Maintaining physician wellness is critical to our nation for surviving the COVID-19 pandemic. Physician burnout is not new, but it’s been exacerbated by the crisis. We contacted Shawn Jones, MD, for his insight.
■ MD-Update: Please describe your duties as medical director of provider wellness at Baptist Health Medical Group and as president of the Kentucky Foundation for Medical Care.
Shawn Jones, MD: As medical director of provider wellness at Baptist Health Medical Group (BHMG) we develop strategies to mitigate the effects of the stress that physicians and advanced practitioners feel as caregivers. We focus on those providers who are impacted by organizational culture and individual factors which impact patient-centered care, safety, enhanced efficiency, and overall quality.
We engage with physicians, physician assistants, and nurse practitioners to develop a vision of wellness consistent with the mission and values of Baptist Health. A return of joy to the practice of medicine is one of our faith-based values, along with integrity, respect, compassion, excellence, and collaboration.
The Kentucky Foundation for Medical Care (KFMC) is the charitable arm of the Kentucky Medical Association. The theme of KMA’s president, Dale Toney, MD, is “Be Well, Stay Well.” It’s an initiative with KFMC that emphasizes simple steps Kentuckians can make to improve and protect their health in the midst of the pandemic. “Be Well, Stay Well” is also focused on the physical, mental, and financial health of physicians.
■ The mental health of physicians is a subject you’ve addressed before as president of the KMA and in your book, “Finding Heart in Art.” How has the COVID-19 pandemic impacted physician mental health?
Jones: The average self-reported rate of burnout among physicians in the U.S. previously hovered in the 50 percent range.1 The 2020 Physician Burnout Survey in Medical Economics reported that 65 percent of physicians felt the COVID-19 pandemic had increased their feelings of burnout. Some specialties have seen burnout rates in the 70 percent range during the pandemic.
There are many reasons for increased burnout during COVID-19. Many doctors had a significant increase in workload. A physician will experience burnout increases for every hour worked over 60 hours per week. The Medical Economics survey also revealed an increased sense of helplessness associated with the pandemic. Social isolation impacts everyone including physicians and makes the physician-patient relationship problematic. Truly connecting with another person, while both are wearing masks, is challenging. Many doctors have reported seeing some patients “die alone,” unable to have family at the bedside. Some employed physicians were “redeployed” to hot spots like the ER or ICU. Some independent doctors had burnout worsened by financial strain. Some employed physicians were negatively impacted financially because some patient services volume dropped 75-90 percent last spring when a 41-day shutdown of elective services was required.
■ Discuss the similarities and differences between physicians and non-medical persons responding to COVID-19 mental stresses.
Jones: Plans of all kinds have been put on hold, changed, or just cancelled. Fear of the unknown and concern regarding our health and loved ones affects all of us. Physicians have these problems plus being a doctor in the midst of a global pandemic.
■ What are some warning signs for physician mental health problems? Are they different in the COVID-19 era, and how/ why?
Jones: Burnout, defined by social psychologist Christina Maslach, is a psychological syndrome that develops secondary to work-related stress and is characterized by emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment.2 These are the signs of how burnout is experienced and what is measured in burnout inventories:
Emotional exhaustion. What started with enthusiasm, enjoyment, and dedication is replaced with anxiety, anger, frustration, and even depression. Individuals feel drained, unable to rewind, and recover.
Depersonalization. The tendency to take an impersonal, distant or cynical attitude toward work and the people one works for and/or with.
Reduced sense of accomplishment. A growing sense of inadequacy and ineffectiveness. What is accomplished feels trivial. There is a loss of confidence in the ability to make a difference.
The definition of burnout that resonates most with my experience is that burnout represents a dislocation between who people are, and what they are called to do in their job, especially when the things necessary to do that job well are not provided. The individual experiences this dislocation and it results in an erosion in values, dignity, spirit, and will. It’s an erosion of the soul.3
The language of clinician distress has shifted in recent years from burnout to moral injury as physicians express their experience.4 While this term was first applied to soldiers to explain the trauma of war, this moral injury—when applied to physicians—is not related to killing another human being, but feeling that one is unable to provide the high-quality care necessary to promote healing.
■ Talk about the stigma of physician mental health and seeking treatment. What are the known facts and misconceptions?
Jones: Most physicians overlook treatment as an option for themselves. It is not, in my opinion, a conscious decision in most cases. We are just so well trained to ignore our own needs, that it never occurs to us that we have a problem. Some doctors do, however, fear seeking treatment for mental health disorders due to the stigma associated with those maladies. Others delay seeking treatment for mental health problems because of the risk of becoming entangled in licensure issues, restrictions, and/or loss of licensure, which could affect the ability to practice medicine in the future. Sadly, some physicians delay seeking treatment and become incapacitated, lose their ability to practice, or even worse, commit suicide. Physicians in the U.S. have one of the highest rates of suicide of any profession. We lose 300 to 400 physicians a year to suicide.
The data says that seeking treatment for mental health issues early is much less likely to result in long term practice difficulties compared to delaying treatment. If you think you may have a problem, speak to a professional. Seek treatment early. Accept good orderly direction.
■ What are treatment options for physicians faced with mental health issues?
Jones: Treatment options depend on the mental health issue and severity, plus the circumstances when the disorder was recognized. For example, a doctor who voluntarily seeks treatment for depression or anxiety because a family member has noticed a flat affect or emotional lability has more options for treatment than a physician who has a DUI-related automobile accident as a driver. In the latter case, it’s likely that the resumption of practicing medicine would require mandated treatment and relatively long-term follow-up. This is one reason why I am a vociferous advocate for routine executive coaching, counseling, and outpatient therapy with a mental health professional and/or some combination for all physicians.
■ What’s your vision for understanding, diagnosing, and treating mental health as part of physician wellness?
Jones: It is critical to understand that physician burnout is not the result of individual problems or defects that inherently exist in doctors. Early in medical school, medical students are more emotionally well-adjusted than their age-matched peers. Later, and in the first years of residency, they suffer from depression, anxiety, and symptoms of burnout at rates much higher than their peers.
The prevalence of burnout in physicians says more about the current state of healthcare and the conditions under which doctors practice than it does about the physicians themselves.5 The following is a list of organizational imperatives that can change the paradigm of physician burnout:
Institutional metrics on physician well-being and burnout need to be routine.
Physician self-care needs to be considered an important aspect of medical professionalism and supported by institutions.
Electronic health record (EHR) stress relief that incorporates strategies unique to individual practices and physicians is one of the primary ways organizational clout can be effectively utilized to mitigate burnout. Regulatory relief must be part of this effort.
Staffing ratios, visit duration, and reasonable panel sizes must be maintained; work conditions with efficiency must be improved in clinics and offices.
Compassion and collaboration must be valued at all organizational levels.
If you are a physician and you want to know what to do because you feel you may be experiencing symptoms of burnout, the first imperative is to tell someone you trust. Often just talking with someone makes a world of difference. To do that takes courage, thus the following is my list of recommendations for individuals:
Keep heart. Keeping heart requires the willingness to admit powerlessness. It is a courageous act, but it’s that simple.
Live in community. It is important—and necessary—to ask people you trust what it is like to be with you. Living in isolation is dangerous.
Love yourself. Compassion for ourselves can be the place where we feel it is most difficult to practice empathy or compassion. Caring for your own physical needs, like eating well and getting sufficient rest and exercise, is part of loving yourself.
Connect with beauty. Data supports improvement in one’s psychological functioning with various forms of creative work or art therapy. Do something that you just simply love to do, something that fills you up.
Develop a spiritual/mindfulness practice. In order to give something a person must first possess it. To give of myself, I must first be in possession of my self, which is another way of saying that I must know, deep down, who I am. If burnout is an erosion of the soul, then nurturing the soul, replenishing, and feeding it has to be a critical aspect of prevention and recovery.
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1Carol Peckham, “Medscape Lifestyle Report 2016: Bias and Burnout,” Medscape, January 13, 2016, accessed June 15, 2017, http://www.medscape.com/slideshow/lifestyle-2016-over-view-6007335.
2C. Maslach, S. E. Jackson, and M. P. Leiter, Maslach Burnout Inventory Manual, 3rd ed. (Palo Alto, CA: Consulting Psychologists Press, 1996).
3Christina Maslach and Michael P. Leiter, The Truth about Burnout: How Organizations Cause Personal Stress and What to Do about It (San Francisco: Jossey-Bass, 1997), 17
4Simon Talbot and Wendy Dean, Physicians aren’t ‘burning out’. They’re suffering from moral injury. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/ accessed 11/1/2020.
5Christina Maslach and Michael P. Leiter, The Truth about Burnout: How Organizations Cause Personal Stress and What to Do about It (San Francisco: Jossey-Bass, 1997), 21