The COVID-19 pandemic has imposed significant challenges to the professional lives and working environments of health care providers. Even if the personal cost of burnout to the health care provider fails to merit the attention of an organization, the financial costs of burnout rise to the top of the priorities related to decreased productive work hours and increased employee turnover, health costs, and time training replacement staff. Physician burnout is estimated to cost the U.S. health care system $4.6 billion per year. The costs to individual organizations are estimated to be $7,600 per physician, per year (Ann Intern Med 2019;170:784-90).
Burnout, as classified by the World Health Organization, is an occupational phenomenon (asamonitor.pub/3iRrs2f). Is resilience the antidote? As defined by Epstein and Krasner, physician resilience is “the capacity to respond to stress in a healthy way such that goals are achieved at minimal psychological and physical cost; resilient individuals ‘bounce back’ after challenges while also growing stronger” (Acad Med 2013;88:301-3).
A large national study prior to the pandemic revealed that U.S. physicians exhibited higher levels of resilience than the general working population. Resilience is protective against burnout. Despite this, burnout rates are substantial even among the most resilient physicians (JAMA Netw Open 2020;3:e209385). Burnout mitigation efforts must be multipronged and not rely on personal resilience alone to promote well-being and professional fulfillment in the workforce.
The Stanford Model of Professional Fulfillment™ acts as a conceptual framework to guide organizational well-being efforts. The Stanford Model comprises three domains: Culture of Wellness, Efficiency of Practice, and Personal Resilience. The model underscores the reciprocal relationship between institutional responsibilities (Culture of Wellness, Efficiency of Practice) and individual ones (Personal Resilience) (asamonitor.pub/3FEOmDA). What can leaders do to promote safe, productive, and healthy workplaces?
Leadership behaviors create a culture of wellness
A culture of wellness begins with supportive leadership behaviors – commitment, accountability, investment, regular measurement, recognition, appreciation, fairness, inclusiveness, transparency, and values alignment (asamonitor.pub/3oPgNcf; JAMA Netw Open 2021;4:e2035622). Trust in leaders is one of the most important factors in workers feeling positive about a workplace and wishing to remain (asamonitor.pub/3mMKA2D). There is a strong relationship between supportive leadership behaviors and physicians’ perceptions of values alignment with their organization (JAMA Netw Open 2021;4:e2035622). When physicians work in an environment that mirrors their values, their daily decisions – no matter how difficult – can be made without the added burden of emotionally draining personal conflict, a state termed moral distress.
Incentives that speak strongly to values will hold more weight than purely monetary rewards (Mayo Clin Proc 2017;92:129-46). Understanding the personal needs and values of each team, and supporting those with tangible approaches, creates loyalty to the organization. Ensuring a sense of transparency in the workplace, with decisions being made in open ways, allows team members to have their voices heard. Whether or not suggestions are met, providing team members with a communication channel to organizational leadership goes a long way toward creating a culture of wellness.
Wellness begins with inclusion
A culture of wellness begins with a culture of equity and inclusion (asamonitor.pub/3vf8W9b; MedEdPublish 2021;10:99). The past two years have tragically revealed acute and chronic issues of health disparities, systemic racism, and social unrest. Now, more than ever, physician leaders are using their voices to advocate for social justice, public health education, and health care reform, and have shared key strategies to move forward toward greater health equity (asamonitor.pub/3FAYIV4; ASA Monitor 2021;85:45-8).
Mistreatment in our workplaces affects marginalized groups at a higher prevalence than non-marginalized ones and has been linked to increases in burnout and suicidal ideation (JAMA Surg 2021;156:e210265; JAMA Netw Open 2021;4:e2036136; JAMA Intern Med 2020;180:665; N Engl J Med 2019;381:1741-52). Addressing mistreatment on individual, group, and institutional levels is necessary to cultivate a culture of inclusion and wellness.
The necessity of optimizing equipment and staffing
Effective leaders acknowledge the frustrating inefficiencies of medical practice as major drivers of burnout and threats to professional fulfillment (Mayo Clinic Strategies To Reduce Burnout: 12 Actions to Create the Ideal Workplace. 2020). Numerous risk factors for burnout among anesthesiologists, including challenges related to personal protective equipment (PPE), staffing, and scheduling, have increased since the COVID-19 pandemic began (J Clin Anesth 2021;73:110356; Anesthesiology 2021;134:683-96). PPE shortages, secondary effects of wearing PPE, and/or related resource constraints have been shown to negatively impact health care setting functionality in pandemic times (J Crit Care 2020;59:70-5; Int J Environ Res Public Health 2020;17:4267). Health care workers have experienced exhaustion, difficulty breathing, extreme sweating, inability to use the bathroom, headaches, thirst, and pressure areas from wearing PPE for prolonged periods (Indian J Crit Care Med 2021;25:134-9; Cochrane Database Syst Rev 2020;11:CD013779).
Unpredictable staffing shortages have threatened scheduling flexibility, control, and work-life integration support. Prior to the pandemic, the U.S. was forecast to experience significant nursing and physician shortages as early as 2030 (Hum Resour Health 2020;18:8; Am J Med Qual 2018;33:229-36). The pandemic has accelerated staffing shortages in all members of our care teams – nurses, respiratory therapists, advanced practice providers, scrub technologists, anesthesia technicians, and physicians (Chest 2021;159:619-33; asamonitor.pub/3FCGcvB; asamonitor.pub/3FBnG72; asamonitor.pub/3mJ0uLh). Once a team becomes unbalanced, the rest of the team feels the burden, must work harder to pick up the slack, and must shift their efforts outside of their primary focus and skill set, setting the stage for loss of professional fulfillment and burnout.
Flexible scheduling opportunities, such as shifts with staggered starts and/or reduced length, and partial-FTE opportunities support work-life integration. Effective leaders ensure that scheduling and staffing allow for healthy rest periods between shifts, adequate recovery from nighttime work, and time to fulfill basic individual care needs, such as hydration or lactation (BMJ 2020;368:l7088; JAMA Netw Open 2019;2:e1913054). Working more than 40 hours per week is an independent risk factor for burnout, and working excessive work hours (defined as greater than 55 hours per week) is the greatest occupational risk factor for cardiac events and stroke (Anesthesiology 2021;134:683-96; Environ Int 2021;154:106595).
What can leaders do to promote personal resilience?
Leaders hold an incredibly powerful role in developing and maintaining personal resilience for their employees. Managers control schedules, develop policies, set moral and cultural tone, provide incentives and rewards, and provide access to programs that promote resilience (Mayo Clin Proc 2017;92:129-46; Mayo Clin Proc 2015;90:432-40). Leaders also serve as role models for key drivers of physical and mental health by paying attention to their own diets, developing effective sleep and exercise routines, balancing work and family priorities, and promoting behaviors that are key to well-being, such as gratitude, self-compassion, and mindfulness (Social Science & Medicine 2020;281:21-38; asamonitor.pub/30ilZv1; Med Sci (Basel) 2019;7:29; J Clin Psychol 2020;76:1543-62). Leaders should promote and provide access to resources that nurture personal resilience in the workplace: peer support, wellness and work-life coaching, communication training, mentoring, social connection inside and outside of work, and emotional and mental health resources (Mayo Clin Proc 2017;92:129-46; JAMA Intern Med 2019;179:1406-14).
Leaders can reduce the stigma of asking for support
We work in an inherently difficult and stressful environment. We make life-and-death decisions on a daily basis. We are frequently caught in “no-win” situations with no good options forward. We support patients and families through the most difficult moments of their lives. No matter how well we support each other and our colleagues, the burden will occasionally be more than we can bear. The suicide rate in physicians is at an all-time high. A recent survey documents that 15% of anesthesiologists are experiencing suicidal ideation (asamonitor.pub/3mJlHor).
In these moments, we must be able to reach out to others for help. With the reduction in social support networks and family connections during the COVID pandemic, the ability for individuals to lean on colleagues, family, and friends has eroded. These connections keep us emotionally whole and resilient. “It is in the actual interactions themselves – the conversations that validate your plans, reframe your perspective on a situation, help you laugh and feel authentic with others, or just encourage you to get back up and try again because the battle is a worthy one – that we become resilient” (“The Secret to Building Resilience,” asamonitor.pub/3mG8VXW). We can and should be there for each other every day.