What all physicians need to know about physician burnout
In this episode of Quick Takes, Dr. Gratzer sits down with Dr. Treena Wilkie, Deputy Physician-in-Chief, Medical Affairs and Practice at CAMH to talk about burnout: what the signs are, and what can – and is – being done to help doctors avoid it.
Before the conversation begins, we hear from Dr. Murray Erlich, this episodes’ Double Take guest, as he expresses his thoughts and feelings while he was in the midst of his own burnout experience. Be sure to listen to Dr. Erlich’s story as well to get a better understanding of what it’s like to struggle with what burnout can feel like.
During Dr. Gratzer and Dr. Wilkie’s conversation they touch the following:
- What exactly is physician burnout?
- What characterizes it?
- How does it differ from depression?
- How common burnout is now and why rates may be rising.
- The effect physician burnout could have on the public health care system.
- What doctors can do if they think they may be experiencing it.
- And what organizations should do to try to ensure their physicians never burn out.
- Things end with a one-minute rapid-fire Q&A between Dr. Gratzer and Dr. Wilkie.
June 19, 2019
Episode #5 – What all physicians need to know about physician burnout
”I started, I think watching the clock during the day, and thinking more about, well, how many more patients? How much time is left in my day? I knew I could get through it, but I didn't know how I would feel at the end of the day. And then that just started getting earlier and earlier in the day and five minutes into the day, I would usually start my days at eight thirty in the morning, and I was aware that sometimes at eight thirty five I was thinking "oh boy, it feels like I've been here a while already, and I have a long day to go and how am I going to do this?"
David Gratzer: That was Dr. Murray Erlich. A psychiatrist and also, somebody who has struggled with physician burnout.
Welcome to Quick Takes. My name is Dr. David Gratzer and today we’re talking about physician burnout. Joining us now is Dr. Treena Wilkie, a psychiatrist here at CAMH, and Deputy Physician-in-Chief, Medical Affairs and Practice. She’ll be talking with us about how physician burnout may be affecting your colleagues – or maybe you. Dr. Wilkie, welcome.
Treena Wilkie: Thank you.
David Gratzer: Dr. Wilkie let's start with a pretty basic question: what is physician burnout?
Treena Wilkie: So, physician burnout is a syndrome that is characterized by three things: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. So, maybe I can describe all three in a little bit more detail.
Emotional exhaustion is usually described as feeling used-up at the end of the day. So, at the end of the day, a physician doesn't have anything more from an emotional perspective that they can offer to patients or the people that they're working with. Depersonalization is described as starting to view patients as objects rather than human beings. And the reduced sense of personal accomplishment is really feelings of ineffectiveness. So, feeling as though you can't be helpful to other people – even though you may be doing the same things that you were always doing. I mean, for me, I think as I was going through the literature a really profound kind of summary was by one of the developers of a tool that will probably talk about today, who spoke about energy turning into exhaustion; involvement turning into cynicism; and efficacy turning into ineffectiveness. So, really this sense that what was once a very meaningful source of productivity, which was work, has become meaningless.
David Gratzer: Historically speaking, physicians also, don't like to acknowledge that they have problems. People get sick. Doctors don't. Do you think that ties in as well?
Treena Wilkie: I think it may, although burnout is a distinct entity to stress or job dissatisfaction or depression. Some of the other things that people may confuse with burnout. And, specifically, burnout is a syndrome that's related to stressors in the workplace. And, so, I think there has been a little bit more of a conversation because there's been less of an emphasis on personal characteristics and a bit more of an emphasis on the environment.
David Gratzer: I think you've made a nice distinction which is that burnout isn't actually an illness it's a syndrome, unlike say, depression.
Treena Wilkie: So, depression is a defined mental disorder in the DSM, with defined criteria, that may have multiple different factors which could be related to the precipitation of an episode. I think, again, burnout is a very specific description related to prolonged exposure to occupational stress.
David Gratzer: How common is this phenomena?
Treena Wilkie: So, I would say here in Canada the most recent study that we have was the CMA's National Physician Health survey in which about 30 percent of physicians across the country were exhibiting symptoms of burnout. And in the States the prevalence is a little bit higher. So, Shannafelt looked at prevalence every three years, from 2011. And in 2011 it was about 45 percent of the physicians that were surveyed in the United States showed symptoms of burnout. That increased a bit in 2014 – probably related to the institution of things like an electronic health record at many of these institutions. And then it's decreased a little bit back to 2011 levels back in 2017.
David Gratzer: But we're talking about a lot of physicians.
Treena Wilkie: It's a lot of physicians.
David Gratzer: Are you surprised when you look at the stats? 30 percent?
Treena Wilkie: I'm surprised at the prevalence. This brings up some of the questions with regard to burnout which is: Is this something that most people experience at different times? I do think this idea of a continuum makes sense – particularly given the fact that this syndrome is related to stressors and the presence of stressors changes over time.
David Gratzer: And we worry about burnout in terms of a public health issue. In fact, some work has been done suggesting doctors who are going through burnout are much more likely to make errors. Can you comment?
Treena Wilkie: Looking at the impact of burnout – there is the personal impact on the physician – but certainly I think what's been written about more frequently in recent years is the impact as well on the system. So, physicians who are experiencing burnout exhibit changes in their professionalism or professional behaviour, have more medical errors, there's decreased quality of care at times. And I think another thing which has been noted is changes in work efficiency. So, there seems to be more physician turnover. Physicians tend to work less hours if they're more burnt out. So, there are a number of impacts on the system which have been more identified in recent years.
David Gratzer: What don't we talk about some things people can do if they feel they're going through burnout.
Treena Wilkie: So, I think the first thing as you mentioned already is to recognize it. So, I think hopefully from the conversations that are taking place that's more likely to happen – whether that's within yourself or a colleague. The other thing that I think has been really important over the last number of years is that through that recognition many institutions are developing interventions or resources within the institution for physicians to take advantage of. So, reaching out to the people around you to look for what those resources may be.
David Gratzer: And you're Deputy Physician-in-Chief here at CAMH, this is part of your job, So, what are things we're doing within this organization?
Treena Wilkie: So, I think here at CAMH we've taken sort of a multipronged approach. Back in 2017 under the leadership of Dr. Vicky Stergiopoulos a physician engagement, wellness, and excellence committee was started and developed. And from there we undertook a burnout and support needs assessment. And from there came a number of different initiatives. So, a few that are taking place right now are the development of a mentorship program, a peer support program, focus on advancement and training opportunities, some professionalism initiatives, and also, developing communities of practice. So, I think one thing that certainly comes through the literature is often a sense of isolation. So, one of the main changes over the last number of years is the increase in bureaucracy. Sometimes that comes with working in institutions and working with an electronic health record. And so, trying to create those senses of community for physicians, despite the fact that many of these external pressures are increasing over time.
David Gratzer: You've mentioned technology, and I don't think electronic health records have a lot of fans, at least amongst physicians, but technology might also, be an opportunity. What are some ways we could use technology, in a sense, to create a community?
Treena Wilkie: Absolutely. And I think it's exactly those kind of opportunities that's been really exciting about these physician wellness initiatives. So, Dr. Tania Tajirian, who's our new CMIO, is looking exactly at this. So, the kind of initiatives that can take place to enhance our use of technology, and also, to identify the areas in the electronic health record that are causing difficulties.
David Gratzer: We've talked about what CAMH is doing – what do you think organizations, in general, should do to address physician burnout?
Treena Wilkie: So, this is sort of – I would describe it as a bit of the new wave of literature, with regard to physician wellness – are the types of organizational strategies that can be developed. And there are a number of different strategies that are being talked about that really focus on things like acknowledging and assessing the extent of the problem over time, the involvement of leadership, developing some targeted interventions, using some rewards or incentives, and really cultivating community. And really gives us a lot of opportunity to interact with individual physicians as to how some of these initiatives move forward.
David Gratzer: We're talking more about this syndrome than we've ever talked before. The research is also, much improved in the last little while. I can't remember an American Journal of Psychiatry paper on physician burnout 20 years ago but certainly there have been more than one in the last couple of years. What's the research question or two that's burning brightly in your imagination that you hope we can answer sooner rather than later?
Treena Wilkie: So, there are few researchers in the United States who have published, I think profoundly, on the issue. And what they seem to be doing is first of all measuring things over time. So, things are changing and, as you said, 20 years ago we weren't measuring any of these things. But we now have you know over a decade of measurements of both burnout and some of the interventions which have taken place. And so, I think taking a longitudinal approach, and not in isolation, thinking of how that's related to the changes in technology, how that's related into other sort of more systemic changes in healthcare, has been really interesting to read over time.
David Gratzer: It's a bit of a Quick Takes tradition that we close out with a rapid-fire minute. Let's put one minute on the clock. Dr. Wilkie, are you're ready?
Treena Wilkie: I'm ready.
David Gratzer: Dr. Wilkie what worries you about burnout?
Treena Wilkie: I think what worries me is that physicians would not feel that they could reach out to a colleague or for resources – that they would become increasingly isolated and think this was just part of the job.
David Gratzer: What advice would you give if you thought somebody was as at risk or going through burnout?
Treena Wilkie: I would say talk to somebody. Really the sense of isolation with burnout is a primary factor. And talk to somebody.
David Gratzer: What's the single thing you would like doctors listening to understand about burnout?
Treena Wilkie: That it is a syndrome. That they're not the only one who's experiencing it. And that there is really a commitment from institutions and in their colleagues to try to help.
David Gratzer: Doctor over your career can you think of a colleague who's had burnout?
Treena Wilkie: I can.
David Gratzer: And, at the buzzer, looking back what's the one thing you wish you had told them?
Treena Wilkie: There's help available.
Outro: Quick Takes with CAMH Education is a production of the Center for Addiction and Mental Health. You can find links to the relevant content mentioned in the and accessible transcripts of all the episodes we produce, online at porticonetwork.ca/podcasts. If you like what we're doing here please subscribe.Until next time.
About this episode's guests:
Dr. Treena Wilkie is an Assistant Professor in the Department of Psychiatry at the University of Toronto, and the Deputy Physician-in-Chief, Medical Affairs and Practice at the Centre for Addiction and Mental Health (CAMH). She has been qualified as a specialist in forensic psychiatry by the Royal College of Physicians and Surgeons of Canada, and is the Associate Chief of the forensic division, in the Complex Care and Recovery Program at CAMH. Dr. Wilkie is a clinician and educator of psychiatry residents. Her clinical and scholarship interests include the alignment of risk assessment and management principles with recovery based care, and physician wellness and professionalism initiatives.
Dr. Murray Erlich retired from psychiatry after a 27-year practice. Since 2010 he has been a certified life coach, devoting much of his work to helping busy physicians, residents, and medical students avoid burnout by finding fulfillment and reaching their career and personal goals. While still in private practice, Dr. Erlich worked at CAMH, Mt. Sinai Hospital, Princess Margaret Hospital, and the University of Toronto Student Psychiatric Service.
Additional information on physician burnout
- Maslach Burnout Inventory™
Recognized as the leading measure of burnout, the Maslach Burnout Inventory™ (MBI) is validated by the extensive research that has been conducted in the more than 35 years since its initial publication.
- CMA Physician Health Policy (Jan. 2018)
- CMA National Physician Health Survey: A National Snapshot (Oct. 2018)
- Rates of burnout, depression reported by doctors, residents is 'shocking' (CTV News story)
- Even resilient doctors report high levels of burnout, finds CMA survey (CMJ online)
Double Take ⚡
In Double Take:
Our bonus content for this episode is a true “bonus” as you get to hear from a psychiatrist who not only experienced burnout, but who successfully bounced back and is thriving. Dr. Murray Erlich is open and honest as he tells his own personal story: what he went through, how he dealt with it, and his advice to all physicians on what warning signs to look out for.
June 19, 2019
Double Take: One physician’s experience with burnout
David Gratzer: Welcome to Quick Takes. My name is Dr. David Gratzer. I'm a psychiatrist here at CAMH and today the topic is physician burnout. We're joined by psychiatrist Dr. Murray Erlich. Doctor welcome to Quick Takes.
Murray Erlich: Thank you. Good to be here.
David Gratzer: You're a psychiatrist.
Murray Erlich: I'm a retired psychiatrist. Yes.
David Gratzer: And you're also a person who's experienced burnout.
Murray Erlich: Yes.
David Gratzer: How did you discover that you were experiencing burnout?
Murray Erlich: Well it wasn't the first time I ever had any degree of burnout. I think I knew I was prone to some degree of burnout – much milder in the past. And I think the first time I was burnt out was during my medical training as a clinical clerk and as an intern. Didn't have a name for it back then, but I had thoughts, just a few months from finishing medical school, I had thoughts of quitting and I just was putting one foot in front of the other trying to go on. Later times what would usually happen with me is I didn't have the energy to do everything that I wanted and needed to do. I worked very hard, as I think many physicians would do, to preserve my work life. To make sure that that I could do my very best there. And if I had to sacrifice something it was elsewhere – which, in and of itself, can be a problem if you start giving up some things that nurture you. There were things holding me in in place in my work: patient needs, a sense of wanting to contribute, and provide for my family as well. And then I started to get burnt out because, or at least partly because, I had a number of personal stressors. And the thing that really impacted me was that my sleep, which had always been pretty good, started to be very poor and I started waking up very early 4:00 or 5:00 a.m. And I just started getting more and more exhausted over time and it became just harder to do things. I worked really hard to make sure I didn't make any errors or do anything that might be harmful to a patient, but it became harder and harder to do that. And it became harder to be as present as I wanted to be.
David Gratzer: Looking over your career, what was the difference from when you graduated to when you were experiencing burnout?
Murray Erlich: Psychiatry was something – it wasn't a question – it was something I really wanted to do. At the end, or towards the end, as I was starting to have some questions about continuing in my practice, intellectually I think I still was all in. Wanting to do everything I could. But it was taking a toll.
David Gratzer: You described to me before – thinking about going home earlier and earlier in the day. Can you talk about that?
Murray Erlich: It used to be very easy for me to go through a full day of seeing patient after patient. And other people, as well, would say to me: "you know I don't know how you do the work you do. I could never do that. I can never be a psychiatrist." And I would think to myself, well you can't, but this is what I do and I'm able to do it and it works. I started I think watching the clock during the day and thinking more about, well, how many more patients? How much time is left in my day? I knew I could get through it, but I didn't know how I would feel at the end of the day. And then that just started getting earlier and earlier in the day and five minutes into the day, I would usually start my days at eight thirty in the morning, and I was aware that sometimes at eight thirty five I was thinking "oh boy, it feels like I've been here a while already, and I have a long day to go and how am I going to do this?"
David Gratzer: Completely different than earlier.
Murray Erlich: Oh yeah, very, very different.
David Gratzer: Did patients ever comment: "You look burnt out. You look stressed out"?
Murray Erlich: Not at the time. Since then, there's a few people that have gone on to work with me in a coaching capacity that were previously my patients and I think when they saw me in the media talking about my burnout, they said, only then did a few people say, "You know, I did notice a difference. You weren't… you weren't the way you had been in the past."
David Gratzer: But it's a big decision for a doctor to talk about problems particularly problems practicing. Why did you choose to speak out?
Murray Erlich: I didn't talk about it with many people when I was going through it, and I thought it'd be helpful to just be someone, who was visible as a physician, who had burnt out. I also found that I was feeling quite relieved after I did talk about it publicly, because now I felt like I could talk with anybody about the fact that I'd gone through this, and before I was selective.
David Gratzer: How did you deal with the burnout?
Murray Erlich: Well first thing I did was take a bit of time off. I really needed that, and I bet I benefited from it. In previous times, when it was milder, I would mostly keep going and I knew that I would equilibrate over a number of weeks because I'd finished whatever was stressful. Things had become easier now. And, slowly, I would just bounce back and that was all fine. This time I didn't. And the big difference, for me, was the sleep – which was really the deal-breaker for me. And how did I deal with it? Well, for a while, I kept trying to go on. And I started, I think, if I remember rightly, I think I started to reduce my work hours a little bit hoping that you know maybe that will be OK. And it wasn't. So, I spent a lot of time thinking about my previous thoughts about maybe not continuing, and whether it was best for me to not go on anymore as a psychiatrist. And this time I realized that I wasn't going to equilibrate. That maybe it was no longer right for me to do what I was doing in my career. I'm no longer working with people that are very ill and one of the things that was quite stressful for me was working with people who had treatment resistant depression. Sometimes nothing one does is helpful. People who were chronically suicidal. And now I'm working with people that are, by in large, healthy, who have some issues in their life and want to change some things. And now most of my coaching work is coaching physicians as well.
David Gratzer: Doctor Erlich we appreciate your comments. It's a Quick Takes tradition that we put a minute on the clock and do a rapid-fire minute of questioning. Shall we begin? One minute on the clock? Let's go. Dr. Erlich, looking back on things, what would you do differently?
Murray Erlich: I think the main thing I would do differently would be to pay more attention to the warning signs and to take them more seriously instead of pushing through.
David Gratzer: What regret do you have?
Murray Erlich: In a way, I regret staying as long in the profession as I did because it became clear that it really wasn't so right for me anymore.
David Gratzer: Piece of advice to our colleagues?
Murray Erlich: Would be to pay attention to any warning signs. And if you think you may be experiencing any degree of burnout you probably are and do something about it. Get some help.
David Gratzer: And just at the buzzer, one last question. Are you sleeping better now?
Murray Erlich: Soon after I retired, I start sleeping about two hours extra a night almost immediately!
David Gratzer: Nice. Thank you very much for your comments and thank you very much for speaking out on this issue.
Murray Erlich: Oh, my pleasure.
(Outro:) Quick Takes with CAMH Education is a production of the Center for Addiction and Mental Health. You can find links to the relevant content mentioned in the and accessible transcripts of all the episodes we produce, online at porticonetwork.ca/podcasts. If you like what we're doing here please subscribe.
Until next time.