Why burnout needs to be addressed now and not later
Burnout in cardiologists has serious implications on the lives of patients. Healthcare experts all over the world draw their conclusions on an issue which is highly prevalent amongst cardiologists and how to maintain sustainability within healthcare.
How energised are you by your work? Are you constantly dissatisfied by your career? Are you victimised or do you feel personally unable to get through the day due to a toxic or negative environment?
If any of those answers are yes, then you may be going through what is known as “burnout”. A term typically used for something which is rising across healthcare workers, in particular cardiologists.
Burnout in healthcare has serious negative personal and professional consequences and is associated with suboptimal healthcare outcomes for patients. More and more healthcare workers are feeling the strain and the time has come for leaders to recommend t he best strategies for promoting wellness.
Burnout is primarily driven by professional and healthcare system demands and inefficiencies such as excessive workload and role complexity, training and certification demands, inefficient compensation models and lack of resources, computerisation, and loss of autonomy.
Moreover, loss of connectedness with patients, difficulties in balancing work and personal life and overvaluing compulsiveness and perfectionism in medical practice further increase the risk of burnout (Panagioti et al. 2017).
Cardiologists suffering from burnout may be best mitigated by organisational strategies complemented by individual stress reduction and reflection techniques under the resilience-based approach. Large-scale strategies are needed in creating a new culture in medicine (Panagioti et al. 2017).
A recent report by the Point of Care Foundation ‘Behind Closed Doors’ (Behind Closed Doors 2017) brought to light the issues that staff face because of burnout, an issue which in fact starts from the apex of the entire healthcare system. The report highlighted how NHS staff have become the “shock absorbers” of an NHS under chronic strain. It raised several issues that take place including discrimination, harassment, and lack of motivation in the workplace, as well as the lack of self-confidence in ability to succeed in their career, either due to no support of career progression or the toxic environment which some staff are surrounded by.
In order for these issues to improve, those at the top end of the power ladder need to show encouragement, support and an example to lead by f rom the outset. Furthermore, there needs to be more motivation for staff who continuously work hard but yet receive nothing back, as well as better working conditions and acknowledgement of a more balanced working/personal life.
Such issues could also be improved by the aid of personal courses and programmes. FutureLearn is a platform that delivers courses at massive scale with discussion between learners at the heart of the experience. They list a number of motivational courses and programmes from top universities and specialist organisations to help people from all walks of life, and these programmes are initiated from all over the world. Programmes and online courses vary from literature, to career, to study skills, to health and psychology.
One such health and psychology programme offers people the opportunity to learn more about how to apply mindfulness techniques, which anyone can enroll in - Monash University's course on the FutureLearn social learning platform: Maintaining a Mindful Life. Assoc. Prof. Craig Hassed, co-ordinator of mindfulness programmes at Monash University spoke to HealthManagement.org about his views on burnout.
“Burnout is a term used to describe a state that covers three main symptoms: emotional exhaustion, depersonalisation (e.g. cynicism, lack of caring) and lacking of a sense of personal accomplishment. It is commonly the result of long-term and unresolved workrelated stress. Burnout is not the same as depression, although people with burnout are more at risk of depression.”
“Burnout is seen in many professional groups but health professionals are a very high-risk group because they not only have high pressure jobs with high expectations placed upon them, but also because the emotional demands of working with patients and their families can be significant.”
Indeed, people are more at risk during times of transition in working life, such as graduation or promotion and naturally the effects of burnout are particularly sensitive during this period, because this is a time when support and training is especially needed, and anything less will affect the quality of communication, care, efficiency, work engagement and quality of work. And as soon as the person starts feeling like they are essentially failing and a disappointment, their state of mind will deteriorate.
One Australian study measured burnout and mental illness every three months amongst new medical graduates (interns) and found that by eight months into their first year of working life, 75% qualified as having burnout (using Maslach's Burnout Inventory) and 73% had a diagnosable mental illness on at least one occasion.
Prof. Hassed explains, “This points to a major deficiency in how we train health professionals to do demanding jobs in that we focus on the technical skills and knowledge during training, but ignore the personal and professional development needed to meet t he demands that go with the job. That is a reason why, at Monash University, all of our health professional students are introduced to skills like mindfulness which have been found to significantly reduce burnout symptoms and foster good mental health.”
Prof. Barbara Casadei, an established professor at the University of Oxford, and President-Elect of the European Society of Cardiology, led a very insightful session at the European Society of Cardiology (ES C) Congress in Barcelona in August where the session discussed the topic of burnout amongst healthcare workers and whether the issue differed between males and females.
Prof. Casadei discussed the recent Medscape survey which took place in the US this year and analysed the population of medical workers suffering from burnout. The survey was discussed with the board of the ES C so that they could address some of the major themes that were problematic.
This problem has been a huge issue in the US where many professionals lack enthusiasm for work, suffer from cynicism as well as low self-accomplishment. The survey showed that 46% of cardiologists complained of having felt like this at work.
Consequences of burnout
There are a number of consequences that can arise from burnout and they range from minor to severe. All of the expected issues including divorce, alcoholism, substance abuse, depression, and worst yet, suicide, may take place.
Prof. Casadei explains, “With regard to professional cases, if an employee feels underappreciated, unmotivated and more, essentially they will give off lower quality of care, and there is indeed a higher chance of medical error, and greater malpractice risk. A situation such as this needs to be avoided, not just for the person in question, but also for the patient.”
As many as 400 doctors, the equivalent of two to three graduating medical-school classes, die by suicide every year, according to the American Foundation for Suicide Prevention – the profession has one of the highest rates of suicide (Physician and Medical Student Depression and Suicide Prevention 2017).
Is there a gender difference in burnout?
When considering the issue of burnout, one must question whether there is a difference between the male and female population, considering the underlying issues of sexism and discrimination that currently exists professionally.
In this year's Medscape Lifestyle Report, as in previous years, a higher percentage of female cardiologists (55%) reported burnout than their male peers (51%). Percentages have trended sharply up for male cardiologists but slightly down for females since this question was first asked in Medscape's 2013 survey. That year, 59% of women and 38% of men reported burnout.
The lifestyle survey, such as in previous years, asked physicians to rate their happiness at work and outside of work on a scale of one to seven, with one equalling "extremely unhappy" and seven equalling "extremely happy." Among cardiologists, 66% of women compared with 54% of men said they are very to extremely happy outside of work, while more men (32%) than women (25%) reported high happiness levels at work. Overall despite the differences between genders, indeed both male and female cardiologists share the same notion of being far happier outside of work.
According to Prof. Casaedi, the ESC is trying to address what kind of institutional support professionals get vs what they need, what kind of commitment from seniors, how supported are workers, and in which regards do they actually receive help?
Prof. Casaedi highlighted how crucial it is that cardiologists have a decent level of relationship and trust, with the ability to express views clearly in a working environment. In addition, how much do staff’s personal values align with their institution? All of these issues ultimately affect a person’s state-of-mind, and essentially can increase the risk of burnout.
“If you’re not aligned with your institution then you’re automatically going to feel distressed,” explained Prof. Casadei.
Calling for culture change
A recent C-Change (for culture change) survey of ESC members across 17 countries found that at least a third of respondents reported burnout. The findings also reveal important differences based on gender and geography.
Of the nearly 4,000 cardiovascular professionals who responded, the poll found that in Eastern Europe, 35% of men feel mentally or physically exhausted while the figure of women was higher, with 45%. In Southern Europe, the ratio is 31% male versus 41% female, while in Northern Europe the gender gap on the issue virtually disappears: 32% male; 34% female.
“The results in Northern Europe are heart-warming, energising, and optimistic that despite the difficulties, the leadership aspirations are very high, people are resilient they still want to succeed and do a good job while the results from Southern and Eastern EU demonstrated that there is not much encouragement and support for them to pursue a successful career within cardiology.
“This survey is a valuable first step to identify problems in the workplace. It will no doubt help the ESC provide appropriate support to cardiologists and cardiovascular scientists and enable the Society to be a more effective advocate for its members,” Prof. Casaedi added.
The C-Change questionnaire is designed to probe the culture of medicine, particularly academic medicine, and was developed by Brandeis University in the USA . The ESC partnered with Brandeis to administer the poll in Europe. Of the respondents, 59% were men, 41% were women, and the majority (69%) were clinicians.
The results, released at the ESC Congress, reveal that women are just as ambitious as men and that both:
- Seek better training opportunities, better standards and more focus on quality
of care delivered (versus quantity);
- Find it difficult to succeed without sacrificing personal and/or family
- Want improved leadership and vision, as well as more opportunities for research
and international connections.
While 80% of the men and women polled want to be influential in making change happen within their department or institution, only about half say they feel encouraged to pursue leadership positions in cardiology or become involved in decision making. Perhaps even more troubling, 20% of men and 28% of women say they have often felt intimidated, coerced or belittled by superiors or colleagues.
“The ESC already supports training in leadership,” says Prof. Casadei, “and there are plans to introduce new training opportunities in negotiation skills and people management to help ESC members better address some of these needs.”
One cardiologist who took part in the survey said “The burnout atmosphere at work is what prevents me from being more successful. Lots of colleagues are depressed, over-worked, there’s not enough positions for the amount of work, and, there’s no time for education and mentoring”.
While another said, “I really love my job, it’s as fun as a game of tennis but sometimes the court is without lines or a net, and the referee is blind. So it’s just politics.”
Taking into consideration all of the answers, the overall highlights include:
- too much routine
- no institutional strategy or vision
- focus on quantity over quality in healthcare
It seems that throughout Europe, bad management and poor leadership are the major issues that have been highlighted.
“The criticism and the way people feel is widespread and common, which is a clear sign that the situation definitely needs to be improved. However, there is a difference in interaction between gender and region. In the Southern and Eastern regions, females have a high level of burnout which is higher and more comparable to what has been recorded in the US.
“This is not because of the typical reason one might argue, i.e. women have children and are stressed,” explains Prof. Casadei, “but in fact, the greater level of burnout is mid-career. And these results echo those that have been recorded in the US.”
Prof. Valentin Sinitsyn, Head of the Radiology Department in the Federal Center of Medicine and Rehabilitation and Head of Radiology, Moscow State University, and board member of HealthManagement’s Imaging department is also in agreement on the issue:
“The professional burnout has turned into one of the most serious problems in radiology. I never thought about it as a young radiologist, but now, in spite of my status and achievements, I feel that “burnout syndrome” has become my problem too.
“My major problem is a clash between multiple academic and professional responsibilities. I wish I could spend more hours in my department, yet at the same time I like to be involved in teaching, training and be part of new research projects. Too many responsibilities, computerisation, meetings and deadlines create stress and the feeling that I have been permanently failing to accomplish my multiple tasks and duties. Now I feel that my work-life balance must be returned and one should think about the definition of new professional and private priorities. I do not want to leave my profession because of this problem and would like to be more productive and more efficient – but without the feeling of burnout and exhaustion. I just hope I will be able to make it.”
In order for the situation to improve, prevent burnout, and therefore maintain sustainability, there are a number of factors that come into play. These include balancing work demands with resources, maintaining a healthy lifestyle, fostering a supportive culture at work, finding meaning within the work, and cultivating practices like mindfulness. As Prof. Hassed explains, “Sometimes a person needs to take a break from work to give them a chance to recharge and establish selfcare practices, and even to consider whether they are really in the right career for their personal goals and needs. Either way, we may need to change the work we do, or change the way we do it.”
Echoing the need for support in healthcare, Oral A. Waldo, MD, and Martin E. Goldman, address the issue of burnout in an article published in the Journal of the American College of Cardiology (JACC). They recommend the “three R’s” – relaxation, reflection and regrouping – as a strategy to avoiding burnout during fellowship.
“Cardiology FIT s (fellow in training) are so keen to increase their productivity and attain new heights in the profession that they frequently forget to take time to replenish themselves,” states Prof. Waldo. “There is no doubt – it is best to avoid burnout rather than [to deal] with it.”
“Ensuring a balance between clinical service duties and education, organising frequent social events for the fellows and by providing support on a personal level when needed. Outside of the work environment, dedicating quality time for family and friends has also been key in preventing burnout,” Prof. Waldo explains.
According to Prof. Casaedi, the weight of patients and citizens should have an impact on the decisionmaking that is really relative to health. There is a great need to support the need for work-life balance, stability and part-timers. Flexibility is more important than the number of hours, staff just require flexibility – a fact prevalent in both the US and Europe.
Indeed, the only way for professionals to be happy and work in an environment that is sustainable, leaders need to work harder to lead by example. That means fighting against discrimination and ensuring females keep striving towards leadership, as well as cheaper congresses, and supporting surgeons, scientists, healthcare with training, education and activities. There also needs to be more support towards minorities and disadvantaged cardiologists.
Based on research and individual views, it is clear a number of regional and gender differences have been uncovered culturally in the working place within cardiologists, but also within healthcare as a whole. The results dispel a mixture of factors which may hinder the careers of women or minority, but more importantly, hinder both male and female’s lives.
Both men and women find it difficult to reconcile personal life – both aspire to better training, support, higher standards, better leadership and vision. Senior and heads of departments need to listen and should take this into account and have a better vision.
The ESC for example have invested in leadership training and also introduced new opportunities, such as training and negotiation skills. This is particularly important for heads of departments, who evidently play a part in helping others. Initiatives like this need to continue, if the issue of burnout is to be reduced.
A strong investment on setting standards and certification and trying to define centres of excellence needs to be put in place – how they do/what they do/what they do with their staff/training and continuing medical education – not so much in the north but other areas of Europe.
What’s clear is that burnout is not just about women or the minorities, it is about how both men and women in a community feel as a whole and how the notion of burnout is felt everywhere. Leaders need to make more effort and help prevent the victimisation of physicians and cardiologists. A new culture of medicine needs to be put into place.