What exactly is burnout? –  Melissa B. Lesko, DO

While you may have come across several definitions, at its core, it is a state of emotional exhaustion, depersonalization in relationships with coworkers or clients, and a sense of inadequacy or reduced personal accomplishment. Burnout most commonly occurs in occupations involved in service and the risk increases when there is a significant workload with inadequate resources to ameliorate these stressors(1).

 

It took me a long time to recognize my own burnout. It is painfully obvious to me now looking back, but then I became so accustomed to the long hours, the monopolization of my life by work, that I didn’t initially realize the other parts of my life were becoming smaller-the ones for self-discovery, trying new things and building/maintaining relationships. The only thing that was evident was my fatigue, and it stood at the forefront of everything else. I spent many weekends on the couch completely drained, frustrated at myself that there was little time or space for something else. I trained in city programs and valued the autonomy I had caring for patients, but as a perfectionist, this was my cost.

 

I would love to say that was a rare phenomenon at this time, but it’s simply not true. Others have experienced this in milder and unfortunately more severe forms, often coupled with depression and substance use. Many of us have lost friends to burnout, as some talented doctors have paid the ultimate price with their life. This was before the ACGME made burnout prevention a focus by making Trainee Wellness a priority to programs across the country.

 

How do we prevent trainee burnout and keep our trainees well? It’s challenging given that the goal is to address all aspects of wellness: nutrition, fitness, emotional health, preventative care, financial health, mindset and behavioral adaptability. To me, the goal is to create an educational environment that balances personal and professional fulfillment, promotes emotional and physical wellbeing, while simultaneously minimizing feelings of apathy and negativity. Creating a program can be challenging given that the tools that are implemented should not feel burdensome to trainees, who often already feel overstretched by their clinical duties.

 

The first step is knowing the answer to a question that program directors may dread. Is there burnout that exists in my program (likely yes) and to what extent? Most importantly, is there someone who is really struggling that needs to be identified? There are several questionnaires that have been validated to assess physician burnout. At my institution we have used the Maslow Burnout Inventory(2) and Mini Z Wellness Questionnaire(3) to get an assessment of the degree of wellness of our fellows and/or faculty. While the completion of the questionnaire is voluntary, we have had high levels of participation. After gathering this information, you can begin to tailor a program to your current group of trainees.

 

There are certain aspects that are important to include. One that I feel is essential is to arrange for a neutral third party to spend time with your fellows, ideally a social worker or psychologist.  There may be issues that the class feels more comfortable discussing in this setting such as work stressors, recent patient deaths, or conflicts within the program. Others will be discussed in detail by my colleague Dr. Brosnahan.

 

Organizing Support For Fellows – Shari B. Brosnahan, MD

Regardless of the content of your program, I think the most important thing about creating a wellness curriculum is that it lets your trainees know that the program leadership is invested in their wellbeing.

 

The structure of a wellness curriculum should focus on multiple aspects of health and support. The first step, as spoken about in Dr. Lesko’s introduction, includes giving fellows (and faculty leaders) the skills and tools needed to identify burnout in themselves and others. We continue to annually screen for burnout via voluntary participation of the Modified Maslow Burnout Questionnaire. After understanding the signs and symptoms of burnout, and its variable presentation, one can help address them head on. Key factors in this balance include nutrition, fitness, emotional health, preventative care, financial health, mindset and behavior adaptability.

 

Introduce the importance of wellness at the beginning of fellowship by devoting a day of orientation to the discussion of maintaining one’s wellbeing in fellowship. The goal of a wellness program should not be to lessen the milestones or achievements a trainee needs to achieve in order to graduate, but rather to give a trainee the rest and stamina to hit the competencies needed to be a successful graduate. Programs should facilitate a discussion at conferences surrounding aspects of training and career building including health, work-life balance, academic portfolio building, and nutrition.

 

We focus on supporting personal health by supplying all fellows with access to comprehensive health benefits through the institution including preventative care, emotional health support available at all times, ensuring healthy lunch options during fellow conferences, facilitating discount gym membership as well as discount movie, theatre, and sporting event tickets. We also provide financial education on the business of medicine, practice management, contract negotiations, financial planning and disability coverage.

 

Our faculty has helped to support this effort by making strides to highlight positive medical decisions in the ICU through our Great ICU Saves and resilience conference aimed at raising up success which helps to balance things like M&M. Our outpatient faculty have fellows partake in mindfulness or positivity sessions weekly prior to the outpatient clinics. Quarterly class meetings facilitated by a psychologist which focus on improving resiliency and promoting stress reduction. We tap into creative energy with Narrative Medicine sessions. Faculty involvement has been key as they too are experiencing burnout, and while all factors are not the same, healing can start together.

 

Additionally, we attempt to create unity and community between our fellows through activities including division softball, hikes for the 1st-year fellows, department happy hours, bowling, class dinners, journal clubs in faculty homes, divisional holiday party, fellowship graduation, Winterfest (house staff Winter Formal), and alumni networking events at national conferences.

 

While this curriculum is what our program employs there are many different ways to have a successful wellness curriculum. Implementation can be different based on institutional limitations but the key is to normalize asking for help, screen often, and provides a multi-faceted support structure that allows time for self-discovery of what healing or diastole is needed on an individual level. A successful wellness program will give trainees the healing toolbox they need to have and maintain a healthy, long, successful career in medicine.

 

References
  1. Gabbe, S.G.; Melville, J.; Mandel, L.; Walker, E. Burnout in Chairs of Obstetrics and Gynecology: Diagnosis, Treatment, and Prevention. Am. J. Obstet. Gynecol. 2002, 186, 601–612, doi:10.1067/mob.2002.122391.
  2. Lall, M.D.; Gaeta, T.J.; Chung, A.S.; Dehon, E.; Malcolm, W.; Ross, A.; Way, D.P.; Weichenthal, L.; Himelfarb, N.T. Assessment of Physician Well-Being, Part One: Burnout and Other Negative States. West. J. Emerg. Med. 2019, 20, 278–290, doi:10.5811/westjem.2019.1.39665.
  3. Linzer, M.; Shah, P.; Nankivil, N.; Cappelucci, K.; Poplau, S.; Sinsky, C. The Mini Z Resident (Mini ReZ): Psychometric Assessment of a Brief Burnout Reduction Measure. J. Gen. Intern. Med. 2023, 38, 545–548, doi:10.1007/s11606-022-07720-0.

 

Melissa B. Lesko, DO is a Transplant Pulmonologist at NYU Langone Medical Center and an Assistant Program Director for the Pulmonary and Critical Care Fellowship Program. Her interests include donor management for transplant, telemedicine, remote monitoring, as well as, trainee and physician wellness.

Shari B Brosnahan, MD is an inpatient Pulmonary and Critical Care Attending and NYU Langone Medical Center and an Associate Program Director of the Pulmonary and Critical Care Fellowship. She serves on the ethics committee, the conscious sedation committee, and teaches in the internal medicine medical student clerkship. Her research interests include pulmonary embolism, medical ethics, and medical education.