Resources

  1. West, CP, Dyrbye, LN, & Shanafelt, TD (2018). Physician burnout: contributors, consequences and solutions. J Intern Med. 2018 Jun;283(6):516-529. doi: 10.1111/joim.12752. Epub 2018 Mar 24 https://www.ncbi.nlm.nih.gov/pubmed/29505159 
  2. West, CP, Dyrbye, LN, Erwin, PJ & Shanafelt, TD (2016). Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet, 2016 Nov 5;388(10057):2272-2281. doi: 10.1016/S0140-6736(16)31279-X. Epub 2016 Sep 28. https://preview.ncbi.nlm.nih.gov/pubmed/27692469
  3. Panagioti, M, Panagopoulou, E., Bower, P., Lewith, G. et al (2017).  Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis.JAMA Intern Med. 2017 Feb 1;177(2):195-205. doi: 10.1001/jamainternmed.2016.7674. https://www.ncbi.nlm.nih.gov/pubmed/27918798
  4. Southwick, F. & Southwick, S. (2018) The Loss of a Sense of Control as a Major Contributor to Physician Burnout: A Neuropsychiatric Pathway to Prevention and Recovery. JAMA Psychiatry. 2018 Jul 1;75(7):665-666. doi: 10.1001/jamapsychiatry.2018.0566 https://www.ncbi.nlm.nih.gov/pubmed/29799941

Transcript

Dr. Frank Domino:
It's another day in the office. You miss lunch again as there were two patients that's still needed to be seen through the lunch hour. It's now 2:00 PM and you're two patients behind and you feel totally drained. Are you recognizing this as a typical day? Are you feeling stress or fatigue or is this really burnout? Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School, and joining me to discuss burnout is Jill Terrien, Associate Professor and Director of the Nurse Practitioner Program at the University of Massachusetts Medical School's Graduate School in Nursing. Jill, thank you very much for discussing burnout today.

Jill Terrien:
Thanks you, Frank.

Dr. Frank Domino:

So it's everywhere, it's in the news, it's in all our publications. Before we get too deep into a discussion of burnout, can you tell us a little bit about its definition, its origins, and why we're so wrapped up in it? 

Jill Terrien:

Sure, so anyways, it can be a somber topic, but we're gonna come out on the optimistic side of things today.

Dr. Frank Domino:

Sounds good.

Jill Terrien:

Okay, so basically, it was first written about what I could find, back in 1974, and what it is is a workplace syndrome involving emotional exhaustion. It's depersonalization, a sense of reduced personal accomplishment and it was described as a staff burnout by Freudenberger in 1974. So since that time, it's got an international prevalence. There's a lot written on the subject itself, and also there has been inventories and surveys that have been developed over time to measure this and they've been validated and reliable. The one that I read about mostly was called Maslach Burnout Inventory. And so that is the principles of burnout, what I described. And really, it can have a lot of consequences both in your personal life and in your work life. 

Dr. Frank Domino:

No, I think that's a really good point because we always focus on how it affects patient care and morale in the office, but I think it involves how we view ourselves, and what we bring home from work, and what happens at home is very much a big part about it. So recognizing those consequences and recognizing that we've been worrying about it now for close to 50 years, what can we look at for its implications in how we live our lives and what sort of thoughts should we be thinking about going forward?

Jill Terrien:

So I think that you have to think about yourself and what you have control over, because you know you can get all caught up in thinking about the many different things that are contributing to your bad day, let's just say, okay? And I think that you really have to look at what you can change personally, 'cause again, that's what you maybe have the most control over, right? So we know that providers that are burned out, they've done... They've looked at patient care being a lower quality, errors, longer recovery times of the patients, and a lower patient satisfaction, which I think we all are measured on, right?

But your own personal health, it can lead to bad habits, it can lead to depression, anxiety, possible substance abuse, and really poor self-care. And then we talk about the system, the system being the problem, and we all know that the system can be a problem that... And depending on where you work and what's going in the system you work within, you're always measured on productivity. You might have... If you have burned-out providers, it shows that there is increased turnover, there's less patient access, and with that comes increased costs for the system. So I think that it's a variety of factors that we have to really talk about, but what it boils down to is what can you do for yourself?

Dr. Frank Domino:

I agree. You're often... Oh, we have to get the system fixed. And I think we've been trying to fix the system since FDR started publicizing health insurance. So it's a work in progress. I love the fact that you say we need to focus as individuals on the things that we have control over. So let's talk about it a little bit. What are some approaches we should have to help ourselves and help our colleagues with regard to burnout?

Jill Terrien:

Well, I think one of the things is your work environment and your work load, so to speak. So what is important to you? Is it getting out the door by 5:00? Is it getting out the door by 6:00? All of us have different clinic schedules. And I think that one of the strategies I use is, if I haven't left the home by 5:00, well, I'm staying till 6:00 to get a few more things done that are gonna make me feel better and my traffic is gonna be less. That's a personal strategy of mine. Does it always work? No. But I think you have to look at when you think about maybe seeing a few less patients a day that will allow you to finish what you have to do for your documentation and not bring that home with you.

Dr. Frank Domino:

So you made two statements of great ideas to change. And what they both started with was "I". One of the things I fear about myself and my peers is that we are often looking for others to solve things, we don't have that internal locus of control. The most important thing we can do to beat burn out is being open to change.

I think about just treating type 2 diabetes. When I finish my residency, there were three medications that we used and now there are over 50. I can't change the number of new things I need to treat, but I can change how I approach things, and maybe I need to not be doing some of the things that I do right now that I think are appropriate, I probably need to change and that's a hard thing for me to do. Any idea about how I find out if I'm burned out?

Jill Terrien:
Sure, well, I think that... You think well, jeez, of course I know when I'm burned out, right, it's obvious, but it's really hard to see sometimes. It might be a colleague telling you "You don't seem happy here, what's going on?" Or it might be your spouse or your partner saying, "You know what, you don't like this any more. I can tell when you come home, it's really, it's not good." Or it might be your patients that have known you and come in and say, "Wow, you're really not happy today." So that's really something when the patients diagnose you.

Dr. Frank Domino:

It's so funny you said that. I was talking with the obstetrician gynecologist just last week and she was mortified to go online and see the recent reviews from her patients and it was on one of those online services, and she had always been a four to five star person and now she was a two star person. And she had no idea and when she read things, it was all about her demeanor rather than the care she gave. So you hit the nail right on the head.

Jill Terrien:

So I also wanna say a couple more things about the system, 'cause I think that we hear so much about the health care system broadly in the US that's negative, right? And then depending on the system you work within, it's gonna be those factors. There is some research that shows that if you are interested in in changing the system where you work, you might wanna get involved in the policy committee, and do some sort of advocacy for the area that you work in. If you're feeling so weighed down by the system you've worked within, you've tried different things, and it's just really not working for you, you might wanna change to a different work setting. There's been studies that show that there is 40% lower incidents of burnout in people that work in occupational and preventative medicine.

Now, it might be the mindset, the prevention mindset and the types of patients they see, but that's... I throw that out as one option. We do know there's a threefold increased odds of burnout if you work in really high intensity environments. So like the emergency room and general internal medicine is one of them. And Frank, I think that your mention of 50 diabetes drugs, and you're just mentioning one of many chronic conditions that we manage in primary care. It's like, how do you stay on top of that to know what's best for the patients. It takes time.

Dr. Frank Domino: 
It takes time and investment, absolutely. Well, Jill, I think this is the first discussion we're going to have about burnout on our podcast for the next few months, and I love your point that we need to a; focus on what we can change and start looking at small changes to make big outcomes. Thank you very much.

Jill Terrien:

You're welcome, thanks for having me. Practice pointer, consider single-tasking your email. Check it only two to three times a day. A suggestion is as you enter practice in the morning, check it at lunch, and check it at the end of the day, and be done with it.

Dr. Frank Domino:
Recognizing that the system needs to change. Today, you can make any of a number of small changes in your practice that will help lessen your stress and get you home sooner. Choose one, and implement it today. And for more timely relevant and practical medical education, check out PriMed.com.