RECOGNITION AND
PREVENTION OF BURNOUT –
YOURS AND THEIRS
Rebecca P. McAlister, M.D.
Washington University School of
Medicine
EDUCATIONAL OBJECTIVES
• This presentation will discuss the
syndrome of burnout, its causes and
effects. We will examine how it may affect
residents, attending physicians, other
health professionals and support staff, and
ourselves. Strategies for identification and
prevention will be reviewed.
BURNOUT DEFINED
• “A PROLONGED RESPONSE TO
CHRONIC EMOTIONAL AND
INTERPERSONAL STRESSORS ON THE
JOB”
• DEFINED BY THREE DIMENSIONS
– EXHAUSTION
– CYNICISM
– INEFFICACY
EXHAUSTION
• BASIC INDIVIDUAL STRESS DIMENSION
• FEELINGS OF BEING OVEREXTENDED
• FEELING DEPLETED OF EMOTIONAL AND
PHYSICAL RESOURCES
• PROMPTS DISTANCING ONESELF TO COPE
WITH WORK OVERLOAD
CYNICISM
DEPERSONALIZATION
• A NEGATIVE, CALLOUS, OR
EXCESSIVELY DETACHED RESPONSE
TO VARIOUS ASPECTS OF THE JOB
• DISTANCE ONESELF BY ACTIVELY
IGNORING PERSONAL QUALITIES
INEFFICACY
• THE SELF EVALUATION COMPONENT
• FEELINGS OF INCOMPETENCE, LACK
OF ACHIEVEMENT AND
PRODUCTIVITY AT WORK
• SEEMS TO ARISE FROM A LACK OF
RELEVANT RESOURCES
ROOTS IN 1970’S
• FOCUSED ON CARE GIVING AND
SERVICE OCCUPATIONS
• CORE OF THE JOB WAS
RELATIONSHIP BETWEEN PROVIDER
AND RECIPIENT
• HEALTH CARE PROFESSIONALS,
SOCIAL WORKERS, TEACHERS
MASLACH BURNOUT
INVENTORY
• MASLACH & JACKSON DEVELOPED MBI IN
1981
• MBI-HUMAN SERVICES SURVEY
– MBI-HSS
• MBI-EDUCATORS SURVEY - MBI-ES
• MBI-GENERAL SURVEY – MBI-GS
• SUBSCALES
– EMOTIONAL EXHAUSTION
– DEPERSONALIZATION
– REDUCED PERSONAL ACCOMPLISHMENT
EFFECTS OF BURNOUT
• JOB PERFORMANCE
–
–
–
–
ABSENTEEISM
JOB TURNOVER
LOWER PRODUCTIVITY / EFFECTIVENESS
“CONTAGIOUS”
• HEALTH
– STRESS RELATED HEALTH OUTCOMES
– NEUROTICISM
– NEGATIVE MENTAL HEALTH EFFECTS
• ?spectrum with depression
WHERE DOES BURNOUT
OCCUR?
• JOB CHARACTERISTICS
• OCCUPATIONAL CHARACTERISTICS
• ORGANIZATIONAL CHARACTERISTICS
JOB CHARACTERISTICS
•
•
•
•
•
•
•
•
WORK OVERLOAD AND TIME PRESSURE
ROLE CONFLICT / AMBIGUITY
SEVERITY OF CLIENTS PROBLEMS
ABSENCE OF JOB RESOURCES
LACK OF SOCIAL SUPPORT
LACK OF SUPERVISOR SUPPORT
LACK OF FEEDBACK
LACK OF CONTROL / DECISION MAKING
OCCUPATIONAL
CHARACTERISTICS
• FOCUSED ON HUMAN SERVICES AND
EDUCATION
• REQUIREMENT TO EXPRESS OR
SUPPRESS EMOTIONS ON THE JOB
• REQUIREMENT TO BE EMOTIONALLY
EMPATHETIC
ORGANIZATIONAL
CHARACTERISTICS
• RULES THAT VIOLATE BASIC
EXPECTATIONS OF FAIRNESS /
EQUITY
• VIOLATION OF THE PSYCHOLOGICAL
CONTRACT (WHAT EMPLOYER IS
OBLIGED TO PROVIDE FOR
RECIPROCAL WORK EXCHANGED)
WHO IS AT RISK?
•
•
•
•
•
•
•
•
•
? LESS THAN AGE 30 OR 40
? FEMALE (MALES MORE CYNICAL)
?UNMARRIED, ESP. SINGLE
HIGHER LEVEL OF EDUCATION
EXTERNAL FOCUS OF CONTROL
PASSIVE / DEFENSIVE COPING
POOR SELF ESTEEM
NEUROTICISM / TYPE “A” BEHAVIOR
“DISORGANIZED” PERSONALITY
THE PEOPLE YOU WORK WITH
• PHYSICIANS IN GENERAL / OBGYNs
• RESIDENTS IN TRAINING
– STUDIES IN PGY-1s
• Acad Med 2006;81:82-5
• HEALTH PROFESSIONALS /
EDUCATORS / SUPPORT STAFF
BURNOUT IN PHYSICIANS
• 25 – 60% MEET MBI CRITERIA FOR
BURNOUT
• CAN LEAD TO INCREASED MEDICAL
ERROR (SELF REPORTED V.
OBSERVED)
• DISSATISFACTION AND DISTRESS
INCREASE COSTS TO SYSTEM
• $240K – 260K TO REPLACE PRIMARY
CARE PHYSICIAN
CAREER SATISFACTION IN
OBGYN PHYSICIANS
CAREER SATISFACTION
WORK-LIFE BALANCE
BURNOUT
Keeton K, et al. Obstet Gynec April 2007
OBGYNs more personal accomplishment and
work/life balance than general surgeons
More career satisfaction than general
internists
BURNOUT IN OBGYN CHAIRS
•
•
•
•
88% MODERATE BURNOUT
4% HIGH BURNOUT
HIGH EMOTIONAL EXHAUSTION
MODERATE – HIGH
DEPERSONALIZATION
• HIGH PERSONAL ACCOMPLISHMENT
» GABBE, AM J OBSTET GYNECOL 2002
STRESS / BURNOUT IN
RESIDENCY
• 76% INTERNAL MEDICINE RESIDENTS MET
CRITERIA FOR BURNOUT
– ASSOCIATED WITH SELF REPORTED
SUBOPTIMAL PATIENT CARE
» SHANAFELT, ET AL, ANN INTERN MED, 2002
• OBGYN RESIDENTS
– 9X MORE LIKELY TO LACK EFFECTIVE COPING
MECHANISMS
– 14X MORE COMMON MALADAPTIVE STRESS
SCORES
» SCHNEIDER, ET AL, AM J OBSTET GYNECOL 2002
BURNOUT AND DEPRESSION
• FAHRENKOPF et al (BMJ 2012) surveyed
123 Peds residents with MBI & Harvard
nat’l depression screening day scale
• 75% burnout, 20% depression (of which
96% also burned out)
BURNOUT AND DEPRESSION
• Burnout- no increase observed errors,
increased reported errors, diff.
concentrating
• Depressed- 6X increased observed errors,
difficulty concentrating, poor health (few
on antidepressants)
• Not assoc with age, sex, PGY, logged
sleep or work hours
THREE LIKELY BURNOUT
SCENARIOS
• PGY4 overheard making derogatory
remarks about clinic patients
• PGY1 tells PD he/she is considering
transferring to Dermatology
• OBGYN PD had poor internal review. DIO
said “terrible data collection.” He/she yells
at coordinator who promptly quits.
BUILDING JOB ENGAGEMENT
• BURNOUT IS THE EROSION OF
ENGAGEMENT WITH THE JOB
– RELATED TO JOB DEMANDS
• ENGAGEMENT CHARACTERIZED BY
ENERGY, INVOLVEMENT, EFFICACY
– RELATED TO JOB RESOURCES
Loss of Control in the Practice
of Medicine
• Frequently part of patient encounters
– Difficult encounters, noncompliance, end-oflife care, uncertainty/ambiguity in dx/mx
• Institutional and systemic factors
– Lack of control over work environment, team
vs. captain, “limit the territory”
• Need to identify constructive ways to
respond to lack of control
EXAMPLES OF TRAINING IN
COPING MECHANISMS
•
•
•
•
•
Reflection /critical incident journaling
Peer group discussions
Balint training
Mindful emotion regulation
Positive vs. Negative Assertion vs.
Yielding
• Journal of Graduate Medical Education Dec 2009
TEACHING /CHANGING THE
INDIVIDUAL
• PEOPLE CAN LEARN NEW COPING
SKILLS
• ?CAN PEOPLE APPLY THIS TO THE
WORKPLACE?
• CAN REDUCE EXHAUSTION, LITTLE
CHANGE IN CYNICISM, INEFFICACY
ORGANIZATIONAL CHANGE
• MUCH MORE DIFFICULT BUT LIKELY
MOST EFFECTIVE
• EXPAND RANGE OF WORK OPTIONS
• PEOPLE TOLERATE GREATER WORK
LOADS IF FEEL REWARDED/VALUED
• BUILD SENSE OF FAIRNESS /EQUITY
• EMPOWER WITH SENSE OF CONTROL
STEPS TO PROMOTE
ENGAGEMENT
PERSONAL WELLNESS
– EXERCISE, COUNSELING, TX PSYCH DZ
ORGANIZATIONAL ENVIRONMENT
– CHOICES, FEEDBACK, FAIRNESS,
CULTURE CHANGE
PROMOTING WELLNESS IN THOSE YOU
WORK WITH
IT’S A BALANCING ACT
“If all of the knowledge and advice about
how to beat burnout could be summed up
in one word, that word would be balancebalance between giving and getting,
balance between stress and calm, balance
between work and home.”
» Maslach 1982