The Blueprint for Overcoming Burnout Exists

“No one is the same,” whispered a physician seated at an adjacent table, echoing the sentiment of the entire conference room of health care workers at Grady Memorial Hospital in Atlanta. We were invited to discuss burnout with the U.S. Surgeon General, Dr. Vivek Murthy during his visit in May. Burnout develops from chronic workplace stress and includes the triad of emotional exhaustion, depersonalization, and a sense of reduced accomplishment.¹ 

Dr. Ajala

Dr. Murthy, along with Mayor Andre Dickens, visited Grady to discuss his advisory “Addressing Healthcare Worker Burnout.”² He sought to gain insight about the state of health care workers’ well-being from nurses, residents, faculty physicians, and administrators. He also visited the historically black college-affiliated Morehouse School of Medicine, which has a 40-plus-year partnership with Grady and whose goal is to increase the number of African American physicians who serve underserved communities, which have been hit hard by COVID-19. I was excited to attend but worried that I could not express my experience as a hospitalist who cared for patients affected by COVID-19.

There are 31 million uninsured Americans and more than 1 million uninsured Georgians.³ Safety-net hospitals like Grady are likely the first encounter some adult patients have had with a physician in many years. Emory University School of Medicine has partnered with Grady for more than 100 years in the care of the metro Atlanta community. Grady is also a level-one trauma center with 953 beds. However, we struggle with a shortage of 200 nurses as well as other essential staff.⁴ Before 2020, the U.S. health care system struggled with staffing, health inequities, and emergency departments with long waits. 

As a hospitalist, I witnessed how this phenomenon was exacerbated by a global pandemic, which placed a collective strain on our health system and its workers, from environmental-service employees and social workers to nurses and physicians. This year, the lives lost to COVID-19 reached 1 million Americans, which included our colleagues, family members, and patients. This has taken a tremendous toll on every person who cares for a patient, as well as on the public health sector. 

There was a collective sigh of relief when we realized Dr. Murthy understood our health care systems were already at a breaking point and in need of a major culture shift. We also need major changes in systemic practices, from licensing boards to medical and nursing schools. In late 2020, the National Health Service Corps surveyed 20,665 health care workers and found that “Approximately 1 in 3 physicians, APPs [advanced practice providers], and nurses surveyed intend to reduce work hours. One in five physicians and 2 in 5 nurses intended to leave their practice altogether.”⁵ One year later, in the same survey, one out of three health care workers considered leaving their jobs. Many who work in health care had experienced bullying or verbal threats by 2021.⁵

Dr. Lorna Breen was an emergency medicine physician and the director of the emergency department at a New York Presbyterian Hospital affiliate, Allen Hospital, in Manhattan. During New York’s early pandemic devastation, she suffered in silence after personally battling a COVID-19 infection and returned to work to help keep afloat an emergency department that was drowning in increasing mortality, lack of personal protective equipment, and the uncertainty of how to manage this novel virus.⁶ On April 26, 2020, she died by suicide and her family lost a beloved daughter and sister. She was 49 years old. Her colleagues lost a friend and leader. 

Annually, 300 to 400 physicians die by suicide in the U.S. Compared to other female professionals, suicide deaths among female physicians are 250-400% higher.¹ The leading cause of death in medical students and male medical residents is suicide.⁷ In early 2020, a cross-sectional survey of physicians found that 1 out of 15 had thoughts of taking their life and reported being less likely to seek help than counterparts that didn’t report suicidal ideation.¹ Sixty-two percent of nurses and 42% of doctors have reported feeling burnout while battling COVID-19.⁵ Burnout has been shown to cause a 200% increased risk of medical errors.⁵ These data ring the alarm for emergent intervention because the well-being of health care workers is at risk. Burnout has additional downstream effects such as limited service availability, erosion of public trust, and worsened population health outcomes.⁷ 

On March 18, 2022, the Dr. Lorna Breen Healthcare Provider Protection Act H.R. 1667 became law. This law has established grant funding and requires the Department of Health and Human Services (HHS) to provide grant-funded financial support to various health care institutions and campaign for mental health resource awareness and support among clinicians. HHS will also be required to disseminate best practices for suicide prevention and resiliency and hold itself publicly accountable for the effectiveness of these federal grant programs. This may seem like a difficult task, but the U.S. Surgeon General’s advisory on burnout creates the roadmap to meet this very important call to action. 

The advisory reports the groups of health care workers whose health and well-being have been disproportionately impacted before and during the pandemic are people of color, females, those who earn low-wages, and those in rural and tribal communities. Examination of equitable interventions will be required. For all health care workers, excessive workload and work hours, the politicization of public health, lack of leadership support, and barriers to mental health and substance use care contribute to burnout.⁷

During the press conference portion of Dr. Murthy’s visit, an emergency medicine resident asked about a plan to address state board licensing requirements to report any mental health care throughout a physician’s life. Most, if not all, states require this reporting and inadvertently uphold a culture of shame around mental health. As Dr. Lorna Breen’s family noted, this must change now. Dr. Murthy acknowledged the trainee’s concern and noted that his advisory asks that “Punitive language in licensing, accreditation, and credentialing of health professionals” be eliminated.⁷ Addressing this will be key to a healthy future for every medical student and resident, and even physicians who currently practice medicine. 

The COVID-19 pandemic was characterized by the politicization of science and public health. Many health care workers were celebrated as heroes but were simultaneously maligned for our participation in patient care. Due to misinformation campaigns, some physicians feared hostile exchanges on social media and uncomfortable interactions with the public. The advisory also called for decisive action to prevent workplace violence just before the June 2, 2022 tragedy in Tulsa, Okla. Inside a Saint Francis Health System medical building, a former patient murdered his surgeon, another physician, an office receptionist, and a fellow patient. Dr. Preston Phillips was a Harvard-trained orthopedic surgeon who attended theology school at Emory University. His colleague Dr. Stephanie Husen was a sports medicine physician. Amanda Glenn was committed to providing a welcoming experience and William Love was a retired Army veteran.⁸ This day of violence rocked the national medical community and influenced hospital systems to reassess health care worker and patient safety. 

The culture of shame and the stigma surrounding mental health is the other mask that we hide behind. However, this kind of mask won’t keep us safe. At the close of Dr. Murthy’s visit, he reminded us that this task is urgent, involves multiple institutions, and must engage multiple stakeholders. The Dr. Lorna Breen law will help ensure funding and decisive interventions to protect health workers. Both the law and advisory will increase awareness, foster discussion, and help save the lives of health care workers and patients. 

Physician, heal thyself by recognizing burnout. Speak up. Reach out. We have the blueprint, let’s hold ourselves and leaders in health and government accountable to put it to use. 

Surgeon General’s Advisory Tips on Burnout

• Transform workplace culture to empower health workers and be responsive to their voices and needs.
• Eliminate punitive policies for seeking mental health and substance use disorder care.
• Protect the health, safety, and well-being of all health care workers.
• Reduce administrative burdens to help health workers have productive time with patients, communities, and colleagues.
• Prioritize social connection and community as a core value of the health care system.  
• Invest in public health and our public health workforce.   

Dr. Ajala is an assistant professor of medicine at Emory University School of Medicine, Atlanta, co-director, education council for Emory Division of Hospital Medicine, assistant site director of education at Grady Memorial Hospital, core faculty for J. Willis Hurst Internal Medicine Residency, and chair of SHM’s Global Hospital Medicine Special Interest Group. 

References

1. Kalmoe MC, et al. Physician suicide: a call to action. Mo Med. 2019;116(3):211-216. PMID: 31527944; PMCID: PMC6690303.
2. Murthy, V. et al. Addressing health worker burnout: The U.S. Surgeon General’s advisory on building a thriving health workforce. Available at: https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf. Published online 2022. Last accessed July 30, 2022.
3. Cha AE, Cohen RA. Demographic variation in health insurance coverage: United States, 2020. Natl Health Stat Report. 2022;(169):1-15. PMID: 35166656.1. 
4. Oliviero H, Hart A. Surgeon general warns of ‘crisis’ level health care burnout during Atlanta visit. Atlanta Journal and Constitution website.  Available at: https://www.ajc.com/news/atlanta-news/surgeon-general-warns-of-crisis-level-health-care-burnout-during-atlanta-visit/JOFRGAGUJRGFHCLMYMWUBNSQYI/. Published online May 27, 2022. Last accessed July 30, 2022.
5. Sinsky CA, et al. COVID-Related stress and work intentions in a sample of US health care workers. Mayo Clin Proc Innov Qual Outcomes. 2021;5(6):1165-1173. doi: 10.1016/j.mayocpiqo.2021.08.007. 
6. O’Connor, M. A doctor’s emergency. Vanity Fair website. Available at: https://www.vanityfair.com/style/2020/09/will-lorna-breens-death-change-doctors-mental-health. Published online September 27, 2020. Last accessed July 30, 2020.
7. Shanafelt TD, et al. Suicidal ideation and attitudes regarding help seeking in U.S. physicians relative to the US working population. Mayo Clin Proc. 2021;96(8):2067-2080. doi: 10.1016/j.mayocp.2021.01.033. 
8. The Associated Press. 2 Doctors, a receptionist and a visitor were killed in the Tulsa shooting. Available at: https://www.npr.org/2022/06/02/1102813156/2-doctors-receptionist-visitor-killed-tulsa-shooting. Published online June 2, 2022. Last accessed July 30, 2022.