5

Deep Dive on Burnout, Identity, and Intersectionality

Planning committee member Kelley Bonner (Burn Bright Consulting) facilitated a roundtable discussion on burnout, identity, and intersectionality with Jean King (Worcester Polytechnic Institute), Joan Y. Reede (Harvard Medical School), and José Rodriguez (University of Utah). A short wrap-up by planning committee chair Reshma Jagsi (Emory University) and National Academies of Sciences, Engineering, and Medicine program officer and workshop study director, Katie Wullert, wrapped up the first day of the workshop.

This panel was developed in recognition of the fact that there is still a relative dearth of scientific literature examining experiences, causes, and implications of burnout for those at the intersection of multiple marginalized identities. It was intended not just to highlight gaps, but as Bonner noted in her introduction, as “an opportunity to get at where there’s absence of research and where we can lean on experiential data and what we know to be intuitively true about intersectional identities” to better understand experiences that are not currently captured in our scientific literature.

TYING BURNOUT TO IDENTITY AND INTERSECTIONALITY

The panelists began by offering thoughts about how burnout is tied to identity and intersectionality for workers in general and science, technology, engineering, mathematics, and medicine (STEMM) professionals specifically. King said as a neuroscientist, she has studied the effect of stressors on the brain for 30 years. “We bring ourselves to every interaction we have,” she pointed out. Each person’s construct is unique. When a person has multiple underrepresented identities, these identities overlap, change in different situations, and become a response and an experience. There is not a lot of research that ties intersectionality with burnout, although there is research on the link with stress, which can serve as a proxy. It is important to identify who is suffering, not specific individuals but the experiences of particular groups at work. If you cannot show up at work as yourself, especially in STEMM, and if you have to buck the system on a daily basis, identity cannot be disambiguated from stress and burnout, she said.

Reede raised the multiple identities that everyone must address, such as those related to race, gender, work, and discipline. Time and place are also critical, such as what is happening in one state in the country versus another, or in the field of public health versus another field. Another variable that changes the stressors is working in an academic STEMM environment versus industry, government, or nonprofit, and, within that environment, being at different stages, such as entry level versus leadership.

Rodriguez commented he is a family physician that until July 1, 2024, was the associate vice president for health diversity, equity, and inclusion (DEI) at his institution. The Utah legislature passed a law that made DEI offices illegal in public institutions in the state. He was able to preserve jobs, and a portion of what employees were doing in the new Office for Health Sciences Workforce Excellence. Burnout can be a diagnosis, but it is almost an identity because the individual has to report experiencing it. That brings up issues in academic medical centers where underrepresented minorities experience “minority taxation” and safety—if you do not say you are burned out, people will not know. Yet, there can be safety issues in telling other people you are hurting, he said.

SELF AND WORK

Reede commented on the expression “bring your whole self to work,” first noting that no one should feel they have to be their whole selves at their workplace. She called for a clearer understanding of what the term means. She described it in terms of whether she has to filter what she says and does, feels safe saying no or disagreeing, or worries about being misinterpreted or made to feel uncomfortable. Everyone has this, but being a woman and person of color is an additional pressure. She also said that another factor in her mind is that what she says does not just have implications for herself, but for others. “These are dimensions of thinking and worrying that others may not have to take into consideration,” she said. Part of survival is not to have to deal with these concerns alone, but through a group and connective process.

Rodriguez agreed about the challenge of bringing one’s whole self to work, and the masking and filtering needed for minoritized individuals to survive particularly in academic medical settings, which he knows best. In terms of easing the experience, he recalled that when he was asked to take on the health equity vice president’s role in 2018, the first thing he did was go to the university’s resiliency center to set up a relationship with a therapist before issues arose. He also continued his work at a Spanish-speaking

clinic in Salt Lake City as a way to reduce isolation. When he was told to stop because he is in administration, he refused because he realized its importance to his own well-being. But he also recognized that early-career professionals cannot assert themselves like he was able to. Those who burn out early cannot access many mitigation strategies because they may not have the voice of more senior professionals.

King added that when she thinks of bringing one’s whole self to work, she considers the impact of multiple identities. For example, she has been asked why she conducts research on Black women and stress and noted the perception that the topic was not “real science.” Being interested in a particular group when one is a member of that group diminishes the work, she observed. Yet, when thinking of the many intersectional studies that are not done, she observed, “Look at most of the principal investigators—they are not at the different intersections, so the questions will not come to them.” Research teams should consciously reflect different communities, she urged. The voices of the voiceless can be where innovation resides. When junior scientists want to bring their whole selves to work, she advises them not to do so to protect themselves. To this point, she commented on the people who chose not to identify by race or ethnicity in the study cited by Lai (see Figure 4-1 in Chapter 4) and their level of comfort in expressing their sense of marginalization.

Reede commented on an added burden for many in medicine who often carry a strong weight and responsibility for the health of their communities. “We have to recognize that we do not own it ourselves, but rather it is the institutions that put or do not put resources in communities,” she said. She urged conversations to recognize wanting to be part of doing a better job while not taking on the pressure of feeling they have to fix everything as individuals. She also reflected that younger scientists often do not realize the ways they are stressed and are not taking care of themselves. Many do not have an opportunity to talk about and acknowledge these issues.

DISCRIMINATION IN THE WORKPLACE

Rodriguez commented on one implication of anti-DEI laws in many parts of the country. Those who study diversity are not seen as pursuing science, while it is also very personal work. He suggested a job for senior leaders is to provide a place for newer people to process the pressures they face, something they do not learn in medical school or residency. Physicians think or are taught that they are different from their patients. Therefore,

he said, “We don’t take sick days or vacation, or take care of ourselves. That may have a sense of nobility, but it is not sustainable.”

Bonner also asked panelists about the role of microaggressions, or everyday experiences of discrimination, that are more common for those with multiple marginalized identities and how this relates to burnout. As another workplace discrimination issue, Rodriguez noted the no-win situation of how to react to microaggressions and discrimination. If a person files a complaint, there can be repercussions. If a person does nothing, they are hurt because they internalize it. “We have not examined how to deal with this effectively yet,” he said, but added that “all the literature that talks about underrepresented faculty is clear on one point: We are the canaries in the mine. [If it is happening to us,] it will happen to others.”

Reede called out the term “microaggression,” noting it makes the experience sound small when it is anything but to the individual facing it. It denies the impact on the recipient, while presenting the concept from the perspective of the person doing the aggression. King concurred and said that if a person asks for help after a microaggression, they are seen as reacting to something that should not be “a big deal.” She also pointed to invisibility faced by women and minoritized scientists, in which one’s ideas or comments are ignored or repeated by someone else who gets the credit. “Being invisible in science is not a good thing,” she noted. Bonner offered another term instead of microaggression, as explored by researchers Tiffany Jana and Michael Baran: “subtle acts of exclusion.” Panelists supported this term and the role this exclusion could have in issues like burnout.

RESEARCH ON RACE AND BURNOUT

A participant asked the panelists their reaction to Lai’s research in which people who experienced a high degree of burnout were reluctant to self-identify by race or ethnicity. Lai first offered that a hypothesis is that these respondents did not feel safe disclosing their identity, but more research is needed about this finding and respondents’ lived experiences. King offered her concurring hypothesis that those with marginalized racial identities might not feel safe both admitting who they are and what they are experiencing because of potential implications this may have for their community. She commented on the need for data about people with multiple identities to better understand how they are affected by stress and burnout. Identity is not just one more factor among many, she said, but intensified wear and tear on the system, in what is known as allostatic load.

She called for research to generate strong data. Reede called for more rigor in DEI-related research to understand nuance, as needed in all types of research. She said she is excited about new people coming into the field with new questions and methods.

Rodriguez commented that in reporting race and other identities, there is a concept that connects identity with advantage or disadvantage. The concept is not as concrete as one would think, as he noted that a large part of the White population thinks they are disadvantaged. It will take some time before people feel comfortable talking about vulnerabilities, like experiences of burnout especially in demanding STEMM fields, without fear of being hurt by doing so.

MENTORSHIP

When asked how mentorship could help navigate burnout, Rodriguez described a fellowship he runs for early-career faculty who identify as underrepresented in family medicine. Aspects of the training include self-care and expectations about what they should produce in the scientific realm. They are learning how to collect information about things they are already doing to show their achievements and how to find help for their scientific work within the academy. The group meets in person and virtually, and they often have questions that Rodriguez and the other fellowship organizers had not thought of. The most important part is to teach them how they can help change the system.

Reede underscored the value of creating safe spaces to ask questions, feel comfortable, and not feel isolated. In the past week, she met with 10 residents of color for valuable conversations about what they hear and how they cope. She also noted that the flip side to mentorship is an added stressor for the mentor and sponsor, especially if they are the only mentor who is a person of color and feel a huge sense of responsibility. Institutions need to recognize and value mentoring in considering promotion and in growing the scientists of tomorrow. She also warned about situations when mentoring is not good, what she referred to as “de-mentoring” and “tormenting.”¹ It is important to protect trainees and younger faculty from

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¹ These terms are used to refer to toxic or unhelpful mentorship relationships. Tormenting in particular has been used colloquially to distinguish from a positive, supportive mentor and a mentor who causes challenges and works against the individual being mentored. For an example of how this distinction has been used, see https://www.forbes.com/councils/forbescoachescouncil/2021/07/22/how-to-know-if-you-have-a-mentor-or-tormentor/.

these situations and types of mentors because they can serve as substantial stressors that promote burnout. King said overall mentoring is “the good news story.” She also suggested support groups and peer-to-peer mentoring as effective and with less burden on specific individuals.

A participant commented on the importance of looking for and disseminating best practices related to mentorship and role-modeling. The literature base on authentic leadership could also be digested and shared. Institutions often offer coaching for people at higher levels, but it is also needed at early levels of leadership. As an example of how to make an intervention more widespread, trauma debriefs used to be opt-in for nurses at the participant’s institution and most did not participate, but now they are required.

FINAL TAKEAWAYS

Bonner asked each panelist for a final takeaway. King said she wants organizations to truly see people of multiple identities, try to understand them, and look for ways to help so that they receive support if they are facing burnout, as well as other stresses at work. “If we could change the invisible to visible, we have a start,” she said. “If no one is looking or talking about it, it cannot get solved.”

Rodriguez acknowledged negative mentors are out there, but there is also the good news of excellent mentors that can help to reduce stress and strain that contribute to burnout. It is a trying time in the United States. Identities are being put on trial with the end of affirmative action and anti-DEI laws and this can generate stress and challenges, but “we have the opportunity to look beyond identity on the surface and address problems more deeply.”

Reede commented on the fact that the conversation is even happening. It would not have occurred in this way 10 years ago. There is backlash, but she urged people to keep in mind that this is not the first time that DEI has been under attack or there has been pushback, but it is important to march forward. Through good scholarship, working together, and understanding the value and work of all, science and health will improve.

WRAPPING UP DAY 1 OF THE WORKSHOP

Planning committee chair Jagsi commented on the complex nature, multilevel causes, and the profound consequences of burnout as seen through an intersectional lens and from a diverse array of disciplinary

backgrounds. She acknowledged that while this is not a happy topic, she was excited and motivated to see the intellectual firepower and energy that was brought to addressing this issue and was anticipating an engaging conversation on interventions for the second day.

National Academies program officer Katie Wullert reflected on some of the points raised for her from the presentations and discussions. She called attention to who reports burnout and how safety is important for people to acknowledge and report it. In looking ahead to the next day’s discussion about interventions, she noted the importance of understanding the environments where burnout occurs to move forward. Shared definitions and goals are needed to know the crux of the issue to solve it. There are gaps in the literature, as was pointed out, but also a lot is known that can be acted upon.

Wullert also conducted a quick online survey to ask attendees what they saw as their main takeaways from the workshop sessions to date. She reported several of the responses: Burnout can be defined and addressed, the importance of making the invisible visible, the complexity of burnout and how to intervene, and burnout is a failure of the system and not the individual. Selected additional responses from participants can be found in Box 5-1.

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