The Extent of Physician Burnout/Moral Injury
October 14, 2020
Most physicians are at least generally aware of the growing problem of physician burnout, also referred to as moral injury. The literature has been filled with articles on physician burnout/moral injury, and many of us have personally known colleagues who are suffering from burnout, or possibly even experienced burnout ourselves. This is a long-term stress reaction characterized by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment. Numerous studies and surveys over the past few years have shown significant rates of burnout in physicians (at or above 50% in some studies) and the problem has been steadily worsening over time. Moral injury/burnout can not only lead to poor patient outcomes, but the effects on physicians can lead to depression, substance abuse, and even suicide. Add in the current COVID pandemic, with all of the stress and uncertainty (clinical, personal, and financial) that this has added to already overburdened physicians, and there is now evidence that burnout is becoming even more widespread.
A recent survey from the Physicians Foundation, released to correspond with National Physician Suicide Awareness Day, shows us a glimpse of the extent of the problem. Of the 2,334 physicians surveyed between August 17-25 of this year, from across the country and across specialties, a staggering 58% admitted to having feelings of burnout/moral injury. Half of those surveyed said that they had experienced inappropriate anger, tearfulness, or anxiety as a result of COVID-19’s effects on their practice or employment. Nearly a third felt hopeless or that they had no purpose due to COVID-19’s effects on their practice or employment situation, and most concerning, 8% of physicians surveyed had actually had thoughts of self-harm as a result of COVID-19’s effects on their practice or employment, with younger physicians reporting thoughts of self-harm at a higher rate than older physicians. 18% admitted to having increased their use of medications, alcohol, or illicit drugs as a result of COVID-19’s effects on their practice or employment situation, while only 13% of those surveyed stated that they were seeking mental health care. Many physicians delay or avoid seeking mental health care due to the lingering stigma of mental illness, but also due to concerns that they could lose their medical license and ability to practice. So we have a group of professionals who in the midst of this pandemic, where they are the tip of the spear, have some of the highest rates of burnout ever recorded and already had one of the highest rates of suicide of any profession. This is a recipe for tragedy.
You may have read the devasting story of Dr. Lorna Breen, an emergency room physician at New York-Presbyterian Allen Hospital in Upper Manhattan, who worked through the tremendous COVID-19 surge that New York City hospitals experienced last March and April, and actually contracted COVID-19 herself. Dr. Breen was like many of us in medicine—‘she always knew she was going to be a doctor’ according to her younger sister. She attended undergrad at Cornell, med school at the Medical College of Virginia, and residency at Long Island Jewish in NY, where she was chief resident in her final year. She snowboarded and played the cello and took salsa classes. One time when she was running a half-marathon, she started having trouble breathing. She finished the race, then took herself to the ED where she diagnosed herself with pulmonary emboli. She was a typical overachiever, and she was clearly strong and resilient. At NY-Presbyterian Allen Hospital, in addition to running the ED, she was also working toward her MBA at Cornell.
She recovered from her acute COVID-19 illness and returned to work, but she had a difficult time dealing with the overwhelming number of sick patients, with a nearly 25% mortality rate at her hospital for patients with COVID-19 during that time. She started to become detached and then depressed, overwhelmed, and nearly catatonic, and finally reached out to her sister for help. One of the most tragic aspects of Dr. Breen’s story is that she actually sought out and received help—she was admitted to an inpatient psychiatric facility on April 9th, stayed for 11 days, was discharged and went to stay with her mother in Charlottesville, and seemed to be doing better. But on April 29th, she took her own life. One of her last conversations was with a friend, who noted that Dr. Breen kept repeating the same idea—"“I couldn’t help anyone. I couldn’t do anything. I just wanted to help people, and I couldn’t do anything.”
Dr. Breen’s story unfortunately isn’t a one-off; an estimated 300 physicians die by suicide each year, and that number may be rising. In the context of COVID, we will likely see further increases.
So what can we do? In the Physicians Foundation survey, an overwhelming 78% of those surveyed this summer said that lack of population compliance with COVID-19 distancing and mask-wearing protocols was their number one source of frustration during the pandemic, so continuing to promote mask-wearing, physical distancing, and hand washing as we’ve been doing for months now can help. In the bigger picture, we know that the solutions to physician burnout need to be implemented at the system level. Individual physician personal wellness is certainly important, but we are not going to exercise and meditate our way out of this problem.
Recently proposed bipartisan congressional legislation, which is actually named after Dr. Breen, may lead the way toward some higher level solutions. S. 4349/H.R. 8094, “The Dr. Lorna Breen Health Care Provider Protection Act”, would establish:
- grants for medical students, residents, or health professionals in strategies to reduce and prevent suicide, burnout/moral injury, mental health conditions, and substance use disorders;
- grants for health professionals to help create and disseminate evidence-based strategies to reduce burnout and associated secondary mental health conditions related to job stress;
- a national campaign to encourage health professionals to prioritize their mental health and use available mental and behavioral health services; and it would establish grants for employee education and peer support programming.
This is a start. The fact that there is growing awareness of the problem of physician burnout, and bipartisan federal legislation that begins to address some of the root causes as well as provide further study, is certainly encouraging.
Here in New Hampshire, the Medical Society has a close relationship with the New Hampshire Professionals Health Program (NHPHP), led by Sally Garhart, MD. This outstanding, completely confidential program helps NH physicians suffering from burnout, depression, substance abuse, and other problems using a personalized multi-modal evidence-based approach. There is much more we need to do as a state and as a country to study and address physician burnout, but today, or tomorrow, or any time that you feel you might need help, contact the NHPHP, or the New Hampshire Medical Society, or the behavioral health team at your organization, or a friend, or a colleague, or anyone you trust – tell someone how you are feeling. You are not alone, and help is out there.
John Klunk, MD
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