How physicians fall apart: how pandemic-era burnout has struck the nation’s healthcare system
With a third of the healthcare workforce exposed to excessive death or threat of death during the COVID-19 pandemic, concern over physician burnout has spurred a nationwide physician wellness movement. Recent studies on physician burnout deepened understanding of work-life wellbeing and prompted programs to be implemented in Yale’s medical system.
In 1985, clinical assistant professor of psychiatry Mark Rego was fresh out of medical school. Thrust into training as an intern resident, he trudged through his first night “on-call.” This meant a 36-hour shift that usually culminated in around three to four hours of sleep before the next workday. Rego was ready to go to bed at around 4 a.m. But there was no place left to sleep — neither a couch nor a cot available. Rego looked around the on-call room and discovered that there were simply not enough places for the entire team to sleep. The following day at lunch, he told the training director.
“He was defensive and referred back to when he was a resident and how hard they had it,” Rego said. “No one at the lunch table supported me. This illustrated the attitude of over-work and its consequences in medicine from the mid-century to when I trained in the 1980’s. There was a machismo, for men and the few women, about being able to take the punishing hours.”
The COVID-19 pandemic unearthed physician burnout as a public health crisis, drawing attention to the longstanding legacy of toughness and over-work in healthcare described by Rego. During the pandemic, people have become acutely aware of just how reliant they are on physicians and the healthcare system as a whole. The past years also saw several studies on how burnout can physically affect physicians’ brains and worsen the level of care they can provide. This years-long pandemic underscores the need for community intervention, beyond the individual, to fight burnout and redefine how healthcare workers themselves are trained and treated. If you also want a fulfilling career in the healthcare industry, you are not limited to becoming a doctor or a nurse. You may also consider a career as a medical assistant.
The culture Rego described started changing slowly in 1984, when Libby Zion, an 18-year-old college student, tragically died from a fatal interaction between medicines at New York Hospital. She had been taken care of by an unsupervised intern, spurring an investigation into resident physicians’ hours. The Libby Zion law in New York outlawed the 36-hour shifts Rego once completed, limiting shifts to 24 hours. The most important outcome, according to Rego, was that “over-work” became an acceptable topic to broach.
The “machismo and silence” that defined physicians’ training evolved into an “approach of care” for residents, Rego said. Though he could not vouch for the effectiveness of any particular program, he found that attitudes had changed since his training. The physician wellness movement pushes to continue opening up conversation about burnout. Most recently, at the core of research on physician burnout is the need to restore work-life balance through structural change.
“The practice environment as currently constructed is creating conditions that alter brain function and contribute to many of the consequences of burnout with respect to quality of care, patient experience and professionalism,” said Tait Shanafelt, Stanford Medicine chief wellness officer. “The primary focus [of recent research on physician burnout] is on trying to address the problems in the work environment, not teaching clinicians to be able to tolerate a broken system.”
Shanafelt and Yale professor of neuroscience and psychology Amy Arnsten collaborated on a study looking at the neurobiology of physician burnout. They focused on the prefrontal cortex, which is the most recently evolved area of the brain, responsible for regulating thoughts, actions and emotions. Their study found that uncontrollable stress impaired the functioning of the prefrontal cortex.
According to Arnsten, the prefrontal cortex is important for metacognition, which is “thinking about thinking.” This includes abilities such as “remembering to remember” and one’s moral values. When uncontrollable stress causes dysfunction of the prefrontal cortex, the result can be impaired concentration and working memory, potentially inviting medical errors. Physicians can also become cynical and less empathetic “as a way of trying to survive,” Arnsten said.
“When [prefrontal cortex] dysfunction occurs, it impairs judgment, compassion, moral conscience, self-regulation and inhibition,” Shanafelt said. “This can lead to people being triggered by and reacting to challenges and problems in ways that are unprofessional — anger, shouting at people, rude remarks and lack of compassion.”
Physician burnout is linked to physicians losing a sense of control over their own practice, weakened connections with patients and colleagues, a work-life imbalance and uncontrolled stress. The pandemic has exacerbated concern over physician burnout, as COVID-19 surges overwhelmed medical systems.
Additionally, women in medicine consistently register higher stress and burnout scores, according to Kristine Olson, Chief Wellness Officer at the Yale New Haven Health System. She said that during the pandemic, female physicians were more “withdrawn from professional activities” such as academic research and grants, which mark the milestones of career advancement. Pre-pandemic, childcare and domestic responsibilities disproportionately fell on women compared to their male counterparts. However, with schools and other social support networks shutting down during the pandemic, households were required to provide childcare on their own, exacerbating stresses put on women in medicine.
When the pandemic hit, Yale Internal Medicine resident Nathan Wood was pulled out of normal rotations to work in the COVID-19 intensive care units. The year 2020 marked his “winter of discontent.” There were no vaccines, patients were dying “left and right” and life was still far from normal. By only being able to see respiratory illness in “patient after patient,” Wood also felt like he was unable to use his clinical training period to learn about other important diseases that he would need to treat as a physician.
“A common feeling of burnout is this depersonalization, where you feel like a cog in the wheel,” Wood said. “Many of us felt like we were warm bodies who could write prescriptions and hook up oxygen and and as soon as we did that and one patient got better, there was another patient who presented in the exact same way … it just became like this never ending revolving door of sickness that we didn’t really have good treatments for.”
Wood encountered difficulty disconnecting his mind from the trauma of the day. According to Olson, a third of health care workers have faced excessive exposure to death or threat of death as a result of the pandemic. As Wood found, the emotional exhaustion and fatigue experienced by healthcare workers was “an unspoken truth.” There was a “fear” that acknowledging these complex emotions felt by the community would only exacerbate the feelings.
Wood stated that this coping mechanism pervaded the medical community. It was not just individuals that were burnt out, but largely “the entire medical profession,” Wood said.
“There’s only so much that’s within [medical professionals’] power when it comes to positive behavioral change and mental reframing and self care, etc. that can positively impact burnout,” Wood said. “There are some systematic changes, like more time off, decluttering the electronic medical record and providing more support staff and giving more time with patients that really will need to change in order to positively impact physician burnout on a community level.”
According to Wood, the Yale New Haven Health System allocated a few days of break every week to Internal Medicine intern residents during the early months of the pandemic. Yale was one of the first healthcare systems to establish a chief wellness officer position, which is a role dedicated to the wellness of physicians. Olson began this position in March 2020, right before the pandemic hit the United States.
Olson stated that in the past, healthcare executives and the public might have seen physicians’ complaints about the healthcare system as “ungrateful” or “disruptive.” But, once the nationwide wellness assessments validated physicians’ concerns and showed that half of physicians were experiencing burnout, it galvanized a movement.
“When one is ‘called’ to duty for the social or moral good and has great responsibility, not being able to perform your best sometimes feels like a ‘moral injury’ and can develop into ‘compassion fatigue’ or ‘burnout’ when facing obstacles in accomplishing goals or living up to one’s expectation for mastery,” Olson said. “We want to create an environment that facilitates, not frustrates, people trying to be their best. What we know about physician burnout applies to other industries too, and informs us on the country’s ‘great resignation.’”
According to Olson, the pandemic could serve as a catalyst for personal growth, helping some people find meaning beyond themselves. In a JAMA article, Olson and Shanafelt proposed a post-traumatic growth model for organizations to incorporate in reflections on surviving a “traumatic disaster.” She hopes to use this model to discover healthcare systems’ lessons learned during recovery from the pandemic, through events that promote open discussion of physician wellness and trauma.
“In the struggle to find stability after a traumatic event, some people may discover post-traumatic growth,” Olson said. “[They are] stronger than they thought, open to new possibilities, [have a] greater appreciation, deeper relationships, and a greater sense of spirituality — meaning, something beyond oneself.”
Sixty percent of emergency medicine physicians reported feeling burnout in 2021, the highest of all specialties.