Monday, March 21, 2016

Burning down the house, Part II

I solemnly swear that no meditations will be introduced in the text of this blog post.

Last time I tried to highlight what puts doctors at high risk for burnout, as well as outlining society's vested interest in addressing the problem. Here I start to look at the more immediate issue of what can be done about it.

Though I'm not a huge fan of numbers, I did a quick scan of the medical literature on the topic to inform this post. That, and I don't need you thinking that I'm pulling all of the blog's contents out of my ass.

Burnout among health care workers is a fairly young area of research. There's some literature on teacher burnout going back into the 80s and 90s, but it's only been about ten years that people have been looking at the problem in doctors and nurses. The research is almost all survey-based, which is straightforward to conduct but not necessarily the most useful. I'll explain why in a moment.

Most studies point to somewhere around half of doctors and nurses reporting moderate symptoms of burnout. Some studies say 45%, others are over 50%, some studies are well-conducted, and others are shite. We can't know the true numbers--we never know about the people who don't complete a survey--but half is a good enough starting point.

Half of all doctors and nurses have moderate symptoms of burnout? How is it that the health care system hasn't collapsed entirely?

For one thing, surveys measuring the prevalence of burnout are snapshots. Until we have good studies that follow health care workers over time, we don't know what to make of these very common symptoms. If half of all doctors and nurses have these symptoms, does it cause any problems for staff or patients? As the prevalence of burnout goes up, do we see increases in staff turnover, absenteeism, disability claims, or medical errors? Or are feelings of burnout just part and parcel of the job, in which case we really don't need to worry about it all that much?

Moreover, the surveys are likely missing the most important subjects i.e. doctors and nurses who've already crashed, quit, or (in the extreme) committed suicide. Even if we do pick up some of that data, the findings are very generalized. That might help somewhat with departmental planning or scheduling, but isn't going to be much help at the level of the individual practitioner, in particular if you're trying to help someone with severe symptoms.

For example, the following article by an accomplished American neurologist offers some broad ideas to reduce symptoms of burnout. You don't need to read it, although I agree with a lot of what he says before he rhymes off his "antidotes" to burnout.

The Antidote to Physician Burnout: A Nine Step Program

Among his ideas: working in an under-resourced clinic; cataloguing your most significant professional mistakes; studying history; being a mentor; getting over self-pity; and "being more realistic".

If any of these were offered to me during my worst days, I suspect my wife would have collected some fat insurance money and I'd be in an urn over the fireplace right now. Working in a poverty clinic or with Doctors Without Borders, where the patients are all victims of trauma? Ruminating even more on my worst screw-ups?

These are fine suggestions if you're fed up with bean counters, bureaucrats, and paperwork but still have passion for the work. On the other hand, someone losing touch with their sense of humanity, withdrawing from their family, or showing encroaching symptoms of depression desperately needs rest and support, not a new challenge. A soldier with PTSD won't be cured fighting ISIS. Why would you do that to a doctor or nurse?

Still, if we're going to try and be helpful, "rest and support" is pretty vague. We need to get a little more concrete when coming up with ways to deal with burnout, both at the individual and system level. Next time.

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