There are few issues in medicine and health care that are the subject of more controversy than the semantics of what wounds physicians. Are we suffering from “moral injury” or “burnout” or “compassion fatigue” or “vicarious trauma” or “depression?”
Take for example, the definition of compassion fatigue: The emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events. It differs from burnout but can co-exist. Compassion fatigue can occur due to
exposure on one case or can be due to a “cumulative” level of trauma. Signs and symptoms of compassion fatigue can include1:
- Reduced ability to feel sympathy and empathy;
- Anger and irritability;
- Increased use of alcohol and drugs;
- Dread of working with certain clients/patients;
- Diminished sense of enjoyment of career;
- Disruption to world view;
- Heightened anxiety or irrational fears;
- Intrusive imagery or dissociation;
- Hypersensitivity or insensitivity to emotional material;
- Difficulty separating work life from personal life;
- Absenteeism (missing work, taking many sick days);
- Impaired ability to make decisions and care for patients; and
- Problems with intimacy and in personal relationships.
On the other hand, the American Institute of
Stress2 defines burnout as a “cumulative process marked by emotional exhaustion and withdrawal associated with increased workload and institutional stress, not trauma-related.” Likewise, many physicians may have heard of the term “moral
injury.” That concept really fits well with examples of the moral distress that physicians face during the pandemic: having to decide who gets a ventilator and for how long; having to reuse PPE and risking infecting themselves and others; separation
from their loved ones to keep them safe. This is really about a health care system that needs revamping. It needs to make major changes so that physicians and other health professionals aren’t put into those kinds of conflicts.
In fact, a quick search of symptoms of depression, anxiety, burnout and vicarious trauma yield similar and overlapping symptoms. The reality is that medicine as a profession is fertile grounds for not just burnout, but also compassion fatigue, vicarious
and direct trauma, moral injury, and a myriad of psychiatric diagnoses. These exposures rarely occur separately or exclusive from each other, yet there’s little discussion in the media about phenomena other than burnout. On the one hand, it is important
not to medicalize burnout because it is not a medical condition – it is an occupational syndrome. Likewise, the debates over semantics and millions spent to study “burnout” as a phenomenon have done little to mitigate what is actually wounding the
The common denominator is the alarming rates at which physicians are reporting dissatisfaction with our jobs, while directly experiencing the consequences of a flawed health care system and the occupational hazards of medicine and its culture. Rather,
this focus on differentiating burnout from other exposures puts the onus of healing themselves back on physicians. Not that we needed a global pandemic and retraumatization of physicians for this reframing, but it’s time that the focus moves away
from individual vulnerability and personal character to accepting that not just burnout but also depression, PTSD, anxiety, and other mental health conditions are occupational hazards of practicing medicine.
Physician, heal thyself. But how?
Help physicians seek help: There are multiple avenues for physicians to seek help. Some are internal to their organizations and places of employment. These can be fraught with anxiety for physicians. Fortunately, there are other avenues, including county
medical societies and the Texas Physician Health Program (PHP). (See “Self-Investment,” page 22.)
It is noteworthy that there is a huge variance in the structure, services, costs and approach of state PHPs across the county, with participants reporting variable outcomes, depending on the program. Even before any formal intervention is needed, there
are a number of virtual Caduceus support-group meetings that health care providers can attend to find peer support in a confidential setting. The self-disclosure from other physicians serves as the gift of vulnerability that normalizes our experience
Destigmatize seeking mental health help – every step of the way: We know that it is not sufficient to address the intrusive questions in licensure applications alone. In 2019, the National Academy of Medicine (NAM) released its report Taking Action Against
Burnout: A Systems Approach to Professional Well-Being.3 In it, NAM set out several critical recommendations, which include tangible and actionable steps that can destigmatize mental health help for physicians:
- State licensing boards, health system credentialing bodies, disability insurance carriers, and malpractice insurance carriers should either not ask about clinicians’ personal health information or else inquire only about clinicians’ current impairments
due to any health condition rather than including past or current diagnosis or treatment for a mental health condition. They should be transparent about how they use clinicians’ health data and supportive of clinicians in seeking help.
- State legislative bodies should create legal protections that allow clinicians to seek and receive help for mental health conditions as well as to deal with the unique emotional and professional demands of their work through employee assistance programs,
peer support programs, and mental health providers without the information being admissible in malpractice litigation.
- Health professions educational institutions, health care organizations, and affiliated training sites should identify and address those aspects of the learning environment, institutional culture, infrastructure and resources, and policies that prevent
or discourage access to professional and personal support programs for individual learners and clinicians.
Make systems changes: NAM’s guidelines for physician well-being are intentional in suggesting systemic change rather than individual interventions. In fact, physician burnout and impairment are a powerful indicator of the health system performance. Systemic
issues require systemic interventions; they cannot be mitigated alone with yoga, mindfulness, and resilience-building. Physicians are already some of the most resilient individuals in society. The system self-selects them for attributes that point
to high work ethic, survival under pressure, and ability to deal with complexity. Therefore, supporting physicians’ mental health is not just about supporting them as they cope with unimaginable situations; it is also about improving the environment,
processes (getting rid of bureaucratic hurdles), policies, and cultures of institutions and medicine.
The variable that is the foundation for change in health care – be it loss of autonomy, scope of practice, reimbursement, mental and moral anguish and burnout, and other contributors to health hazards of medicine – is leadership. Hospitals and the health
care system are increasingly run as businesses, rather than service organizations dedicated to the well-being of their communities and staff. Physicians are now defined by numbers and Press-Ganey scores throughout their career with metrics following
us all the way from premedicine to practice without reprieve or respite. We need leadership that reflects physicians who actually practice medicine and can relate to the plight of their colleagues.
Organized medicine is one such avenue for bringing positive change to physician well-being. Advocacy is another. In response to the suicide of New York emergency physician Lorna Breen, MD, during the pandemic, and with the help of the Dr. Lorna Breen
Heroes Foundation, Virginia recently changed the questions on its state licensing application forms to no longer ask about a history of mental illness, but only about current impairment, and created a process for physicians to receive confidential
mental health care.4 And Congress is considering the Dr. Lorna Breen Health Care Provider Protection Act (Senate Bill 610 and House Resolution 1667), a bipartisan legislation to create programs that offer behavioral health services for
frontline health care workers and make mental health non-discrimination against physicians the law.
Until these kinds of changes take effect, however, physicians will continue to remain in a vulnerable position. We have an epidemic of physician attrition which is being haphazardly filled with nonphysician providers rather than addressing the underlying
cause of attrition – broken health care systems. Facebook is full of groups where physicians are looking to move abroad; make a nonmedical field their work purpose part-time; or switch careers altogether. Yet others are choosing to retire early, taking
pay cuts to have a better work-life balance, or leaving oppressive health care systems as a revolt against the status quo to open direct-care practices to restore joy and meaning in medicine.
Despite the many challenges of the health care system today, the number of medical school applicants were at an all-time high in 2020 and 2021, termed the “Fauci Effect,” partly in response to a personal call to serve amid the pandemic.5 There
is no dearth of bright and dedicated future doctors. However, the questions that linger are: How many will stay in medicine long enough to realize a long, fulfilling personal and professional life? How might we change our systems and culture to support
the new generation of doctors?
AEKTA MALHOTRA, MD, is a psychiatrist in Plano and a member of the Dallas County Medical Society Physician Wellness Committee.
1. Bereiter, J. (2017, August 24). Vicarious Trauma & Burnout in Healthcare Providers and How a Trauma Informed System Can Help. Retrieved April 20, 2021, from https://www.ihs.gov/sites/telebehavioral/themes/responsive2017/display_objects/documents/slides/traumainformedcare/ticmedicalthree082417.pdf.
2. Compassion fatigue. The American Institute of Stress. (2017, January 4). Retrieved April 14, 2021, from https://www.stress.org/military/for-practitionersleaders/compassion-fatigue.
3. National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. (2019). Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. National Academies Press (US).
4. “Dr. Lorna Breen Heroes’ Foundation on Physician Mental Health.” American Medical Association, 16 Sept. 2021, https://www.ama-assn.org/practice-management/physician-health/dr-lorna-breen-heroes-foundation-physician-mental-health.
5. Cervantes, J. (2021). Fauci effect? When the heart is in the right place, but reality is not. Journal of Investigative Medicine, 69(5), 951–953. https://doi.org/10.1136/
Tex Med. 2021;117(11):6-7
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