Clinician Well-Being

DEFINING TERMS

Well-Being

Well-being is not simply the absence of burnout. It also includes the presence of positive emotions (e.g., contentment and happiness), the absence of negative emotions, satisfaction with life, fulfillment, engagement, and positive functioning. Professional well-being allows clinicians to thrive and achieve their full potential through the experience of positive perceptions and an environment that supports a high quality of life at work. The terms wellness and well-being are often used interchangeably. Efforts to promote wellness have traditionally focused on physical and emotional health and maintaining a healthy lifestyle. Although physical and emotional health are critical to overall well-being, they are only part of the equation. In addition to these two domains, well-being encompasses several distinctive, interdependent dimensions that can be internal or external to the individual ( Fig. 3.1 ). Drivers of clinician well-being can be organized into a hierarchy of needs, starting with basic needs at the lowest level and leading to self-actualization at the highest level ( Fig. 3.2 ).

WHY WELL-BEING IS IMPORTANT

Physicians with high levels of well-being generally have enthusiasm for life and work, along with a sense of accomplishment and belonging. However, personal characteristics such as perfectionism, self-doubt, inability to delegate, and high levels of commitment despite adversity can contribute to emotional exhaustion. Maslach and colleagues suggested that the best workers are more predisposed to burnout because they will continue to expend significant energy to meet their goals even in the face of barriers. Not surprisingly, the prevalence of burnout observed among physicians compared with other U.S. workers is significantly higher even after adjustment for work hours, age, and gender.

Chronic occupational stress is linked to neurobiologic findings. High levels of norepinephrine and dopamine are released in the brain during episodes of uncontrollable stress, weakening the abilities of the prefrontal cortex and impairing higher-order functions, including reasoning, social cognition, attention regulation, and complex decision making. In contrast, controllable stressors (such as a meaningful challenge) do not result in the same chemical changes. Structural magnetic resonance imaging (MRI) findings obtained longitudinally in both a control population and a group with occupational exhaustion syndrome strongly suggested links between chronic occupational stress and thinning of the prefrontal cortex, enlargement of the amygdala, and caudate reduction. These findings were gender-specific, with women affected to a greater degree than men.

Professionalism, teamwork, and patient safety can all suffer as a result of burnout. Multiple studies have suggested a relationship between physician burnout and an increased incidence of both self-perceived medical errors and suboptimal care. Anesthesia residents at greater risk for burnout and depression reported more medication errors and mistakes with negative consequences for patients than residents with lesser risk. Perhaps most concerning is the finding that emotional distress demonstrated during residency can have implications for future burnout as a practicing physician. In a longitudinal study of internal medicine physicians with early signs of emotional distress the persistence of emotional distress along with an association with depersonalization was identified 10 years after residency.

The negative financial impact of burnout on health care systems is considerable. Studies have found that physicians with self-reported burnout were approximately twice as likely to leave the institution; the societal cost of turnover and reduced productivity caused by physician burnout in the United States is estimated to be greater than $4 billion annually. Clinicians may also elect to reduce their work hours or retire early, resulting in decreased system productivity and reduced access to care for patients. Physician turnover also adversely affects colleagues and increases the risk of burnout for other health care team members.

The provision of optimal health care is the end product of a successful relationship between those providing care and those seeking care. Recognizing the negative impact of clinician burnout on health care organizations, the American Medical Association (AMA) has outlined five critical arguments for supporting well-being: (1) moral and ethical, (2) business, (3) recognition, (4) regulatory, and (5) tragedy. The moral and ethical case may be the most important, as clinician burnout may contribute to excessive alcohol use and suicide.