Burnout and Compassion

Even before COVID-19, burnout was a major problem in health care. A 2012 study[1] found that 46% of physicians had at least one symptom of burnout, and many other studies cite the figure that at least 1 in 3 nurses suffer from burnout at any given time. More recent studies suggest that this 46% number might be a low estimate, and I feel confident that if the same surveys were conducted in this current climate, the percentage would jump considerably. Remember back to my patient story from last week, in which providers all did their very best by the patient, and yet the patient’s story ended in heartbreak because our institution didn't provide the support we needed for long term success. Now consider the definition of professional burnout, as defined by the WHO[2]: “a syndrome resulting from chronic work stress (unsuccessfully managed) and features emotional exhaustion, depersonalization (cynicism, loss of idealism, withdrawal), and feeling ineffective.”

The studies I referenced were about physicians, but the definition applies to all health professionals, including physical therapists. When I was unable to provide further therapy to my patient due to financial and insurance limitations, but there was no staff available to maintain his progress, I felt ineffective. When the restorative nurse was unable to perform her job because the facility was understaffed, she also felt ineffective. We both felt a strong loss of idealism in that situation, as well as emotional exhaustion trying to keep our own anguish about the situation under control while encouraging the patient to remain calm in a situation where he had every right to be angry. This is how provider burnout is created and sustained by the very health systems that want engaged, passionate providers to provide the highest quality of care.

When providers suffer burnout, the result is dangerous to patients. Often burnout leads to decreased professionalism, decreased quality of care, increased medical errors, and early retirement or career change[1]. Also interesting to note - physician burnout leads to decreased patient adherence to medical recommendations[3]. Unsurprisingly (or maybe surprisingly?), the problems posed by burnout are the same that compassionate care solves. When providers are given the space and institutional support to provide compassion to their patients, patient safety improves, patient satisfaction increases, health care costs decrease, patient adherence doubles, and healing improves. Additionally, providing space for compassion can lead to increased staff connectedness, which also results in decreased provider burnout[4]. After a difficult patient, it's cathartic to retreat to a shared office space to share the story with colleagues who can relate!

The Mayo Clinic is working at the forefront of burnout prevention, and in 2017 they published a well-researched framework for decreasing provider burnout[8].

I put a link to the article that explains their framework and their research at the bottom of this post, as well as in the research tab of the blog. The framework consists of 9 components that institutions need to implement in order to prevent burnout. In short, they recommend allowing providers to make medicine personal, to share human connection, and to focus on things other than the financial bottom line. The 9 steps are as follows, along with my one line description:

1) Acknowledge and assess the problem – check in with employees about their burnout levels the same way institutions check case mix and payer mix

2) Harness the power of leadership – actually train hospital leaders in effective leadership principles

3) Develop and implement targeted interventions – identify the most at risk groups in the health system to target first

4) Cultivate community at work – give providers time in their schedule and private space to share work stories and provide support to each other

5) Use rewards and incentives wisely – tying financial incentives to productivity does not work

6) Align values and strengthen culture – ask employees how the health system is meeting its stated mission statement and listen to the difficult truths they share

7) Promote flexibility and work-life integration – policies that make it difficult to use vacation or sick time lead to faster burnout

8) Provide resources to promote resilience and self-care – this step only works if the health system is also working to decrease burnout at an organizational level, otherwise it’s just putting more pressure on individual providers to forge their own solution

9) Facilitate and fund organizational science – use the best available evidence to create practice policies, and then further assess these policies to contribute to the evidence pool

Many of these solutions do not cost much in terms of dollars, but they do require the administrators and upper management of health systems to keep an open mind and to trust that compassionate, engaged providers are a key economic benefit to the system. These solutions also stand to have a huge impact on both employee and patient experiences.

Imagine last week’s patient scenario in this light. My patient calls the therapy department and tells me that he is ready to walk if he can get some prosthetic legs. We arrange appointments with the prosthetist and work toward increasing strength and endurance in preparation for walking. My patient puts in the hard work of exercising, stretching, walking, and achieves his goal of walking in the facility with a nurse standing by in case he loses his balance. I discharge him from therapy and turn over his care to the restorative nurse. She goes to his room 5 days a week, helps him put on his prosthetic legs, and walks beside him for 20 minutes, singing songs and sharing stories. I feel pride and deep satisfaction in my job every time I see them walking together. She feels that she is making a difference every day she comes to work. We are both less likely to look for alternative employment, resulting in reduced staffing issues. The patient feels seen, cared for, and proud of his efforts. His body is stronger, his bone density is increased, he has improved cardiovascular function from the exercise, and he has made friends now that he gets out of his room regularly, which improves his mental health. The health system can advertise (accurately!) that they provide restorative nursing to keep residents healthy and mobile. All this benefit could have been achieved by hiring one additional $12 per hour employee.

None of the strategies suggested by the Mayo Clinic or even in this example address the even greater national issues contributing to provider burnout, such as insurance reform, excessive documentation requirements, reimbursement rates for medical care, or population health. Compassion put forth organizationally allows providers to behave compassionately toward their patients, which decreases provider burnout and improves patient outcomes. It’s evidence based, and when I read the research, it resonates as truth.

[1] Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1351351 [2] Fostering compassion and reducing burnout: How can health system leaders respond in the Covid-19 pandemic and beyond? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295512/ [3] Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. https://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/fulltext [4] Hiding in Plain Sight: Compassion as an Antidote to Burnout in the Post Covid Era. https://www.apsf.org/article/hiding-in-plain-sight-compassion-as-an-antidote-to-burnout-in-the-post-covid-era/