Mounting pressures forcing doctors, nurses to cope with devastating problem of burnout
The Daily Reflector
Sunday, April 1, 2018
This is the first of two parts.
Dr. Mark Bowling is considered by his peers and patients to be the model of today’s compassionate caregiver.
For years, the pulmonologist with Vidant Cancer Center and ECU’s Brody School of Medicine has given all his time and energy to making sure people who have the most serious lung diseases, including cancer, have received the best possible care.
Bowling makes sure each patient — up to 40 or more each day — gets his full attention to the details of their care plans. He stays on top of all the latest diagnostic and treatment approaches and monitors each patient’s progress with understanding and compassion, absorbing and sharing their fears and anxieties. He never misses an opportunity to deliver the best possible outcome, even when death seems inevitable and imminent.
“That’s the way it’s supposed to be, what a doctor does,’” he said during a recent conversation with The Daily Reflector at the end of a long work day.
What Bowling did not easily recognize were the signs that his dedication was wearing him down. During his decades of medical practice, Bowling’s patients have remained at the very top of his priority list, he said. The trouble was that his was a very short priority list.
“Doctors are raised to be tough. You don’t complain or whine. You do the work. Patients are No. 1 and always will be,” he said. “It starts to wear on you mentally. It’s one death talk after another with families, and it eats at you constantly, but you don’t want to go home and talk to your own family about it. At some point, you just feel bad.”
Bowling is among health care providers across eastern North Carolina who are sounding the alarm about a burden they have been quietly carrying for years — a burden created by the emotional toll of caring for critically ill patients, the sheer volume of cases they must handle and an ever-growing mountain of paperwork required for the administration of care.
The physician and his colleagues are saying that the burden is not theirs alone, but a serious national industry-wide problem that can put patient health and lives at risk and ruin careers. They call it burnout.
Bowling, now 49, was in his early 40s when he began to notice inward consequences that, at first unnoticed by others, could not be kept hidden.
“I found my personality changing to someone I didn’t know or would ever choose to be like,” he said. “I noticed my temper got shorter and I got much harder to deal with at work. I just wasn’t me. Then I started to be preoccupied at home. My wife called me out on it. Your family can be a huge casualty. That’s one of the things that made me decide I had to change.”
The doctor’s decision coincided with efforts initiated by scattered groups of health care practitioners to address the problem, and Bowling and others have helped bring them to the attention of administrators and employers at East Carolina and Vidant Health System as well as the public. Now the institutions here are scrambling to be responsive their alarm.
The burnout phenomenon is characterized in professional journals by physical and emotional exhaustion, chronic fatigue, internal health issues, insomnia, anger and depression, sometimes leading to thoughts of suicide. Other signs include cynicism and a pessimistic attitude, demoralization, emotional detachment from patients, colleagues and friends and a low sense of accomplishment.
A 2017 research report by prominent research physicians Tait Shanafelt of Stanford Medicine and Christine Sinsky of the American Medical Association showed that more than half of U.S. physicians are experiencing substantial symptoms of burnout. Physicians working in the specialties at the front lines of care — emergency medicine, family medicine, general internal medicine, neurology — are among the highest risk of burnout. Burnout is nearly twice as prevalent among physicians as workers in other fields, according to the report.
Burnout can affect patient safety because depersonalization is presumed to result in poorer interactions with patients, according to a 2015 Shanafelt-led study for the Mayo Clinic based on physician self-reporting. Clinicians with burnout are more likely to subjectively rate patient safety lower in their organizations and to admit to having made mistakes or delivered substandard care at work, Shanafelt said.
Several studies also have found a high prevalence of burnout and depression among medical students and residents. Individual clinicians and health care organizations have tended not to speak openly about the problem, let alone confront it, Bowling said.
“Every clinician, nurse, respiratory therapist and everyone else at this institution that I know cares about their patients above everything else,” he said. “That can wear on you after a while. You go home consumed with it, then you get withdrawn because you’re always thinking about it. Then, on top of that are your administrative duties, the paperwork and new medical regulations you have to know and follow. It gets to you after a while.”
Bowling said he is even more concerned about burnout among nurses. A 2016 survey of America’s 3.6 million nurses by the American Nurses Association showed that 82 percent of respondents reported that they are at significant risk for workplace stress.
Vicki McLawhorn, 44, a Vidant nurse practitioner, and Christine Smith, 47, a unit nurse, work in the hematology and oncology wing of Vidant Medical Center, a busy 36-bed unit for patients receiving cancer-related chemotherapy. In addition to sharing the care of Bowling’s patients, they, like many of their nursing colleagues, bear similar signs and symptoms of burnout.
“As a caregiver, we intersect with people at one of the worst moments of their lives,” McLawhorn said. “In order to be an effective caregiver, you have to be able to connect on a human level, and oncology patients stay much longer on the unit, so we get deeply connected and involved with many levels of their care. That can be exhausting. There have been moments when I knew a patient or family needed me to be emotionally present and I glossed over it because I just didn’t have anything. You think, ‘God, they deserve better than that.’”
The nurses acknowledged that such moments contribute to their low self-value.
“We come into this profession because we want to help people,” Smith said. “When we don’t, we feel like we’ve failed. It’s particularly stressful for newer nurses who feel the performance expectations placed on them.”
Changes in health care the last several years have placed a heavy burden on nurses, McLawhorn said.
“We have to do much more with fewer resources, demanding more of our time,” she said. “There isn’t enough staff support to go around now that most care has been pushed to the outpatient world. I don’t think it’s any one person’s fault, just the way health care is now. It makes for a stressful shift. I know a lot of people on our team who suffer from burnout. I can see physicians looking emotionally disengaged due to fatigue. We nurses talk to each other about patient-centered care, but you can’t give effective care if your providers are empty.”
A recent Vidant Health survey indicated that 12.5 percent of the system’s advanced practitioners and doctors who responded said they are burned out. Perhaps a more potent indicator of the problem was the extent to which those same doctors believe the problem extends among their colleagues. About 23 percent said they believe their colleagues are burned out.
Among Vidant Health nurses, nearly 19 percent report they are burned out, while more than 32 percent believe their nursing colleagues are burned out.
The condition of burnout is insidious, Bowling said.
“It starts in medical school or nursing school, where the dedication to training is very intense from the beginning. It’s a lot all at once,” he said. “But you’re young, so you deal with it, and you have energy and some outlets at that age. Later, as an attending physician with ultimate responsibility for patient outcomes, you get consumed by (your work), and some of the very traits that make you a good physician are the ones that drive you to burnout. You can’t do it all but for so long, and you can’t fix every patient,” he said.
The burnout phenomenon is increasingly pushing practicing doctors and nurses away from clinical care and making the professions less attractive, adding to the shortage of health care professionals at a time when surveys show the need for them is at an all-time high.
A health care system designed to help can, in some ways, be more burdensome than helpful, Bowling said. An electronic records system that involves layer after layer of administrative responsibility, important for patient care and cost management but extremely time consuming and energy-draining, is a common example.
To solve the problem, clinical professionals need administrative support, but speaking publicly about their challenges strikes fear among doctors and nurses, often adding to the sense of isolation and hopelessness. They speak more openly to Theresa Raphael-Grimm, Ph.D., a psychotherapist and professor with a joint appointment in the schools of nursing and medicine at UNC-Chapel Hill. Raphael-Grimm spoke recently about burnout and efforts to increase resilience in the profession to a packed audience of nurses, doctors and social workers at Eastern Area Health Education Center in Greenville.
“People talk openly to me about their burnout because they know it’s done in complete confidence,” she said. “They are reluctant to talk openly about its impact on them, even among their colleagues. They’ll complain about the system to each other, but not how it’s affecting them emotionally and affecting their sense of well-being and their interpersonal relationships.”
Continuing advances in medical care require providers to keep up with an often overwhelming level of information, Rapheal-Grimm said. Patients also have unrealistically high expectations of their providers. There is tremendous pressure to make it all better with pills rather than months of therapy, which often is the more effective course of treatment.
“Patients leave dissatisfied, which leads to poor patient satisfaction evaluations that leave doctors feeling defeated,” she said. “Sometimes what patients want is not in their best interests.”
Adding to the pressures are administrative requirements that increase the number of patients seen in a day, leaving clinicians to decide what to discuss and what to ignore, which does not necessarily match patients’ priorities, the therapist said, creating a feeling of disconnect between patients and their doctors.
“Once we put all the effort into training clinicians, how do we make sure they stay on the job rather than drop out or switch to an administrative or education position?” Raphael-Grimm said. “It’s too grueling and the pace is too demanding. You can lose exceptional and compassionate clinicians because they’re so overwhelmed by the system.”
The therapist’s visit to Greenville last month is among a growing number of signs that the industry is recognizing the problem and beginning to own it, participants in the AHEC program said. Audience members eagerly grasped the need to speak up and share their concerns.
Now that providers are opening up more publicly about their challenges, some health care organizations are beginning to more openly acknowledge burnout in the workforce, according to administrators interviewed by The Daily Reflector. They say they are learning to spot its characteristics and consequences and are beginning to search for effective ways to help their employees.
Institutions are faced with the problem of what to say and do about burnout. They support doctors and nurses in trying to deal with the downstream consequences, but few tackle the problem head-on, Raphael-Grimm said. “This situation presents hospitals with an opportunity to show that they are aware of this national phenomenon and are taking proactive measures to address it.”
Part two of the series will examine approaches and caregiver strategies for coping with stress and building resilience.