Despite highly skilled physicians and advanced technology, the U.S. has not yet figured out how to provide effective affordable health care to everyone. Meanwhile, the health care system is increasingly fractured and stressed—and so are our doctors. Physician burnout impacts nearly half of all seasoned physicians in practice and up to 75% of resident physicians in training1. Over water cooler conversations, as well as in my work as a psychiatrist at the University of North Carolina at Chapel Hill (UNC), I hear more and more physicians report anxiety, stress and emotional exhaustion. Many feel as if they are perpetually swimming upstream; others feel there is no joy or meaning in their work; some want to quit medicine altogether. These good doctors are in crisis in increasingly high numbers — an epidemic that requires immediate attention.
Last year, the UNC School of Medicine launched the Taking Care of Our Own program to address the problem of physician burnout and we have been met with a deluge of physicians asking for help. Burnout, however, is not a diagnosis. It is a constellation of symptoms that include emotional exhaustion, depersonalization and loss of perspective that work is meaningful2. Untreated, burnout syndrome can erode professional behavior at work and healthy relationships at home. This leads to decreased empathy and compassion, poor communication and potentially worse patient outcomes. The personal consequences include disrupted relationships with family and friends, self-medicating with alcohol or other substances, depression and an increased risk of suicide, which is higher among physicians than the general population, in part due to the stigma associated with seeking mental health treatment.
Not a day goes by without my hearing from a physician in distress who has learned about the Taking Care of Our Own program. These conversations have a striking degree of similarity. They typically begin with an apology—a statement about how embarrassing it is to ask for help in dealing with anxiety or depression; or a recent loss; or other emotional stressor that makes it too difficult for the doctor to remain professional and compassionate while managing a demanding workload.
What is Driving Physician Burnout?
The culture of medicine has changed dramatically since I entered medical school more than 20 years ago. Although we worked more hours in the hospital than today’s physicians, there was greater camaraderie and a shared sense of mission and purpose among colleagues. Over the last decade, however, I have observed a growing cynicism and frustration among practicing physicians as they grapple with the complexities and challenges of our struggling healthcare system.
Factors that drive burnout syndrome in today’s environment include overall loss of control and autonomy, along with the ever-growing demands of rigorous computer documentation of all patient care encounters that intensively increase workload and decrease critical face–to-face contact with patients. Other obstacles, such as shortened lengths of stay, increased patient turnover, decreased time for interactions with colleagues and changes in reimbursement also contribute to burnout,. In the younger generation of physicians attitudes have changed, and most resident physicians now expect to have a “balanced life” with idealized ratios of time spent at work versus time with family that may be difficult to reconcile. Despite interventions focused on reducing resident duty hours and sleep deprivation, neither of these factors has been associated with reductions in burnout. New approaches are needed to combat this epidemic and provide appropriate mental health care.
How Do We Take Care of Our Own?
Medicine can be an unforgiving profession. On the one hand, we deal with life and death issues while, on the other, any outward show of distress is often not tolerated and can have grave consequences. Physicians, in general, have good coping skills honed over years of training. They are taught to ignore basic human needs (like hunger and fatigue) and to remain capable, competent and compassionate under highly stressful conditions. As a result of the stigma associated with asking for help for emotional problems, doctors wait too long to seek treatment—often until there is a mental health crisis that may require the psychiatric equivalent of intensive care. Barriers that prevent doctors from seeking mental health treatment include concerns about confidentiality, worries that colleagues will find them inadequate or incompetent or fear that they are failing if they are unable to “handle the stress”. Further compounding the problem is the lack of consistent self-care by many physicians. Resident physicians who consistently work very long hours have trouble finding time for restorative activities that help them emotionally refuel. Peak childbearing years often correlate with residency training, leaving individuals to juggle the demands of residency with the challenge of starting a family.
Taking Care of Our Own offers educational programs about burnout and mental health for resident physicians, and strategies for avoiding and/or addressing it. We work with each clinical department to implement these educational programs and customize material for each clinical specialty, as the demands and stressors vary among the diverse fields of medicine. Residency training directors play an important role when they embrace the need for mental wellness, and give trainees permission to discuss these issues and ask for help. We actively work to remove the stigma associated with seeking care and encourage self-referral. We work with the training directors and other faculty to make necessary changes that greatly increase the odds that the resident physician will be successful. One year into our program, the numbers demonstrate that this has been a winning approach. Rates of referral and demand for services of the program are constantly increasing, now occurring on a daily basis, and have increased 200% in just over 6 months.
The program also provides a mental health evaluation and treatment program for residents and fellows. All physician trainees are eligible to self-refer, although referrals often come from concerned faculty. We have developed a mechanism for triage and referral of resident physicians in need of assessment and treatment to attending faculty throughout our institution. We offer multiple different forms of mental health treatment that include evidence based therapies for burnout, depression and anxiety, and have developed a comprehensive referral base of providers who have experience caring for this patient population.
Burnout and physician wellness can no longer be ignored and must be addressed by leadership in academic medicine6. Our initiative is aimed at increasing awareness, providing psychoeducation and offering assessment and treatment in a confidential and supportive setting that is optimized to destigmatize seeking help for emotional distress. The goal is to provide timely, cost effective and efficient care to identify and treat physician mental health issues ensuring improved performance and professionalism. Ultimately, this is good for the doctors, great for the patients and critical for the health care system. We strongly believe that this type of program needs to be offered at all institutions involved in training the next generation of physicians.