By Dr Suzy Jordache, Senior Medical Educator at Medical Protection

Rates of burnout within the medical profession are significant. Studies from across the world quote rates of 12– 80 percent depending on the dimension of burnout studied (1). Prevalence varies according to specialty, gender, age or career stage, and practice setting.

The impact this has on physician well-being, patient safety, and patient satisfaction is now a recognized challenge for all who work in health care. Singapore is no different.  Doctors work extremely long hours in a high pressure, high expectation culture. Determination and dedication to meet the demand and fulfil expectations can lead individuals into a very unhealthy relationship with work that spills over into family life and personal health.   As Professor David Peters, Head of the Centre for Resilience in the UK states: “Long term drowning in high levels of adrenaline and cortisol eventually makes you ill. But before that, it makes you stupid and unfriendly.” (2)

Litigation and complaints are often seen to arise against the background of a burnt-out, unhealthy doctor – diagnoses are missed, errors occur, and patients and families experience unempathic, dismissive care (3 & 4)

What exactly is burnout?

Burnout is an occupational hazard.  The well recognized Maslach Burnout Inventory (MBI) (4) proposes three domains:

• Emotional exhaustion (EE)
• Depersonalization (DP) - a cynical attitude with distancing behaviors
• Low sense of personal accomplishment (PA)

A study published in the Singapore Medical Journal earlier this year (6) reported that residents in Singapore had lower empathy and higher rates of burnout compared to US counterparts.

Residents were from 34 different programmes and training sites that spanned three general hospitals (Singapore General Hospital, KK Women’s and Children’s Hospital, and Changi General Hospital), five National Specialty Centres, and nine community clinics in Singapore. Three-hundred sixty out of 446 (80.7 percent) residents were found to have high burn out rates in at least one of the MBI domains.

Burnout reflects an uneasy relationship between people and their work. Avoiding burnout is about building the opposite of burnout - engagement. Christina Maslach and Michael Leiter proposed that: “When burnout is counteracted by engagement, exhaustion is replaced by enthusiasm, bitterness by compassion and anxiety with efficacy.” (7)

What can be done to avoid or reverse burnout?

Avoiding or reversing burnout and building resilience requires careful attention to developing good individual coping strategies in the workplace. Organizational policies and procedures must ensure these coping strategies are respected and enforced.

For healthcare workers, evidence suggests this requires focus on physical and emotional well-being and ensuring a sense of calling is not eroded.

Physical well-being
Developing rituals and routines that promote regular healthy eating, hydration, and sleep underpins all other more sophisticated strategies. Unfortunately, many doctors find that the organizational culture requires them to have considerable courage to ‘say no’ to skipping breaks and taking on extra shifts. Prioritizing personal well-being can be a significant challenge for many. Often doctors give much of their energy to their work and arrive home exhausted and unable to enjoy or participate fully in time with family and friends; fail to exercise or eat healthy food; or relax into restorative sleep.

Emotional well-being
Coping with the stress of working with suffering patients day after day requires attention to emotional well-being to avoid secondary traumatic stress disorder or compassion fatigue. Mindfulness, journaling, and Schwartz rounds are evidence-based techniques that promote self-awareness and resilience (8).  Many organizations in the UK, US, and Australia are embedding Schwartz rounds into their institutions to enable all staff to come together and talk about the effect of caring for themselves and teams.

Sense of calling
A sense of mission and purpose can also build resilience. Remembering why an individual chose medicine and celebrating achievements that align with these   values can be a powerful way to bounce back in an environment that constantly challenges and surprises.  Organizations can support this by collecting evidence and stories of good practice and rewarding, thanking and celebrating.

Evidence strongly suggests that individuals cannot build or maintain resilience in isolation.  It is crucial that the organization understands this and works with individuals so that they can be happy, healthy, safe, and productive at work.

Physical well-being

Individual strategy

• Regular, healthy meals and snacks throughout the day
• Drink water frequently throughout the day
• Ensure you get 6-8 hours good quality sleep per 24 hours
• Be comfortable: wear suitable clothing for temperature and tasks

Organizational support

• Provision of hot and cold healthy food 24 hours a day
• Drinking water available throughout clinical and non-clinical areas
• Shift patterns that allow adequate preparation and recovery time, flexibility and autonomy over swaps and allocation
• Ensure good climate control through all clinical and non-clinical spaces

Emotional well-being

Individual strategy

• Ensure adequate energy to enjoy time away from work; develop ability to ‘say no'
• Avoid boredom: ensure variety of work and delegate where possible
• Become self-aware:mindfulness, reflective practice and journaling
• Talk to others about the impact of caring especially when things go wrong or are particularly distressing

Organizational support

• Consider enforcing maximum hours – promote a culture where courage is not required to ‘say no’
• Provide spaces for quiet thinking/walking/being
• Encourage debriefing after critical events and consider implementing Schwartz Rounds
• Careful attention to job plans to ensure doctors are spending at least 20 percent of their time at work on tasks that are meaningful to them. Offer training in good delegation skills
• Enforce breaks between patients, operations or on long ward rounds

Sense of calling

Individual strategy

• Reconsider why you went into medicine in the first place
• Recognise and celebrate your own achievements and successes
• Thank others

Organizational support

• Use corporate language that reflects the values, mission, and purpose of healthcare practitioners
• Collect evidence of individual and team success and celebrate
• Congratulate and reward events and achievements of individuals

1. Kumar, Burnout and Doctors: Prevalence, Prevention and Intervention. Healthcare (Basel) 2016; 4.pii:E37
2. https://secure-hwcdn.libsyn.com/p/b/0/e/b0e14b1c951912ff/INO_David_Peters_resilience_podcast_FINAL_Feb2016.mp3?c_id=10992843&expiration=1524480825&hwt=ddf81174d664f9ec0f372f179e0d0bdc3
3. Shanafelt et al. Burnout and Medical Errors Among American Surgeons. Ann Surg 2010;251:995-1000.
4. Baer et al, Pediatric Resident Burnout and Attitudes Toward Patients Pediatrics 2017;139.pii: e20162163.
5. Maslach et al. The Maslach Burnout Inventory (3rd ed). Consulting Psychologists Press 1996.
6. Lee et al. Empathy and burnout: a study on residents from a Singapore institution. Singapore Med J 2018;59:50-54.
7. Maslach C and Leiter MP. Reversing Burnout.  How to rekindle your passion for your work, Stanford Social Innovation Review, 2005: https://ssir.org/pdf/2005WI_Feature_Maslach_Leiter.pdf
8. The Schwartz Center for Compassionate Health- care: http://www.theschwartzcenter.org/supporting-caregivers/schwartz-center-rounds/