Burnout for Physicians who Hate Discussing Burnout

Physician burnout for physicians who hate hearing about burnout.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

Dr. Cifu (00:05):
On today's Clinical Excellence Podcast. We have Dr. Wei Wei Lee talking about physician burnout.

Dr. Lee (00:10):
The average is around, you know, between 45 and 50% when you look at the average right? One in two... are experiencing burnout.

Dr. Cifu (00:30):
We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss dissect and promote clinical excellence. We review research, pertinent, clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship. And we host conversations with patients and doctors. I'm Adam Cifu, and I'm joined today by Dr. Wei Wei Lee. Dr. Lee is a general internist and associate professor of medicine. Her academic research focuses on developing innovated patient-centered models of care and improving patient physician communication. She's the associate Dean of students in professional development and director of wellness programs at the Pritzker School of Medicine. She's a senior faculty scholar at the Bucksbaum Institute for Clinical Excellence and a fellow of the Academy of Distinguished Medical Educators. Whoo! Thank you for joining us, Dr. Lee.

Dr. Lee (01:26):
Dr. Cifu, it's a pleasure to be with you today.

Dr. Cifu (01:29):
It was kind of exhausting going through all that stuff. I'm almost burnt-out.

Dr. Lee (01:34):
Good thing we're talking!

Dr. Cifu (01:35):
Anyway. So I've asked you here, so I can ask you a couple of questions about physician burnout, which I think you have spent an enormous time—not only sort of researching and thinking about—but actually like acting on and trying to figure out ways to, I don't know, make life better for physicians. And I'm kind of a doctor who hates to talk about burnout. So I was really looking forward to talking to, so can you just start us off with kind of definitions? Like what is burnout? How do we define burnout?

Dr. Lee (02:04):
Yeah, no, that's a that's a really good place to start. And I think burnout is certainly a condition and something that we've talked about in the medical profession more and more over the past 15 or 20 years, the formal definition is typically related to the Maslach Burnout Inventory. So this is one of the, key tools that's used to assess burnout, not just in medicine, but across many different professions. And it has three elements to it. So burnout is typically defined as emotional exhaustion. So feeling completely bone exhausted. You know, really, really tired emotionally from the work that you're doing, you know, in the workplace—for us medicine. But then deep personalization is also a big part of it. And so that is feeling distance from your patients, compassion, fatigue, seeing your patients more as objects than the human beings that they are.

(02:54):
And lastly, just a very low sense of personal accomplishment or loss and meaning in the work that you do and feeling that your own personal efficacy is at a quite low place. And importantly, you know, the the idea of burnout is that it's actually a workplace related syndrome. So related to a lot of chronic stress at work. That is not related to personal resilience, you know, an individual's ability to be able to manage stress cuz as physicians going through medical school and residency and you know, for us in, in academic medicine, I think all of us have incredibly high levels of resilience. And when you take a look at studies around resilience, physicians often have higher resilience than peers in other professions and even physicians who score the highest in the ratings for resilience experience burnout. So those are kind of the things to think about.

Dr. Cifu (03:45):
So I think maybe—as you said—that I had a question and I think maybe you answered it, but my question is like, is some degree of burnout like normal and unavoidable? I sort of think about: I, you know, came back from vacation a week ago and my first afternoon in clinic, I was so struck by like how good I was, you know, I was incredibly relaxed. I really listened to people, nothing bothered me. And I was like, boy, you know, a week ago I was not like this. Right? And I wouldn't back then have considered myself burnt-out. Especially given the things that you just talked about with kind of depersonalization and all, but I don't know, is it sort of a spectrum of like, boy there's just regular work fatigue and angst and then burnout is beyond that or how do you think about that?

Dr. Lee (04:34):
I do think that it is a spectrum. I think that, you know, we're not gonna experience our work lives and our lives and preparing to be physicians in medical school and residency without high levels of stress. High periods of really needing to be productive in whatever that means, whether it's research or really thinking about, you know, your standardized exams at that point in your life. Or there are always high periods of stress in your life and career. Right? But burnout is beyond that. It's sort of that chronic feeling of being completely depleted for very long periods of time. I do think stress and burnout are part of the lived experience for every physician. Yeah, but I think there are points at which burnout becomes you know, impactful on your own quality of life, but also the impact it has on the meaning you're bringing to work and then on your patients as well.

Dr. Cifu (05:25):
So you mentioned which I loved when you sort of went through your first spiel on this, you know, that it's very much related kind of to the job right? To this situation. And I feel like there was a time that a lot of the responsibility was put on the physician, like it's your fault that you're burned-out because we could probably design a job that would burn-out anybody. Right? But, so what I was gonna ask is about kind of predictors of burnout and I'm interested like: Are there predictors based on the job, but are there also predictors based on the people like who's more likely to get burnt-out in the same job?

Dr. Lee (06:02):
Absolutely. So those are really great questions. You know, I mentioned that, you know, the idea and study of burnout and physician well-being is a fairly new field, I would say the past 20 years or so we've seen a really large, you know, number of publications around burnout. And so what we do find is that there are some factors that can predict burnout and some of them are just the specialty you choose. Right? So when we look at studies on burnout, the average is around, you know, between 45 and 50%, when you look at the average, right? One in two of our colleagues are experiencing burnout. Right? But it's also a wide range, it ranges from like 30 to 70%, depending on specialty. And so those in sort of the lower burnout realm, so below the mean are like pediatric subspecialties.

(06:48):
People think about ENT, Ophtho sort of in that realm... uhm, psychiatry is also lower burnout. The ones that are higher are emergency medicine, OB, family medicine, internal medicine, and subspecialty. So there's a whole wide range of burnout within specific fields. And some of that is work related. Right? Workplace related. Other things are also more obvious, right? Number of work hours that you are putting in, number of nights and weekend calls. Work life interference. Right? So this is an idea that Mark Linzer at Hannepin has done a lot of work around who's also a general internist. And so how much work are you bringing home, right? Is it the work after, you know, work hours with the EHR, documentation burden, all of that, but then there's also other things related to, you know, EHR, how inefficient it can be loss of autonomy or control at work. So how much you're able to think about your schedule in a way that really allows you to do the work you need to do, but also manage the, the things on the life front that are important and then malpractice, you know, that always has a, a role to play in burnout.

Dr. Cifu (07:50):
Like if someone's experiencing a malpractice suit at the time. Uhm, this is gonna be more personal experience, not getting personal with you. You know, you spend a lot of time with trainees at every level medical students residents. And I imagine do a lot of kind of career counseling as part of that. Do you sort of, you know, as you talk to an individual and you get a sense of them and what they're like, what they're looking forward to their future, do you sort of consider burnout when you make recommendations about the field people go into? Not that they're gonna listen to you really, but uhm...

Dr. Lee (08:32):
I do. And I do that because I do think that it's really important to acknowledge and I think that's, what's really happened in medical education, you know, in the past decade or two. My role is an associate Dean of students, but part of my role is actually directing the wellness program. And I know when I was in medical school, wellness programs did not exist. Right? And right now residency programs have, you know, committees, you know a lot of the faculty workforce are thinking about burnout and how to address it within the academic and other settings. Right? So infrastructure is there and that sets us up to really talk about burnout early on because the studies are there. We know that there needs to be something done in our pipeline to address it because we talk about burnout being a work-related syndrome.

(09:18):
And for our students that a lot of that is, is medical school, the dealing, managing with the known stressors that we all have to deal with. And so what's nice is that now it is literally built into the talk I give at orientation around wellbeing. Like this is the, this is the data, this is epidemiology 40% of our workforce experiences burnout. We have data on, you know, depression and mental health prevalence in medical students and in, you know, in physicians, we wanna really draw attention to these concepts of how to recognize when you yourself are unwell so that you can tap into resources, but also to normalize because so much of our culture in medicine is around: power-through, you know, keep working hard, that's what we value, patients come first, etc. And so a lot of that I think is something, you know, that we're thinking about really actively and culture change is hard, you know? And so when I advise students as a career advisor about their specialty choice about what do they see in their life? Beyond just their career and professional, what are the things that are most filling for them? We talk about all that in the context of how, you know, your personal choices and your professional choices are intimately going to impact each other. Because, you know, I think having that information and having that, data available is really helpful to them.

Dr. Cifu (10:35):
You know, one of the things that makes me super proud about being a physician, and I think it's one of the things that brings us, you know, respect in our society and all the privilege that it takes is that... you know, a lot of us see this as vocation, a lot of us see the selflessness that you talked about—about being really core to the mission. And maybe it's just being an old man. You know, sometimes when I hear people talking a lot about, you know, self care, I worry that boy, you know, does the pendulum go too far? And obviously look, if you, as a doctor, feel terrible and are miserable, you're gonna do a terrible job taking care of your patients like period. We all understand that. But I guess it's just finding that balance of like, when are you caring for yourself enough? And when are you caring for yourself too much and not caring for your patients enough?

Dr. Lee (11:33):
I love that. I think self-care is a really charged word. Sometimes I do think that I love that perspective. I mean, so many of us went into medicine because we do want to do something that is incredibly hopefully helpful for our patients, helpful for society. You know, there is that part of, you know, working hard that's part of our work ethic. Right? But at the same time, I think physicians have a hard time drawing boundaries, you know, there's a lot of mouth out to perfectionism. There's a lot of the sense of like, I need to do it because no one else will. And there's a lot of like lack of self-compassion at times, right? If you make a mistake, we're in a culture where it's really hard to talk to colleagues about mistakes. It's really hard to feel like everyone else around you is incredibly smart and incredibly productive and successful.

(12:20):
And so I think that within that culture, it's really challenging to draw boundaries that are healthy. And so if you even take a look at some of, you know, a lot of the data around physician burnout, part of it is, even our internal data here at University of Chicago and we look at burnout amongst our faculty, one of the major things, especially, you know, during the COVID pandemic has been just having a hard time turning it off. Right? Like going home and not being able to fully engage in those things that will help you recharge, you know, not being able to turn off the work or those expectations. And so I think it is a spectrum because that self-care piece, you know, you're not gonna yoga your way outta depression or like meditate your way out of, you know, massive burnout.

(13:01):
We need to address those organizational and systemic drivers of burnout. And again, I don't think it's a self-care piece. That's where the literature is moving these days. Right? There's a model that's outta Stanford that looks at burnout. And the major drivers are the culture, of the organization, as well as efficiency of practice. How easy it is to practice in your particular setting to do your research, your administrative work, and the smallest piece of that pie is that personal resilience and self care piece. So the self care piece is not gonna get us out of the burnout conundrum. It's really systemic interventions to address kind of the workplace conditions.

Dr. Cifu (13:40):
That's I think really well said, because for me, it's sort of separating, it's making sure the things that I personally see as I wanna say magical, but that's a little bit like too strong, you know, about physicians. It's, about the fact that we are like committed to like beneficence and grace and things that almost sound spiritual and religious, and I don't want it to sound like practicing in that way, is at odds to becoming burnt-out Right? And you I think do a really nice job of articulating why those are totally different things. Why, you know, you can be that physician, which you sort of hope to be without killing yourself.

Dr. Lee (14:24):
Yeah. And I think for so many physicians people do see it as a calling. Right? And for many of those wonderful characteristics that you just mentioned as far as being why you were drawn to the profession but it is that being able to find meaning in your work, being able to, you know, have those connections with your patients with your mentees, with the work that you do, making a difference, like that idea of being able to find that meaning in your work is a large part of protecting against burnout in many ways. And that's what I think some of the other stressors that exist around practicing in medicine from the systems perspective, from the efficiency perspective. That's where it encroaches on.

Dr. Cifu (15:03):
Okay. Let me ask you one more question then, and maybe to sort of put this to use in a way... actually I have two questions. My first question is, so when you, yourself are feeling like, Ugh, boy, you know, I am pushing the edge here, you know, and I feel myself, you know, patient sits down and starts telling me their problems and I'm like, God, why does everybody complain to me? You know? What do you do when you start feeling like that? How do you sort of step out and like almost rescue yourself or...

Dr. Lee (15:35):
Yeah, it is so tough. We've all been there. I mean, I've been so, burnt-out in many points of my career and life, you know, whether it's life stressors or work stressors, I think the first part is acknowledging it. Right? If you're noticing that, that pattern is happening as you're stepping into patient rooms, as you're trying to deal with, you know, the normal issues and questions that come up in clinical care. I try and pay attention to that and you know, my husband has an expression that he often uses with me. Like if he sees that I'm extremely tired and really burned-out, he's like, "It's, an eight o'clock night. Right?" Like you gotta go to bed at eight o'clock tonight and you are just, you just need a good night's sleep. Right? And so listening to those people around you is actually really important as well.

(16:18):
I find when I'm getting short with my son at home or I just have extremely little patience with the things that I can typically brush off. That's when I will try and, slow it down. And so for me, that really means limiting the work that's interfering often with my life outside. So the things I try and do are trying to move any after hour meetings sort of back into the day hours saying "no" to more things, and then, you know, trying to find those ways that allow you to just feel in more control, you know, so for me, a lot of that is kind of taking inventory and just understanding what I need to get done in which period of time, and trying to find a light at the end of that tunnel. Right? Because you're really high busy and stress periods hopefully, you know, are not often more than, you know, a few weeks at a time. And so trying to really understand, "Okay, after this period, I'm going to really focus on that diastole." Like being able to fill your cup and kind of just being able to integrate more of that balance. And so every day is not a balance. Right? But over the course of months you really do hope that you can create more time for that.

Dr. Cifu (17:30):
Yeah. You talk a lot about control, which I think is important. And we know that from, you know, job satisfaction outside medicine that that's important. And it is true that most of our jobs are a combination of things that we can control and things that we can't control. And probably that those periods that you are, you know, feeling on edge, are the time to, you know, really take control of the things that you can control, maybe leaving space for the things that you can't. I really like that as a recommendation. Do you think, I'm sure you're gonna say yes to this, but I kind of have to ask. I mean, when I like think back on my career and I often tell the residents, like when I'm, you know, telling days of the giant story about, you know, the absolute low point of my life in September of my internship. And like, as I think back on that, like there's no question, you know, I had burnout, but at the time, you know, there was no word for it. There was nobody to talk to. It was like, I think the response was "Yeah, yeah, Internship sucks". You know, and you'll get through it. I assume that with the work you've done and with the effort you've done, that you sort of feel like this attention to it. And this acknowledgement actually helps individuals.

Dr. Lee (18:43):
I really think it does cuz we've named it. Right? Like we've defined what the problem is. I remember, I think the lowest point of my burnout was probably when I was a resident as well, my second or third year. Uhm, there was no way to describe it. Right? I just was deeply unhappy and I was probably clinically depressed at the time as well. Right? And just trying to power through and kind of finish and I think that I didn't feel safe. I didn't feel comfortable talking to my program director about it. I didn't really even understand, you know, more that the, the cycles or just, the experience of it. Right? And I think now there is open discussion about burnout. And I actually think that, you know, it is a spectrum we talked about earlier, there's stress there's burnout, but then there's also more, concerning mental health issues that come up.

(19:32):
For physicians, I think oftentimes burnout is a safe way to talk about mental health. Right? It's a safe way to really just say, listen, I am struggling and I just need a little bit of help or I need to take a little distance and be able to step back in when I need to, I need to lean out at this point. I, you know, I think it's helping us to create maybe more understanding of you know, the impact that brown has on our ability to care for patients to be, you know, productive in our academic lives to do the work that's meaningful for us, for our patients, for our students, and I think having these structures in place, you know, a wellness director at the medical school the DIO who has to think about wellbeing as part of accreditation and then, you know, the alphabet of soup of, you know, the AMA the, you know, and, you know, National Academy of Medicine, like every single organization that pertains to education, they're paying attention and they're making calls.

(20:27):
But I do think the problem is we have to find the problem excessively, you know, there's so many studies out there about the prevalence of burnout, the prevalence of, you know, depression, mental health, those types of issues. And while there are some early studies that are taking a look at what interventions are effective, that's still really quite young as far as understanding, okay, what are the things that we can do as a profession to really address this workforce issue that we have? And so I do think that the next steps in being able to really tackle this are really going to be around more studies that are you know, really well done around organizational interventions with the EHR, with, you know, team based care with documentation with really thinking about the culture and leadership around medicine that there's, you know, a push towards having, chief wellness officers does that work? You know, and that's a, that's a phenomena...

Dr. Cifu (21:18):
You can put yourself out of a job.

Dr. Lee (21:19):
Yeah. Right? I mean, you know, that just started in 2015 when Tait Shanafelt stepped into his role at Stanford and obviously in the interim, the pandemic has been happening and so that's challenging, but you know, just having that high level of accountability and someone whose job it is to wake up in the morning and think about burnout in the physician and clinical workforce, like what are those things that we can do to really address it at that level? So we can help the individuals who are here.

Dr. Cifu (21:48):
That's great. Thank you very much Wei Wei this was really a wonderful conversation.

Dr. Lee (21:53):
Thank you, Adam.

Dr. Cifu (21:54):
We're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.