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clinical burnout

Maslach burnout inventory (MBI) has 3 components of burnout

  • emotional exhaustion
    • Reduced energy and job enthusiasm
    • Emotional and cognitive distancing from the job
    • NB: reciprocal causation: high levels of emotional exhaustion cause stress while high levels of stress cause emotional exhaustion 1)
  • depersonalisation
    • Cynicism
    • lack of engagement and distancing from patients
    • treatment of patients as inanimate, unfeeling objects
  • lower scores of personal accomplishment
    • A sense of efficacy and effectiveness:
      • of involvement, commitment and engagement
      • of capacity to innovate, change and improve
  • “What started out as important, meaningful and challenging work becomes unpleasant, unfulfilling and meaningless. Energy turns into exhaustion, involvement turns into cynicism, and efficacy turns into ineffectiveness” 2)

red flags suggestive of burnout

  • Cognitive rigidity
  • Difficulty with ambiguity
  • Problems with setting boundaries
  • Inability to forgive oneself or blaming others
  • Irritability, sarcasm or cynicism
  • Feeling of emotionally exhausted
  • A sense of depersonalisation (cynical and detached)
  • Disengagement
  • Decreased enthusiasm for work
  • Anhedonism
  • Low sense of personal accomplishment and professional satisfaction.
  • Muscle tension/headaches

aetiology of clinical burnout

  • personality factors
    • neuroticism (undifferentiated personal anxiety), introversion, negative affectivity appear to account for 10% of the causation of burnout 3) 4)
    • BUT, those who are more neurotic can learn to transcend their anxieties (and indeed neuroticism may be beneficial if sublimated into a professional concern for detail in critical situations, rather than merely being undifferentiated personal anxiety). 5)
  • resilience to stress
  • the demands of electronic medical records (EMRs)6)
    • according to NEJM 2017, in the US, 80% of physician burnout is really due to workflow issues and the way the electronic medical records have evolved — unlike in other industries where automation has made work easier — the electronic medical records have added work.
    • negatively impacted face-to-face time with patients
    • clinicians have become sophisticated coders
    • distracted clinicians and others from some of the important interactions that lie at the core of health care
    • excessive “best practice alerts”
    • excessive inbox messages of tasks such as reviewing investigation results, etc
    • poor user interfaces
  • high workloads and loss of autonomy
    • perception of never being able to get on top of workload, being constantly behind, and never doing quite well enough
    • perception that the hospital-based manager’s principal role is to keep raising productivity targets, with the expectation that physicians will work harder while in reality, the rising complexity and expectations of patients make this impossible
    • perception that KPIs trump being able to “take the time to get to know my patients and intervene in ways that actually improve their lives.”
    • perception that one is being assessed on “quality” KPIs that do not reflect quality care and what patients want
    • perception of having to make a choice between falling further behind, or to cut corners on being really present and attentive to patients
    • efforts to convert medicine from a relationship-centered profession to an efficiency-focused production process have shifted the focus of attention from important aspects of care and as a result, hospitals and health systems are becoming increasingly detached from the reality of medicine and as health care shifts from relationships to data-driven, process-oriented approaches, it inevitably discounts the needs of particular patients and the people who care for them.
  • cognitive burden of the challenges of rapid medical progress
    • technology and medical knowledge is expanding exponentially, and so rapidly that it is now becoming impossible for an individual to keep up with all the changes and know when to eradicate older theories or treatments from their cognition - as a result clinicians become more specialised and it becomes more difficult to be able to provide a more generalised thorough assessment, while peers are also struggling with this workload overburden and as a result less inclined to collaborate with issues they are not directly required to collaborate on - timely help cannot be relied upon anymore
  • workplace bullying and harassment
  • increasing disconnect between what patients expect and what medicine can deliver
    • patients perceive doctors are paid well and can solve all their problems even social or life style issues
    • patients need to learn to accept that death, sickness, and pain are part of life and politicians and the media need to stop creating unrealistic expectations
    • the reality is, doctors and medicine have limitations, they don't know everything, they need decision making and psychological support, and their investigations and treatment does involve risks
  • stress of traveling to work and finding a car park
    • “Luke Filde's 19th century painting of a contemplative doctor alone with a sick child might now be replaced by a harassed doctor trying to park his car to get to a meeting on time.”7)
  • clinical error
    • if you perceive that you’ve committed a major medical error, that is associated with subsequent distress across multiple domains, whether you look at burnout, depression, quality of life.
    • systems are often not in place to ensure excessive self-blame is addressed during investigation of adverse events
  • underlying depression laying the seed for burnout
    • in the US 1/3rd of residents suffer from depressive symptoms and 10% have suicidal thoughts
  • neglect of work-life balance
    • the importance of away from work time - prioritise family, self-care, hobbies - it is NOT for work emails, etc. - create firewalls around non-work priorities to ensure work does not intrude
burnout.txt · Last modified: 2019/06/09 16:28 (external edit)