A Call for Action: Cultivating Resilience in Healthcare Providers

Case Vignette

“Dr. B” is a third-year internal medicine resident, supervising junior residents for the fourth consecutive month on an inpatient medicine service at a tertiary care hospital. Over the preceding 28 months, she has experienced more death, illness relapse, and treatment-resistant disease than she ever anticipated. Time and again, she has empathized with her patients’ caregivers, often longing to express how intimately she understands their pain. For fear of being seen as unprofessional, she avoids sharing her feelings not only with patients’ families, but also with her colleagues and even herself.

Dr. B presents to employee health for her annual wellness visit. She endorses feeling persistently fatigued and says that engaging as she typically would with patients has become too cumbersome. She denies feeling hopeless, depressed, or suicidal but does disclose feeling dread about entering the hospital each day, fearing that things will inevitably go wrong under her care. With her family across the country and no current partner, she struggles to cope. Her sleep has been disrupted, and she often finds herself drinking 3–4 glasses of wine to get to sleep. Dr. B is hesitant to engage with a mental health provider when given a referral. She is perfectionistic and self-critical, making the thought of sharing how vulnerable she has become all but unbearable.

Burnout

Burnout describes a human response to chronic emotional and interpersonal stress at work, defined by exhaustion, cynicism, and inefficacy (1). The three main dimensions of burnout assessed using the Maslach Burnout Inventory (MBI) include emotional exhaustion, depersonalization, and a sense of low personal accomplishment (1). Burnout affects approximately one in three physicians at any given time (2). Risk factors for burnout in healthcare providers include long years of training, extended work hours, and witnessing patients die, suffer, and decline. The uncertainty inherent in treating human beings, the exorbitant cost of medical training, and traditionally low reimbursement rates also contribute to physician burnout (3–5). Compassion fatigue and vicarious traumatization describe cognitive and schematic sequelae that overlap with posttraumatic stress disorder (PTSD) (6–8). These syndromes assume that by empathically engaging with patients’ trauma and pain, being a healthcare provider might not only cause burnout, which waxes and wanes over time, but can produce enduring effects on one’s experience of the self, others, and the world.

While the exact nature of the association between burnout and suicide is unknown, we know the ratio for male physicians, compared with the general population, was 1.41, with a 95% confidence interval (CI) of 1.21–1.65, while female physicians took their lives at a rate 2.27 (95% CI=1.90–2.73) times that of the general population (9). Approximately one physician dies by suicide every day, and suicidal ideation increases approximately 4-fold during the first 3 months of residency training (10). The present review attempts to elucidate sources of burnout and to highlight ways to promote resilience.

Burnout in Trainees

The effect of burnout on trainees cannot be underestimated. Investigators in the Netherlands measured burnout in 41.3% of trainees who completed the MBI. They found that 20.6% of trainees were classified as burned out based on survey results. Moreover, 12% reported having suicidal thoughts at least one time during their residency, and 1% reported suicidal thoughts more than one time during residency. Suicidal thoughts were also significantly more prevalent in the group with burnout compared with those without burnout (20.5% compared with 7.6%, p<0.001), supporting an association between burnout and suicide (11).

A 2010 prospective cohort study of 740 interns across 13 hospitals in the United States found that the proportion of patients who met Patient Health Questionnaire-9 (PHQ-9) criteria for depression increased from 3.9% prior to internship to 26.6% after internship (p<0.001). The study revealed that 41.8% of the 740 interns met criteria for severe depression (PHQ-9 score ≥10) on at least one of four quarterly assessments. Of the criteria assessed by PHQ-9, all increased significantly over the course of the internship year, with thoughts of death increasing by 370% (10). This study supports that while some people entering residency training have risk factors for depression, the internship year itself negatively influences mental health.

Resilience

Resilience is defined as the ability to adapt successfully in the face of trauma, adversity, tragedy or significant threat (12, 13). While the capacity for resilience might be innate, research also demonstrates that it can be learned. Resiliency building has been shown to lessen the severity of PTSD symptoms (14). Since burnout is a stress response much like PTSD, resiliency building might be critical in helping us to combat trainee and physician burnout.

In interviews with 17 family practitioners, Jensen et al. (15) identified several aspects of physician resilience, which included 1) certain attitudes and perspectives, such as valuing the physician role, maintaining interest, developing self-awareness, and accepting personal limitations; 2) balance and prioritization; and 3) supportive relationships, which include positive personal relationships, effective professional relationships, and good communication. While the findings of this qualitative study are limited by a small sample of Canadian family practitioners, the study highlights what can be intuited: that finding value in the process of being and becoming a physician, continuing to build one’s life outside of work, and staying interpersonally engaged can offset some of the stressors of being a healthcare provider (15)

In another study, researchers conducted interviews with 200 physicians who self-identified as resilient, representing >21 different disciplines across many settings in Germany (16). None of them exhibited burnout, and all had low scores on the MBI. Resilient physicians focused on cultivating hobbies. They considered complex diagnostic questions opportunities for growth and reflection. They prioritized tasks, took “time out periods,” and maintained clear boundaries with patients and colleagues.

While promoting resilient attitudes and practices is indispensable, research also supports the integration of explicit programs to enhance resilience. For example, in a randomized controlled trial conducted at two university hospitals in the United States, 100 incoming interns were assigned 30 minutes of web-based cognitive-behavioral therapy (CBT) for 4 weeks preceding internship, while 99 interns in the control group were sent e-mails with general information about mental health. During at least one point over the course of the internship year, 12% of interns assigned to web-based CBT endorsed suicidal ideation compared with 21.2% of interns assigned to the control group (relative risk=0.40, 95% CI=0.17–0.91, p=0.03). This is compelling evidence that an easily accessible resiliency building intervention, for little cost, can help prevent adverse mental health outcomes in healthcare providers (17).

Another promising resiliency building intervention is mindfulness-based stress reduction (MBSR), known to promote relaxation and cultivate nonjudgmental awareness of sensations, thoughts, and feelings. In a randomized control trial of MBSR for medical and premedical students, MBSR was found to significantly decrease depression and anxiety and to increase the capacity for empathy (18). A functional MRI study found a significant correlation between burnout severity and reduction in empathy-related brain activity (19). In this study, reduced empathy-related brain activity was seen in burned out individuals and correlated with higher dispositional empathy scores and emotional dissonance (conflict caused by one’s inability to show empathy despite one’s self-perception as empathic). The authors concluded that an inability to regulate negative emotion may lead preternaturally empathic people to dampen their empathic responses in the work setting, which over time might contribute to burnout. MBSR is a promising intervention in that it has been found to increase the activation of brain regions involved in emotion regulation as well as empathy (20). Integrating mindfulness practices into medical training might allow residency programs to cultivate physicians capable of experiencing and displaying empathy without becoming overwhelmed by their emotional responses at work.

Conclusions

In reference to the above vignette, Dr. B.’s predicament is an all too common scenario, demonstrating the converging effects of multiple stressors and too few resources to cope. At one point, high achievement comes easily to most people who are in a position to pursue a career in medicine. Finding a way to succeed is usually the priority rather than finding a way to recover from adversity. Physicians have to juggle multiple expectations and stressors. To a perfectionist like Dr. B, finding herself in a scenario where she fears she has little more of herself to give is a nightmare. This sense that one’s resources have been depleted, that one is no longer herself, coupled with emotional exhaustion, loss of purpose, and loss of self-efficacy, underlie the burnout phenomenon that characterizes the doctor that Dr. B has become. Dr. B is not only struggling to take care of herself, but it is also easy to see how she will ultimately struggle to provide for her patients.

Finding ways to prevent this type of burnout is imperative. Making resiliency building a core part of medical training would help to prevent burnout and provide trainees with the tools they need to cope with stressors throughout their careers. This would also help to promote a culture of mutual openness, understanding, and support that would encourage struggling healthcare providers to accept the help they desperately need.

Key Points/Clinical Pearls