Burnout in Gastroenterologists and How to Prevent it
2014; Elsevier BV; Volume: 147; Issue: 1 Linguagem: Inglês
10.1053/j.gastro.2014.05.023
ISSN1528-0012
AutoresRajesh N. Keswani, Laurie Keefer, Christina M. Surawicz,
Tópico(s)Innovations in Medical Education
ResumoHave you ever been 2 hours behind in an overbooked clinic, experienced a complication from a "routine" diagnostic procedure, or submitted a grant that did not get funded? Physicians are at daily risk for burnout and from a variety of different stressors. However, burnout is not the result of a single event—it is cumulative. The good news is that it is potentially preventable and certainly treatable. Burnout, occasionally called "compassion fatigue," is a serious, chronic, and progressive condition that can ultimately lead to career morbidity and even mortality. Burnout is not synonymous with depression, high work stress, or job dissatisfaction, although these may be both causes and consequences. Burnout is a real psychological syndrome characterized in simple terms by exhaustion, cynicism,1Freudenberger H.J. Staff burn-out.J Soc Issues. 1974; 30: 159-165Crossref Scopus (2823) Google Scholar and inefficiency.2Maslach C. Schaufeli W.B. Leiter M.P. Job burnout.Annu Rev Psychol. 2001; 52: 397-422Crossref PubMed Scopus (9117) Google Scholar Burnout cuts across the human services professions, affecting teachers, police officers, lawyers, nurses, physicians, and religious leaders and may even be contagious in clinical settings.3Bakker A.B. Le Blanc P.M. Schaufeli W.B. Burnout contagion among intensive care nurses.J Adv Nurs. 2005; 51: 276-287Crossref PubMed Scopus (312) Google Scholar To meet criteria for burnout syndrome, carefully operationalized by social psychologist Dr Christina Maslach in the 1970s and 1980s,4Maslach C. Jackson S.E. The measurement of experienced burnout.Journal of Occupational Behaviour. 1981; 2: 99-113Crossref Scopus (6938) Google Scholar one must have 2 of 3 symptoms: Emotional exhaustion, depersonalization, and a low sense of personal accomplishment. There are several measures of burnout, but the most widely used and validated is the Maslach Burnout Inventory.4Maslach C. Jackson S.E. The measurement of experienced burnout.Journal of Occupational Behaviour. 1981; 2: 99-113Crossref Scopus (6938) Google Scholar The measure has 22 items and captures information across the 3 factors of emotional exhaustion, depersonalization, and low sense of personal accomplishment (Table 1). Individuals answer on a 7-point Likert scale the frequency with which they experience a symptom (0 [never] to 6 [every day]), and scores, although continuous, can also be divided as low, intermediate, or high. High scores on emotional exhaustion and depersonalization, in particular, can identify physicians who are "burned out." A low score on the sense of personal accomplishment may also indicate burnout. To facilitate screening for burnout in clinical practice, 2 rapid screening measures may be useful: A single-item question of emotional exhaustion5Hansen V. Girgis A. Can a single question effectively screen for burnout in Australian cancer care workers?.BMC Health Serv Res. 2010; 10: 341Crossref PubMed Scopus (59) Google Scholar or a 2-item measurement (Table 2) of emotional exhaustion and depersonalization.6West C.P. Dyrbye L.N. Sloan J.A. et al.Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.J Gen Intern Med. 2009; 24: 1318-1321Crossref PubMed Scopus (447) Google ScholarTable 1Symptoms of BurnoutSymptomDescriptionEmotional exhaustionCharacterized by having no available capacity to provide emotional support to others. It is often the first sign of burnout and is the most sensitive index of burnout. Common examples include low tolerance to minor frustrations, difficulty paying attention or lack of motivation. Some people may feel physically fatigued as well.DepersonalizationCharacterized by disconnecting from or dehumanizing others. Physicians may notice that they blame their patients for their troubles more, or that they have become unfeeling, cynical or uncompassionate. Feeling numb, feeling as if you are "going through the motions" or that you are observing yourself are other signs of depersonalization.Low sense of personal accomplishmentA negative evaluation of oneself, particularly with respect to work with one's patients. Common examples include feeling like your work is meaningless, accomplishments no longer feels satisfying, believing that you cannot affect change or that nobody listens to you. In severe cases, this factor may coincide with suicidal ideation. Open table in a new tab Table 2Are You Suffering From Burn Out?Although the Maslach Burnout Inventory is a well-validated instrument, it might be difficult to implement for routine use. One study6West C.P. Dyrbye L.N. Sloan J.A. et al.Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.J Gen Intern Med. 2009; 24: 1318-1321Crossref PubMed Scopus (447) Google Scholar suggested that physicians answering yes to both of these 2 simple questions might be experiencing burnout(1) "I feel burned out from my work."(2) "I have become more callous towards people since I took this job." Open table in a new tab Burnout occurs in approximately 45% of all physicians,7Shanafelt T.D. Boone S. Tan L. et al.Burnout and satisfaction with work-life balance among US physicians relative to the general US population.Arch Intern Med. 2012; 172: 1377-1385Crossref PubMed Scopus (2185) Google Scholar with the highest levels in emergency medicine, critical care, and general internal medicine. The rate of burnout in gastroenterologists was lower in a recent internet survey, with 37% of gastroenterologists reporting burnout (available from: http://www.medscape.com/features/slideshow/lifestyle/2013/public). Moderate to high levels of emotional exhaustion were reported in 32%–63% of gastroenterologists, varying based on years of experience.8Keswani R.N. Taft T.H. Cote G.A. et al.Increased levels of stress and burnout are related to decreased physician experience and to interventional gastroenterology career choice: findings from a US survey of endoscopists.Am J Gastroenterol. 2011; 106: 1734-1740Crossref PubMed Scopus (52) Google Scholar Gastroenterology is a unique subspecialty of internal medicine. Whereas training in internal medicine is primarily cognitive in nature, the majority of gastroenterologists perform procedures on a daily basis. These procedures, including diagnostic and therapeutic colonoscopy and upper endoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and liver biopsy, are all associated with procedure-related adverse events. Furthermore, in addition to the risks of adverse events, there is the risk of a missed diagnosis (such as colon cancer on colonoscopy or early pancreas cancer on endoscopic ultrasonography) as well as misdiagnosis. In aggregate, these procedural stresses liken the practice of gastroenterology to a surgery practice in contrast with non–procedure-based internal medicine subspecialties. Thus, insights into the source of burnout among gastroenterologists may be gained from examining the work of both our medical and surgery colleagues. Based on available literature, there are several relevant factors that likely contribute to gastroenterologist burnout: Younger physician age, increasing procedure complexity, experiencing procedure-related adverse events, work–life imbalance, and changes in health care reimbursement. Younger physician age is an established risk factor for burnout, although initially many experts hypothesized the converse.9Campbell Jr., D.A. Sonnad S.S. Eckhauser F.E. et al.Burnout among American surgeons.Surgery. 2001; 130: 696-702Abstract Full Text Full Text PDF PubMed Scopus (336) Google Scholar We previously reported that younger gastroenterologists had higher burnout scores, with the most junior physicians (<3 years of experience as an attending physician) reporting greater levels of emotional exhaustion and a decreased sense of personal accomplishment.8Keswani R.N. Taft T.H. Cote G.A. et al.Increased levels of stress and burnout are related to decreased physician experience and to interventional gastroenterology career choice: findings from a US survey of endoscopists.Am J Gastroenterol. 2011; 106: 1734-1740Crossref PubMed Scopus (52) Google Scholar Endoscopists with fewer years in practice were also most likely to worry that their procedural skill would be questioned by the referring physician after an unsuccessful procedure. Conversely, older age can be thought of as protective against burnout.10Peisah C. Latif E. Wilhelm K. et al.Secrets to psychological success: why older doctors might have lower psychological distress and burnout than younger doctors.Aging Ment Health. 2009; 13: 300-307Crossref PubMed Scopus (101) Google Scholar In a study of attending physicians, qualitative interviews with older physicians revealed that they experienced decreasing psychological distress as they advanced in their careers attributed to 2 main factors: (1) Increased consciousness related to burnout with intentional development of protective barriers (eg, reduction in clinical hours or saying "no" to clinic overbooks) and (2) "liberation" afforded by accumulated clinical experience (eg, confidence in skills). Endoscopic practice has evolved significantly over the past decades, with several major shifts in diagnostic and therapeutic endoscopic procedures.11Sivak M.V. Gastrointestinal endoscopy: past and future.Gut. 2006; 55: 1061-1064Crossref PubMed Scopus (63) Google Scholar A focused interest on procedure quality, notably with regard to diagnostic colonoscopy, has shifted the attention of patients, physicians, and payers to rates of adenoma detection and interval cancers. Many procedures now have recognized errors of commission (eg, perforation) and omission (eg, missed lesions). In an effort to ensure a high-quality procedure, endoscopists might spend more time examining the colon for abnormalities. However, endoscopists also report feeling pressured by the nursing staff8Keswani R.N. Taft T.H. Cote G.A. et al.Increased levels of stress and burnout are related to decreased physician experience and to interventional gastroenterology career choice: findings from a US survey of endoscopists.Am J Gastroenterol. 2011; 106: 1734-1740Crossref PubMed Scopus (52) Google Scholar or institutional productivity measures to move faster during procedures. Thus, gastroenterologists may struggle to balance the need for procedure quality with the needed efficiency of the endoscopy unit, all while complying with an increasing burden of documentation. Beyond diagnostic procedures, advanced endoscopic procedures are increasingly complex. Endoscopic retrograde cholangiopancreatography is now almost entirely therapeutic in nature, resulting in fewer total procedures but for more complex indications. Endoscopic resection of advanced neoplasms is now standard of care, but remains associated with an higher risk of adverse events. Reflecting the effect of procedure complexity on burnout, interventional endoscopists report greater levels of burnout than other gastroenterologists.8Keswani R.N. Taft T.H. Cote G.A. et al.Increased levels of stress and burnout are related to decreased physician experience and to interventional gastroenterology career choice: findings from a US survey of endoscopists.Am J Gastroenterol. 2011; 106: 1734-1740Crossref PubMed Scopus (52) Google Scholar Furthermore, after a procedure-related adverse event, many gastroenterologists report ruminating about mistakes they may have made after the work day had ended and compulsively checking on their patients from home out of concern for procedure-related complications. In many areas of medical practice, the line between "work" and "home" is blurred. Attendings are often expected (or expect themselves) to be constantly available, even when on vacation. In an early study of surgeons, younger surgeons were the most likely to report work–life imbalance with less time for personal growth and development as well as feeling that work was "overwhelming."9Campbell Jr., D.A. Sonnad S.S. Eckhauser F.E. et al.Burnout among American surgeons.Surgery. 2001; 130: 696-702Abstract Full Text Full Text PDF PubMed Scopus (336) Google Scholar Younger surgeons also took significantly fewer weeks of vacation. A study of surgical oncologists found that a vast majority of respondents put their personal life "on hold" to advance their career, with nearly half reporting tension between time devoted to work versus time available to family.12Guest R.S. Baser R. Li Y. et al.Cancer surgeons' distress and well-being, II: modifiable factors and the potential for organizational interventions.Ann Surg Oncol. 2011; 18: 1236-1242Crossref PubMed Scopus (40) Google Scholar The impact of an imbalance between work and home likely extends beyond the physician, with physician spouses also reporting modest rates of burnout.13Sargent M.C. Sotile W. Sotile M.O. et al.Quality of life during orthopaedic training and academic practice: part 2: spouses and significant others.J Bone Joint Surg Am. 2012; 94: e145Crossref PubMed Scopus (29) Google Scholar The interplay between medical errors, malpractice, and physician stress and burnout is complex and likely bidirectional.14Fahrenkopf A.M. Sectish T.C. Barger L.K. et al.Rates of medication errors among depressed and burnt out residents: prospective cohort study.BMJ. 2008; 336: 488-491Crossref PubMed Scopus (821) Google Scholar, 15Campbell Jr., D.A. Physician wellness and patient safety.Ann Surg. 2010; 251: 1001-1002Crossref PubMed Scopus (15) Google Scholar Surgeons with high levels of burnout were more likely to have experienced a major medical error over the past 3 months than their colleagues16Shanafelt T.D. Balch C.M. Bechamps G. et al.Burnout and medical errors among American surgeons.Ann Surg. 2010; 251: 995-1000Crossref PubMed Scopus (1364) Google Scholar; furthermore, increasing burnout scores were associated with an increased risk of having experienced a medical error. The majority of surgery respondents blamed the medical errors on an "individual issue" (eg, lapse in judgment or concentration, stress/burnout, or fatigue) rather than a "system" issue. In contrast, the majority of methods in place to prevent medical errors are system-related (eg, electronic health record interventions to prevent inappropriate medication dosages). We also previously found that gastroenterologists experienced greater psychological distress after experiencing a medical complication.17Taft T.H. Keefer L. Keswani R.N. Friends, alcohol, and a higher power: an analysis of adaptive and maladaptive coping strategies among gastroenterologists.J Clin Gastroenterol. 2011; 45: e76-81Crossref PubMed Scopus (25) Google Scholar Similar to surgeons, many errors associated with gastroenterology occur at the individual level (eg, inattentiveness during colonoscope withdrawal). If influenced by burnout, they may only be addressable by dealing with the root cause (burnout) rather than redundant check-points in the medical system. Compounding the problem, it is clear that the adverse event itself contributes to physician burnout, creating a vicious cycle. Surgeons involved in malpractice lawsuits within the past 24 months were more likely to report burnout and depression.18Balch C.M. Oreskovich M.R. Dyrbye L.N. et al.Personal consequences of malpractice lawsuits on American surgeons.J Am Coll Surg. 2011; 213: 657-667Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Of greatest concern, these physicians were also more likely to report suicidal ideation. Unfortunately, approximately 42% of physicians report having a medical liability claim against them at some point in their career (available from: http://www.ama-assn.org/resources/doc/health-policy/prp-201001-claim-freq.pdf). Thus, the impact of a medical malpractice lawsuit on physician well-being cannot be overstated. Burnout often strikes those most dedicated to their careers, those who are treating the most complex patients, and furthermore affects them at the earliest stage of their career. Previous studies have shown that physicians who suffer burnout tend to retire earlier than their counterparts,19Guntupalli K.K. Fromm Jr., R.E. Burnout in the internist–intensivist.Intensive Care Med. 1996; 22: 625-630Crossref PubMed Scopus (137) Google Scholar robbing their patients and colleagues of their accumulated experience. Thus, it is imperative that we work collectively to find and implement solutions to identify and combat burnout. Burnout is not static; studies have shown that it can be reversed with a variety of focused interventions (Table 3).20Krasner M.S. Epstein R.M. Beckman H. et al.Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.JAMA. 2009; 302: 1284-1293Crossref PubMed Scopus (1126) Google Scholar The best studied interventions involve stress management programs, including mindfulness-based stress reduction; participants focus on techniques such as breathing and body awareness and the practice of mindfulness, or the nonjudgmental, moment-to-moment awareness in everyday situations.21Ludwig D.S. Kabat-Zinn J. Mindfulness in medicine.JAMA. 2008; 300: 1350-1352Crossref PubMed Scopus (615) Google Scholar Mentorship is another method to fight burnout. Partnering a junior colleague with a helpful senior mentor benefits both physicians—the younger physician benefits from discussing procedure-related adverse events, difficult or unsuccessful procedures, work–life balance tips, or an unsuccessful grant application with someone who has undoubtedly experienced the same. The senior physician almost assuredly finds satisfaction in mentoring the junior gastroenterologist, helping to shape the future of the individual and the profession. Additionally, beyond educating our trainees and colleagues on the frequency, signs, and symptoms of burnout, we must proactively identify and address signs of burnout.Table 3Preventing and Treating BurnoutThe following techniques or activities may be helpful tools in the prevention of burnout:•Mindfulness-based stress-reduction exercises. Examples of this include:○Deep breathing exercises, meditation, and non-judgmental awareness of moment-to-moment events: eg, "I am observing myself tensing up as this patient criticizes my approach."○Take a deep breath at the door before entering the room for the next patient encounter•Mentorship (either mentoring junior colleagues or being mentored by senior colleagues)•Teaching of medical students or other professionals in training•Participation in meaningful hospital committee work•Participating in our national and international gastroenterology, hepatology, and endoscopy societies•Participation in research activities•Give up procedures you do not feel comfortable performing or seeing patients with medical diseases you do not feel comfortable treatingIf you begin to experience symptoms of burnout, consider these "burnout-busters":1.Take a real vacation—getting away and having an opportunity to regain perspective can make a world of difference. If a vacation is not on the horizon, alter your routine slightly to make time for yourself—come into the office an hour later each morning or leave an hour early.2.Identify your main stressors and which ones are potentially solvable. If a problem is solvable, take the steps required. If it is not solvable, decide how you will cope. Don't be afraid to set time limits on your problems—eg, "I will worry about '______' until the end of April and then it is out of my hands."3.Occasionally be selfish and take care of your own needs first. This includes getting enough rest, exercise, nutrition.4.Make a list of all of your responsibilities and determine whether any of them could be delegated or dropped. Remember burnout impairs performance!5.Get positive social support—reduce the time spent with others who are unhappy and seek out friends, colleagues and mentors who have a more positive perspective. A therapist may also be a great way to confidentially share your frustration with someone objective.6.Make a defined time to unplug from your devices: looking at email right before bed can disrupt sleep as this often adds new work or problems. Open table in a new tab Our leaders must do their part in combating burnout. We should carefully consider the need of the 6 am or 6 pm meeting; this may be the only opportunity in the day for an overworked gastroenterologist to see his or her child, exercise, or spend time with a friend or significant other. Physicians should be encouraged to become involved in nonclinical professional activities. Participating in our local and national medical societies or advocacy groups provides opportunities to create friendships around the world and provide opportunities for physicians to "give back." We should encourage academic pursuits including teaching or research, whether or not funded; this allows opportunities to work with trainees and peers and can be similarly rejuvenating. Participating in hospital committees, such as quality improvement or medical ethics, should be similarly supported. Retention of staff must be prioritized and leaders should model work–life balance themselves. Hospital culture must encourage this as well by proactively screening for burnout in health care's most valuable asset, physicians, and intervening before it is too late. We must remember that burnout is a treatable and preventable disease, much like the other complex diseases we manage daily, and requires the same compassionate and comprehensive care we provide our patients. Identifying and treating burnout in ourselves and our colleagues facilitates our continued contributions to the highly rewarding and privileged specialty that each of us worked hard to join.
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