Compassionomics

  When you consider all of this evidence together—the effects on patients and patient care plus the effects on costs of care—and then add in the enormous prevalence of the problem, it becomes clear that burnout among health care providers is a major and growing public health emergency. It’s no secret in health care circles.

  But you know what else? The general public knows about it, too. The epidemic of burnout in medicine has been widely covered in the press, from The Atlantic and The New York Times Magazine to The Wall Street Journal and scores of other media outlets.369, 370, 371

  Burnout among health care providers is serious business. What you may not yet appreciate, however, is the full effect of burnout on health care providers themselves—the effects on the individual caregiver. This is the other side of the human toll, and these effects can be staggering.

  In Chapter 7, you learned that health care providers are leaving the profession in droves. But what are they actually experiencing before they “pull the rip cord” on the career for which they have been training their whole lives?

  The Personal Toll of Burnout

  Did you know that approximately four hundred physicians die by suicide every year? Research going back more than fifty years demonstrates that physicians die by suicide at a rate that significantly exceeds that of the general population.372 In fact, recent research reports that physicians experience the highest suicide rate of any profession.373

  Physicians die by suicide at a rate that significantly exceeds that of the general population.

  A systematic review of the medical literature reported that the suicide rate among physicians is 28 to 40 per 100,000, which is more than double the rate in the general population (12 per 100,000).373 Research from the Mayo Clinic found that almost 40 percent of U.S. physicians have some symptoms of depression, and an astonishing 6 percent of those are depressed enough to think about suicide.30

  What about nurses? Nobody knows precisely. According to researchers at the University of California San Diego, there is an alarming paucity of data on the nurse suicide rate. Considering the extreme occupational pressures on nurses, the National Academy of Medicine is concerned that nurse suicide is a hidden tragedy: “Until such data are available, silence and the preventable loss of life will prevail.”374

  So burnout is not just a serious concern for patient care, or for the costs of care, but also for those who care for patients. It’s a multi-dimensional syndrome that stems from a combination of factors.375 Certainly, fatigue—being overworked—is one component. Cynicism is another.

  Cynicism can arise when a person feels a loss of autonomy, insufficient support or unattainable goals. It might be due to a feeling of being surrounded by impediments with no way out.

  Frustration is another component of burnout. It can show up as a negative response to self and dissatisfaction with one’s own performance (i.e., “beating yourself up”). Ultimately, all of these aspects of burnout combine into a downward spiral, culminating in the most dangerous manifestation of all: withdrawal. A person gives up and loses his or her motivation to make things better. A burned out physician starts to depersonalize relationships and becomes detached.

  Here’s another important consideration: Burnout isn’t just about being overworked; it’s also about the absence of meaningful human connection in one’s work. You saw the data (way back in Chapter 1) that, in the era of electronic medical records, health care providers now spend more time looking into a computer screen than looking into the faces of their patients.

  According to Dr. Atul Gawande, a surgeon, prolific writer, acclaimed public health researcher, and author of The New Yorker article “Why Doctors Hate Their Computers,” this is fuel to the fire for the burnout epidemic.376 Gawande asserts that doctors’ computer screens are increasingly coming between them and their patients. He sees this as directly eroding what is supposed to be a fulfilling experience…the human connection of caring for patients.

  Most applicants to medical school say that they are going into medicine to help people. And yet, a valuable piece of that rewarding experience is being lost through a required attention to computer screens in lieu of the patient in the room.

  So burnout isn’t just about exhaustion. It’s about much more than that. According to Stanford’s Dr. Emma Seppälä, whom you met earlier, burnout is also about loneliness. In a Harvard Business Review article, she reported that our professional relationships with colleagues (and specifically our compassion for each other during difficult times) are a key protective factor against the development of burnout.377

  Seppälä warns that without meaningful relationships in the workplace, the risk of developing burnout skyrockets. Accordingly, it’s vitally important for colleagues to take good care of each other.

  The symptoms of burnout are numerous and include physical complaints (illness or other somatic manifestations), insomnia, irritability, negative attitude, being hypercritical of others, desensitization, apathy, feeling empty, disengagement, hopelessness, and pulling away emotionally. Sometimes burnout manifests with unprofessional behavior, and possibly outbursts in the workplace (“acting out”).375

  Another common manifestation of burnout is dread of going to work. Recently, an emergency physician from a large, very busy community hospital in suburban Boston relayed the story of his experience struggling with burnout. It was, quite frankly, a shocking example of what it means to dread going to work.

  After experiencing the stages and symptoms of burnout described above, he had one event that pushed him past the breaking point. During one of his shifts in the emergency department, a patient came in who was at the end-stage of a serious illness.

  That is not uncommon in emergency medicine. What was uncommon was that the patient was just a teenager. A short time after arrival in the emergency department, the patient took a sudden turn for the worse and went into cardiac arrest. The physician had to perform cardiopulmonary resuscitation (CPR) on the boy for almost an hour. Ultimately, the physician could not bring him back. The boy was gone.

  The physician went to tell the family. It is not uncommon for an emergency physician to have to pronounce someone dead and notify next of kin, but it is uncommon to pronounce a teenager dead. It is especially uncommon to pronounce a teenager dead when he is the son of the physician’s best friend. The physician knew this boy like he was part of his family…a child this physician had, in fact, watched grow up.

  No one would question how traumatic this must have been. The physician was already suffering from burnout, and then this intensely personal tragedy happened right before his eyes. It culminated in such severe dread of going to work that after this tragic event, just before starting his shifts in the emergency department, he frequently found himself sitting in his car in the hospital parking lot, violently throwing up.

  Thankfully, this physician got help. And thankfully, he never became one of the suicide statistics that are alarmingly prevalent in medicine today.

  Certainly, this is a shocking example of a physical manifestation of burnout. But it is also important to recognize that many of the health care providers in the grips of burnout do not demonstrate such overt signs of it.

  Health care providers going through burnout may not show overt signs. They often suffer in silence.

  Often, they suffer in silence, and you may never know they are suffering. But make no mistake: Burnout is real even if you cannot see it. The human toll on a personal level can be immense.

  Treating Health Care Provider Burnout

  So what are the most effective, proven treatments for burnout among health care providers? There is no shortage of lectures, webinars, and conferences claiming to hold the solutions to the burnout epidemic. There is plenty of conversation. Many people say they have answers. However, at the present time, burnout still remains an unconquered challenge in medicine.

  Recently, two independent groups of researchers published rigorous meta-analyses in The Lancet and JAMA Internal Medicine, report
ing on the effectiveness of interventions to combat burnout. Some interventions have been targeted at the individual physician level, and some interventions have been targeted at the organizational (health system) level.378, 379 In other words, the interventions that have been tested are very heterogeneous. But what is striking about the vast majority of them is that, collectively, they represent what could be labeled “escapism.”

  Essentially, escapism is the act of getting away from patient care as much as possible to achieve a better “work-life balance.” Strategies include minimizing stress by working less with patients (in order to spend more time on restorative activities like nature hikes, yoga, meditation, etc.). Another approach is to cut down on working altogether by going part-time.

  The mantra goes like this: “Detach…Pull back…Get away more.” Escapism is built upon the belief that if health care providers just spent less time caring for patients in favor of more self-care (“me time”) that burnout would no longer be a problem.

  Without question, maintaining a healthy work-life balance is critically important; it’s vital for good health and well-being among health care providers. That’s intuitive. But is detaching and pulling back from patients an effective treatment for burnout? It sounds like a plausible solution. But what is the evidence?

  Research shows that many interventions based in escapism do reduce burnout…to some extent.378, 379 But the effects are only modest at best. Accordingly, at the present time, there is no magic bullet for treating health care provider burnout.

  Escapism interventions do reduce burnout, but the effects are only modest at best.

  Perhaps that is because escapism alone is an inadequate approach to solving the problem. Or perhaps it is because better work-life balance is just part of the story and does not solve the fundamental problem: A paucity of meaningful (and fulfilling) human connection in one’s work.

  Perhaps it is because a vital ingredient of treating burnout can only be found at the point of care with the patient. And perhaps the real antidote to burnout is leaning in rather than pulling back.

  Rethinking Dogma

  Historically, physicians-in-training have been taught: “Don’t get too close to patients.” The thinking was that keeping a safe distance from patients—at least emotionally—would protect the caregiver by preventing emotional overextension and thus reduce the risk of getting burned out.

  Accordingly, physicians may be taught not to cross what Kenneth B. Schwartz—the lung cancer patient who inspired Schwartz Rounds—called the “professional rubicon” in caring for patients. Really connecting with patients in their times of suffering could be psychologically costly, according to this teaching. Essentially, the belief was that too much compassion would burn you out.

  But you won’t find this teaching in any medical textbook. Rather, it’s part of the “hidden curriculum” of medical training that you learned about earlier. This teaching has been passed down, albeit informally, to generations of physicians.

  But here’s the problem with that historical thinking: It’s actually not evidence-based. In fact, the available scientific evidence tells a very different story.

  Of course, it is intuitive to some extent that there could be risk of burnout with repeated or excessive exposure to human suffering. However, the preponderance of data in the scientific literature supports a different view: It shows that human connection can transform the experience for the giver of compassion, trigger positive emotion, and build resilience. (That’s the ability to maintain one’s own well-being despite stressful conditions, including witnessing suffering.)

  Let’s look at the data. If there were scientific studies that supported that historical thinking (i.e., “Don’t get too close; too much compassion will burn you out.”), we’d expect them to show a positive association (correlation) between compassion and burnout. That is, we’d expect that high compassion would be associated with high burnout, and that low compassion would be associated with low burnout, right? Compassion and burnout would go in the same direction.

  But if you systematically analyze the available evidence in the biomedical literature, you will find that the preponderance of data among health care providers actually shows the opposite to be true. A recent rigorous systematic review published in Burnout Research reported that the vast majority of published studies testing the association between compassion and burnout in health care providers found an inverse correlation.380 Inverse!

  That is, high compassion was associated with low burnout, and low compassion was associated with high burnout. So when you actually dive into the published scientific data, compassion and burnout go in opposite directions.

  So these data do not support the historical thinking that too much compassion will burn you out. This rigorous systematic review of the biomedical literature suggests that the historical thinking may actually be propping up a complete myth.

  A quick side note: For millennia, philosophers and thinkers have intuitively understood that compassion for others could be beneficial for one’s own well-being. For example, way back in the 13th century, the famed mystic and poet Rumi said, “When we practice loving kindness and compassion, we are the first ones to profit.”

  Then, in the late 1800s, American writer and philosopher Elbert Hubbard noted that, “Human service is the highest form of self-interest for the person who serves.” Later, Dutch theologian Henri Nouwen said, “Our greatest fulfillment lies in giving ourselves to others,” and, “The joy that compassion brings is one of the best-kept secrets of humanity. It is a secret known only to a very few people, a secret that has to be rediscovered over and over again.”

  More recently, Buddhist teacher and compassion activist Joan Halifax explained that “Many of us think that compassion drains us, but I promise you it is something that truly enlivens us.”381 This is not a new idea!

  Crime of (Mis)Interpretation?

  Many people in health care who understand there is an inverse relationship between compassion and burnout tend to interpret the inverse relationship (that high burnout correlates with low compassion) this way: Burnout crushes one’s ability to be compassionate. They believe that when health care providers get burned out this drains their compassion.

  However, it is very important to recognize that one should not infer causation from the available data, only association. Inferring causation when only association is known is a really common mistake people make when interpreting scientific studies.

  In academic medicine, it’s considered a crime to mix up association and causation. Maybe it’s not a felony, but it’s a misdemeanor for sure. And it happens all the time.

  Here is a famous example: People who own a washing machine are more likely to die in a car crash. Why? Do clean clothes make you a worse driver? Does using the small knobs on a washing machine make it harder to use a steering wheel?

  Of course not. The two are only correlated, which is an association, rather than causation. People that have the economic means to own a washing machine (versus having to take their clothes to a laundromat to do laundry) are also more likely to have the economic means to own a car. Also, people who own cars are at higher risk for getting in a car crash. So, when it comes to owning a washing machine and crashing a car, the two just go together. It is not something about washing machines that causes car crashes or vice versa.

  This mistake is so common in the interpretation of scientific data that it spurred a popular (and humorous) website that has now become a book, called Spurious Correlations, where the purveyor collects data on quirky correlations in which causation is ridiculously implausible.382 (One example: There is a 99 percent correlation between the divorce rate in Maine and the per capita consumption of margarine.)383

  While causation might exist with correlated data, you just can’t assume it. Making the assumption of causation is considered a crime in the world of statistics, including academic medicine. But, again, it’s just a misdemeanor. People make this mistake all the time.

>   But beware of a potential felony! An academic crime worse than mixing up association and causation is the crime of assuming causation in the wrong direction…mixing up which factor is the cause and which is the effect. So if you assume causation when you should not, you may get off with just a fine. But if you go beyond that to assume causation in the wrong direction, you will be thrown behind bars (academically speaking, of course).

  Consider this example: Smoking is associated with lung cancer. It is also undeniable, based on decades of iron-clad research, that smoking causes lung cancer. Everybody knows that. But did you know that frequent alcohol consumption is also associated with lung cancer?

  Mainly, it’s because people who smoke are also more likely to drink alcohol. Alcohol is not the major driver of the risk of lung cancer; it’s smoking that is causing lung cancer. But alcohol use and lung cancer go together, for sure, even though smoking is the main cause. It would be a crime (and an error) to attribute all of the causation that is due to smoking to the consumption of alcohol. And yet, as noted, that’s just a misdemeanor.

  You know what’s a felony? Interpreting that data to suggest that lung cancer causes smoking or alcohol consumption. In academic circles, if you make this mistake they will throw the book at you! And it doesn’t take a background in medicine to know how silly it would be to think that lung cancer causes smoking.

  A Contrarian Interpretation