Addressing Burnout: Symptom Management Versus Treating the Cause.

Over the last decade, burnout among physicians and other healthcare providers has received considerable attention. What is the optimal way to address what appears to be a growing pattern of burnout among pediatric providers, subject to administrative and productivity burdens, while they care for pediatric patients, who themselves often have expensive and complex, multisystem diseases? What is the best path to wellness for providers?

See related article, p 87

In this volume of The Journal, Hente et al consider one solution. They report a pilot study of 24 providers in the Cincinnati Children's Hospital Medical Center cystic fibrosis clinic who took part in 6 mindfulness-based, cognitive therapy sessions to assess the efficacy of this therapy to reduce stress and improve provider well-being. After the intervention, participants had improvements in empathy, depersonalization, perspective-taking, perceived stress, anxiety, negative affect, and resilience. The research team undertook this intervention due to the high risk of burnout for their interdisciplinary team. , Symptoms of burnout classically include malaise, fatigue, frustration, cynicism, and inefficacy. The personal, health system, and financial costs of burnout are substantial. In a baseline evaluation, before initiating the mindfulness intervention, the cystic fibrosis interdisciplinary team endorsed numerous stressors and scored in the average range for work-related stress. The researchers should be applauded for their use of numerous validated tools and the length of time for follow-up in this study. Demonstrating sustained benefits at 15 months is impressive.

As in this pilot study, many of the efforts to address burnout focus on techniques to reduce stress or improve resilience. , Mindfulness has been associated with positive impacts for healthcare providers, so this intervention was logical to pursue. , That said, what is more important is addressing the underlying reasons healthcare providers experience burnout in the first place. This approach would be akin to treating the disease itself, rather than just treating the symptoms. To treat the disease effectively, we should recognize that burnout in healthcare has an important cause: moral injury. , As defined by the Syracuse University Moral Injury Project, moral injury is “the damage done to one's conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one's moral beliefs, values, or ethical codes of conduct.” Although much of the research in the area of moral injury is conducted with war veterans, there is a growing emphasis and a body of literature that frames the experience of healthcare providers in terms of moral injury. ,

Healthcare providers have a fiduciary responsibility to their patients. We are taught how to advocate best for our patients' needs by uncovering disease and providing effective treatments using shared decision-making techniques. This responsibility is deeply ingrained in us, and we have given over our lives to this work. When healthcare providers cannot act in accordance with our moral obligations to our patients, profound psychological distress can result. , It is morally distressing, for example, to have increasing clinical productivity standards coupled with additional administrative tasks that infringe upon the patient–provider relationship. Repeatedly, healthcare providers face circumstances when they cannot provide optimal care because of a malalignment with the values and objectives of the healthcare environment in which they work. Symptom interventions, such as mindfulness training, are valuable and can play an important role in the management of clinician distress, but a shift to addressing the root causes is truly necessary. Focusing on burnout suggests that the healthcare provider has the problem and that the locus of intervention should be at the provider level. The implication is that healthcare providers who experience burnout (more than one-half of us) are not mindful enough or not resilient enough. , , It may seem insulting to many healthcare providers to be told that their distress is their weakness and that their symptoms can be adequately addressed with meditation or mindfulness. It should be distressing when the care of patients is hindered by increasing work expectations that make providing that care effectively nearly impossible. Healthcare providers are in a double bind that no amount of ‘baby goat yoga’ will fix. Of course, working day in and day out under unfavorable circumstances severely challenges their ability to fulfill their ethical commitments to provide the best care.

In the immediate short term, we should that the moral injury crisis in healthcare will worsen. In light of the coronavirus disease 2019 (COVID-19) pandemic, healthcare workers have faced knowing that they must do what they can with limited and depleted resources. The basic essence of moral injury for a healthcare provider is going against what is known to be the right and just thing to do because of circumstances beyond their control. We have seen this moral injury play out in real time during this pandemic. , , Healthcare providers are putting their own health (and subsequently their families' health) at risk when treating patients without proper personal protective equipment. Healthcare providers are overwhelmed while watching patients struggle and having so little to offer them. Healthcare providers are emotionally exhausted holding the hands of dying patients without their family members at the bedside because of the infection risk. Healthcare workers suffer when the public health response is inadequate. The souls of healthcare providers are hurt when capacity is exceeded and people die because of it.

Looking toward a future when COVID-19 looms less large, it will be imperative to focus on fixing what is broken in the way we deliver healthcare. Optimizing population health and the health of individual patients will require attending to the misaligned goals of healthcare providers, health insurers, hospital administrators, regulators, and the public. In the realignment of healthcare, patients' needs should be the top priority, and everything that does not facilitate the achievement of improving the health, functioning, and well-being of patients and populations should reconsidered. Although mindfulness practices, relaxation techniques, exercise, and the like will still have a role in the management of burnout, what we really need is collective action to promote clinician well-being that helps healthcare providers carry out their lives' work—to provide the best possible care to the patients and communities whom they serve.