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Interventions to Manage Burnout: Deep Dive on Medicine

A second deep dive workshop discussion focused on burnout in medicine and healthcare. In introducing the session, planning committee chair Reshma Jagsi (Emory University) said healthcare settings have a unique intensity, although some of the ideas will fit to other settings. Natalia Cineas (NYC Health and Hospitals), Eve Kerr (University of Michigan Medical School), Julie Silver (Wake Forest University School of Medicine), and Liselotte Dyrbye (University of Colorado School of Medicine) provided perspectives based on their research and workplace experiences.

The purpose of this panel was to give greater attention to medicine and other healthcare professions given especially high rates of burnout in this field. This panel examined the unique case of healthcare as well as variation in burnout across care settings and discussed effective interventions for those in medical fields.

UNIQUE FACTORS AFFECTING BURNOUT IN MEDICINE AND HEALTHCARE PROFESSIONS

The panelists began by discussing unique factors about healthcare that provide context for particularly high rates of burnout in these domains. Cineas said data from 2018 to 2022 from the Centers for Disease Control and Prevention show the critical state of the healthcare workforce. One in four U.S. essential workers had a mental health diagnosis, and burnout increased from 11.6 to 19 percent during this time (Nigam et al., 2023). Suicides among nurses and other providers increased. Three in 10 resigned during the “great resignation.” Kerr noted the heavy workload healthcare professionals face and the unique demands of being in a helping-focused role. “Professionals feel it all the time. You don’t know when your day ends, yet you are driven by service,” she said, both to treat patients and train the next generation. There is not only a stigma around acknowledging a mental health condition, but also doing so in some states can affect licensure. She also noted the differential impact on women, who generally have more home responsibilities in addition to work responsibilities. Silver highlighted the match system for physician trainees as another unique factor in medicine that could heighten burnout. In this lottery-type system, on a certain day, trainees

are notified where they will be deployed. The system can create trauma and stress for the trainees and their families as they wait to find out where in the country they may have to move and may need to be far away from their current support systems. Dyrbye related that the substrate of undergraduate students entering medical school is strong, but the situation flips in a few years when depression and burnout are high. In large studies conducted every 3 years since 2014, she and colleagues have seen that physicians are more likely to experience burnout than other U.S. workers, even adjusting for work hours. “It is a good moment for us to reflect on what is happening,” she said. Some aspects might be related to moral distress and mistreatment by patients and their families, which contribute to job stress and to burnout.

Jagsi commented on several relevant studies by the National Academies of Sciences, Engineering, and Medicine’s Committee on Women in Science, Engineering and Medicine, including on sexual harassment, bias, and family caregiving (NASEM, 2018, 2020, 2024) that highlight challenges and lack of support in the medical system particularly for women that may contribute to burnout.

BURNOUT ACROSS HEALTHCARE

Medicine is not a monolith, Jagsi pointed out, and asked how burnout affects different groups by specialty, level of experience, or other factors. Kerr sees a lot of distress as a primary care physician because primary care is the foundation of the healthcare system. As an example, there is a 50 to 100 percent increase in the number of portal messages that primary care physicians receive. Women physicians receive more and longer messages than their male counterparts and spend more time in patients’ electronic health records than their male counterparts. The expectation is to respond 24/7, without being paid for this time. There is a need to acknowledge that individuals are not on duty all the time. When physicians, particularly women, reduce their hours, they often end up working what is still a full-time schedule while being paid less. She referred to Jagsi and colleague’s study of successful clinical researchers that showed that gender and climate affect burnout (Paradis et al., 2024).

Silver spoke about the importance of taking an individual lens for each group in medicine given the needs and challenges they have. She then turned to suicide as one example, where nurses are at particular risk and discussed the importance of a sense of belonging in combatting this. She highlighted the Interpersonal Theory of Suicide from Joiner and colleagues (2009), which has two key components: perceived burdensomeness and thwarted belongingness. As an example of how these factors relate, she noted

that many women in medicine who may take leave to give birth or care for children return and are expected to immediately get back into work with no ramp up and with expectations that she “owes call, she owes long shifts.” The system is not set up to support reentry and can leave individuals feeling as if they are failing and as a result can internalize that they are a burden to their colleagues and do not belong in their role. These systems issues thus can produce circumstances that sit at the heart of the interpersonal theory of suicide.

Dyrbye pointed out that the primary driver of burnout is work hours and workload. Within healthcare, different job categories have specific drivers, and no one size fits all. Some solutions can be found at the systems level, such as those related to electronic health records or policies about mistreatment, but the level of the work unit is what drives stress. Changes can be made at a high level but, most importantly, must be felt by the local work unit or team.

Cineas commented on the effect of specialty selection, in her case, as a nurse. People need more tools to understand what each specialty involves. For example, oncology nurses say they are used to dealing with patients’ death, but the impact on their mental health has not been fully explored. Night nurses deal with fatigue, which can lead to more errors, yet new, young nurses are usually placed in night shifts. The workforce is getting younger, and they need more resources. She called attention to the Impact Wellbeing Guide: Taking Action to Improve Healthcare Worker Wellbeing recently enrolled by National Institute for Occupational Safety and Health as a useful tool in this regard.¹

TARGETING STIGMAS

Jagsi reflected that the intensity described by the panelists stems from medical providers’ commitment to mission, often to the detriment of their own health. “Regardless of the specialty or level of training, we have internalized that expectation,” she commented. The flip side is the tremendous stigma that exists when people feel a need to slow down, take a break, or attend to other commitments outside of work. She asked the panelists how to recognize, call out, and target stigma.

Silver called for normalizing behavior to combat stigma. She also called out structural sexism and racism, which she defined as policies, practices, procedures, and culture that predict a certain outcome along race and

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¹ See https://www.cdc.gov/niosh/healthcare/impactwellbeingguide/index.html for a link to download the guide.

gender lines. Drawing on the example of anesthesiologists giving birth, Silver suggested developing policies or practices that help them return to a high level of work while considering physical characteristics such as their recent surgery or lactation. Making policies, practices, and procedures standard, not special, could destigmatize them.

Dyrbye said dealing with stigma starts at the top. The reluctance to engage in self-care for fear of looking selfish needs work at the top of healthcare organizations. Modeling and talking about self-care can tackle the stigma. Outside of the healthcare organization, there needs to be work on medical licensure and hospital credentialing questions, such as not asking intrusive questions about mental health. “Stigma in medicine comes in multiples places, from the healthcare industry and also inside our own walls,” she said.

Cineas agreed with the need for self-care and noted that many employees do not take the personal leave time they are due. She also called for the integration of well-being into daily operations. Her institution has developed a care delivery model that integrates peer-to-peer well-being. At the beginning of every shift, nurses huddle, articulate a value, then discuss methods and operations. A staff member volunteers to be the well-being buddy for the day to ensure colleagues have taken breaks and check how they are doing. This normalizes the reality that things may not be okay on any given shift. Though they are just starting to examine the impact of this approach, Cineas noted that, based on early results, they are seeing that because some unexpected people have emerged as volunteer buddies, the staff has gotten to know each other better, they are providing better care for patients, and bullying has been mitigated. Wellness becomes integrated into operations.

Kerr highlighted the stigma around vacations and taking time off. She detailed an experience where she emailed colleagues to explain that she was missing an important meeting to celebrate her wedding anniversary. In response, she received emails thanking her for sharing the information and helping to normalize her choice. Systems must be in place for coverage so as not to burden others. As one idea, she pointed to a practice that employs a dedicated individual, such as a nurse or other provider, to serve as an “inbox-ologist” who handles the in-box of a colleague when they are away.

OPEN DISCUSSION

A participant asked about dealing with organizations that believe that burnout during the COVID-19 pandemic was an outlier, rather than a continuing issue. Dyrbye agreed that burnout spiked during the pandemic,

but emphasized it is not new. Research from 20 years ago showed burnout was most intense in hospitals and critical care, and that has persisted. Most recent studies show a decline in burnout in the healthcare workforce compared with the peaks of the COVID-19 pandemic but is still high compared with the rest of the U.S. population. When asked whether there are fields without a high rate of burnout, Kerr shared results of a survey that showed relatively high levels throughout her institution but especially for those in clinical care. Researchers and those with limited clinical care had lower levels.

Another participant who researches childbearing physicians reported on a ripple effect: As efforts are made to regulate women in their third trimester or when they give birth, others have to take up their work and they feel more burned out. Given limited resources, more support cannot be brought in, so she asked how to implement policies and procedures without further stigmatizing the accommodated group. Silver commented that this dilemma is “why we are all here.” Big system-level issues are not getting the attention and resources to solve them. In a resource-constrained environment, the burden shifts to others. There is no way around the fact that there must be another model with additional resources. Trying to make it work otherwise is a “nonstarter,” she said.

A participant queried how the medical industry is learning from those who experience burnout to feed that information back in the system. Cineas said one way is to reengineer exit interviews to understand why employees are leaving. She acknowledged that this comes late in that the person is leaving and each person is different, but they provide information that could help others. She also suggested “stay interviews” to ask employees what will lead them to stay. Another participant commented that the culture for early-career professionals, including lack of sleep and pressure not to speak up, has burnout baked in. Dyrbye acknowledged the extra challenges for early-career workers. They may work less advantageous shifts, have more work-home conflicts, and need to establish their reputations. Another participant pointed to the work of Mark Linzer, who runs the Institute for Professional Worklife at the University of Minnesota. He has conducted a randomized control trial on physician well-being and found workplace champions are helpful, as Cineas described. Dyrbye also pointed to work by Tait Shanafelt on how to galvanize improvements in the work environment at a local level to lead to meaningful change. His model is like one used at her institution, she said, in which funded well-being leaders develop and share a local-level climate assessment and then galvanize action within the

department’s sphere of concern and control. Developing local leaders to lead systems-level change is part of the path forward.

PRIORITIES FOR CONSIDERATION

Following this panel, the workshop moved into breakout sessions where participants and presenters would discuss interventions. To kick this off, Jagsi asked each panelist for one point that the groups should consider in their discussions. Dyrbye urged thinking about leadership buy-in and the role of leadership development and fostering wellness-centered leadership behaviors within a work environment. Cineas pointed to architectural design, and how spaces where healthcare providers work, sleep, and eat while they are on a shift can affect well-being. Kerr called for creating a climate of inclusion and advancement at the macro, meso, and micro levels. Silver urged attendees to consider ageism and ableism. Older physicians are now a more homogenous group. Behind them are more diverse individuals, but what will happen to this workforce in the decades ahead, she asked.

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