Burnouts: when caregivers become patients
Author: Côme Bommier (Young EHA Ambassador)
Affiliations: Hôpital St-Louis (Paris, France) & Mayo Clinic (Rochester MN, USA)
Burnout is a state of "physical, emotional, and mental exhaustion that results from prolonged investment in emotionally demanding work situations"1. Being a physician not only constitutes the most beautiful profession in the world, but also entails living in contact with suffering and death, always responding courteously to the demands of peers and patients, striving to always give one's best while being confronted with the perpetual uncertainties of illness and future. In short, being a physician is a risk factor for burnout. Recently, a survey conducted among all French academic physicians (associate professors and full professors) showed that 40% of them exhibited severe burnout symptoms, and 12% reported suicidal ideation2. This is shocking, yet so common. Already in 2007, among ICU healthcare workers, severe burnout syndrome was present in 50% of critical care physicians and in one third of critical care nurses3. Regardless of age or position, ICU caregivers are exposed to burnout4. One might think that intensivists are specifically exposed to difficult situations to cope with, but they do not differ from other specialties. In surgery, the same rate of 40% severe burnout was found among a population of French residents5. Among pediatric residents, the prevalence of burnout was 37.4%, and burnout was significantly associated with the number of hours worked per week and anxiety scores6. In primary care, 44.8% of French general practitioners (GPs) were experiencing burnout. The main risk factors in this study were a high workload with more than 28 appointments per day or 50 hours of work per week, and the main protective factors were related to social cohesion, such as having a teaching role and working in a group practice with back-office support7. In a meta-analysis, the pooled prevalence estimate of burnout was 49% among French physicians8. Similar rates of burnout have been reported in hematology, both in pediatric and adult settings, including in the USA (36% of hematologists reported burnout)9,10. One limitation of these publications lies in the tool that is used for burnout assessment. Indeed, using the dimensions of the Maslach Burnout Inventory (MBI) tool, three definitions of burnout syndrome can be considered: tri-, bi-, and unidimensional definitions. In a European meta-analysis, the pooled prevalence rate of burnout was estimated at 8% with the tridimensional definition, 20% with the bidimensional definition, and 43% with the unidimensional definition11.
Burnout is assumed to be a consequence of unresolvable job stress, and unresolvable job stress has been causally linked to depression12. Among the commonly reported associated factors are work overload, work encroachment on private life, feeling the need to constantly put on a brave face, having experienced harassment, and being a woman. These factors are often associated with burnout prevalence because they are the ones that are measurable by questionnaires. From my point of view, the problem is deeper. Concurrently with this outbreak of burnout, we are witnessing the uprooting of medical practice. In all countries, healthcare is becoming increasingly expensive, public hospitals no longer have the means to keep up with health rising prices, and working conditions are deteriorating. In all countries, “publish or perish” adage leads to scientific misconducts, and there is currently no concrete renewal of the researchers’ assessment. In all countries, the need for efficient practices and institutional profitability leads to a decrease in time spent with patients and with students. However, since Ancient times, medicine has found its meaning in the care provided to the sick and the time shared with the youngers. To be a good doctor, learning from books is not enough, one must be inspired and helped by mentors: this is called companionship. To face suffering and death, it is not enough to have a personal philosophy, one must be able to share it with colleagues and peers: this is called medical community. To maintain the desire to heal, one must believe in the illusion of life: this is called medical vocation.
Uncertainty generates symbolic violence that we are not able to channel by ourselves13,14. On a daily basis, healthcare workers are dealing with death, the greatest of uncertainties. And the problem with death is that it is undepictable. Outside the hospital, writers, painters, sculptors, give us a sight on what cannot be seen. Similarly, composers and musicians give us a hearing of what cannot be heard. In medicine, while we examine our patients’ corpses and we stand by our patients until their last instant, we are heavily exposed to death but have no way to depict it with our senses. Therefore, we often have that need to remain in the room in silence (hearing) and to take the patient’s hand (touch). And like in all other death rituals, it would be relieving to communion with the team around some food and drink (touch, smell and taste). With these kinds of rituals (nota bene. rituals can be secular (non-religious)), a medical culture might bond caregivers together. Without this time together, members of one same team become lonely. Some may have their own rituals15. Some other may find an escape in various addictions. For example, it is estimated that substance use disorders might concern 8-15% of physicians and several barriers to seeking help were already identified16,17. In a recent meta-analysis, problematic alcohol use increased over time from 16.3% in 2006 to 2010 to 26.8% in 2017 to 202018. Lastly, narrative medicine, debriefing sessions and mindfulness exercises were reported to help caregivers in coping with work difficulties19–21.
So, medicine is an art (and not just a science) because it is coping with death, and each relationship we have in this framework (with patients and colleagues) reveal our own relationship with death. Without collective management of the great uncertainty that is death - real or symbolic (illness, suffering, depression) - caregivers will continue to accumulate the violence they experience on a daily basis within themselves, up to burnout or even suicide.
These topics of reflection overlap the fields of ethics, public health, occupational health, and have to do with medicine, the transmission of knowledge, and the care relationship22,23. Hematologists, like other specialists, should feel particularly concerned. If we as healthcare providers only wait for changes at the political or institutional levels, we will have only ourselves to blame. As is already the case in many services around the world, change must come from healthcare providers themselves, supported by their national and international societies. Let’s hope that in the future, EHA will value initiatives aimed at caring for caregivers even more, whether at the annual congress or in the Hemasphere journal. This would make us even prouder to be hematologists.
- Schaufeli, W. B. & Greenglass, E. R. Introduction to special issue on burnout and health. Psychology & Health 16, 501–510 (2001).
- Dres, M. et al. Job Strain, Burnout, and Suicidal Ideation in Tenured University Hospital Faculty Staff in France in 2021. JAMA Netw Open 6, e233652 (2023).
- Embriaco, N., Papazian, L., Kentish-Barnes, N., Pochard, F. & Azoulay, E. Burnout syndrome among critical care healthcare workers: Current Opinion in Critical Care 13, 482–488 (2007).
- Berger, B. et al. Incidence of Burnout Syndrome among Anesthesiologists and Intensivists in France: The REPAR Study. IJERPH 20, 1771 (2023).
- Faivre, G. et al. Burnout syndrome in orthopaedic and trauma surgery residents in France: A nationwide survey. Orthopaedics & Traumatology: Surgery & Research 104, 1291–1295 (2018).
- Treluyer, L. & Tourneux, P. Burnout among paediatric residents during the COVID-19 outbreak in France. Eur J Pediatr 180, 627–633 (2021).
- Dutheil, F. et al. Burnout in French General Practitioners: A Nationwide Prospective Study. IJERPH 18, 12044 (2021).
- Kansoun, Z. et al. Burnout in French physicians: A systematic review and meta-analysis. Journal of Affective Disorders 246, 132–147 (2019).
- Whitford, B., Nadel, A. L. & Fish, J. D. Burnout in pediatric hematology/oncology-time to address the elephant by name. Pediatr Blood Cancer 65, e27244 (2018).
- Lee, A. I. et al. Burnout in U.S. hematologists and oncologists: impact of compensation models and advanced practice provider support. Blood Adv bloodadvances.2021006140 (2022) doi:10.1182/bloodadvances.2021006140.
- Hiver, C., Villa, A., Bellagamba, G. & Lehucher-Michel, M.-P. Burnout prevalence among European physicians: a systematic review and meta-analysis. Int Arch Occup Environ Health 95, 259–273 (2022).
- Tennant, C. Work-related stress and depressive disorders. Journal of Psychosomatic Research 51, 697–704 (2001).
- Caux, C., Dupuis, F., Lechasseur, K. & Lecomte, J. Ethical situations in practice and nurses’ occupational health: A qualitative study of their narratives. Ethics, Medicine and Public Health 22, 100763 (2022).
- Thomas, L.-V. Anthropologie de la mort. (1988).
- Bommier, C., Charlier, P. & Hervé, C. What symbolic answers to death in the medical world? J Int Bioethique Ethique Sci Vol. 31, 85–96 (2020).
- Vayr, F., Herin, F., Jullian, B., Soulat, J. M. & Franchitto, N. Barriers to seeking help for physicians with substance use disorder: A review. Drug Alcohol Depend 199, 116–121 (2019).
- Thiebaud, P.-C. et al. Alcohol consumption among French physicians: A cross-sectional study. Drug Alcohol Depend 218, 108356 (2021).
- Wilson, J. et al. Characterization of Problematic Alcohol Use Among Physicians: A Systematic Review. JAMA Netw Open 5, e2244679 (2022).
- Nélaton, C. La philosophie dans l’éthique narrative. Narration, prise de décision et souffrance morale. Ethics, Medicine and Public Health 1, 558–564 (2015).
- Gunasingam, N., Burns, K., Edwards, J., Dinh, M. & Walton, M. Reducing stress and burnout in junior doctors: the impact of debriefing sessions. Postgrad Med J 91, 182–187 (2015).
- Ireland, M. J. et al. A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners. Med Teach 39, 409–414 (2017).
- Rabow, M. W. Meaning and relationship-centered care: Recommendations for clinicians attending to the spiritual distress of patients at the end of life. Ethics, Medicine and Public Health 9, 57–62 (2019).
- Bommier, C., Tudrej, B. V. & Hervé, C. Narration médicale : un traitement prophylactique contre la souffrance du médecin ? Ethics, Medicine and Public Health 8, 51–55 (2019).