Summary

We know that burnout in doctors is related to their response to stress, a maladaptive approach to high standards of care and the type of personality of the doctor. But many of the factors causing burnout originate from their working environment, outside their control. The paper considers how doctors themselves, their employing organisations, education and training providers, their professional organisations, and their patients, can all act to prevent or reduce the pressures on doctors, or support them in their work and well-being, and thus help them to resist burnout.

摘要

醫生過度勞累與個人對壓力的反應，不能適應高要求的工作以及個人性格有關，但還有很多因素，來自不可控制的外在工作環境。本文分析醫生、僱用機構、教育和訓練提供者、專業學會和病人，如何共同預防或減少醫生的壓力，對他們的工作和健康予以支持，以助他們對抗過度勞累。

---

Introduction

Is burnout in doctors inevitable? If we could fully understand the interplay of individual and organisational causes of burnout in doctors and act accordingly, can burnout be avoided? What are the responsibilities of the individual doctor and the health service as a whole in resisting burnout in doctors - a condition that has been keenly observed to affect substantial proportions of doctors over the last 25 years, without obvious solutions being put in place.^1-4

What is burnout?

Burnout is a "syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do 'people-work' of some kind."⁵ Burnout is a popular term rather than a scientific diagnosis. Without an agreed definition, aspects of burnout in practising doctors have been described as emotional exhaustion - where a doctor is worn out by human interaction and no longer able to give of themselves at a psychological level; having a callous or depersonalised perception of others - such as patients and colleagues; having a negative view of themselves and being dissatisfied with their job.⁵

Burnout seems more likely to occur in doctors who have a heavy work commitment, rather than those who practise part-time.⁶ Burnout has been linked with stress and increased use of alcohol and drugs.⁷ It is a matter of debate as to how long it takes for high levels of personal accomplishment to lead to burnout and higher stress levels.⁸ Although depersonalisation is a key aspect of burnout, it also seems to reduce stress "presumably through an ego-defence mechanism. By contrast personal accomplishment increases stress both directly and also indirectly by increasing emotional exhaustion. An increasing emphasis on higher professional standards might therefore increase stress and burnout in doctors."⁹

Some personality characteristics render doctors more vulnerable to developing burnout. Higher burnout scores have been significantly correlated with low self-esteem, feelings of inadequacy, obsessive worry, social anxiety and withdrawal from others.¹⁰

Compulsiveness in doctors includes doubt, guilt feelings and an exaggerated sense of responsibility. This compulsiveness trait may be useful in small measure to get work done conscientiously. When it becomes maladaptive, the doctor may have an inappropriate and excessive responsibility for things beyond their control, difficulty setting limits on work, reluctance to take holiday leave - all of which are precursors of burnout.¹¹

Long working hours and health service pressures might trigger marital and family disharmony; or contribute to depression, stress or anxiety, or poor coping responses that result in alcohol misuse or drug dependency. All of these are recognised as being more common in the medical profession than in other professional groups.^7,12 Their presence can impact on the doctor's performance at work and produce a deleterious effect on the quality of patient care provided by the doctor, even if they deny that this is so.¹³ Such affected doctors may lack insight into the reasons for their diminished performance, and mistakenly blame factors in their work setting rather than acknowledge the nature of their own condition. We do know that doctors tend to take less sickness absence than other health professionals do - reviews of burnout find that the frequency and length of sickness absence is correlated with burnout.^14,15 Maybe doctors' tendency to deny their poor mental well-being, the effort of sustaining high professional standards coupled with their determination to stay at work, increases stress and drives them towards burnout?

When does burnout start?

It is a matter of debate whether or not burnout evolves insidiously with successive years spent in clinical practice and/or age.¹⁶ There has long been evidence of raised levels of stress and depression in junior doctors¹⁷ and even at the start of a doctor's career during medical training.¹⁸ A recent study of the psychological morbidity of Hong Kong medical students confirmed that they too had developed higher depression, anxiety and stress levels when compared with their peers in non-medical tertiary education.¹⁹ Medical students' distress levels escalated in their third year as they experienced more patient contact, worked longer hours and expectations of them increased. Those medical students with poor coping skills including denial, self-blame or disengagement were more likely to experience depression, anxiety or stress.¹⁹ Longitudinal studies of doctors' personality have shown that for some students, their longstanding maladaptive personality tendencies predated their medical training and exposure to the intrinsic stresses of medical practice.¹⁰

Possible roles and responsibilities in avoiding burnout in doctors

Doctors themselves

Individual doctors have a professional responsibility to maintain their competence. That is not only about staying up to date in respect of clinical care or legislation, but also performing well. Just as there is increasing interest in promoting and supporting self-care for patients, we should expect a similar culture of self- care by the medical profession for themselves. This is not to advocate inappropriate self-treatment of their symptoms or condition by prescription drugs, or an overlong delay in seeking professional help for conditions that warrant it - as some doctors have tended to do if they regard admission of a health or performance problem to a colleague as a failure or stigma on their part.²⁰ Self-care is a continuum, starting from the individual responsibility a doctor takes in making daily choices about their lifestyle and risk taking, or more profoundly, their way of working or match of their personal preferences or strengths with their career pathway. These choices may be in their work, travel and hobbies, and other aspects of their everyday lives.

Doctors working in primary care share six core competencies which could be generalized to doctors working in other health care settings: management, person-centered care, specific problem-solving skills, comprehensive approach, community orientation and holistic modelling.²¹ Adopting self-care for themselves would require all these skills. Management would cover the work/out-of-work interface, with a manageable workload via good time management, delegation and other personal management techniques. Person-centered care would involve prioritizing their own needs and what ingredients are essential for them to have in place to combat burnout - maybe career diversity, new challenges, learning new skills. Specific problem-solving skills enable doctors to focus on areas of their working life that threaten their mental well-being or are intolerably pressurized- or boring. A comprehensive approach refers to the wide perspective a doctor needs to keep stress levels within sensible limits, thinking of the huge array of potential stressors and life events that might produce undue pressures on them. Community orientation might be interpreted as their awareness of, and self-satisfaction from, the value of their contribution as a doctor to the community. Holistic modelling would include the psychosocial and cultural dimensions of a doctor's life. Prevention would involve them as individuals in pursuing a healthy lifestyle with time off work for happy relationships with a partner, friends and family, fun, leisure and exercise.²²

Doctors need to be more aware of the nature of their own personality type and if that is associated with an increased tendency to suffer from stress in working with patients.²³ Such doctors need to be more self-aware of pressures they find difficult to cope with and learn coping techniques that they consciously practise from an early stage. If they have a competitive Type A personality, made worse by sustained parental pressures and expectations from an early age of great achievements, they must learn to push themselves less hard, be kind to themselves if they do occasionally fail, expect less and enjoy their achievements.

The doctor's employing organisation

For doctors who are employed, the organisation they work for will be concerned about their performance. To sustain effective performance throughout their career will require a supportive culture in their workplace. In practice this means being valued and having access to sufficient resources to allow them to work in a competent manner. Minimal pressures from realistic targets directing their work, along investment in their personal and professional development are all part of such an enabling culture. If there are concerns about a doctor's performance at a local level, their employer should consider and intervene if they have mental health problems, misuse alcohol or other substances, have a cognitive problem, recent significant life event or team difficulties - all of which are generally linked to burnout.¹²

Doctors will work best in an organisation with good teamworking, effective strategic planning and strong leadership. They need clear roles and responsibilities with reasonable autonomy, workload capped at manageable limits and adequate resources.^24,25 The organisational climate should be fair and supportive, not engendering fear - such as from making mistakes or uncertainties about job contracts. If this kind of culture is not in place, doctors can become alienated, dissatisfied and isolated.^26-28 Managers should be looking out for the doctors for whom they are responsible, offering pastoral support, practical help or occupational health care proactively, to doctors displaying any kind of difficulty or those they know are working under unavoidable pressures. Continuing professional development should be expected or required as an antidote to burnout. Encouraging peer learning and review, providing opportunities for sharing experiences and worries, celebrating achievements and competence, increasing self-confidence through personal reflection should all help doctors resist burnout. Doctors should be able and encouraged to take sabbatical leave to recoup their energies and revitalise their professional interests.

The range of proactive support through organisational interventions should cost less than covering doctors' sickness or other absence, suspensions or remedial support for poor performance, patient litigation for errors etc.^7,14

If doctors are self-employed they need to create a similar ethos in their specialty or general practice units to nurture themselves and medical colleagues throughout their career.

Education and training providers

As stress and depression are more common in medical students than their non-medical peers, educational establishments should re-examine how they train doctors, in order to find a format where students can learn comfortably with minimal pressure. This is an ideal period for medical students to learn good coping techniques to apply when stress is inevitable, such as in caring for a dying patient or in emergency situations. Professional associations should work with educational providers to help medical students cope with the expectations upon them and anticipate their future responsibilities in a confident way. The format of learning should be aligned with the best evidence for a supportive approach rather than the traditional learning by rote or humiliation. Nothing beats reflection for enabling doctors to realize their strengths and weaknesses as an integral part of coping with stresses in their working lives.

Professional organizations

Doctors' professional organizations should ensure that there are networks of support available to doctor members. These might take the form of a gateway to various sources of support such as careers guidance, mentoring, coaching, legal or financial advice, help with stress management, buddies etc. They should promote medical professionalism - to preserve the values, behaviours and relationships that underpin the trust that patients in general have in doctors. Doctors can be isolated in their role and subject to commercial or corporate pressures from employing organizations that can undermine such professionalism.²⁹

Patients

And what of patients? Have they got any role or responsibility in helping doctors to resist burnout? They are not passive recipients of health care. A minority are abusive or disrespectful. Many consult for conditions or symptoms they could manage themselves and are overly dependent, thus increasing the workload for individual doctors. Some patients have false expectations that the medical consultation will solve all their ills - social, financial, spiritual, psychological and physical. If we move from that patient dependent attitude to a culture where patients take more responsibility for their own health and initiate self-care, there should be less pressure on doctors. Patient groups attached to hospital or primary care practice could provide a supportive network, giving positive feedback as well as indicating areas for improvement.

Conclusion

Employing organisations or responsible authorities could introduce cost-effective interventions to reduce pressures on doctors and increase support mechanisms; educational bodies might re-think their training and approach; doctors themselves could be more determined to prioritise their own health and well-being through self- care. We cannot afford to have doctors burn out. We cannot afford it, in terms of risks to patient safety from doctors who are more forgetful or accident prone, or ending up with sub-optimal patient care as a result of emotionally exhausted and disengaged doctors with low energy levels. We cannot afford to have burnt out doctors retire early on the grounds of sickness or boredom - not whilst the costs of replacing them or dealing with their problem behaviour at work are so high. So, let us see some concerted action from every-body with a part to play in resisting burnout in doctors - that is, from doctors themselves, their employing organisations, education and training providers, professional organisations and patients themselves.

Key messages

1. Burnout has been commonly reported in doctors.
2. Heavy workload, long hours, poor coping mechanisms, low self-esteem are all associated with burnout in doctors.
3. To protect against burnout, doctors' self-care should include practising good personal management techniques, adopting a holistic approach to lifestyle and well-being, prioritising their own needs, and achieving career satisfaction.
4. The doctor's employing organisation has a responsibility to provide a supportive working environment to minimise burnout; with good teamworking, effective strategic planning and strong leadership.
5. The teaching format in education and training of medical students and established doctors should enable them to enjoy learning and apply good coping skills that help them resist stress and burnout.
6. Doctors' professional organisations should generate networks of support.
7. As patients take more responsibility for their own health and recognise the limitations of medical care, this will reduce pressure on doctors.

---

---

References