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Clinician well-being has emerged as a critical issue because of widespread clinician burnout. There is growing recognition that a combination of individual strategies and systems-level solutions is required to successfully promote clinician well-being. Interventions to prevent burnout are more effective than those that address burnout after it has occurred.
In its 11 revision of the International Classification of Diseases (ICD-11) the World Health Organization (WHO) defines burnout as an occupational phenomenon rather than an individual mental health diagnosis (e.g., depression). The term burnout was initially coined by Freudenberger in the 1970s, who described 12 progressive stages of burnout experienced by individuals in the helping professions in response to severe stress: (1) compulsion to prove oneself, (2) working harder, (3) neglecting of needs, (4) displacement of conflicts, (5) revision of values, (6) denial of emerging problems, (7) withdrawal, (8) obvious behavioral changes, (9) depersonalization, (10) inner emptiness, (11) depression, and (12) burnout. Three key dimensions of burnout are commonly evaluated: emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. Burnout rates in U.S. anesthesiologists and anesthesiology trainees range from 14% to 51%. , Clinician burnout is associated with negative consequences for (1) patient care, (2) the clinician workforce and health care system costs, and (3) clinicians’ own health and safety. Both work environment and individual factors can influence the risk of burnout in anesthesiology ( Table 3.1 ).
Anesthesia Work Environment Factors | Individual Factors |
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Resilience refers to the ability of both individuals and social groups to withstand, adapt, recover, or even grow from adversity, stress, or trauma; in other words, the ability to bounce back from challenging life experiences. Traditionally, resilience in the context of clinician well-being has focused on individual personality traits, behaviors, and attitudes. Resilience is a continuous, dynamic state that can be nurtured and trained.
Moral injury was first described in war veterans. It refers to the lasting negative effects on an individual’s conscience or moral compass when that person perpetrates, fails to prevent, or witnesses acts that transgress one's own deeply held moral beliefs and expectations. Emotions of guilt, shame, and remorse are frequently associated with moral injury. In medicine moral injury describes the distress that clinicians experience when they are unable to provide high-quality patient care because of factors beyond their control. During the coronavirus disease 2019 (COVID-19) pandemic, concerns about adequate personal protective equipment (PPE), witnessing patients dying alone in isolation, and the need to make allocation decisions to ration scarce medical resources were among numerous factors that contributed to clinician moral injury.
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 ).
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.
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