Francine Hughes, MD

Physician burnout was recognized as a growing problem in the medical field well before the start of the coronavirus disease (COVID-19) pandemic. Burnout is characterized by exhaustion, reduced professional efficacy, and a feeling of negativity or cynicism towards work.

It occurs in response to chronic work stress in which one’s perceived needs outweigh the perceived resources available. Prior to the pandemic, studies demonstrated that 35% to 54% of US nurses and physicians had symptoms of burnout.

Any professional who is exposed to high levels of stress is at risk of developing burnout. 

“Unfortunately, medicine has always prided itself on this toxic culture of invincibility: the imperturbable physician, one who rises above daunting circumstance ever calm and collected. We idealize ourselves as superhuman, yet in reality, we are so plainly human.” 

The characteristics that are emphasized and rewarded during medical training are the same ones that make a physician vulnerable to burnout. They include dedication, compassion, altruism, being detail-oriented, and putting others above self.

Although these traits are important for the day-to-day work of the physician, they also have the potential to exacerbate burnout when taken to the extreme. Over a prolonged period, 

 and our ability to connect in a meaningful way with ourselves, our loved ones, and our patients.

The consequences of burnout are far-reaching and can have implications on a personal and institutional level. Physicians who are suffering from burnout can have decreased career satisfaction, strained personal relationships, abuse substances, and be at higher risk of suicide. 

Physicians with burnout have lower patient satisfaction scores.

 From an institutional perspective, burnout decreases physician retention, leading to higher faculty turnover and lower productivity.

In times of crisis, as the medical community is now experiencing with COVID-19, chaos and trauma can stress an already fragile community. During the pandemic, physician self-care and organizational efforts to protect physician wellbeing are vital to maintaining a healthy and able workforce, which in turn enables a strong response to the ongoing health crisis. 

Many health organizations and institutions have created programs to address this pervasive issue and have made strides to remedy the problem. 

we will review how individual physicians can recognize and prevent burnout, as well as how to use an institution's position to mitigate physician burnout and deal with traumatic events.

The first step to addressing burnout on an individual level is recognizing the symptoms. Burnout can manifest both emotionally and physically and can present in varying degrees of severity. Physicians can feel a range of emotions, including sadness, fear, or apathy. 

“The most important patient we have to take care of is the one in the mirror.” 

They can feel easily frustrated, irritable, or anxious, which can affect work and personal relationships. Physical symptoms of burnout can include weight gain or loss, palpitations, fatigue, and poor sleep, which can have long-term health consequences. 

Physicians who suffer from burnout may also distance themselves from colleagues and family. Social distancing, whether forced or as a result of burnout, can lead to feelings of isolation and disruptive behaviors, which in turn lead to further isolation. 

In certain vulnerable individuals, isolation can contribute to depression and create barriers to seeking professional help. Several tools have been developed to identify physicians with burnout, including prominent ones such as the Maslach Burnout InventoryⓇ and Mini-Z Burnout Assessment, which is adapted from the work of Mark Linzer, MD.

From early in training, physicians are taught and valued for their ability to “power through,” whether it be the long hours, difficult rotations or physical deprivations of food, sleep or bathroom breaks. The ability to persevere is important for withstanding short-term challenges but is not sustainable in the long term. Practicing self-care can help individuals withstand longer periods of hardship.

A core principle of self-care is prioritizing one’s own needs in some way that is valuable to the individual. Therefore, self-care is different for everyone. Carving out time and energy to do something that is important to you is the key. Self-care is a practice that is rarely taught during medical training but is essential to prevent or mitigate burnout. 

The well-known phrase, borrowed from the airline industry, illustrates this concept: 

One must secure her own mask before helping others.

 By caring for themselves first, physicians are in a better position to give quality care to patients, leading to both patient and physician satisfaction. Methods to prevent and combat burnout can be addressed at the personal and institutional levels.

Fundamental to self-care is ensuring that basic needs are met. This includes obtaining adequate sleep, eating regular meals, and taking adequate breaks as needed throughout the day. Fatigue is a common cause and symptom of burnout, leading to difficulty in concentrating, poor communication, and emotional lability. 

To combat fatigue, prioritizing sleep, and creating a regular pre-bedtime routine can aid in restful sleep. Strategically timed naps can also be helpful in combating fatigue, particularly during night shift work. 

Nutrition is another important factor in maintaining well-being and can also play a role in fatigue. Alcohol and caffeine should be consumed judiciously.

The practice of medicine and medical culture can be isolating. As such, it is important to remain connected to loved ones. In the time of social distancing, this can be done through regular communication via phone calls or video chats. 

 lists several options for remaining connected to loved ones. Taking regular breaks throughout the day can also provide respite from stressful work. 

Breathing exercises can be done during these breaks or during high-stress situations to ground oneself. Practices such as mindful meditation and yoga can be helpful in creating a calm and balanced mind.

 Meditation has recently gained attention as an effective method for alleviating stress. 

Several applications exist that can be downloaded to a phone for use. For example, 

 has been used by surgeons prior to an operation to improve focus and relaxation.

Exercise, especially if done outdoors, can be invigorating and can boost mood. Checking one’s emotional “temperature” is imperative to recognize the early signs of burnout, and if necessary, obtaining professional help. Seeking professional help is encouraged, and these days, there are many options, including teletherapy, group therapy, and group webinars.

Physician resilience is not only key in preventing and combating burnout but can lead to improved work satisfaction, workplace retention, and patient outcomes and satisfaction. 

Resiliency training can be done at any stage of a career but is best initiated during medical training. It involves self-reflection and self-awareness to identify negative deep thoughts and emotions that are ingrained as a result of medical culture. 

Rephrasing these negative thoughts and developing healthy patterns of thought can go far in creating and maintaining a healthy engagement with the practice of medicine.

Institutions play a significant role in creating an environment that fosters physician well-being. Studies have shown that institutions can promote well-being by first creating a positive work environment and a positive learning environment.

These two factors create an environment of support and growth that can improve the education and health of physicians and trainees. Studies have also shown that providing support to clinicians and learners can improve the environment and ultimately lead to better care.

Many hospitals offer workplace wellness programs that address stress management in addition to routine physical health. 

, many hospitals use the annual National Hospital Week to recognize employees for their contributions and to bring awareness to employee health and wellness.

The role of institutions and leadership becomes more important during times of crisis. The chaos and confusion during a crisis can lead to additional stress. 

Institutions can help by creating methods for communicating transparently and effectively as well as avenues for feedback. This helps to create an environment of collaboration and camaraderie. 

Leadership can also provide for the physical needs of employees, including ensuring access to meals, access to break rooms for adequate rest, time off, and lodging as needed. They should provide resources for emotional support and schedule regular check-ins to address concerns.

During times of crisis, resources may be scarce and the demands and rules governing the practice of medicine may change on a near-daily basis. 

In addition, physicians bear witness to unprecedented suffering and death of the patients under their care. At the same time, physicians have been asked to put their own lives and the health of their families at risk. 

The stress and anxiety of this time are unparalleled. 

As a result, the risk of developing burnout as a physician is high.

 Furthermore, such unpredictable conditions and stressful situations can lead to post-traumatic stress disorder (PTSD).

PTSD in health care workers has not been well-studied, but the few studies done during infectious outbreaks or in traumatic environments have demonstrated a prevalence ranging from 10% to 33% and a strong correlation between burnout and development of PTSD.

Second victim syndrome in a physician can also be a consequence of a traumatic event or crisis. In these instances, the physician who is involved in the care of patients feels personally responsible for the outcome. 

A physician experiencing this may feel guilt, shame, and remorse. For fear of repercussions or demonstrating weakness, the second victim can often suffer in silence, leading to further isolation and depression.

The recent COVID-19 pandemic is an example of a health care crisis that is affecting physicians and putting them at risk for burnout, depression, and PTSD. 

Physicians are being asked to work in unfamiliar environments and specialties and to care for extraordinarily ill patients battling a virus with unpredictable outcomes. They are experiencing trauma daily as they care for an increasing surge of sick patients, many of whom cannot be saved. 

Health care workers witness their colleagues becoming ill, as they work in a setting of equipment and personal protective equipment shortages. Recognizing the effect of this unique circumstance is important because burnout can be an avenue to PTSD and serious long-term physical comorbidities.

During the COVID-19 pandemic and resultant social distancing, standard practices for self-care may not be possible. Because the risk of isolation is especially high, it is important to create and maintain connections with family and colleagues. 

These connections can create an environment of support and camaraderie, while fostering creativity and novel ideas. During times of crisis and isolation, connections with loved ones are key to maintaining emotional health. 

While it is important to stay abreast of news and new developments, setting limits on media exposure may be necessary to preserve well-being. Performing regular self-check-ins or check-ins with a colleague may be a way of recognizing the early signs of burnout so they can be addressed in a timely manner.

remains a serious and pervasive problem in medicine. Medicine has created a culture that values dedication, independence, and excellence, often to the detriment of the physician. 

This can then have consequences that jeopardize patient care and the life of the physician. As a community, we can alter our culture to support self-care and a safe environment that fosters healthy lifestyles in physicians.

 is an Instructor in the Department of Obstetrics & Gynecology and Women’s Health, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY.

 is a Professor in the Department of Obstetrics & Gynecology and Women’s Health, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, NY.

Nakhasi, A. New rules fuel toxic culture and harm my patients. 

 April 4, 2017. Accessed May 9, 2020. https://www.forbes.com/sites/realspin/2017/04/04/new-rules-fuel-toxic-culture-and-harm-my-patients/#67fbfd4226df

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://doi.org/10.17226/25521

International Classification of Diseases, 11th Revision. World Health Organization. Accessed May 9, 2020. https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/129180281

Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: can you make the switch? 

Shanafelt T. Enhancing meaning in work: A prescription for preventing physician burnout and promoting patient-centered care. 

Shanafelt TD, Sloan JA, Habermann TM, The well-being of physicians. 

Linzer M, Poplau S, Grossman E, et al.A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: Results from the Healthy Work Place (HWP) Study.

 2015;30(8):1105–1111. doi: 10.1007/s11606-015-3235-4

Caruso CC, Funk R, Butler CR, et al. Interim NIOSH training for emergency responders: reducing risks associated with long work hours. Published 2014. Accessed May 9, 2020. https://www.cdc.gov/niosh/emres/longhourstraining/

Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. 

. 2012;43(2):119-128. doi:10.2190/PM.43.2.b

Yang E, Schamber E, Meyer RML, Gold JI. Happier healers: Randomized controlled trial of mobile mindfulness for stress management. 

. 2018;24(5):505-513. doi:10.1089/acm.2015.0301

Aryankhesal A, Mohammadibakhsh R, Hamidi Y, et al. Interventions on reducing burnout in physicians and nurses: A systematic review. 

How headspace helps physicians, medical students tame stress. American Medical Association. September 5, 2019. Accessed May 9, 2020. https://www.ama-assn.org/practice-management/physician-health/how-headspace-helps-physicians-medical-students-tame-stress. 

https://www.ama-assn.org/practice-management/physician-health/how-headspace-helps-physicians-medical-students-tame-stress

Hospital Employees’ Health. Centers for Disease Control and Prevention website. Updated May 28, 2020. Accessed August 10, 2020. https://www.cdc.gov/workplacehealthpromotion/features/hospital-employees-health.htmlhttps://www.ama-assn.org/practice-management/physician-health/how-headspace-helps-physicians-medical-students-tame-stress

Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. 

 Published online April 07, 2020. doi:10.1001/jama.2020.5893

Center for the Study of Traumatic Stress. Sustaining the well-being of healthcare personnel during coronavirus and other infectious disease outbreaks. Publication date unavailable. Accessed May 9, 2020. https://www.cstsonline.org/assets/media/documents/CSTS_FS_Sustaining_WellBeing_Healthcare_Personnel_during_Infectious_Disease_Outbreaks.pdf

Luftman K, Aydelotte J, Rix K, et al. PTSD in those who care for the injured. 

2017 Feb;48(2):293-296. doi: 10.1016/j.injury.2016

Metregiste D, Boucaud-Maitre D, Aubert L. Explanatory factors of post-traumatic distress and burnout among hospital staff 6 months after Hurricane Irma in Saint-Martin and Saint-Barthelemy. 

. 2020 Mar 10;15(3):e0229246. doi: 10.1371/journal.pone.0229246.

Wu P, Fang Y, Guan Z, et al. The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk, perception, and altruistic acceptance of risk. 

Second Victim: Error, Guilt, Trauma, and Resilience. 

Articles

During the pandemic, physician self-care and organizational efforts to protect physician wellbeing are vital to maintaining a healthy and able workforce, which in turn enables a strong response to the ongoing health crisis.

Francine Hughes, MD

Articles

Physician burnout and self-care