Episode 3: Burnout and Its Effects on Healthcare Workers

Leigh Steiner:

Welcome to the Vitals and Vision podcast. I’m your host, Leigh Steiner, partner for Behavioral Health Solutions at Relias. In today’s episode, we will be exploring a topic that has garnered significant attention over the past couple of years the issue of burnout among healthcare workers and how it affects retention. Burnout has always been a prevalent issue in health care, but the COVID 19 pandemic has intensified its impact and shed light on its far reaching consequences.

The U.S. Surgeon General, Vivek Murthy, defines burnout as an occupational syndrome characterized by a high degree of emotional exhaustion and depersonalization. Today, we have the privilege of exploring this important subject with our highly regarded guest, Dr. Jack Gorman. Dr. Gorman is the co-founder and president of Critica Inc., a nonprofit dedicated to countering science denial in health and safety decision making.

He’s also the CEO and chief scientific officer of Franklin Behavioral Health Care Consultants, providing expert guidance to enhance mental health care. So, Jack, why don’t we just start today’s conversation by having you define burnout. From your perspective, what is it and what does it mean?

Jack Gorman:

Sure. Well, you started by giving Surgeon General Dr. Vivek Murthy’s definition, which includes this high degree of emotional exhaustion and depersonalization, often to the point of actual cynicism about their role. And it engenders a low sense of personal accomplishment at work. Now remember that healthcare providers for the most part are people who are very driven to help people and they want to be successful at their job. And people who experience burnout in the healthcare world feel they just are not getting their work done. They’re not getting their jobs done. They’re not able to help people the way they would like to. And this makes them feel fatigued, exhausted. often angry and sometimes cynical about their work. Now you’re right that not everybody likes the term burnout, as we’ll discuss as we go along I’m sure, because it implies that the problem is within individuals. And although individual remedies are important, it’s very important to recognize that this is a systemic issue that involves the whole healthcare system. not just individual predilection for burnout, but the whole way the healthcare system is working these days.

Leigh Steiner:

So we all know, I mean, everybody has been exhausted with their jobs from time to time. What is it about healthcare that makes, well, let me ask, let me back up and say, how pervasive is burnout? And then what is it about healthcare that makes it so pervasive, assuming the science tells us it is?

Jack Gorman:

Yes, well there are a number of studies now. They use different definitions, sometimes of burnout, so it’s hard to compare, but as a rule of thumb, and the rate that Dr. Murphy gave in his report, about 50% of healthcare workers meet criteria for burnout now, and that number is even higher among primary care physicians and healthcare workers, where it can be in the 70 to 80% range. And that of course is leading to this increased fleeing of the field by so many healthcare professionals.

Leigh Steiner:

So follow-up, what is it, I mean, what do we think it is about health care that makes or contributes to that 50% of persons meeting the criteria?

Jack Gorman:

You know, when people go into healthcare, as you know, there’s the expectation that you’re gonna work very hard. Everyone knows that doctors and nurses stay up late at night working and doing the things they have to do, so that’s expected. But increasingly, the volume of demand, the volume of the workload on healthcare professionals for a variety of reasons has… and really increase substantially. So it’s already a situation where people are at the limit of their ability and now being pushed even further. And that again creates this terrible mismatch because as I said before, healthcare professionals really have the notion that they’re gonna be able to help their patients. and spending time with their patients is the primary thing they say that they are there to do. And as they start to feel that they’re pushed to the limit and not doing what they want to do, what they feel they should be doing to take care of their patients, they develop this burnout syndrome.

Leigh Steiner:

And so things like EHRs or interactions with third party payers, rules, increasing rules, policies, regulations, I would imagine those things are all contributors.

Jack Gorman:

Absolutely. So let’s look at the electronic health record, for example, which has revolutionized record keeping and the transmission of information in the healthcare field. But as all healthcare workers will tell you, it’s also increased the burden on them to spend time doing documentation into the electronic health record. And clinicians don’t like doing that. They, again, want to be with their patients. They don’t want to be sitting. behind a computer terminal for hours and hours. And so that’s one of the increasing demands on their time that is leading to burnout. Another are things like prior authorization, which started out as you know as a pretty good idea to try to cut down on unnecessary prescribing and unnecessary prescribing of expensive medications when less expensive alternatives are available. but has now ballooned into a enormous bureaucratic system that takes a lot of time for clinicians to navigate.

So doctors and other healthcare professionals report spending hours interacting with health insurance companies, trying to get authorization for medications and procedures for their patients. Again, something that they don’t like doing, they wanna be with the patient. And so… these kinds of things plus a lot of increased demands to meet various rules and regulations, many of which are with good intention. For example, the Drug Enforcement Agency is now requiring that in order to keep your DEA certification for prescribing, clinicians have to attend an eight-hour learning session.

Now, I think that’s a great idea because after the opioid crisis we want clinicians to know as much as possible about the proper and safe prescribing of controlled medications. But that’s eight more hours that the clinician has to take out of their time. That’s a whole day that they would rather be spending taking care of their patients. So as you can see, these are just increasing enormously and there’s really little thought given to the impact it’s having on the healthcare worker, him or herself.

Leigh Steiner:

Well, I would imagine that, I mean, we’ve recognized this problem in its enormity post-COVID or during the middle of COVID. So talk a little bit about the effect that COVID pandemic has had on this phenomena.

Jack Gorman:

Yeah. So COVID made a situation that was already a problem. Burnout was already a problem before COVID. That much worse. First of all, especially in the first couple of years of COVID, as everyone knows, the workload just increased enormously. So hospitals were overwhelmed all over the country with patients that were very sick and for which there was at first very little option for treatment. So this was frustrating. Doctors and nurses and other healthcare workers faced a shortage of protective equipment. They didn’t always have the supplies that they needed because supply chains were challenged, as you know, during the pandemic. So there were a lot of things that made this a perfect storm.

And also clinicians reported feeling the pressure from misinformation from people who were coming in unvaccinated because they had heard things about the vaccines that are just not true. And this also was very frustrating. It’s hard to take care of someone who is really sick, who could have been in a much better situation had they followed medical recommendations and been vaccinated. So clinicians felt that they were fighting this battle against misinformation at the same time that they were overwhelmed with their workload. And that has made burnout much worse.

Leigh Steiner:

So Jack, one more sort of definitional thing before we move on. There is the concept of moral injury, and that’s a bit more recent concept than burnout, but talk a little bit about moral injury, how it is the same as or differs from burnout and how it affects healthcare workers.

Jack Gorman:

Absolutely. So moral injury begins with what we call moral distress. And that occurs when a healthcare professional knows the best healthcare decisions to make, but feels relatively helpless and unable to act due to limited resources or circumstances beyond their control. So you know that your patient in the emergency department should be admitted to the hospital and be in a hospital bed, but there’s no hospital bed. And so your patient is staying in the emergency department for 24 or 36 hours. That’s an easy example of the kind of thing that causes moral distress. And there are many examples of that occur increasingly. And that can lead to moral injury, which is the response that the healthcare worker has to acting or witnessing things that go against his or her values and moral beliefs. And this has been linked to feelings of profound guilt, shame, anger, and other psychological impacts. So the healthcare worker knows what they should be doing and they can’t do it and that leads to moral injury.

Leigh Steiner:

So it is certainly related to burnout, yet also a separate phenomena.

Jack Gorman:

That’s right. That’s exactly right.

Leigh Steiner:

So, with that platform established, talk about what the risks of burnout are for the person themselves, for the organization, for the client, or the patient. and how this affects the quality of health care.

Jack Gorman:

So we know that burnout, besides the obvious problem of leading people to retire or quit their jobs, which has led to, among other things, this tremendous nursing shortage in the United States. But burnout leads clinicians to feel anxious, depressed, angry. It may actually contribute to the relatively high suicide rate among healthcare workers. And so the impact on the clinician is profound. You can imagine the impact on the patient. First of all, if there are not enough doctors and nurses to take care of you, then that’s a problem. But in addition… The coping mechanisms that the healthcare worker may take to deal with burnout may not be in the best interest of the patient. So the patient doesn’t want to have a fatigued, exhausted, cynical, angry clinician taking care of him or herself. And for the healthcare organization, obviously, it makes it incredibly difficult to retain doctors and nurses and social workers and other health care professionals because of this increasing rate of people quitting their jobs.

Leigh Steiner:

Well, we know and you’ve addressed that healthcare workers, I’m not sure solely, but certainly particularly, have expectations to be tough and resilient. The expectations on nurses are immense. And of course, we’re all human beings and we’re susceptible to the same stress and trauma as the rest, but there remains a pretty wide stigma and discrimination among healthcare workers who show vulnerability and seek the help when they need it. Can you talk about that a little bit? Obviously that’s an effect on the individual healthcare worker.

Jack Gorman:

Absolutely. You know, I remember when I was in medical school learning that you just did not say you were tired. And you never are supposed to be angry. You’re supposed to be resilient, enjoy your work, tough it out because it’s a calling. After all, it’s not a job. that kind of very high expectation of how you’re supposed to behave, it’s very hard for human beings to actually sustain that kind of standard. And we know that puts enormous pressure. Clinicians are suppressing those things all the time. They’re suppressing their fatigue. They’re suppressing their worry and anxiety. And they’re suppressing their anger at the system. And those obviously cause enormous psychological distress.

Leigh Steiner:

Do we see different degrees of burnout across various roles? Like, obviously, in COVID or I guess on any day of the week when you go into the emergency department, it’s stressful. Maybe hospice workers or behavioral health care professionals, is there a…do we know anything about a differentiation among different? categories within…health care.

Jack Gorman:

We know some things, we don’t know enough about this. As I mentioned before, we know that primary healthcare clinicians, primary healthcare doctors, for example, have much higher rates of burnout than at the average healthcare professional. People on the front lines who are relatively less well compensated than, say, an orthopedic surgeon or a heart surgeon. Emergency department workers really struggle with burnout, as do ICU workers. Again, two areas where there’s usually a shortage of supplies, resources, and beds, and an enormous demand. You’re working in ICU, the demands on the workers are tremendous, very, very sick patients and you don’t have enough beds to handle it for everybody. You don’t have enough staff.

Imagine being in an ICU and there are not enough nurses. The nurses that are there become very stressed out. Behavioral healthcare workers also suffer very high rates of burnout, in part because they’re the, generally, the least well-compensated workers in the healthcare system.

But this can apply to everybody. You can imagine social workers on inpatient units becoming burnt out because they just can’t do their job. They can’t find places for people to go when they’re ready to be discharged because of shortages of follow-up placements. And how awful that can be to face that every day when you know what you want to do and what should be done, and you just can’t do it because the system won’t allow it.

Leigh Steiner:

So some of the situations we’ve talked about, especially working in an emergency department or certainly working in any kind of healthcare at the height of the pandemic, it strikes me that part of the phenomena could also be related to almost a PTSD. Could you talk a little bit about that and the relationship of burnout PTSD.

Jack Gorman:

That’s a wonderful question, and I think you’re absolutely right that in a way, this is a trauma, because the healthcare worker is of course witnessing life-threatening situations all the time, feeling inadequate many times to deal with them, and that can be traumatic. I’ve actually not seen a study giving the rates of PTSD in healthcare workers, but I would not be surprised if that’s a growing problem. And the very interesting way to look at it is a kind of trauma that could then lead to things like avoidance of the situation, which could be one of the reasons why the healthcare worker decides to resign.

Leigh Steiner:

if it’s a system issue, of course, or if a significant portion of this is a system issue, what can health care leaders do to shift this paradigm to provide support and encouragement to those who need it.

Jack Gorman:

So many things can be done on so many levels. Obviously, starting with recognizing the problem, acknowledging it, and making sure that healthcare professionals in your system feel valued, know that the administration understands the pressures they’re under, doesn’t take them for granted. All of those kinds of things can be the beginning, just the beginning, but the beginning of making the situation better.

Now, there are large system issues that need to be fixed, and people are working on those issues. So lots of people now are working on making the electronic health record easier for clinicians to navigate and reducing the time that they have to spend on them.

And this actually is substantially involving artificial intelligence, for example. So ways that AI can actually do many of these tasks for documentation that right now clinicians are spending their time in front of computers doing need to be sped up so that this can be definitely made more efficient.

And Congress itself is working very hard on the prior authorization problem now and I’m hoping that some resolution occurs because that’s again a big time drag on clinicians and something that really makes them upset. So there are these large systemic things that can be taken care of, sometimes by federal and state government bodies, sometimes through technology. So that’s one thing.

There are a lot of things that a local administration, a hospital administration, for example, can do to try to help with burnout. One is that the clinicians often feel very divorced from decision making. And there’s some evidence that… creating systems, committees, different methods of allowing the clinician to feel part of the decision-making system in the organization can help with burnout. When people feel more empowered, they’re less likely to feel cynical and disengaged. So that’s another thing to definitely keep in mind.

Of course, burnout is going to happen. And while hot bubble baths are probably not the solution, making stigma-free mental health care services available to healthcare workers is another very important step. That’s an uphill battle because healthcare workers often resist getting help themselves.

And there’s always stigma and a problem with who gets to know that they’ve accessed those systems. But there’s generally been a large call for making stigma-free mental healthcare services available. And that is, I think, a very important thing to do. And many hospital systems now have adopted the policy of appointing a chief wellness officer. So that really makes it clear to everybody that they’re taking this seriously, that they’re organizing support groups, time out to discuss issues that lead to moral distress and burnout, stress reduction programs, things that are much more sophisticated than simply telling people to have a glass of wine.

Leigh Steiner:

Well, Jack, you have been working in the healthcare for a few years…And I’m sure that you have seen this syndrome up close and personal. Can you talk a little bit about your personal experience with burnout or experiencing it or seeing it so we understand a little bit the personal relationship of you and this topic.

Jack Gorman:

You know, I have seen surveys of healthcare workers that say that, again, something like 40, 50% of them are unhappy with their jobs. And that’s been my personal experience as well, dealing with people in the field. The healthcare workers, doctors, nurses, social workers that I’ve dealt with were all very idealistic when they started out, all on this mission to save lives, help people, make the world better. And in many ways, years ago, I think that was more possible. That’s becoming increasingly difficult for them. So I see doctors, for example, just complaining bitterly about the time they’re spending documenting things in the health record. And you can just ask any doctor nowadays, how do you feel about the electronic health record, and watch out because you’re gonna be in for a lengthy diatribe on how burdensome it is, how difficult it is, how it distracts their attention from what they want to do.

There’s a tremendous consolidation of ownership of healthcare services now that has led to more pressure on clinicians to see more patients in shorter periods of time. And so you see the doctors and nurses complaining again about how they want to spend more time and they’re just not allowed to. They have to see more patients.

So I see this all the time, especially among doctors that I see, that they’re unhappy with what they’re doing and they all say in those situations, I can’t wait to retire.

Leigh Steiner:

So what, Jack, when you review our conversation here, what haven’t I asked you that may be important to say right now? And really, what do you want our listeners to take away?

Jack Gorman:

I’d like our listeners to really focus on the fact that this is a solvable problem. I don’t think this is an impossible problem to solve. I think that if people really put their minds to it, the healthcare world has developed some amazing technologies for… doing the things that we do. And so it is absolutely within the realm of belief that, for example, technologies can help to make the administrative burden on clinicians become much less. What I really want is for everybody, not just the healthcare professionals themselves, but their patients, to start really thinking about this problem and really advocating for these solutions. I think that’s the important thing.

Leigh Steiner:

Well, Jack, it has been wonderful having this conversation with you. Thank you so much for adding to our episode series here on retention and. just for spending the time with me and for having the conversation so our listeners could learn more about burnout. Thank you.

Jack Gorman:

My pleasure. It’s always great talking with you.

Leigh Steiner:

Thanks, Jack.

Leigh Steiner:

Thank you for listening to this episode of Vitals and Vision. I’ve been privileged to work with Jack for over 20 years and always come away with greater understanding. We hope our discussion on burnout has also been insightful and eye opening for you. Remember, success starts with a clear vision and vital strategies. We look forward to having you join us on future episodes.