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Spring 2021 (Volume 31, Number 1)

Physician Well-being in the Midst of a Pandemic: From Individual Well-being to Compassion Culture

By Allison Crawford, MD, PhD, FRCPC

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There is an inter-relationship between our own wellness as health providers, and our ability to deliver quality healthcare to patients and families.1 Further, given that we invest so much in caring for others, we should also ensure that we thrive, individually and within our families and communities. And yet, even prior to the pandemic, physician well-being was a concern.

A recent review summarizes the alarming statistics that up to 42% of physicians in the U.S. report experiences consistent with burnout, with 14% experiencing thoughts of suicide.1,2 Compounding this, even in the most severe instances, only a third seek treatment.1 In a 2018 national survey by the Canadian Medical Association, similar findings showed that 30% of Canadian physicians reported high levels of burnout, 34% had symptoms consistent with depression, and 8% had thoughts of suicide in the preceding 12 months.3

The COVID-19 pandemic has added additional strain for all, and for those health providers already struggling, well-being and resilience may be further eroded. During the pandemic, health providers have shown higher rates of distress, insomnia, anxiety, and depression, particularly for those engaged directly in the treatment of patients with COVID-19.4 Additional stressors contributed by the pandemic include: uncertainty and anxiety for the well-being of self and loved ones; increased workflows and demands at work; increased isolation and decreased opportunities for protective activities, such as social connection; and, for many, losses, including losses of patients.5 In addition to the direct impact of increased demands and exhaustion, many have also identified the psychological toll of moral distress, or the distress that ensues when one’s values and beliefs come into conflict with existing circumstances.6

What are the warning signs of burnout?

  • Feeling down, sad, depressed
  • Feelings of anger, impatience, irritability
  • Thoughts of death or suicide
  • Decreased feelings of satisfaction and meaning from work
  • Increased absenteeism from work; or conversely, trying to work more/harder
  • Decreased feelings of compassion for patients
  • Increased medical errors

There are also self-report measures that can be used to assess symptoms of burnout. The most commonly used is the Maslach Burnout Inventory.5 Recent work by Trockel and colleagues also looks at a continuum of experience from burnout to satisfaction.7

How can we ensure that we sustain our own well-being?
Polizzi, Lynn and Perry (2020) offer a useful framework for considering useful interventions, focusing on control, coherence, and connectedness.8

Control includes activities that shore up our personal resources by engaging in protective practices such as establishing routines, sleep hygiene, and exercise. We can draw upon our self-awareness of coping practices that have helped in times of previous adversity, and can use tracking tools such as mood, sleep, and activity journals to look for areas that require attention.

Coherence emphasizes the importance of the meaning that we make out of adversity. Asking ourselves what our narrative is of the current pandemic, and of ourselves, as well as reflecting on our own values can help us gain new perspective on current events, and our own role within them. They suggest reflective questions, including, for example, “What is important to you?” “What makes you feel good, even when confronted with a situation you can’t fully control?” Reflection can be complemented with practices such as mindfulness that can also nurture more acceptance of our emotional reactions, and also of situations over which we have little control.

Connectedness emphasizes our need for others and for support, and the known benefits of social connection to mitigate adversity. They encourage finding ways to maintain meaningful connection, even in the midst of public health measures that can intensify isolation.

However, the effectiveness of interventions to reduce burnout and boost resilience requires more research. A recent Cochrane review demonstrates the limited evidence for interventions to support health providers during a pandemic.9 Factors that were associated with effective implementation of interventions included adapting interventions for local needs; effective communication in organizations; and ensuring that learning environments are safe and supportive. Corollary barriers to supporting health providers during a pandemic included both individuals and organizations being unaware of supports that are needed, as well as a lack of equipment, staff time, and skills needed to support interventions.

The findings of this review suggest the importance of a fourth "C" which may be called Culture, or perhaps Compassion Culture. Organizational culture and support is critical to the well-being of health providers. In the Canadian Medical Association survey, one of the most notable findings was that even personally resilient physicians were not immune to experiencing burnout.3 An overemphasis on individual coping and resilience will likely only compound burnout. It is up to organizations to prioritize the wellbeing of all providers and to create a culture of compassion in which well-being is modelled and supported at all levels of the organization, and time and resources are devoted not only to ensuring the resilience of individuals, but also the resilience of teams.

Resources
If you are experiencing any of the signs of burnout listed above, please reach out to a trusted colleague. Most organizations have an employee wellness or occupational health program.

Allison Crawford, MD, PhD, FRCPC
Psychiatrist,
Centre for Addiction and Mental Health
Associate Chief, Virtual Mental Health
Associate Professor,
Department of Psychiatry,
University of Toronto
Chief Medical Officer,
Canada Suicide Prevention Service
Toronto, Ontario

References:

1. Yates SW. Physician Stress and Burnout. Am J Med. 2020; 133(2):160-164. doi: 10.1016/j.amjmed. 2019.08.034. Epub 2019 Sep 11.

2. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018; 320(11):1131-1150.

3. Vogel, L. Even resilient doctors report high levels of burnout, finds CMA survey. CMAJ. 2018; 190 (43): E1293.

4. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020; 3(3):e203976.

5. Norful AA, Rosenfeld A, Schroeder K, et al. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry. 2021; 69:20-26. doi: 10.1016/j.genhosppsych.2021.01.001. Epub ahead of print.

6. Anderson-Shaw LK, Zar FA. COVID-19, Moral Conflict, Distress, and Dying Alone. J Bioeth Inq. 2020; 17(4):777-782. doi: 10.1007/s11673-020-10040-9. Epub 2020 Nov 9. PMID: 33169271; PMCID: PMC7652046.

7. Trockel M, Bohman B, Lesure E, et al. A Brief Instrument to Assess Both Burnout and Professional Fulfillment in Physicians: Reliability and Validity, Including Correlation with Self-Reported Medical Errors, in a Sample of Resident and Practicing Physicians. Acad Psychiatry. 2018; 42(1):11-24.

8. Polizzi C, Lynn SJ, Perry, A. Stress and Coping in the Time of COVID-19: Pathways to Resilience and Recovery. Clinical Neuropsychiatry. 2020; 17(2): 59-62.

9. Pollock A, Campbell P, Cheyne J, et al. Interventions to support the resilience and mental health of frontline health and social care professionals during and after a disease outbreak, epidemic or pandemic: a mixed methods systematic review. Cochrane Database Syst Rev. 2020;11:CD013779.



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