EDITORIAL

On the health of doctors: why we need to look after ourselves first

John Yaphe*

*Associate Professor, Community Health, School of Health Sciences, University of Minho

Endereço para correspondência | Dirección para correspondencia | Correspondence

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The wounded healer is a familiar archetype in the medical landscape.¹ Physicians who have overcome illness or injury may have increased sensitivity that improves the quality of their care. In contrast, what do we know about physicians who are impaired by illness and drop out of the workforce? How can we prevent, diagnose and treat this? This editorial will look at doctors’ health and well-being and present the case for promoting this issue on our service, educational and research agendas.

We begin by acknowledging that medicine can be a stressful profession. Physicians experience the joyous aspects of life along with pain, suffering and death. There are boring, repetitive, and less challenging aspects to the job as well. As a result, we experience intense emotions during the course of our work. Adapting to and coping with stress is challenging for all doctors.

It may help us in this effort to recall the work of Aaron Antonovsky and his illuminating concept of salutogenesis that explains how we stay healthy.² Healthy people have a sense of coherence. They feel that all the elements of their lives fit together. This three parts: a sense of control, a sense of rationality, and a sense of meaning. When doctors feel that they can control some aspects of their work, that what they do makes sense, and that their work has a higher meaning or purpose, then they can probably stay healthy on the job.

The other side of this coin shows the face of burnout. The term burnout, used by Freudenberger in the 1970’s, can be defined as mental or physical exhaustion caused by prolonged stress. Christina Maslach, developed the Burnout Inventory,³ which has different validated version for educators, health and human services workers, and a student version which has also been validated for use in Portugal.⁴ Its three components are emotional exhaustion, or the feeling of fatigue without pleasure, depersonalization, or the feeling of going through the motions at work like a robot, and third, a reduced sense of personal achievement or a sense of not being good enough or of the work not being worthwhile.

Burnout may affect doctors, trainees and medical students with negative effects on the quality of care, on doctor patient relationships, and the incidence of medical error.  Perhaps 50% of medical students may already show signs of burnout.⁵ Up to one quarter of the trainees in family medicine in the north of Portugal had high scores on at least one of the component scales of burnout and 9% had high scores on all three.⁶ Similar rates of were burnout found among family doctors in practice in Portugal⁷ and elsewhere in Europe, as reported in a 12-country study.⁸

Personality factors that may predispose to burnout include Type A or obsessional personality, conscientiousness and over-ambition, reluctance to decline work or say «no», loss of control of workload, and reluctance to delegate.⁹ Young, single, childless, full-time doctors have also been found to be more prone to burnout than their older married colleagues with families.

Trainees are typically exposed to long hours, an excessive workload, sleep deprivation, changing work conditions and competition with peers. Graduate physicians find new stresses in practice. They are expected to work faster and longer hours with increasing demands from administrative tasks. We are challenged increasingly to explain and to defend our work. Defensive postures develop because of the threat of malpractice suits. Instability in the economy makes economic security elusive. We also have difficulties keeping up to date in the face of an information explosion in medicine.

Marital disharmony, emotional disorders, alcoholism and drug abuse have been found to be associated with burnout in doctors. This is related to to increased rates of depression and suicide.

How can we stop this downward spiral in ourselves or in our colleagues or even prevent its occurrence? There are many effective strategies. Most require taking control of our lives, changing our expectations and restoring a healthy work-life balance. Exercise, hobbies and time of work with our families are all parts of this plan. The most effective interventions were directed at both individuals and organizations.¹⁰

Hilton Koppe has provided us with a wellbeing checklist on the Australian general practice trainees’ website.¹¹ He advises us to be aware of our physical health, our physical, emotional and spiritual wellbeing, our relationships, healthy activities, and our physical environment. Participation in support groups like Balint groups can help prevent burnout. Each one of us needs to find our own personal doctor as well and consult wisely, as we advise our patients to do.

Medical employers can help by educating doctors, nurses and administrative workers about the signs of burnout to help with early detection and promote a good work-life balance. Confidential counselling services may also be provided at work.

Our educational institutions also have a role to play in promoting professional health. Medical schools and residency training programs need formal sessions on prevention, recognition and treatment of burnout.¹² Abusive teaching practices including humiliating examinations and inhuman call schedules need to be identified and eliminated.

We invite our readers to help us understand burnout and describe effective interventions for prevention and treatment. Your efforts will be welcome on these pages.

 

REFERENCES

1. Bradley N. Wounded healers. Br J Gen Pract 2009 Nov; 59 (568): 803-4.         [ Links ]

2. Lindström B, Eriksson M. Salutogenesis. J Epidemiol Community Health 2005 Jun; 59 (6): 440-2.         [ Links ]

3. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav 1981 Apr; 2 (2): 99-113.         [ Links ]

4. Maroco J, Tecedeiro M. Inventário de burnout de Maslach para estudantes portugueses. Psic Saúde DoençaS 2009; 10 (2): 227-35.         [ Links ]

5. Dyrbye LN, Schwartz A, Downing SM, Szydlo DW, Sloan JA, Shanafelt TD. Efficacy of a brief screening tool to identify medical students in distress. Acad Med 2011 Jul; 86 (7): 907-14.         [ Links ]

6. Mendes P. Burnout em Internos de Medicina Geral e Familiar. Report of final year option project. Braga: University of Minho, School of Health Sciences; 2009.         [ Links ]

7. Marcelino G, Cerveira JM, Carvalho I, Costa JA, Lopes M, Calado NE, et al. Burnout levels among Portuguese family doctors: a nationwide survey. BMJ Open 2012 Jun 18; 2 (3). pii: e001050. doi: 10.1136/bmjopen-2012-001050.         [ Links ]

8. Soler JK, Yaman H, Esteva M, Dobbs F, Asenova RS, Katic M, et al. Burnout in European family doctors: the EGPRN study. Fam Pract 2008 Aug; 25 (4): 245-65.         [ Links ]

9. Matía Cubillo AC, Cordero Guevara J, Medalla Bravo JJ, Pereda Riguera MJ, González Castro ML, González Sanz A. Evolución del burnout y variables asociadas en los médicos de atención primaria. Aten Primaria 2012 Sep; 44 (9): 532-9.         [ Links ]

10. Awa W, Plaumann M, Walter U. Burnout prevention: a review of intervention programs. Patient Educ Couns 2010 Feb; 78 (2): 184-90.         [ Links ]

11. Koppe H. Wellbeing Checklist. Available at: http://www.gpra.org.au/wellbeing-checklist (accessed on 20/04/2013).         [ Links ]

12. McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA. Resident burnout: is there hope? Fam Med 2008 Oct; 40 (9): 626-32.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

yonahyaphe@hotmail.com

 

Conflict of interest

None.