Burnout in medicine
Need to know:
- Burnout is distinct from depression, and management requires consideration of both individual and workplace factors.
- Burnout is not a sign of low resilience, failure or inadequacy. It is a sign that the demands placed on the individual have been persistently greater than the resources available to them to meet them.
- Doctors are at high risk of burnout during their junior training years, when studying for exams, and at major transition points which require increased responsibility.
- To sustain wellbeing, doctors must have their own trusted GP to turn to. When burnout is present, this is essential for diagnosis, and assessment of severity and safety.
- Sustained recovery is optimised by regular professional support, alteration of workplace factors over which the individual has a level of influence, setting healthy boundaries, engaging in social networks, and addressing individual factors, including stress responses and perfectionism.
Burnout has increasingly appeared in the literature and media over the last five years, and particularly since the pandemic.1 More workplaces are recognising the impact of burnout, and are interested in staff wellbeing, although this commitment may now be declining.1
Public awareness is increasing, and with it, people are more likely to open up about the struggle to manage the mounting pressures of work and life, and to seek an elusive solution.
The concept of burnout has appeared in literature in various forms for thousands of years. However, it wasn’t first described formally until 1974, when psychologist Herbert Freudenberger coined the term ‘burnout’ to describe the experience among healthcare workers of loss of motivation, a growing sense of emotional depletion, and cynicism.2
The World Health Organization (WHO) recently included it in the 11th revision of the International Classification of Diseases (ICD-11) as an “occupational phenomenon”, described as “a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed”.3
Some suggest the concept should apply more broadly than as a strictly workplace phenomenon, and include roles such as caring, studying, volunteering and parenting.4
A particularly colourful definition describes burnout as the accumulation of hundreds or thousands of tiny disappointments, each one hardly noticeable on its own.2 This description resonates with many who have experienced burnout.
Burnout particularly affects those who work in people-oriented professions, including healthcare professionals, teachers and emergency service workers.5
Such professionals tend to approach their work in a selfless and self-sacrificial manner, frequently work long hours, and go ‘above and beyond’ to provide good care.5
Over time, it has been recognised that burnout has become more widespread and affects all sectors to some degree.
Incidence among doctors
Burnout rates in doctors may be as high as 80.5%.6,7 Among GPs, 73% have experienced feelings of burnout in the past 12 months.8 Junior doctors have particularly high rates of burnout, although the phenomenon can occur at any time throughout a medical career.9
In recent years, doctor burnout has increased due to the demands of the COVID-19 pandemic, floods, bushfires and Australia’s ageing population.8,10 This convergence of events has led to increasing complexity of patient needs and consultations, difficulty accessing leave entitlements, and exam disruption and postponement, on top of the usual demands of the role.
Furthermore, many doctors are reducing their clinical work hours and intend to retire earlier due to burnout, which in turn exacerbates workforce shortages.8,11
Causes
Burnout results from complex interactions between workplace, individual and circumstantial factors.12
Six key components of the workplace environment contribute: workload, control, reward, community, fairness and values.13
When there is a mismatch between an individual and their employer in these areas, the individual is more likely to burn out.
Doctors experience widespread mismatches in all six areas, which makes it unsurprising that burnout rates are high in the medical profession.
Workloads for doctors are generally very high, often with limited opportunity to take adequate breaks, significant unpaid overtime, rising administrative tasks, taking on additional tasks and responsibilities due to staffing shortages, physically and emotionally draining work, limited support, and insufficient time to adequately recover between episodes of work.8,9,12
This is exacerbated by the emotional nature of the work, which tends to affect doctors beyond their formal working hours, making their rest time less effective. Inadequate organisational support makes this workload and emotional toll unsustainable long term, without risking a significant impact on wellbeing.13
Doctors often have limited control over their work, with competing demands that make it difficult to set priorities or influence their workload to match their capacity.13 There can be significant role ambiguity, in which there isn’t clarity on precise expectations, or the official expectations are different to what is required day to day.13
A sense of reward is vital to sustain motivation and prevent burnout.13 Adequate financial reward is of practical economic importance, as well as a reflection of contribution and appreciation. Other rewards include emotional reward, social recognition, prestige, respect, and pride from family and friends.
Emotional reward from interactions with patients and colleagues diminishes as doctors become overworked and exhausted, especially in understaffed systems. In such settings, doctors often say they feel their remuneration doesn’t reflect the intensity and quantity of their work.8
Workplace and social support are important in preventing burnout.13 These are lacking for many doctors, particularly when they have moved from overseas, rotate interstate or to rural locations, participate in shift-work, or have heavy workloads, including attaining additional qualifications and exam study. Workplace support can be inadequate due to under-staffing, bullying, microaggressions, suboptimal clinical support from senior staff, and limited sense of community with colleagues.
In stressful work environments, staff look to organisational leaders for optimism and fairness.13 Fairness is a sign of a strong community. In medical settings, it’s particularly important to consider fairness in distribution of rewards, opportunities and recognition,13 including rostering, leave requests, clinical learning opportunities, rotation allocation and payment of overtime.
Values are the principles and standards that bring someone to their specific career or job.5 Burnout increases when an employee is required, as part of their job, to be involved with actions that conflict with their personal values.
Diagnosis
Burnout poses significant diagnostic challenges, often leading to misdiagnosis and ineffective management. Limited awareness leads to under-recognition, as symptoms are dismissed as minor or acceptable, or are incorrectly attributed to depression or anxiety. This leads to inadequate or inappropriate treatment, or to the burnt-out doctor feeling invalidated, which reduces the likelihood of seeking further support.
Some contend that burnout is a form of depression, although most researchers acknowledge it is a distinct entity.5 Features of burnout do overlap with those of depression and anxiety. These include low energy, reduced motivation, low mood, isolation, cynicism, procrastination, irritability and feelings of exhaustion.12 However, burnout is considered to be more job- or role-related and situation-specific.5
Recent data have found no prominent cluster of depressive symptoms among burnout participants.4 Depression can co-exist with burnout or can develop as a consequence.4
Burnout also frequently results in physical symptoms such as headaches, gastrointestinal upset, muscle tension and hypertension.5 These overlap with many organic illnesses, highlighting the importance of correct diagnosis.
Diagnosis has predominantly been based on the Maslach Burnout Inventory (MBI), a diagnostic tool that has largely influenced the ICD-11 classification of burnout.14 The MBI identifies three core features of burnout (see box 1).
Several other diagnostic tools have been developed over the years, and many argue that the MBI doesn’t adequately detect the core symptoms. The Sydney Burnout Measure is an alternative assessment tool, based on research indicating that burnout symptoms are more complex, variable and frequently include impaired cognitive functioning, which isn’t encompassed in the MBI definition.4 Difficulties with cognition may include impaired memory, concentration and attention.4
| Box 1. Three core features of burnout |
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Impact and prognosis
Burnout affects all areas of work and life. It can impact career progression and work engagement; it can increase the risk of mistakes; it can lead to poor communication, aggression, social withdrawal, relationship difficulties or breakdown, substance misuse, and suicide.5 Burnt-out doctors often reduce their work hours, leave their job, move into a non-clinical or less stressful area of medicine, or transition into an entirely different field of work.5
The prognosis of burnout is variable due to the complexities of individual circumstances and the presence of comorbid mental illness.
Recovery time is variable depending on burnout severity, treatment engagement, and ability to alter causative factors. If no significant changes are made in work or life, burnout tends to worsen, not resolve spontaneously with time.15 ‘Recovery’ is not a permanent cure, but rather reflects a return to the individual’s usual level of energy, hope, engagement with work, connection to others, and feeling that life is sustainable.
Optimal recovery also involves the acquisition of a repertoire of strategies that allow recognition of signs of recurrence as the inevitable challenges of life arise, and effective timely response. For milder cases, recovery may take a few months, whereas in severe cases it can take up to three years, although most of this occurs within the first 12 months.
Management
There is no universally agreed approach to management. Indeed, some of the popular approaches are incomplete, at best, and have the potential, at worst, to do harm.
Many workplaces place the responsibility for wellbeing and burnout prevention on employees, with proposed solutions including self-management of fatigue levels, accessing health providers (including Employee Assistance Programs), ‘resilience training’, engaging in healthy eating and regular exercise, and seeking work-life balance.
This approach largely abrogates the workplace of its responsibilities for occupational health and safety, doing little to acknowledge or address workplace contributions to burnout. Employees tend to respond to such strategies with increasing resentment and burnout, and this approach can in fact lead to a reduction in individuals participating in healthy behaviours.
An emphasis too far in the opposite direction can be similarly unhelpful. When employees see the workplace as not only the source of all their challenges, but also as responsible for all the solutions, then they miss out on the potential for positive change through self-reflection and addressing personal responses to circumstances.
To best manage burnout, both workplace and individual factors warrant consideration, as well as identifying specific action areas in which there is scope for change. Individual factors include the way in which the person responds to stress as well as personality factors such as perfectionism.4
Anyone who suspects they are burnt out warrants an initial assessment with their GP to receive an objective diagnosis and consideration of differential diagnoses, and to assess severity and safety. This is best facilitated by doctors already having their own GP with whom they are comfortable discussing mental wellbeing. Unfortunately, 40% of doctors do not have such a relationship with a GP.16 Persisting stigma poses an ongoing barrier to disclosure of burnout, so it is important for doctors to consider carefully who they disclose to.9 Simply acknowledging the presence of burnout often provides a sense of relief and validation, and instils a sense of hope that things can improve.15 A period of leave from work is often beneficial and recommended but will not lead to recovery on its own.15
Workplace factors are a helpful starting point. This involves consideration of workload, work hours and responsibilities. It’s important to identify where the individual has agency, and how their choices can be leveraged to reduce stress and improve wellbeing.15 Certain workplaces or stages of training limit autonomy and scope for change, in which case it’s necessary to optimise the individual’s stress response strategies and protective factors to endure a fixed period of training, or to seriously consider a change of workplace.15
Perfectionism is a key contributor.4 This may result in perpetuating behaviours such as longer work hours, excessive time creating thorough notes and letters, repeated checking of assessments and results, and over-preparing for presentations. It can also lead to procrastination and avoidance of new opportunities and responsibilities, due to a fear of failure.
Connection and support are important, 15 including spouses, children, colleagues, mentors, and more formal arrangements such as Balint groups, social media groups and other wellbeing support groups.
Professional psychological support is particularly important in addressing the vicarious trauma intrinsic to many medical roles. Engagement can be challenging, as burnout frequently leads to a desire to withdraw and isolate. Counterproductive interpersonal interactions such as bullying, harassment and poor boundary-setting are also vital to consider and address.15
Maintaining interests outside of work and medicine is important so that being a doctor doesn’t become the individual’s core identity. Outside interests aid the capacity to view work challenges from a different perspective and enhances capacity to take meaningful action. To maintain wellbeing over the long term, doctors must make time for important people in their lives, hobbies and other interests.
An individual with mild or evolving burnout will usually achieve good recovery by addressing these factors. Those with severe burnout may require a prolonged break from work, moving to a new job, or even an entire career change. This is best done with professional guidance to avoid unnecessary reactive decision-making, which can have a large and ongoing negative career impact.
To achieve optimal outcomes, it’s critical that we accurately identify burnout, assess its severity, and tailor management strategies to the individual’s personality, work and circumstances. With acknowledgement of the issue and good support, doctors can achieve a sustainable career that also allows space for personal wellbeing.
| Tips for dealing with burnout |
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Resources:
- The Burnout Project:
The Burnout Project provides burnout counselling, group support programs, online courses, events, workshops, training and burnout packages. - The Black Dog Institute’s ‘Navigating Burnout’ online course:
- Burnout: A guide to identifying burnout and pathways to recovery by Gordon Parker, Gabriela Tavella and Kerrie Eyers
- Doctors 4 Doctors:
24/7 peer support, information, and training.
Dr Amy Imms is a medical practitioner in Tasmania, with a special interest in burnout, particularly in health professionals.
References on request from kate.kelso@adg.com.au
