Challenges in treating physician burnout: The psychologist's perspective

Original

article

Challenges

in

treating

physician

burnout:

The

psychologist’s

perspective

Anne-Laure

Lenoir

*

,

Caroline

De

Troyer

,

Carole

Demoulin

,

Ingrid

Gillain

,

Marie

Bayot

a

URSoinsprimairesetSante´,De´partementdeMe´decinege´ne´rale,CHUduSart-Tilman,QuartierHoˆpital,B23,avenueHippocrate13,4000Lie`ge,Belgium

b 1325Chaumont-Gistoux,Belgium c 4210Burdinne,Belgium d_{5000Namur,Belgium} 1. Introduction

Burnout has been described as a work-related syndrome combining emotional exhaustion, depersonalization, and low personal accomplishment [1]. Although we lack systematic procedures for burnout rates calculation, the prevalence of burnoutinphysiciansseemshigherthaninthegeneralpopulation (e.g.,with22%amongBelgianphysiciansversus0,8%inthegeneral population) [2,3]. Yet, physician burnout can have serious

professionalandpersonalconsequences[4].Physicianssuffering fromburnout providesuboptimalcaretotheirpatients, charac-terizedbyaheightenedriskofmedicalerrorsaswellasreduced professionalismandempathy[5].Theymaytakeprolongedsick leavesorabandontheprofession,leadingtoworkforceissues.Ona personallevel,theyareathighriskofdepressionandsuicide.Asa consequence,boththeresearchcommunityandstakeholderscall forefficientinterventions.

According to the literature, both individual-focused and structural or organisational solutions are required to reduce physician burnout [6]. While training programs based on mindfulnessorstressmanagement,andgroupdiscussionsettings havebeenstudied,littleresearchhasbeendoneontheindividual psychologicalsupportthat canbeprovided todistressed

physi-ARTICLE INFO Articlehistory: Received29April2020

Receivedinrevisedform14July2020 Accepted23November2020 Availableonline

ABSTRACT

Objective.– Burnoutisamultidimensionalstresssyndromethatisparticularlyprevalentinphysician

populations.Whiletheliteratureexpandsonpreventiveandcurativeinterventions,relativelylittleis

knownaboutfactorsthatmayhampertheirsuccess.Theaimofthisstudywas(1)toidentifythespecific

challengestotreatphysicianburnoutand(2)toexploretheoriginsofthesechallenges.

Methods.–We conducted semi-structured interviewswith twelve psychologistswhohad treated

physicianswithburnoutandperformedthematicanalysisofdata.

Results.–Psychologists identified two specific challenges in treating physician burnout. First,

physicianswerereluctanttoseekhelpfromhealthprofessionalsand tendedto soatmoresevere

stagesofexhaustion.Second,physicianswerefeelinguncomfortableintheroleofpatient,andmanyof

them had difficulties to accept treatment. Psychologists suggested the following causes of these

challenges:(1)mostphysiciansdidnothaveageneralpractitioner,(2)theyfeltguiltyaboutreducing

their workload, and (3) tended to confuse professional and personal engagement. According to

participants,medicaleducation,theprofessionalcultureandtheimageoftheprofessioninthewider

communitywerelikelyfactorscontributingtophysicians’reluctancetoseekandacceptcare.

Discussion.– Thisresearchshowedthatthespecificchallengestotreatphysicianburnoutaremostly

relatedtotheirreluctancetoaskforhelpandtoputtheirtrustinothercaregivers.Amongthereasonsfor

thisbehavior,mostarelinkedwithphysician’srepresentationofprofessionalidentityasenduringand

selfless.

Conclusion.–Furtherstudiesareneededtoexplorehowmedicaleducationandprofessionalculturecan

bechangedtoreducetheriskofphysicianburnoutandfacilitatecarewhenitnonethelessarises.

C2021TheAuthors.PublishedbyElsevierMassonSAS.ThisisanopenaccessarticleundertheCC

BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Correspondingauthor.URSoinsprimairesetSante´,De´partementdeMe´decine ge´ne´rale,CHUduSart-Tilman,QuartierHoˆpital,B23,avenueHippocrate13,4000 Lie`ge,Belgium.

E-mailaddress:[email protected](A.-L.Lenoir).

Available

online

at

ScienceDirect

www.sciencedirect.com

https://doi.org/10.1016/j.lpmope.2021.100006

2590-2504/ C_{2021TheAuthors.PublishedbyElsevierMassonSAS.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(}

cians. Beyondthematteroftechnique,Swensenandcolleagues highlighttheimportanceofphysicians’engagementandperceived controlintheimplementationprocessofanintervention[7].

Interestingly, Walsh and colleagues interviewed hospital physiciansabouttheirexperienceofworkstressandburnout,as wellastheirsuggestionsandpreferencesregardinginterventions to prevent or reduce workstress and burnout [8]. Aside from adequatestaffinglevels,accesstostatutoryleave,andcoverwhen on leave, physicians set as a high priority intervention the development of psychologicalsupportin theeveryday working environment.Suchsupportincludes:

 debriefing of everyday challenges and difficult cases with a seniorteammember;

 regularpsychologicalcheck-insbyasupervisororclinicalline manager,and;

 a psychological service for self-reflection and professional developmentasdistinctfromatreatmentservice.

At a secondary level of intervention, physicians mentioned teachingofself-careskills(i.e.,prioritizingone’shealth,maintaining boundariesbetweenworkandpersonallife,andcultivatinginterests outsideofwork),andconsideredthesetobeofequalimportancewith clinical skills. Furthermore, theyexpressedthe need tobreak the culture of stigmawithin medical practiceand thenormalizing of suffering atwork.Thiswillbeachievedthroughhealthpromotion interventionsandpeersharingfromrecoveredphysiciansoftherisks andcarepathways.Atthetertiarylevel,physicianssuggestedtraining professionals in how to identify distress in their colleagues and providethemwithadequatesupport,aswellasthedevelopmentofa moreeffectivelinemanagementforsickphysicians(i.e.,atthestages ofhelpseeking,recoveryandreturntowork).

Importantly,interviewedphysiciansraisedseveralobstaclesto the prevention and treatment of work stress and burnout. As regard tothereasonswhyphysicians donot tendtoseek help whennecessary,respondentsidentified alackofself-awareness (i.e.,impactofworkstressorburnoutontheirhealth),beingtoo busy,aswellasfearsofconsequencesattheprofessionalandsocial levels(i.e.,imageofweakness).Asamatteroffact,stigmaagainst seekinghelpconstitutesasubstantialbarriertophysiciancarethat needstobeaddressed[9].Furthermore,whenphysiciansdoend up seeking help, additional obstacles may be encountered. Althoughtheyimpacttreatmentoutcomes,theseimpedingfactors and underlyingmechanismshave beenunderstudied.Forthese reasons,theaimofthisstudywas:

 toidentifythe specificchallenges totreat physician burnout and;

 toexploretheoriginsofthesechallengesfromtheperspectiveof clinicalpsychologists.

2. Methods

Thisstudyusedaphenomenologicalapproachtoexaminethe specific challenges that psychologists experience in treating physicianburnout.Throughthisapproach,researcherssoughtto understand the phenomenon exclusively from real clinical situationsencounteredbypsychologists.Indeed,the phenomeno-logical approach is characterized by the systematic use of experiences’descriptionwithoutreferringtoatheory[10]. 2.1. Population

Psychologistswererandomlyselectedfromthelistofmembers of the Belgian Federation of Psychologists (available on the

website).Diversityintermsofgender,jobtenureandlocalization weresought.Researchershadnoconnectionswithrespondents.

Apre-requisiteforparticipantsisthattheyhadtreatedatleast twophysicianswithburnoutandagreedtotakepartinthatstudy. 2.2. Datacollection

Forty-threepsychologistswerecalled.Fiverefusedto partici-pate and twenty-four didn’thave the pre-requisite experience. Fromthequalifiedpoolofrespondent,tenwereinitiallyselected andinterviewed.Aftercompletingtheanalysisofthedata,itwas decided to add further participants to achieve data saturation, whichwasreachedwithtwelveinterviews.

Semi-structuredinterviewswereconductedbythreeclinicians with expertisein burnout treatment in a place chosen by the respondent.Theinterviewguidewasfocusedonthepsychologists’ experiencewithphysicianssufferingburnout.Interviewslastedin averageforty-fiveminutes.Allofthemwererecorded,transcribed andanonymized.

Afterinformedconsent,psychologistswereinterviewedabout threemainthemes:specificchallenges,theiroriginsandpotential solutions.

2.3. Dataanalysis

Thematicanalysiswasperformedbyinterviewers,underthe supervisionofthefirstauthor[10].

First,theanalyticalframeworkwasdefineddependingonthe interviewguide:challenges,origins,andpotentialsolutions.

Then,twointerviewersperformedseparateinductivecodingfor eachinterview.Theyconstructedacodebookbyclassifyingcodes intothemes.Datatriangulationwasperformedbythefirstauthor toyieldconvergence.

Finally,thefirstauthorconstructedthecodingtreethatwas approvedbytheresearchteam.

Anoverviewoftheidentifiedcausalpathwayforchallengesin treatingphysicianburnoutisrepresentedinFig.1.

3. Results

AssummarizedinTable1,oursamplecomprisedbothmaleand femalepsychologistswithvariousclinicalapproaches.Dataaboutthe numberandkindofphysicianstreatedlackedformostrespondents. 3.1. Specificchallenges

Respondents identified two specific challenges in treating physicianburnout.

First,fewerphysiciansconsultedandatalaterstagethanother professionals. If the risk factors were the same, their burden seemedtobeheavier.Thesefactorscoulddifferdependingonthe contextofpractice,butpsychologistsdidnot makeadifference betweenphysiciansconcerningthechallengesandtheirorigins.

‘‘Ioftenhearaboutphysicianburnout,butIhavefewphysicians amongmypatients’’

‘‘They’rewaitinglongerthanotherpatients.Whentheyconsult, theyareinadeeperexhaustion.’’

Second,physicians had difficultiesidentifyingthemselvesas patients.Somerespondentssaidthatphysicianshadn’taccepted theirtherapeuticstrategieseasily.Othersdidn’tfeelrecognizedas competent professional therapists by these patients. For these reasonstheyexpressedthattheestablishmentofthetherapeutic relationshiphadbeencomplicated.

‘‘At best, I am a colleague. They never accepted to be my patients.’’

‘‘The creation of the therapeutic relationship is very, very sensitive.’’

3.2. Originsofthesechallenges

Accordingtotherespondents,threereasonscouldexplainthese challenges.

The first reasonwas thatphysicians consider themselvesas theirowncaregiver,withtheunderlyingbeliefthatiftheyareable totreatpatients,theyshouldbeequallyabletotreatthemselves. Additionally, asking for help could be considered a sign of weaknessorincompetence.Thesetwoperceptionscanbelinked with:

 the fear of professional and social judgement by peers and patients;

 thepromotionofan‘‘enduranceculture’’bymedicalfaculties, and;

 thefactthatsupportprogramsarenotacommonpracticefor physicians.

‘‘Aphysiciandoesn’taskforhelpfromanothercaregiver.They cantreat themselves.It’sverydifficulttosay,‘Icannottreat myself’’’.

‘‘Theyaretrainedtoendurealotofthings.Theyhavetobitethe bulletandnotcomplain’’

Secondly,physicians havestrongfeelings ofguilt whenthey reducetheirworkingtimeorhavetotakesickleave.Thesefeelings seemtobelinkedwithadeepsenseofresponsibilitytowardstheir patients.Indeed,somephysicianssacrificetheirownwell-beingto meet patients’ needs. Moreover, society reinforces this selfless behaviourbypromotingarepresentationof theprofession asa vocation,withpowerbutalsogreatresponsibility.

‘‘There is a societal vision of the physician’s role: the self-sacrificeforotherpeople’’

‘‘Theyhaveapower overotherpeople.For somephysicians, that mean that they have to balance that power by being availableforpatientsalways.’’

Thirdly,some physiciansconfused professional and personal identity. Indeed,a lot ofphysiciansdefined themselvesbytheir professionalidentity.Insomecases,medicinewasavocationsince childhood. Furthermore, family, peers and society deem the professionprestigious.Asaconsequence,careerchangeorreducing workengagementappearsalmostimpossibletophysicians.

‘‘Forotherprofessional,therearesometimestheopennessto thing‘Icouldchangejob’.Forphysicians,thatneverhappens.’’ ‘‘Everybody dreams that his child become a physician. It’s wonderfultosavelives!So,whenyoubecomeaphysician,you needtoloveyourjobandneverreconsiderthem.’’

Fig.1.Overviewoftheidentifiedcausalpathwaysforchallengesintreatingphysicianburnout.

Table1

Demographicandprofessionalcharacteristicsoftherespondents.

Respondent Gender Age Typeofpsychotherapy Physicianstreated P1 M 43 Cognitive-behavioral Hospitaldoctors(n=4) P2 F 52 Psychoanalysis HospitaldoctorsandGPs(n=10) P3 F 42 Humanistic HospitaldoctorandGP(n=2) P4 M 35 Integrative HospitaldoctorsandGPs(n=3)

P5 F 57 Systemic GPs(n=2)

P6 F 52 Cognitive-behavioral GPs(n=10)

P7 F 37 Cognitive-behavioral HospitaldoctorsandGPs(n=5) P8 F 42 Cognitive-behavioral HospitaldoctorsandGPs(n=7) P9 F 65 Systemic HospitaldoctorsandGPs(n=35)

P10 F 60 Systemic GPs(n=2)

P11 F 58 Systemic HospitaldoctorandGPs(n=20) P12 F 37 Cognitive-behavioral HospitaldoctorsandGPs(n=7)

3.3. Proposalsofinterventions

Psychologistsidentifiedseveralinterventionsthatmayimprove preventionofphysicianburnout.Theseincludedtheintroduction ofthenotionofself-careduringmedicalstudiesandcontinuous training,aswellastheimplementationofsupportgroups.

Asforthetreatmentofphysicianburnout,specificprograms couldbedevelopedtoaddresstheabovechallenges.

Finally,somerespondentshighlightedtheneedforchangeat theculturalleveloftheprofession.

4. Discussion

This research showed that, according to psychologists, the specificchallengestotreatphysicianburnoutweremostlyrelated totheirreluctancetoaskforhelpandtoputtheirtrustinother caregivers. Among the reasons for this behavior, psychologists identifiedphysician’srepresentationofprofessionalidentityasa vocationaljobwherephysiciansareabletoendureworkstressand prioritizepatient’sneedsabovetheirown.

Theseresults are consistent withother studieswhichhave shownthatphysicianstendtoneglecttheirownhealth[4].For example, high sickness presenteeism is observed because physiciansmayhave difficultiesinevaluatingtheirownhealth andidentifyingwhentheyneedtostopworking[11–15]. Further-more,physicianswouldbelessinclinedtotakeabreakformental health problems than for somatic reasons [15]. Yet, sickness presenteeismcanaffectqualityofworkandphysicians’long-term health[5,16–18].Indeed,psychologistsinterviewedinourstudy reported more severe symptomsinphysiciansas comparedto burned-out patients fromother professions.They also posited that lacking regular medical care, was one of the reasons physicians were at higher riskof burning out. Indeed, having their own caregiver could be beneficial to physicians as they wouldgetamoreobjectiveassessmentoftheirhealthstatus.Asa matteroffact,asurveyamongsurgeonsshowedalowerrateof burnoutamongthosewhohadseenageneralpractitionerinthe previousyear[19].Moreglobally,peers’supportseemsessential torecognizethattheyneedhelp,encouragethemtoaskforitand beopentoreceivingthehelp[15,20,21].

Ourdataalsoconvergewiththeliteratureshowingphysicians’ dependency on their work. As expressed by one of Walsh and colleagues’ respondents, physicians’ workand identityare very closelyentwined,puttingthemathigherrisksofworkstressand burnout.Indeed,aslittleenergyisinvestedinactivitiesoutsideof work, physicians mainly derive meaning and satisfaction from their professional activities. As a consequence, professional shortcomings may weaken physicians’ well-being to a greater extent than individuals whose professions are less consuming. Corollary, thematterofsickleaveis difficulttohandle,astheir workisviewedasacorepartofthemselves[15].

Furthermore, our data highlight the interaction between culture and individual functioning in the medical domain. As suggestedbytheliterature,professionalculturehasindeedamajor influence on physicians’ behavior. For example, going to work despite poor health tends to be a shared standard within the medical community, while going on sick leave is typically perceivedas asignofweaknessora lackof loyalty[13,15].As our respondents suggested, medical studies reinforce sickness presenteeismbyconveyingintoleranceforsickleave[22].Inthat sense,Montgomerydemonstratedthatnotaskingforhelpwasa normalised behaviour among medical students [14]. Therefore, psychologists from our study echo Walsh and colleagues’ statement about the need for a cultural change in medicine: ‘‘from stigmatisation and competitiveness to compassion and collaboration’’[8].

Overall, our study further demonstrates that physicians’ tendency toavoid seeking help is linked withobstacles at the personal,social,organizationalandculturallevels.Futurestudies areneededtofindwaysaroundtheseimpedimentstophysicians’ professionalwell-being.

To our knowledge, this study was the first to approach physician burnout from the perspective of professionals who providephysicianswithpsychologicalhelp.Thismethodallowed us to explore specific challenges to treat physicians and the possiblerootsofthesechallenges.Althoughourdatapartlyderive fromrespondents’interpretationsofphysicians’experience,they wererelatively consistentacrossinterviews, and strongly align withdataextractedfromphysiciansinotherqualitative studies

[8,23].

Humanandanimalrights

Notapplicable.

Informedconsentandpatientdetails

The authors declare that thisreport does notcontain anypersonal

informationthatcouldleadtotheidentificationofthepatient(s).

Disclosureofinterest

Theauthorsdeclarethattheyhavenocompetinginterest.

Funding

Thisworkdidnotreceiveanygrantfromfundingagenciesinthepublic,

commercial,ornot-for-profitsectors.

Authorcontributions

AllauthorsattestthattheymeetthecurrentInternationalCommitteeof

MedicalJournalEditors(ICMJE)criteriaforAuthorship.

Anne-LaureLenoir:conceptualization,formalanalysis,supervision,and

validationandwriting.

CarolineDeTroyer,CaroleDemoulin,andIngridGillain:investigation

andanalysis.

MarieBayot:validationandwriting.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,athttps://doi.org/10.1016/j.lpmope.2021.100006.

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