Exhausted tired nurse

Burnout in healthcare professionals, and physicians in particular, was high pre-COVID.

We are hearing stories every day about healthcare delivery professionals being caught up in the intense, long hours necessary to deliver care to COVID-19 patients. There has been an ebb and flow in the intensity and number of patients for just about a year now. Presently, after the end-of-year major holidays, the surge has been as predicted, but at unprecedented levels.

These changes are not just limited to affecting only physicians, either. The delivery of this care involves so many different individuals, all playing an integral part, and it is leading to a significant singular unintended result – burnout.

Let’s start with a definition of “burnout.” Edelwich and Brodsky define burnout as “a state of physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations.” That definition could not describe this pandemic any better, as the effects are so far-reaching, affecting the lives and daily activities of everyone. This writing will focus on the direct and indirect care of patients, and those delivering it.

Is it Just Stress?

We all have stress in our lives, and yes, some have more than others, but how we deal with it varies. Some will handle stress with exercise, talking with others, reading, going to the movies, or taking a vacation. In extreme situations, people may resort to therapy, prescribed medications, alcohol, street drugs, and even suicide. This pandemic has made some of these solutions somewhat unobtainable and insufficient. There is no doubt that stress can be a contributor to burnout. Below are some of the essential characteristics of both.

Stress vs. Burnout
Characterized by over-engagement.Characterized by disengagement.
Emotions are overreactive.Emotions are blunted.
Produces urgency and hyperactivity.Produces helplessness and hopelessness.
Loss of energy.Loss of motivation, ideals, and hope.
Leads to anxiety disorders.Leads to detachment and depression.
Primary damage is physical.Primary damage is emotional.
May kill you prematurely.May make life seem not worth living.

Suffice to say, the stressors are not inherently the cause of burnout – it is the individual’s perceptions and reactions to the stressors that can trigger the burnout cycle.

Is Burnout the Same as Post-Traumatic Stress Disorder (PTSD)?

PTSD is typically associated with military conflict, and not necessarily with workplace challenges. It has been said that in the past, there are generally not-life-threatening situations in the workplace, but that is not the case today. Healthcare workers are being exposed to workplace dangers of many kinds, including contracting COVID, and so many have acquired the disease and become seriously ill or died. Yet they invariably carry on with the performance of their duties, utilizing their skills. Dr Geri Puleo has provided a brief comparison of the similar elements of burnout and PTSD:

“Six characteristics of burnout have emerged that were identical to those associated with post-traumatic stress disorder (PTSD):”

Understanding a Cause of Burnout

I want to take a slightly different way of looking at some of the causes of burnout in a pandemic, some of which are similar to causes in the pre-pandemic era. It is well beyond the scope of this writing to review burnout statistics among healthcare professionals, but the incidence is clearly high.

Burnout in healthcare professionals, and physicians in particular, was high pre-COVID. According to the Cleveland Clinic, “while physician burnout is not new, the pandemic is rapidly accelerating the many negative repercussions of uncertainty and inadequate support, and the consequences are being felt by patients, physicians, and healthcare systems.” 

Although the following paragraphs focus mainly about physicians, it is really all about the entire healthcare continuum. Every part of that continuum has its own story, from pre-hospital care to end-of-life care. And then there are the patients and the families.

Elisabeth Kübler-Ross, MD, in the classic book “On Death and Dying”, talks about the five stages of grief and grieving in illness and death: denial, anger, bargaining, depression, and acceptance. As part of patient care and family support, we have had to learn to help our patients and their families understand their journey through these stages. We must not only know how to help our patients learn how to live, but we also have an obligation to help them learn how to die. Our problem is also this: how do we help ourselves transcend these stages in our personal grieving of patient suffering and loss? You may argue that we cannot allow ourselves the luxury of going through these stages, noting that we must maintain objectivity, but that is not correct. We face them, whether we are aware or not. We owe it to our patients and their families to understand that which we teach. Take a typical day in the life of a practicing physician, pre- and during COVID. In the course of seeing and treating anywhere from 10 to 50 patients every day, the following types of scenarios may occur:

  • Outlining a plan of treatment for a diagnosed illness;
  • Meeting a patient for the first time for an acute illness, and ordering tests and X-rays;
  • Telling a patient that he or she has cancer, and answering the questions of the patient and family;
  • Pronouncing the expected or unexpected death of a patient who we may or may not know and spending time speaking with the family, maybe even crying with them (yes, crying is OK);
  • Telling a patient that he or she is cured of a malady;
  • Going through routine hospital and office visits;
  • Going back to the hospital after office hours to check on a critical or postoperative patient;
  • Calling the intensive care unit upon arriving home to find out how a patient is doing; and
  • Making numerous phone calls and/or going back to the hospital in the middle of the night while on call.

That workload has increased with the pandemic.

We now go from patient to patient to patient, changing emotions, changing mental pathways, constantly, without missing a beat. We never get the time to account for our own emotions and feelings. Doing this day after day after day empties our emotional bank, whether we are aware of it or not, leading to the point of overdraft or even bankruptcy of our own personal ability to continue to deal with the stress. We never allow ourselves to process our grieving, and over time, this “bankruptcy” of emotions can lead to burnout.

We can’t take it anymore. But how do we treat burnout? How do we reinspire our love for what we do? Truly, all healthcare workers are the best at what they do. We must allow ourselves not the luxury, but the necessity, of going through the grieving process. It will help decrease the stress. We need to reignite the fire of passion for the practice of medicine and surgery again. If it is good enough to teach and help our patients, then, as the Bible says, “physician, heal thyself” (Luke 4:23). This advice applies to all healthcare workers; heal thyself.

This may make me sound like a Pollyanna

 I don’t think there is a person reading this article who doesn’t realize that healthcare workers across today’s pandemic continuum are suffering from burnout. I also believe that we understand the “why” it is occurring, but may not internalize it. From the tragic scenes we deal with to the overwhelming number of patients to the lack of personnel available, changing responsibilities, furloughing of staff, lack of equipment and resources, the risks of acquiring the disease, lack of personal protective equipment, fear of spreading the infection to family members, long hours, tragic loss of life, watching patients die alone, etc., etc., etc.; the list goes on and on and on. In addition, the rationing of care is here, and is going to get worse.

This is more than a paradigm shift; it is a life-altering shift. Healthcare workers are a strong group, and will survive this, and become stronger because of it. In her book “Kitchen Table Wisdom,” Rachael Naomi Remen, MD, says it so well: “it is not that we don’t care; we care too much.”

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