Burnout, patient and physician safety

Nada Khan is an Exeter-based NIHR Academic Clinical Fellow in general practice and GPST4/registrar, and an Associate Editor at the BJGP. She is on Twitter: @nadafkhan

Can one word sum up a multitude of experiences amongst a diverse population?  Burnout is described as a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job and involves a three dimensional model with an interplay between overwhelming exhaustion, a sense of depersonalisation and detachment, and feeling a lack of accomplishment.¹   We often use this word in a collective way, describing burnout in doctors, but often it is a deeply individual experience.  Whatever you might call it, burnout can have serious implications.

Burnout amongst healthcare workers has been highlighted again recently with the publication of a recent BMJ systematic review looking at the association of physician burnout with career engagement and quality of patient care.²  Physician burnout is not good for the workforce, and was associated with almost fourfold decreases in job satisfaction, career choice regret, and up to threefold increases in turnover intention. Worryingly, physician burnout impacted upon patient care; burnout was associated with a doubling in the risk of patient safety incidents and reduced patient satisfaction.  The review used a broad definition of patient safety, including prescribing errors, potentially avoidable adverse events and monitoring issues, and many of these were self-reported by physicians, so the authors do urge some caution in interpreting the pooled effect sizes.  Research has highlighted the specific risks of burnout in patient safety outcomes and ‘near-misses’ in general practice.  Specific occupational variables such as higher number of hours on administrative task and on-call duties, seeing a higher number of patients each day, along with feeling less supported, can mediate the associations between burnout and patient safety.³  The risks to patients of exhausted and depersonalised doctors should be treated as a preventable harm.

There is a research field devoted, rightly so, to patient safety and preventable harm.  What about physician safety?  Inherent to the commonly used definition of burnout (emotional exhaustion, depersonalisation and a feeling of reduced personal accomplishment) is the impact on the mental health of doctors.  Much of the research touches on this; the paper by Louise Hall and colleagues looking at burnout and patient safety classified 93.8% of their GP sample as experiencing at least a minor psychiatric disorder.  Doctors, and particularly female doctors, are at increased risk of mental illness and suicide.⁴  Workplace factors such as excessive workload, poor work-life balance and interpersonal conflict impact on the mental health in doctors.  This is frustrating when workplace factors have the capacity to be protective – consider the benefits of working productively in an autonomous setting with good support.

Sometimes, the responsibility of dealing with burnout falls on the individual: trying to build ‘resilience’, engage in more self-care, and improving stress management.  Medical students are now trained on resilience; perhaps putting on onus more on the individual whilst not always fully acknowledging the responsibilities of the system.  Christina Maslach, after whom one of the most widely used scales of burnout is eponymously named, highlighted that burnout says more about the workplace than it does about its employees, is a sign of major dysfunction within an organisation, and that accountability for burnout should lie squarely with the organisation.¹  Given that burnout is a sign of a floundering organisation, ‘treatment of burnout solely as a disease or failure of individual practitioners is unlikely to be effective…addressing burnout on an individual level will not be enough’.⁵  The discord between individual versus organisational approaches to burnout made me reflect on Rosie Marshall’s piece here on BJGP Life about her experiences of burnout, and how some doctors will need more than just a prescription and short course of CBT.

Given the organisational impacts of burnout, including risks to patient safety, patient dissatisfaction and workforce losses, one might think that it makes sense to take an organisational approach alongside individual support.  Last year, in an ‘SOS’ for general practice, the RCGP outlined a five point plan to prevent GPs from burning out. The plan focusses mainly on organisational approaches including an increased GP workforce, reducing bureaucratic burden, improving recruitment of additional roles to general practice, improvements in infrastructure and making sure GPs have a meaningful input to integrated care systems (ICS).⁶   An organisational approach is difficult in a huge system like the NHS with frequent changes in the top leadership; there have been five different Health Secretaries in the past four years of government.  We could try to reduce organisational and occupational mediators of burnout at the practice level, such as reducing administrative load, providing a more supportive environment and reducing on-call and patient appointment load.³  Will this be realistically achievable in an increasingly pressured environment where a depleted workforce of GPs are now being asked to see patients within a two-week timeframe? With increasing pressures, targets and expectations, and a higher risk of workforce burnout, it seems that both patient, and physician safety remain at risk.

References

1. Maslach CL, M.P. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About it. San Francisco: Jossey-Bass; 1997.
2. Hodkinson A, Zhou A, Johnson J, Geraghty K, Riley R, Zhou A, et al. Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis. BMJ. 2022;378:e070442.
3. Hall LH, Johnson J, Watt I, O’Connor DB. Association of GP wellbeing and burnout with patient safety in UK primary care: a cross-sectional survey. Br J Gen Pract. 2019;69(684):e507-e14.
4. Harvey SB, Epstein RM, Glozier N, Petrie K, Strudwick J, Gayed A, et al. Mental illness and suicide among physicians. Lancet. 2021;398(10303):920-30.
5. Epstein RM, Privitera MR. Doing something about physician burnout. Lancet. 2016;388(10057):2216-7.
6. College sounds SOS for general practice – and calls for rescue plan [press release]. Royal College of General Practitioners, 29 July 2021.

Featured photo by Elia Mazzaro on Unsplash