Writing about burnout in medicine in 2020 has a different flavour than six months ago. Our lives have changed. The impact has been felt across the globe. The era of COVID is upon us and in a very short space of time, as medical professionals, we’ve had to dramatically change how we work.

Depending on where we are working, we’ve had to change our clinical practice, literally move our clinics, change to performing clinics via Telehealth, learn all about PPE (accessing PPE!), implementing safe operative practices often across multiple hospitals, study how we transition between our work and home environments and then also manage the impacts upon our home and family lives. This may have involved supervising children at home doing their schooling, supporting elderly parents in their homes or combining living and working in isolation.

For most of us, we’ve never before had to face such an unprecedented time. There was cause for significant anxiety, particularly in the first six–eight weeks where it was unclear if Australia was to head down the path that some of our international colleagues were facing in worst affected countries such as China, Italy, the UK and the US. Fortunately, with our excellent public health response and the Australian community’s adherence to these early measures, we seem to have avoided the tsunami of patients with COVID and the associated morbidity and mortality and widespread impact on our health system and community that comes with that.

There are still many potential longer-term impacts on our community, our health system and us as healthcare professionals. There are many experienced mental health clinicians and services available to support our health workforce through the different phases that may come with the COVID pandemic. Work done in the first week of the COVID crisis by the Stanford group with multidisciplinary participants explored three key concerns: what healthcare professionals were most concerned about, what messaging and behaviours they needed from their leaders, and what other tangible sources of support they believed would be most helpful to them. The results are laid out as clearly as: Hear me, Protect me, Prepare, Support me, Care for me.¹ ‘Minding our Healthcare Workers’ is an excellent resource and, in particular, describes the different phases of the psychological responses and is available here: https://dhasq.org.au/coronavirus-covid-19-information. In addition, the British Psychological Society released a paper called ‘The psychological needs of healthcare staff as a result of the Coronavirus pandemic,’ which is an excellent resource that offers practical recommendations for how to respond at individual, management and organisational levels. It is available here:
www.bps.org.uk/news-and-policy/psychological-needs-healthcare-staff-result-coronavirus-pandemic. The Pandemic Kindness Movement was created by clinicians across Australia, working together to support all health workers during the COVID-19 pandemic and the website of curated resources is available here: https://aci.health.nsw.gov.au/covid-19/kindness

We’ve seen many challenges with COVID but also opportunities – or as some are calling it, their ‘COVID silver linings’. There have been incredible examples of collaboration and innovation in the medical and healthcare community and many say a positive sense of camaraderie as well as support from the community. Perhaps there are things we will want to retain on the far side of the pandemic.

Burnout in medicine

Burnout in medicine has been an escalating issue over the past several decades and has been increasingly described. Burnout, put simply, is a state of mental and physical exhaustion that can zap the joy out of your career, friendships and family interactions. It is very common for doctors,² and between 40–75% of O&Gs³ or trainees⁴ will be currently experiencing symptoms of burnout. Let’s pause and reflect on that statistic. It is sobering. It’s important that we recognise symptoms of burnout, in ourselves and our colleagues, so that we can intervene early before it progresses.

In the past several years, there has been more discussion of burnout and mental health in medicine than ever before. It was unbelievably powerful to have the RANZCOG President, Prof Steve Robson, come forward publicly in October 2018 and talk of his personal lived experience⁵ and then to go on and become a strong advocate for doctor’s health and wellbeing. Robson’s invited Editorial on Burnout in 2019 was recently recognised as one of the most read in ANZJOG, showing the level of interest in this topic amongst our colleagues.⁶

There has fortunately been an evolution in the field to better understand that burnout is a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed. In addition, in May 2019, WHO recognised burnout as a medical condition for the first time in the International Classification of Diseases. While the term burnout is clearly defined, it’s focused on the individual rather than an occupational framework, when perhaps it should be viewed as a symptom of a deficient healthcare system. This is important because our response as a profession must involve addressing the system-wide and organisational issues that led to this increasing prevalence of clinician burnout. Two reports released in late 2019, one from the US and one from the UK, both address systemic and organisational approaches to addressing clinician burnout.^{7 8} In Australia, we need to advocate, collaborate and mobilise as a profession to transform the healthcare system for the future.

Key dimensions of burnout

There are multiple formal definitions of burnout; however, the key features are that it is a work-related syndrome characterised by:

• Overwhelming exhaustion – feeling the physical and emotional response of stress and fatigued by the work environment
• Depersonalisation – feeling unemotional and distant towards one’s work
• Cynicism – represents the interpersonal aspect of burnout and refers to negative, callous or excessively detached response to various aspects of the job, usually resulting in a negative reaction to people, loss of idealism and the dehumanisation of others
• Low professional efficacy – feelings of incompetence and a lack of achievement and productivity in work and represents the self-evaluation aspect of burnout⁹

Some of these symptoms may resonate with you, whether you have felt them before, often or even experiencing them now. If you are concerned, it’s a good time to reflect and think about what may be causing these symptoms for you and whether you need to change something about your work, gather some support or seek help. Similarly, you may recognise colleagues when you read this piece; perspective and a compassionate approach are effective approaches in this situation.

Phases of burnout

There are several phases of burnout that a person may move through.

The physical symptoms can range from headaches, insomnia, palpitations, GI problems and teeth grinding through to more significant alcohol and/or substance use, loss of libido and progressively intrusive symptoms.

At a personal level, people may initially try to work harder, and this may result in emotional exhaustion, feeling drained and depleted, which can then make it harder to recover and find the motivation to go to work. Some people can become irritable, callous towards others, or lose compassion for their patients. There may be a change in the standard of their work or behaviour that might flag something is going on. At more advanced phases of burnout, cynicism, depersonalisation, procrastination and a profound sense of inner emptiness or exhaustion can be pervasive.¹⁰

There are, of course, many variations on this pattern. Fatigue may not be relieved by rest and family members or colleagues may start to notice behavioural changes including lack of enjoyment of usual activities or angry outbursts. There may be some cognitive impairment with short attention span and impact on memory. Some people may find they have a diminished sense of accomplishment, work no longer gives them a sense of fulfilment and they progressively start to withdraw from family and friends. Apathy and depression including suicidal ideation can occur, so it is important to be alert to these more advanced features of burnout.

It is important to note that many studies have found a correlation between burnout and rates of depression and they frequently co-exist, but not all doctors with symptoms of burnout have depression and vice versa. There is, however, a very strong relationship between burnout and suicidality. It is one of the reasons it is important to address burnout.

Factors driving burnout

There are usually several factors that may interact or build up and cause burnout. In fact, the numbers often help tell the burnout story: physicians who spend less than 20% of their week on a work activity they find meaningful are three times more likely to experience burnout compared to those who spend 20% or more on a favourite work effort.¹¹

Sometimes these drivers build up and swirl together as a ‘perfect storm’ – sometimes they slowly accumulate over time, sometimes they peak with a busy period of ward service or because of a particularly difficult patient encounter at work or coinciding with a time when you are vulnerable in your personal life.

Factors driving burnout include:¹²

• Workload
• Flexibility and control over your work
• Efficiency
• Work-life integration
• Alignment of individual and organisational values
• Social support/community at work
• Sense of meaning derived from work

A lot of doctors in this modern era talk about their sense of loss of community at work and professional loneliness, the burden of administrative tasks and loss of autonomy and flexibility.

There is a risk of losing the humanity in healthcare, which is important because it is likely what drew most, or all, of us to medicine. The humanity restores and renews us through the contact we have with our patients, the compassionate care we give and the connection we get in return. Think back to when you started medical school. Reflect on what you have loved about the type of medicine you practice. Is that passion still there or is it diminished? What is getting in the way of you enjoying your job?

Consequences of clinician burnout

The high prevalence of burnout is a cause for concern because it can impact the quality and safety of patient care, professionalism, healthcare system performance and the clinician’s own health.¹³

For doctors, this can lead to:

• Reduced empathy, productivity and presenteeism or absenteeism
• May consider a career change or leave the profession
• PTSD, suicidal ideation, increased substance use
• Relationship impact, divorce
• Impact on teamwork and impaired job satisfaction
• Physical: coronary heart disease, IDDM, MSK pains, fatigue, sleep disorders / insomnia, headaches, GI issues, reduced libido

Beyond burnout

Being able to recognise the signs of burnout in yourself or your colleagues is important. Having tactics to address them at a personal level is essential, as is starting to tackle them at a health system level as a profession.¹⁴ As doctors, being able to have these discussions amongst ourselves and in our teams should be something we can do with ease and some expertise. Doctor’s health and wellbeing should no longer be the elephant in the room. Keeping ourselves well throughout our careers, from day one of medical school through to retirement, with all the ups and downs that life throws at us, is something we can learn to do together.

If this article has raised issues for you, help is available at:

• Your own treating doctor is a good first contact
• Your Doctor’s Health Service:
  • NSW and ACT: 02 9437 6552
  • NT and SA: 08 8366 0250
  • Qld: 07 3833 4352
  • Tas & Vic: 03 9280 8712
  • WA: 08 9321 3098
  • New Zealand: 0800 471 2654

Need crisis help right now?

AMA Peer-to-Peer support service 1300 853 338 (this is anonymous and confidential, 8am–10pm, trained medical peer supporters, you do not have to be an AMA member)
Lifeline on 13 11 14
Beyond Blue on 1300 224 636

Websites that can provide further advice and resources:
Doctors for Doctors: www.drs4drs.com.au
Doctors’ Health Advisory Service: www.dhas.org.au
Beyond Blue: www.beyondblue.org.au
The Australian Doctor’s Health Network: www.adhn.org.au
Pandemic Kindness Movement: www.aci.health.nsw.gov.au/covid-19/kindness

1. Shanafelt TD, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA. Published online April 07, 2020. doi:10.1001/jama.2020.5893.
2. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018;320(11):1131-50.
3. Roger RP. Burnout in Obstetrics and Gynaecology. Obstet Gynecol Clin North Am. 2017;44(2):297-310.
4. Morgan HK, Winkel AF, Nguyen AT, et al. Obstetrics and Gynecology Residents’ Perspectives on Wellness. Obstetrics & Gynecology. 2019;133(3):552-7.
5. Robson S. Learn from me. MJA Insights. 2018. Available from: https://insightplus.mja.com.au/2018/41/learn-from-me-speak-out-seek-help-get-treatment.
6. Robson S, Cukierman R. Burnout, mental health and ‘wellness’ in obstetricians and gynaecologists: Why these issues should matter to our patients – and our profession. ANZJOG. 2019;59:331-4.
7. National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. 2019. Available from: https://doi.org/10.17226/25521.
8. General Medical Council, West M, Coia D. Caring for doctors, caring for patients : How to transform UK healthcare environments to support doctors and medical students to care for patients. 2019. Available from: www.gmc-uk.org/about/how-we-work/corporate-strategy-plans-and-impact/supporting-a-profession-under-pressure/uk-wide-review-of-doctors-and-medical-students-wellbeing
9. Maslach C, Leiter MP. New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Medical Teacher. 2017;39(2):160-3.
10. Salvagioni D, Melanda A, Mesas A, et al. Physical, psychological and occupational and consequences of job burnout: A systemic review of prospective studies. PLoS One. 2017;12(10):e0185781.
11. National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: The National Academies Press. 2019. Available from: https://doi.org/10.17226/25521.
12. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-46.
13. West CP, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-81.
14. Shapiro D, Duquette C, Abbott L, et al. Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level. Am J Med. 2018. doi: 10.1016/j.amjmed.2018.11.028.