Burnout affects the mental health of pediatricians and other health care providers treating children – and the quality of care they provide, according to two Pediatrics articles highlighted by editor in chief Lewis R. First, MD, MS.
The studies investigated the prevalence and effects of burnout among pediatric residents, and all health care providers, working in intensive care units. They were among those published in 2017 that Dr. First deemed potentially practice changing – ones whose clinical implications may have immediate relevance in your daily work.
“There are a variety of ways to overcome burnout and promote our resiliency that starts with our ability to find joy in caring for children and our lifelong learning” through professional development sessions and academic journals, according to Dr. First , professor and chair of pediatrics at the University of Vermont in Burlington. He also serves as chief of pediatrics at the University of Vermont Children’s Hospital. He spoke at the 2017 annual meeting of the American Academy of Pediatrics and in later interviews.
High prevalence of burnout
The study by Baer et al. found that almost two in five pediatric residents experience burnout, often accompanied by poorer care of patients (Pediatrics. 2017. doi: 10.1542/peds.2016-2163 ). Using a 7-point Likert scale ranging from “never” to “every day,” 258 residents from 11 different residency programs filled out an anonymous Web-based survey on how often they felt emotional exhaustion (“I feel burnout from my work”) and depersonalization (“I’ve become more callous toward people since I took this job”). They also answered seven questions about patient care attitudes and behaviors.
Of the 258 respondents, 39% had burnout, defined as answering affirmatively to either of the above questions with at least “weekly.” Most of the respondents were female, white, and married or in a long-term relationship without children, but the burnout rates did not vary across gender, race/ethnicity, relationship or parental status, or among different characteristics of the residency program and schedule. Higher burnout rates did occur among those feeling sleep deprived.
Those with burnout also had substantially higher odds of providing lower-quality care. Residents with burnout were seven times more likely to make treatment or medication errors not related to inadequate knowledge or experience, six times more likely to feel guilty about how they had treated a patient, more than four times more likely to report having little emotional reaction to a patient’s death, and four times more likely to discharge a patient earlier to make service more manageable. Burned-out residents had more than nine times greater odds of paying “little attention to the social or personal impact of an illness on a patient,” the study showed.
Burnout symptoms and solutions
Symptoms of potential burnout, Dr. First said in an interview, include emotional exhaustion, feeling a loss of meaning in work, feelings of ineffectiveness, a tendency to view people as objects instead of human beings, increasingly poor communication, and poor interpersonal and clinical skills and behaviors.
Other symptoms include “decreased engagement and enthusiasm, increased cynicism, and a loss of feeling of personal accomplishment or competence at work,” the study’s lead author, Tamara E. Baer, MD, MPH, of Boston Children’s Hospital’s division of adolescent and young adult medicine, said in an interview.
Other research also has found burnout linked to doctors’ errors, self-reported negative attitudes toward patients, and less time spent with patients, she said. “Thus physicians should be on the lookout for burnout within themselves as well as in their colleagues and medical trainees.”
Both Dr. Baer and Dr. First noted the importance of organizational leadership in preventing burnout.
The Association of Medical School Pediatric Department Chairs is sharing a toolbox of strategies that they have found effective for reducing burnout and developing wellness among physicians, Dr. First said in the interview.
“Some of those suggestions include personal attention to wellness via good nutrition, exercise, mindfulness for emotional self-regulation, and developing supportive relationships,” he noted. In addition to organizational mindfulness programs and ones that foster work-life integration and social activities, prevention programs should “create wellness and resilience, and a sense of pride and meaning in the work that is being done.”
Drs. First also pointed to ways of addressing triggers of burnout:
Burnout risk in the NICU
Similar interventions may help with burnout in neonatal ICUs (NICUs), the focus of the second study Dr. First discussed. Tawfik et al. surveyed 2,760 personnel from 41 NICUs in the United States to learn the prevalence of burnout and how it was associated with NICU organization (Pediatrics. 2017. doi: 10.1542/peds.2016-4134 ).
Among the 1,934 providers who replied (a response rate of 70%), 27% had burnout; at individual NICUs, burnout prevalence varied from 8% to 43%. The majority of respondents (72%) were registered nurses, followed by respiratory therapists, physicians, neonatal nurse practitioners, and others. The highest burnout rates occurred in NICUs with higher average daily admissions and higher average occupancy – and those using EHRs.
“Don’t assume that just because you use the EHR every day means you know how best to use this tool to improve your efficiency and effectiveness in generating and deriving information on your patients,” Dr. First said in the interview. He encouraged physicians to find out what resources their institutions might offer to help, such as EHR hospital teams or office support who can look at providers’ EHR usage, and show them shortcuts and time-savers to improve efficiency based on their usage patterns.
“Nursing burnout was more sensitive to the setting than physician burnout, especially in regard to average daily admissions, late transfer numbers, nursing hours per patient day, and mortality per 1,000 infants,” Dr. First noted.
Interestingly, burnout prevalence was not associated with the proportion of high-risk patients seen in the NICUs, the number of attending physicians in the unit, or whether the institution was a teaching hospital or not, he said.
Dr. First listed strategies to reduce burnout risk in NICUs that the study authors also described: expressing thankfulness each day, focusing on positive events at the start or end of each day, performing random acts of kindness for colleagues and staff, and encouraging providers to identify the strengths in one another.
Addressing burnout requires efforts from everyone
“Given the potential effects of burnout on patient care and professionalism and physician wellness, it is important for physicians to speak up if they have concerns about burnout in their colleagues,” Dr. Baer said in the interview.
Burnout is common, she said, occurring in more than half of physicians at some point in time, so a doctor experiencing it is almost certainly not alone among colleagues.
“Physicians can work together and with their leadership to prevent and mitigate the effects of burnout by promoting personal and professional wellness, effective teamwork, and reducing the administrative burdens that impact time spent directly with patients and have been demonstrated to contribute to physician burnout,” Dr. Baer noted.
She also pointed to the need to address it in medical education, given the downstream risks of burnout on the next generation of physicians.
“Medical schools and residency and fellowship programs should address the risks and signs of burnout, as medical students and trainees are likely seeing signs of burnout in some of their physician teachers and mentors,” Dr. Baer said in the interview.
Some burnout among providers may be inevitable at times, but it’s important to continue looking for ways to combat it.
“We need to do more to remind each other of why we chose our profession, and how good it makes us feel to strive to make a difference in our patients and families each and every day,” Dr. First said in the interview.
Dr. First reported having no disclosures and no external funding. The residents’ study by Baer et al. was funded by the Boston Children’s Hospital’s Fred Lovejoy Resident Research Award and a grant from the Health Resources and Services Administration. The NICU study by Tamfik et al. was funded by the National Institutes of Health, grants from the National Institute of Child Health and Human Development, and the Jackson Vaughan Critical Care Research Fund. The authors of both studies had no relevant financial disclosures.
