Individual physicians, Article 3 of 3
by Jeremy Lazarus, MD, Past President, American Medical Association; and Alexander von Hafften, MD, Physician Health Committee, Alaska State Medical Association
Featured in the May-June-July 2022 Colorado Medicine Colorado Medicine.
This is the third of three articles on physician burnout. Burnout is a syndrome of emotional exhaustion, depersonalization, cynicism, detachment, and sense of low personal accomplishment.(1) Approximately 50 percent of physicians and medical students were experiencing burnout prior to the COVID pandemic.(2,3) Burnout is an individual response to a systemic problem and interventions focusing solely on individual physician resilience are inadequate and miss the national, organizational and practice environment contributors to physician burnout. Organizational and practice environment interventions were the focus of the second article. This article summarizes recommendations and resources for physicians and medical students to promote health and wellbeing and to reduce burnout.
Education and awareness
Increasing awareness about physician distress and burnout is the first step. In 2015, the American Medical Association (AMA) launched AMA Steps Forward, an online resource to help physicians learn about wellbeing, burnout, and resilience (https://edhub.ama-assn.org/steps-forward/pages/professional-well-being). Many physician organizations such as the American Academy of Family Physicians (AAFP), American College of Emergency Physicians (ACEP), American College of Physicians (ACP), American College of Surgeons (ACS), and the American Psychiatric Association (APA) have online information, resources, and continuing medical education programs (CME).
How burned out am I? The National Academy of Medicine (NAM) website has links to several valid and reliable survey instruments (https://nam.edu/valid-reliable-survey-instruments-
Measure your well-being and burnout by completing the Oldenburg Burnout Inventory and the PHQ-9 (https://www.apa.org/depression-guideline/patient-health-questionnaire.pdf), both available without charge.
What is resilience and how to enhance resilience
Myers defines resilience as the ability to confront adversity and still find hope and meaning in life.(5) Tregoning defines resilience as the ability to bounce back or recover from stress.(6)
There are skills and mindsets that improve resilience. Psychological interventions such as Mindfulness-Based Stress Reduction (MBSR) and Cognitive Behavior Therapy (CBT) calm our mind and decrease negative rumination. These interventions improve wellbeing and resilience by reducing distress, anxiety, and depression. It is unclear if MBSR and CBT reduce burnout directly. This is understandable since national, organizational, and practice environment factors are primary contributors to physician burnout.
Distress and burnout lead to isolation and isolation is more likely when accompanied by anxiety, depression, substance use, and thoughts about suicide. Isolation reinforces psychological distress. Preventing and overcoming the tendency to isolate are important. Develop and foster supportive relationships with colleagues at work and away from work. Colleagues, mentors, and physician coaches may help by recommending ways to manage workplace stress and communication.
Meet with a group of colleagues to discuss the interpersonal aspects of clinical care. Balint training and Balint group participation lower rates of burnout in some physicians and residents. Form a group or participate in an online Balint group through the American Balint Society (https://www.americanbalintsociety.org/content.aspx?page_id=22&club_id=445043&module_id=406070).(7)
Meet with a peer-coach. Physician coaching is a peer-to-peer/coach-to-client interaction; not a physician-patient clinical interaction. There is no medical evaluation, diagnosis, or treatment. Corinna Muller wrote an article for Alaska State Medical Association’s Heartbeat newsletter in December 2020 summarizing the positive evidence for physicians coaching physicians.(8)
We have to care for ourselves to be able to care for others. Examples of self-care include nurturing our spiritual connections, investing in intimate relationships, seeing the good in others, extending kindness to others, sharing experiences and vulnerabilities with colleagues, and reaching out to colleagues in response to adverse events and stressful situations. AMA Steps Forward has a seven-minute webinar titled Stress First Aid for Health Care Professionals.(9)
The prevalence of depression in male and female physicians is 12 percent and 19.5 percent respectively.(8) Approximately 400 physicians suicide each year.(10,11) Suicide is 40 percent more common among male physicians and 130 percent more common among female physicians than the general population.(12) Approximately 10 percent of physicians have a substance use disorder during their career.(13,14) There is no replacement for medical evaluation and treatment when necessary.
Obstacles to seeking help
Even among physicians, there is a gap of understanding about the effectiveness of psychological and psychiatric care. Fear and stigma about seeking help are barriers, too. Individual physicians are fearful of being ostracized by colleagues, jeopardizing their medical license, being excluded by employers and insurers, and having no privacy or confidentiality safeguards.
Many medical boards, physician employers, and insurers ask about any history of mental or emotional conditions and substance use disorders, not whether the physician is currently suffering from a condition not being appropriately treated which impairs judgment or adversely affects one’s ability to practice medicine in a competent, ethical and professional manner.(15)
All stakeholders of the health care system should encourage physicians to seek and obtain help when needed, not discourage physicians from seeking help until after a crisis arises. In 2018, the Federation of State Medical Boards adopted a policy promoting physician wellness. The policy includes specific recommendations for state medical boards, state governments, Centers for Medicare and Medcaid Services, accreditation organizations, insurers, EHR vendors, hospitals, employers, professional medical societies, training programs and physicians.(15)
Sometimes we are approached by a colleague or observe a colleague struggling with burnout, anxiety, depression, substance misuse, or suicide. The Physicians Foundation has specific recommendations for conversations with a colleague. First: Be prepared. Second: Try to find the right time and circumstance so there won’t be interruptions, distractions, and lack of privacy. Third: Use language that communicates patience, understanding, and hope. Fourth: Listen without interrupting, judging, or trying to “fix” the colleague’s concerns. Fifth: Follow up with the colleague after the initial conversation. The colleague will likely have mixed feelings about having shared with you. The colleague’s ambivalence, withdrawal, and denial may increase.(16)
The Physicians Foundation has a one-page template to help physicians manage a personal crisis. The personal crisis management plan is built around answers to five questions.(17)
- What are my warning signs?
- What are my healthy internal coping strategies?
- Who are a few people or social settings that can provide me with distraction?
- Who can I ask for help?
- Who are the professionals or agencies I can contact during a crisis?
The availability and comfort of telecoaching, telepsychology, telepsychiatry, and telemedicine have increased greatly since the pandemic. Resources are no longer limited by physical location. In fact, some people prefer telephone and video conferencing over in-person meetings because of greater convenience and greater sense of privacy and confidentiality.
The Colorado Physician Health Program (303-860-0122) is another resource. CPHP may help by providing local and national resources for physician coaching, peer support, and comprehensive evaluation if appropriate.
- Burnout is an individual’s response to a systemic problem.
- Interventions that focus solely on individual physician resilience are inadequate and miss the national, organizational and practice environment contributors to burnout.
- There are individual physician interventions that may help reduce distress, anxiety, depression, substance misuse, and suicide.
- There are specific skills physicians may practice to promote resilience.
- There are specific actions and behaviors physicians may take to promote wellbeing.
- There are steps physicians may take to help colleagues who are in crisis.
Colorado Crisis Services 1-844-493-8255
Colorado’s suicide prevention hotline
Colorado Physician Health Program 303-860-0122
Accreditation Council for Graduate Medical Education (ACGME)
American Medical Association Steps Forward (AMA)
Association of American Medical Colleges (AAMC)
The Physicians Foundation
- Maslach C, Jackson SE: The measurement of experienced burnout. Journal of Occupational Behavior 2:99-113, 1981
- Dyrbye LN, Shanafelt, CA, Sinsky PF et al: Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC, 2017
- American Psychiatric Association. APA Wellbeing Ambassador Toolkit Physician Burnout and Depression: Challenges and Opportunities, Slide 16, January 2018
- National Academy of Medicine https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/
- Myers MF: Why physicians die by suicide: Lessons learned from their families and others who cared. New York, Michael F. Myers, 2017.
- Tregoning C, Remington S, Agius S: Facing change: developing resilience for staff, associate specialist, and specialty doctors. BMJ 348:g251, 2014
- The American Balint Society https://www.americanbalintsociety.org/content.aspx?page_id=22&club_id=445043&module_id=406070
- Muller C: Physician coaching: Providing a cure for a silent pandemic. Heartbeat December:1-12, 2020
- Westphal RJ, Watson P: Stress first aid for health care professionals: Recognize and respond early to stress injuries. American Medical Association Steps Forward. May, 2021 https://edhub.ama-assn.org/steps-forward/module/2779767
- Gold KJ, Sen A, Schwenk TL: Details on suicide among US physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry 35(1):45-49, 2013
- Schernhammer ES, Colditz GA: Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 161(12):2295-2302, 2004
- American Medical Association Steps Forward: Physician suicide and support: Identify at-risk physicians and facilitate access to appropriate care, slide 2, 2015
- Dupont RL, McLellan AT, White WL, et al: Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat 36(2):159-171, 2009
- Flaherty JA, Rickman JA: Substance use and addiction among medial students, residents, and physicians. Psychiatr Clin North Am 16(1):189-197, 1993
- Federation of State Medical Boards, Policy 2018. Physician wellness and burnout. 2018 Available from: https://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf
- The Physicians Foundation Vital Signs Attend To Your Wellbeing: Open your hear conversation starter https://physiciansfoundation.org/wp-content/uploads/2019/08/PF-Vital-Signs-Conversation-Toolkit.pdf
- The Physicians Foundation Vital Signs Attend to Your Wellbeing: A personal crisis management plan for physicians https://physiciansfoundation.org/wp-content/uploads/2021/04/Physicians-Foundation-Crisis-Management-Tool-for-Physicians.pdf
This article was originally published in the Alaska State Medical Association (ASMA) bimonthly newsletter, Heartbeat. It has been edited slightly to include Colorado resources and has been reprinted with permission.
Categories: Communications, Colorado Medicine, Resources, Initiatives, Physician Wellbeing Resource Center