From Burnout to Rebirth Via Discipline
Burnout can lead to depression and suicide. Regulator discipline can help clinicians find a better path.
Regulator discipline is almost always painful. For clinicians struggling with burnout and depression it can seem catastrophic. And yet, as painful as the regulator’s judgment feels at the time, many clinicians come to regard it not as a career-ending catastrophe but rather as a shot at redemption.
The Burnout Crisis Predates the Pandemic
There’s been a lot of talk this past year about the terrible toll Covid has taken on clinicians. The problem is especially severe in ICUs. Recent articles in Scientific American and the Washington Post point to a growing exodus of ICU physicians and nurses exacerbated by the extreme stress of Covid.
But the burnout crisis didn’t begin with Covid. As the Scientific American piece notes, “We had a dysfunctional health care system in the U.S. well before the pandemic.” In fact, Medscape’s latest report on National Physician Burnout & Suicide found that 79% of today’s burned-out physicians say their problems began before Covid.
And unless there are radical changes, the burnout crisis will still be with us long after Covid has faded. Despite more than a decade of attempted remedies, burnout remains as firmly entrenched as ever. When Medscape conducted its first survey in 2013, 40% of respondents reported at least one symptom of burnout. This year’s report showed a slight uptick to 42%.
The Relationship Between Burnout and Depression
Burnout is frequently associated with depression, whether as a cause or a consequence. So, it’s not surprising that depression among clinicians is also at crisis levels. Forty percent of physicians surveyed by the Mayo Clinic in 2014 described themselves as depressed. In 2021, 69% of Medscape’s respondents said they were “colloquially” depressed (feeling down, blue, sad). One in five met the criteria for clinical depression. Thirteen percent said they had thought about suicide. Another 1% had attempted to kill themselves.
Tragically, most of these burned out/depressed clinicians resist professional help. More than half (52%) told Medscape their problem wasn’t bad enough to warrant the effort. Another 46% said they could handle it themselves. And 40% claimed they were just too busy. Instead of trying to solve their problems, they resort to a range of coping mechanisms. Many said they relied on exercise (48%) and sleep (39%) to manage their emotional struggle. Others indulged in junk food and alcohol (35% and 26% respectively).
While 43% of burned-out clinicians isolated themselves from anyone who might help, an equal number did at least talk with friends and family. But PBI founder Stephen Schenthal, MD, MSW, suspects these casual interactions may have been less than helpful.
“Many practitioners tend to minimize their condition when talking to people they’re close to. And friends and family often shy away from difficult topics,” he explains. “Avoidance leads to avoidance.”
Clinician Burnout also Puts Patients at Risk
Patients often end up paying a heavy price for their practitioner’s burnout. Burned out clinicians are more likely to leave medicine altogether and those who remain tend to make more mistakes. Some 15% of depressed physicians told Medscape they were making more errors than in the past and a 2018 meta-analysis found that distressed/depressed physicians were twice as likely as others to be involved in safety incidents.
It’s not just their clinical skills that suffer. Burned out physicians also score poorly in terms of professional integrity, communication practices, and empathy, according to the 2018 meta-analysis. It’s not surprising, says Schenthal. “Professionalism is about making the right choices, often in trying situations. You have to be able to focus and pay attention, keep track of information, set priorities, and resist powerful impulses. All of these executive functions are diminished when someone is depressed.”
The signs are everywhere. Gabe Wardi, a critical care specialist with the University of California, San Diego, told Scientific American, “I have seen many ICU physicians with somewhat uncharacteristic outbursts, apathy and sloppiness in patient care that I haven’t seen before.” The Medscape survey bears this out. Depressed clinicians said they were more easily exasperated by patients (36%), less intent on keeping good records (24%), and more likely to express their frustration in front of patients (13%).
Sooner or later these lapses lead to an ethics or boundary violation and regulators are forced to act. Except in the case of revocation, their goal is remedial. Regulators may restrict or suspend a clinician’s license if they feel patients are at risk, but such actions are always paired with steps, often including remedial education, designed to help the clinician return safely to practice.
To the burned-out clinician, though, it can feel like yet another slap in the face from a profession that’s continually abusing them. By the time the regulator confronts them, these clinicians already feel overwhelmed by the often conflicting demands of patients, employers, and government agencies. On top of all this, the regulator’s demands are hard to endure, let alone respond to constructively.
Forcing a Hard Reboot
It’s no wonder overwhelmed clinicians arrive at PBI courses feeling like they, too, are victims. But according to Schenthal, this sense of victimization is often the biggest obstacle to someone’s recovery. It’s not that clinicians’ complaints aren’t valid, he explains. They often are. But as long as they remain mired in their own anguish and anger, they struggle to move forward.
Too often people just want to go back, return to the way things were. “That’s not possible,” says Schenthal. “And until they realize that, until they can let go of their anger and look objectively at what wasn’t working in the past, they can’t figure out what has to change to make things better or safer.”
That’s not easy. Almost no one can do it by themselves. “Most people need to be jolted pretty hard to jar them loose from their comfort zone,” Schenthal explains, “which is what impactful discipline does.” He compares the process to a hard reboot. The regulator’s action forces people to unplug from their current state and day-to-day concerns so they can begin to re-evaluate their situation.
PBI instructors call on years of experience to give each participant the help they need to reorient themselves. Some need to be pushed to move beyond their own defensiveness. Others need to be coaxed. Everyone needs to feel supported as they consider, many for the first time, what their profession demands of them and what they themselves truly want out of their careers and their lives.
It takes time, but gradually as participants share experiences with each other and offer constructive feedback, they start to see their own situations more clearly. They begin to recognize and reject unrealistic demands they can never meet and embrace deeply felt needs they have never acknowledged. And by working together collaboratively during the course, they also regain a sense of community.
Before they graduate, PBI participants create a Personalized Protection Plan to help them solidify and build on the progress they’ve made during their course. For many, it’s a transformative experience. As they retake control of their careers and lives, the helplessness they felt as victims begins to lift and with it the depression that clouded their thinking.
One PBI graduate described the process this way: “I wouldn’t wish this on my worst enemy. But in a weird way I’m grateful for what happened. I wouldn’t have been able to make the changes I needed to and build a better life for myself if the medical board hadn’t knocked down my old life.”
Barber, C. (2021, August 9). Critical Care Doctors Are in Crisis. Scientific American. https://www.scientificamerican.com/article/critical-care-doctors-are-in-crisis/
Kane, L. (2021, January 22). “Death by 1000 Cuts”: Medscape National Physician Burnout & Suicide Report 2021. Medscape. https://www.medscape.com/slideshow/2021-lifestyle-burnout-6013456
Peckham, C. (2013, March 28). Physician Lifestyles — Linking to Burnout: A Medscape Survey. Medscape. https://www.medscape.com/features/slideshow/lifestyle/2013/public#1
Wan, W. (2021, April 22). Burned out by the pandemic, 3 in 10 health-care workers consider leaving the profession. Washington Post. https://www.washingtonpost.com/health/2021/04/22/health-workers-covid-quit/