meaning in work. Physicians now spend two-thirds of their time on clerical work or electronic health record-related tasks. Only 1 in every 3 hours is spent on performing direct clinical work.7

If not addressed appropriately, the presence of sustained burnout has important repercussions on the health care delivery system such as higher risk of medical error, job dissatisfaction, higher turnover rate, decreased quality of care, increased risk of substance abuse, and suicide.8,9 The effect of burnout on the health care workforce has been studied extensively over the past 20 years. Burnout raises risk of medical issues, including cardiac disease,10 in the person suffering from burn out, presumably via increased inflammation; the extent of nonspecific inflammation correlates with the job demands–resources model score.11 With increasing exhaustion (the first step of burnout) comes increasing errors,12 and with sustained burnout people start detaching from their environment and their patients, prompting potential to move or make a career change.13

Despite recent efforts to raise awareness of physician burnout, discussing and seeking help for burnout among individual physicians remains a taboo subject in the medical community. Medical education, residency training, and the overall culture of medicine normalize and even idolize high tolerance of stress. It is common that physicians hesitate to talk about their burnout symptoms for fear of being perceived by their colleagues as weak. Practicing physicians also have other reasons to delay help. Licensing boards across the country require detailed disclosure of any mental health diagnosis or treatment that may affect a physician's decision-making or performance. For many physicians, the fear of losing their medical licenses is combined with worry that they will not get clearance from medical boards once they disclose burnout-related treatment.14

How the COVID-19 Pandemic Has Affected Drivers of Burnout

Drivers of physician burnout have been divided into seven dimensions within the modern workplace, representing the interface between personal and organizational influences on the development of burnout symptoms: (1)work overload and job demands, (2) lack of efficiency and resources, (3) lack of control over work, (4) suboptimal work-life integration, (5) nonalignment of personal and organizational culture and values, (6) breakdown of community, and (7) the degree of meaning derived from work15 (Figure 2).

The COVID -19 pandemic has negatively affected many of these drivers of physician burnout. The pandemic has inflicted worldwide medical and psychological distress to the general population, but more so to the frontline health care workers, particularly in geographical areas with the highest rates of infection, resulting in distress, anxiety, insomnia, and depression to this group of frontline workers.16 Physicians on the frontlines have seen exhausting increases in their workload, lack of access to proper personal protective equipment, dealing with sick and dying patients, trying to make sense of conflicting guidance on disease diagnosis, prevention and treatment, and social isolation causing breakdown of community of colleagues. Physicians have also had to acquire new technological skills as they learn how to conduct effective telemedicine visits. Excessive media coverage and confusion due to mixed messages regarding the disease also further worsened the anxiety. Excessive health anxiety was widespread when many aspects of the disease were still unknown, even to health professionals. People commonly misinterpreted unrelated bodily symptoms to contracting COVID-19, further heightening anxiety. Multiple past epidemiological studies linked people's distress and anxiety with higher risk of sleep disturbances, which is the second most common symptom of mental distress.17 Although health care workers did not face unemployment or the risk of it at the same magnitude as the rest of the country, physician groups performing elective surgeries and procedures suddenly saw their revenue stream quickly dry up, and occupational and financial uncertainty is strongly associated with mental health deterioration.18 In addition to distress endured by the general population, the pandemic also caused unprecedented psychological burden on physicians with relentless waves of patients presenting for care. In some parts of the US, health care systems were overwhelmed with new COVID-19 cases in the period from March to May 2020.19

The struggles of the public can also affect physician burnout by affecting people in our social circles: the US witnessed a dramatic jump in unemployment rates, and job losses and the economic and financial fallout affected the nation's mental health. Mass layoffs and prolonged unemployment (defined as a period of 15 to 26 weeks) increase suicide risk among people who are unemployed;20 therefore, patients are now more fragile than ever. Strategies deployed during this pandemic, such as mass lockdown and social restriction, lead to prolonged isolation and confinement, causing universal anxiety and distress, which resulted in increasing need for counseling and depression treatment, overwhelming mental health providers. Similar to past outbreaks of highly contagious diseases, there have been higher levels of anger, frustration, irritation, depression, anxiety, loneliness, and suicide.21

During the onset of the COVID-19 outbreak, virus testing capacity presented another major public health hurdle at most hospitals, effectively removing a highly useful tool that could have significantly improved patient care and safety as well relieving some psychological burden on physicians. Health care professionals already faced a high level of burnout prior to the COVID-19 pandemic, and were now burdened with an extra workload of treating a poorly understood disease while poorly equipped to do their job. Not only do they have a fear of contracting the virus themselves, they also have the fear of bringing the virus home to their families. An analysis of data from US and United Kingdom showed frontline health care workers “with a nearly 12-times higher risk of testing positive for COVID-19 compared with people in the general community.”22

The upheaval caused by this pandemic has upended many norms in medicine. Clinicians in the US, where shortages of medical resources are not commonly seen, faced unprecedented moral and ethical dilemmas once thought unimaginable when treating severe cases of COVID-19. With a shortage of ventilators and intensive care beds, physicians were forced into making triage decisions that they had never had to make before, and there was no textbook or guideline to which they could turn. Numerous physicians reported witnessing COVID-19 patients dying in the emergency department because there were not enough providers or hospital beds. Helplessly witnessing COVID-19 patients rapidly deteriorating and dying in an overwhelmed and unprepared health care system further traumatizes the physicians and exacerbates feelings of hopelessness. Social restriction during the pandemic also removed the much-needed interpersonal aspect of medicine. When patients' family and friends were not allowed to be with them due to hospital policy, clinicians further extended their role into providing emotional comfort in what could be patients' last moments of their life. Sometimes, these treating physicians feel guilty that their patients “died alone.”

Burnout and Suicide

Burnout is not categorized as a distinctive mood disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition,23 and it is an occupational phenomenon, not a medical diagnosis, in the ICD-11.3 Whether burnout should be considered a distinct syndrome or a subtype of depression remains a subject of debate. A 2016 cross-sectional study by Wurm et al.14 investigating symptom overlap of burnout and depression showed “depressive symptoms are particularly important in the process of burnout as severe burnout is likely to be a form of depression and the means of all ten depression items increased gradually between unaffected, mildly burnt-out, moderately burnt-out, severely burnt-out and depressed physicians.”

Burnout, depression, suicidal ideation, and completed suicide can be linked together. Although lifetime prevalence of depression among physicians is similar to that of the general population, their suicide rate is alarmingly high: “1.5 to 3.8 times higher among male physicians and 3.7 to 4.5 times higher among female physicians as compared with the general population.”24 Another sad statistic is that, on average, about one physician or medical student completes suicide every day in the US.22 This number has remained steady over the last decade despite interventions. Of all completed suicides, depression and substance abuse are the most common associated psychiatric diagnoses.24,25

Unlike other professions, higher level of education is not a protective factor in burnout among physicians. The risk of suicide and suicidal ideation dramatically increases once medical graduates enter residency training, going from 4% before internship to 25% during intern years.25 Sadly, the risk of suicide continues to rise after residency training and is at its highest among physicians in late middle age.25

There are several different theories used to predict suicide independent of depression. The interpersonal psychological theory of suicidal behavior is helpful in modeling suicidal behavior.26 Thwarted belongingness, perceived burdensomeness, and acquired capability are all needed to become suicidal and to make an attempt. More recent studies have shown that this model can also be applied to suicidal behavior in physicians.27 Perceived burden relates to financial debt, feelings of responsibility toward their patients and themselves, role conflict, burnout, emotional distress, and mental health issues. As we have discussed, burnout is likely to increase and is already elevated among physicians.28 The addition of the stressors of the pandemic with new moral and ethical dilemmas to face that can lead to increased risk of depression can add to their perceived burden. Thwarted belongingness is a failed sense of belonging. Our feeling of belongingness arises from multiple areas of our lives, including colleagues, team, family, and friends. The isolation and quarantine measures placed on the population would contribute to a decreasing sense of belonging.

Finally, acquired capability relates to the decreased fear of pain and death needed to actually attempt suicide. Physicians have a unique training environment that involves facing injury, pain, and death.29 Further research has shown that provocative work events and provocative and painful events outside of work can account for acquired capability.27 In these extraordinary times, making decisions about allocation of limited resources, moral dilemmas, and the increased deaths associated with the pandemic could all potentially create acquired capability.

Using the interpersonal psychological theory of suicidal behavior, physicians continue to be at an increased risk of suicidality compared to the general population (Figure 3). A few unfortunate cases have already come to light. In the authors' opinion, without intervention and support, there will be more physicians lost during the COVID-19 pandemic.

Approach to burnout, depression, and suicide.

Figure 3.

Approach to burnout, depression, and suicide.

Personal and Organizational Strategies to Prevent or Overcome Burnout

As negative workplace factors are the major drivers of physician burnout, it is crucial that organizational strategies are developed and implemented to eliminate these. Some organizational strategies already implemented at the medical school/residency training level include (1) innovative wellness curricula increasing awareness of burnout and self-care, (2) new educational strategies like adopting pass/fail grades in preclinical years and reorganizing students into smaller learning communities, (3) implementation of the ACGME-CLER (Accreditation Council for Graduate Medical Education—Clinical Learning Environment Review) pathway in 2014, which was designed to evaluate and improve the clinical learning environment within US teaching hospitals, medical centers, and health systems. The goal of CLER initiatives is to ensure that residents have effective supervision, work in a supportive culture, and have a manageable workload, all of which have the potential to reduce burnout.

Research has shown that the most important personal strategy to avoid burnout is to identify the part of medical practice that is especially meaningful to the person and overtly aligned with his or her own core values, and then to devote 20% of work time to that part to maintain meaning in their practice of medicine. Some of the proven and novel strategies like adopting healthier lifestyles, exercise routines, meditation, mindfulness activities, yoga, and hobbies outside of medicine are increasingly finding a place in many physicians' routines and are essential to finding balance,9 but they do not alleviate a toxic work environment. Another important strategy is focusing on family and maintaining social interactions both in and out of the workplace.

Effective organizational strategies to decrease burnout for physicians in practice have proven more elusive. Many hospitals and health care organizations have put in place “wellness programs” and appointed “chief wellness officers” in an attempt to address burnout. Whether these interventions meaningfully decrease physician burnout remains to be seen. In essence, as burnout is the result of an imbalance between demand, resources, and the person's effort, a change in structure is often needed to produce a happy workforce. The transactional aspect of burnout is important to keep in mind, and interventions have to incorporate personal improvement as well as organizational structural efforts.

Many organizations are trying to prevent the physician burnout problem by exploring strategies to lessen the impact of COVID-19–related stressors. The American Medical Association's public health message “Caring for our caregivers during COVID-19”30 has detailed many of these initiatives. They include assessing physician stress and identifying specific drivers, paying attention to workload redistribution, providing social support through “connection groups” via video conferencing tools, and providing mental health support hotlines.

Following the initial surge of COVID-19, a brief lull has been replaced by a stark second wave. As with other traumatic events, we have only seen the more immediate effects of the pandemic on burnout. Only time will tell whether the strategies discussed here work to lessen physician burnout in the long term.

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Authors

Nidal Moukaddam, MD, PhD, is an Associate Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Kimberly Parks, MD, is an Assistant Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Hai Le, MD, is an Assistant Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Lubna Khawaja, MD, is an Assistant Professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine. Asim A. Shah, MD, is the Barbara & Corbin J. Robertson Jr. Chair in Psychiatry, the Executive Vice Chair, and the Professor of Psychiatry, Family and Community Medicine, Baylor College of Medicine; the Chief of Psychiatry, Ben Taub Hospital/Harris Health System; and the Chief, Division of Community Psychiatry & Director of Mood Disorder Research Program, Ben Taub Hospital.

Address correspondence to Asim A. Shah, MD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Room 2.125, Neuropsychiatric Center, 1502 Taub Loop, Houston, TX 77030; email: aashah@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20201103-02

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