Burnout isn’t a personal failure…but it feels like it is when you’re on the way there

I don’t know why it has taken me so long to connect the word burnout with myself. I could have saved myself a great deal of angst if I had done so sooner.

It was only after I left my job as a GP that I came across the latest International Classification of Diseases definition of burnout and the raft of American Medical Association resources, including the STEPS Forward action documents.¹

I imagined burnout as the realm of a cigarette-smoking, scotch-swilling, male executive with poor insight and a trench coat. I can’t explain the latter; in my imagination he seems to be living in a film noir.

This is not to say I would have been any more successful than “that guy” in stamping out the smouldering but, had I been better informed, I might not have attributed my burnout to personal weakness for quite so long.

Burnout as a response to social and working conditions is understandable. As an experience, it is a prolonged, frustrating, confusing, exhausting straitjacket of personal failure and weakness.

WHO characterises burnout as an occupational phenomenon. Its features are:

• exhaustion/tiredness
• lack of compassion/cynicism, and
• poor performance.

I certainly had no interest in continuing medical education nor learning about new medications

As we all know, exhaustion/tiredness has multiple potential causes. I’ve even written a patient handout on the subject. It’s normal to flop on the sofa the moment you get home, and to never want to cook dinner, and to force yourself out the door to exercise because it’s good for you – not because you want to. It’s normal to drink and watch Netflix all evening. It’s normal to sleep badly. Except it’s not normal, just normalised. And the trouble is, this is a non-specific feature.

The second characteristic from WHO is easy to identify. Most of us develop an exasperated shake of the head at the foibles of our patients, an outrage shared with colleagues, a little gallows humour, a little distance in order to get by.

After the novelty of portal email wore off, at about 7pm on a Thursday evening I’d open one which would read something like, “Hi Doc, you got my prescription wrong – there were only 30 tablets, and my middle name is spelled wrong on this thing, and when did Lucy have her MMR and I’ve had pelvic pain for three weeks, what should I do?” which would elicit the verbal response “for f**k’s sake” and I’d know it was time to go home. My downfall could have been graphed by the time of day I used the f-word like that. Near the end, I uttered it one day at 8.27am.

Feature three is pretty hard to accept about oneself. I certainly had no interest in continuing medical education nor learning about new medications.

There was some cognitive slowing, and not making connections I’d normally expect to, but again, there were potential physical causes for that. As for poor clinical judgement – I don’t think so, but I guess that’s the point. You can’t judge that for yourself, and that’s why professional colleagues are important.

After I resigned, I worried about making a dreadful mistake in my last few months that would cancel out all the good I had done in the previous 20 years.

As intensely personal as this experience has been, it would be impossible not to be aware that others are also affected in this way. The rising frequency of health professional burnout is causing concern worldwide.

My impression is that those of a more thorough, more empathetic persuasion seem particularly vulnerable.

Having either firm boundaries or no boundaries at all seem to protect a GP from getting burned out. So that means the GP who sticks with just one problem per consult and never lets appointments run late, and the one for whom the GP persona is the core of life, may not be as likely to burn out. I’d be curious to know if females and business owners are more vulnerable.

A word about social and health demands from outside work: they have a role to play in resilience to work stressors. This is universally true of every human. There is a bottom line – there is work that needs to be done, and colleagues are affected negatively when it is not. But workers with experience of adversity or of being part of a family are good for a workplace too. Every workplace needs to take the humanity of its workers into account when planning its systems.

As I stepped away from the coalface and began trying to work out what on earth had happened to me, several articles widened my view from the personal to the systems level.

I’ve been trying to figure out what got harder over the 20 years of my general practice career. This includes, but is not limited to:

• Patients live longer, so they have more years with more comorbidities and more complex, potentially interacting, medication regimes.
• Expectations got higher.
• More medications and tests are available.
• More diseases are diagnosable.
• More treatments are on offer for previously undiagnosable or untreatable diseases– so more consultations, more referrals, more follow-ups, more letters.
• The internet – we spend more time explaining why we don’t think they have a rare disease, and what the marginally low sodium doesn’t mean.
• The most complex patients consult more often, so make up a greater proportion of a GP’s daily consultations.
• Patient-centred medicine, joint decision-making, informed consent – all good things, but time-consuming.
• Patients have less respect for our time. Very few people worry about bothering the doctor any more, except the ones we would rather did bother us.
• Nurses are in short supply. Patients can easily email us via portals.
• COVID-19: everything is harder in PPE. Running two different streams is cognitively tiring. Acute respiratory illnesses aren’t very intellectually satisfying when they make up a large proportion of your consultations, and mental health consequences of the pandemic are very emotionally demanding when they make up a large proportion of your consultations.
• Services previously provided in secondary care have been shifted onto primary care with no or little shift of resources.

The following is written by NHS GP Gavin Francis, but will sound familiar to New Zealand GPs:

“I now face daily decisions on how best to manage my patients given that the services I was taught to rely on are no longer available. There’s pressure on me from patients and from hospital colleagues to prescribe medications for everything from skin conditions to mental-health problems that are supposed to be the domain of specialists. During my training I took it for granted that a functioning hospital service would be able to see my patients when their problems went beyond my expertise.”²

In the US, surgeon and academic Simon Talbot and psychiatrist Wendy Dean hold burnout to be a symptom of a broken healthcare system. They prefer the concept of moral injury – “perpetrating, failing to prevent or bearing witness to acts that transgress deeply held moral beliefs and expectations”.

The deeply held moral beliefs and expectations boil down to the belief that doctors are there to help patients – “failing to consistently meet patients’ needs has a profound impact on physician wellbeing — this is the crux of consequent moral injury”.³

Drs Talbot and Dean highlight several areas that are becoming more problematic over time. These may sound as real to you as they do to me (within the limitations of our local differences – for physician read doctor, for litigation read complaints to the Health and Disability Commissioner).

“Physicians must consider a multitude of factors other than their patients’ best interests when deciding on treatment,” they write.

“Financial considerations – of hospitals, healthcare systems, insurers, patients, and sometimes of the physician himself or herself – lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant spectre of litigation drives physicians to over-test, over-read and over-react to results...[A focus on] patient satisfaction…can also silence physicians from providing necessary but unwelcome advice to patients, and can lead to over-treatment to keep some patients satisfied…These routine, incessant betrayals of patients’ care and trust…repeated on a daily basis…coalesce into the moral injury of healthcare.”

The pair go on to say: “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.”

Being a smart, tough, durable, resourceful person who has tried working harder, smarter and differently feels a lot better than being weak, compromised by family commitments and my own health, lacking resilience and not being up to the job. If I squint my eyes just right and drum up enough self-compassion, I can believe it.

Emma Dunning, of Wellington, is a specialist GP who is no longer practising