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Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already.  Simon G. Talbot & Wendy Dean; STAT 7.18

Burnout or secondary trauma?

The practice of medicine today is death by paper cut 

Physicians have the highest suicide rate of any profession

Every day there is a new and worrisome report about physician burnout, a term that until very recently was not clearly defined. Burnout is used broadly to describe high levels of physician dissatisfaction and disenchantment, and it is incredibly common – at any one time, nearly 50% of practicing physicians are experiencing some signs of burnout.

 

Unfortunately, the “burnout” label is often misused to imply that physicians are to blame for their unhappiness, essentially accusing them of inadequate self-care, of poor work-life balance, or of inefficiency at work. The term also doesn't account for the severity of symptoms many physicians are experiencing. The term secondary trauma much more accurately describes the myriad of symptoms and discontent so prevalent in the practice of medicine today.

There exists no single, underlying cause of rising incidence of physician dissatisfaction. However, it is known to be due at least in part to a divergence between the ever-increasing demands placed on physicians – one recently described the mounting practice demands, particularly with regard to EMR as “death by click” – and the resources available to help them deal with those demands. This discrepancy leads to disengagement and exhaustion, and these issues often spill over destructively into the physician’s interpersonal relationships, both at work and at home.

 

Burnout often presents as intense anxiety and/or anger that colors interactions with colleagues, subordinates and patients, and can be interspersed with periods of apathy and exhaustion in which care for patients is no longer given top priority. Joy, pride, social interaction and intellectual satisfaction – once hallmarks of the profession – are replaced with frustration, isolation, anger, dissociation and career dissatisfaction.  Additionally, physicians frequently report symptoms consistent with delayed response to trauma, including persistent fatigue, disordered sleep, anxiety, depression, and avoidance of emotions, sensations, and activities. These are hallmark symptoms of secondary trauma and can lead to self-medication, depression, anxiety and suicidal ideation.

One doctor commits suicide in the U.S. every day – the highest suicide rate of any profession. New research shows that the number of doctor suicides – 28 to 40 per 100,000 – is more than twice that of the general population (12.3 per 100,000).  This is a matter of urgency. Physicians who are suffering are high risk for making diagnostic errors, poor patient interactions and satisfaction, and poor collegial interactions. Additionally, their career dissatisfaction leads to attrition and career change, both of which are incredibly costly to hospital systems – replacement costs for a physician can top 1 million, even before accounting for legal fees.

 

The rapidly changing healthcare work environment has created significant pain points for physicians, but provide no outlet for relief and little or no built-in support within the system. Physicians are not simply suffering from burnout; they are suffering secondary trauma and moral injury.

“Most physicians enter medicine following a calling rather than a career path. They go into the field with a desire to help people. Many approach it with almost religious zeal, enduring lost sleep, lost years of young adulthood, huge opportunity costs, family strain, financial instability, disregard for personal health, and a multitude of other challenges. Failing to consistently meet patients’ needs has a profound impact on physician well-being — this is the crux of consequent moral injury."

We should be greatly alarmed by the incidence of burnout, secondary trauma, and moral injury occurring in our colleagues, and wholly dedicated to intervening before it leads to depression, anxiety, self-medication and suicide. Although physicians are high-achieving and fully committed to the health and lives of their patient’s, they also are programmed – by years of schooling and intensive, sometimes brutal training – to cope alone and with a survivalist mentality.

 

While many of the contributors to secondary trauma and moral injury in our physicians and surgeons are endemic in medicine today, physicians can be equipped with skills to mitigate the effects. Rarely do engaged physicians become burned out. Honing soft skills that allow for better patient and collegial interactions and conflict resolution is a key towards reengagement.

Finally, the critical importance of feeling heard by a colleague who understands the demands and challenges of the profession, and who is willing to hold space in non-judgement as fears and anger are processed cannot be overstated. 

Coaching is not therapy, but great coaching can be incredibly therapeutic.

Physicians are often reluctant to seek help due to fear of stigma

Rarely do engaged physicians become burned out