Thriving, Not Just Surviving: Recognizing Burnout and Simple Tips to Start Feeling Better.

Burnout has been prevalent since before COVID-19 and continues to affect a large portion of the health-care workforce. At JADPRO Live Virtual 2021, Margaret Leddy, PA-C, MMSc, defined burnout in the setting of the oncology/hematology advanced practice role, described symptoms you can recognize in yourself and others, and provided three tips to combat burnout.

An estimated one third of oncology providers had burnout prior to COVID-19. Unfortunately, these percentages have risen substantially since the start of the pandemic. During JADPRO Live Virtual 2021, Margaret Leddy, PA-C, MMSc, physician assistant and Duke Wellness Ambassador, defined burnout in the setting of the hematology/oncology advanced practice role and discussed recognizing symptoms of burnout in oneself and others. Ms. Leddy also shared three tips to combat burnout.

“This is a topic that is near and dear to my heart,” said Ms. Leddy. “We need to be discussing burnout more and doing more things about it.”

DEFINING BURNOUT

According to Christina Maslach, PhD, Professor Emeritus at University of California, Berkley, who has spent her career studying the phenomenon, burnout is defined by the three following pillars (Maslach et al., 1996):

Depersonalization: callousness and seeing others as objects

Inefficacy: diminished sense of accomplishment and feeling like nothing you do matters

Emotional exhaustion: being overwhelmed, drained, and unable to meet demands

Ms. Leddy described her own struggle with burnout to attendees at the JADPRO Live conference: “It was everything I could do to get through the day,” she said. “I didn't have anything to give to my patients. I had zero empathy. And then I’d get home and I would have nothing to offer my family. I was just running on empty all the time.”

THE STATS ON BURNOUT: ONCOLOGY IS HIGH RISK

Ms. Leddy reported pre-COVID rates of burnout between 25% and 35% among medical oncologists, between 28% and 36% among surgical oncologists, and 28% among radiation oncologists (Shanafelt et al., 2012).

However, the phenomenon is not limited to physicians. Oncology physician assistants experience burnout at a rate of 35% along with high rates of emotion exhaustion (30.4%), high depersonalization (17.6%), and a low sense of personal accomplishment (19.6%; Tetzlaff et al., 2018), and the rates for oncology nurse practitioners are nearly the same (Bourdeanu et al., 2020).

Ms. Leddy, who has worked in numerous subspecialties, including orthopedics, general surgery, and cardiothoracic surgery, listed several unique elements of oncology that may be driving the high rates of burnout.

These challenges include constant life-and-death decisions, administration of potentially toxic therapies, long work hours, increasing productivity requirements, new information and regulations, loss of autonomy, reduced work/life balance, and limited ability to prolong life for many patients.

“I don't think anybody can be in a room and watch a family suffer and cry and have all these emotions and not have it take a toll,” said Ms. Leddy. “In oncology, I think this also contributes significantly to the amount of burnout.”

“Even if you are not burned out right now—and I would be surprised if there is somebody out there in health care right now who is not burned out—the person next to you likely is,” she added.

SIGNS OF BURNOUT

Signs of burnout include headaches, muscle tension, trouble with sleep, feeling overwhelmed, irritability, losing your temper, sense of apathy or over-complaining, feeling depleted after work, and not wanting to go to work on Monday.

“When I was completely burned out, I thought this was normal,” said Ms. Leddy. “I thought that everybody in health care felt this way…but this is not normal. This is burnout.”

According to Dr. Maslach, burnout is a psychological syndrome that emerges as a prolonged response to chronic interpersonal stressors on the job. While acute elevations in cortisol levels are beneficial to promoting survival of the fittest as part of the fight-or-flight response, said Ms. Leddy, chronic exposure to stress results in reversal of the beneficial effects, with long-term cortisol exposure becoming maladaptive (Russell & Lightman, 2019). This can lead to a broad range of problems, including metabolic syndrome, obesity, cancer, mental health disorders, cardiovascular disease, and increased susceptibility to infections.

“Your body literally starts to suffer from prolonged chronic stress,” said Ms. Leddy, who also described the phenomenon as “insidious.”

“You don't wake up one morning and suddenly go from being happy to being completely burned out,” she said. “It happens over a span of time, very slowly.”

The effects are not just physiological, however. Burnout is also associated with lower quality of relationships/mental satisfaction, depression/PTSD/suicide, traffic violations and accidents, personal injury, depressed immune system, and shorter lifespan.

OUTDATED OPERATING SYSTEMS

According to Ms. Leddy, one of the main problems driving burnout is our maladapted brains.

“We all have an outdated operating system,” she said. “Our brains function from the caveman days.”

In prehistoric times, she explained, our brains were structured just to keep us safe from danger. When we were running from a saber-tooth tiger, for example, we didn't stop to enjoy a flower on the path. That may have kept us safe at the time, but this programming continues to influence how we see the world today, even though we stopped running from saber-tooth tigers long ago. Put another way: our brains have not evolved as quickly as society and technology have.

In fact, a recent eye-tracking study demonstrated that burned-out eyes see the world differently (Bianchi & Laurent, 2015). When given both positive and negative stimuli to look at, the subjects who were burned out focused more on the negative or dysphoric stimuli and less on the positive.

“In medicine, that is what we are trained to do,” said Ms. Leddy. “We are trained to look for the negative: ‘What is the next thing that is going to hurt our patients?’”

BREAKING THE BURNOUT CYCLE

According to Ms. Leddy, breaking the burnout cycle requires change.

“When I was working and trying so hard, I always thought ‘If I just do it harder, if I just work harder, I will feel better,’” said Ms. Leddy. “If whatever you are doing isn't working, don't do it harder. We have to change something to break the cycle.”

The good news, however, is that change is possible because of neuroplasticity, or the brain's ability to form and reorganize synaptic connections, especially in response to learning or experience or following injury.

“Right now, if you are burned out, you have a mega-highway to see the negative,” said Ms. Leddy. “That is how your brain is wired, and that is the easiest default for our consciousness to stream into.”

For those with burnout, the pathway to see the positive may be tiny, but it's there, said Ms. Leddy, and because of neuroplasticity, exercises can be used to help the brain flip its perspective.

“Neuroplasticity allows us to underutilize the path for seeing the negative and set up a big highway for seeing the positive,” she said.

3 TIPS TO HELP REWIRE YOUR BRAIN

Ms. Leddy recalled three tips to combat burnout and its deleterious effects on health-care providers and the entire care team: three good things, core values, and mindfulness.

Three Good Things

Designed by Martin Seligman PhD, a psychologist treating severely depressed patients, this exercise involves writing down three good things per day for 7 days (Seligman et al., 2005). After following patients for 6 months, Dr. Seligman found sustained levels of increased happiness and decreased depressive symptoms. Ms. Leddy emphasized the importance of timing with this exercise: “Either do it every day for 1 week or extend to 14 days, and do it within 2 hours of bedtime,” she said. “Your brain rewires at night, so doing it closer to bedtime helps your brain go into that sleep state with the right mindset.”

Core Values

“If you’re in a job that doesn't match your core values, you will always have some level of burnout,” said Ms. Leddy. “In order to make that better, you have to know what your core values are. Core values are like your compass.”

The best exercise for getting to the root of one's core values takes only 10 minutes and involves circling 10 to 15 words from a list of values. Participants then condense those words down to two core values that can be used to guide decisions. “Your life will start aligning with your values,” said Ms. Leddy.

Mindfulness Meditation

Like bicep curls for the brain, mindfulness meditation can increase attention control, emotional regulation, and self-awareness by connecting the amygdala with other parts of the brain to eliminate brain fog (Tang et al., 2015). Importantly, creating new synaptic connections doesn't require “sitting like a monk for hours and hours,” said Ms. Leddy. Rather, it can be as simple as “feeling the warmth of the first sip of coffee in the morning go from your mouth all the way down to your stomach. This is how I started being mindful. There is nothing better than the first sip of coffee in the morning.”

“Mindfulness meditation is just being present in the moment—not thinking about your past and not thinking about your future,” said Ms. Leddy. “That's what builds those new synaptic connections.”

“All I want you to do is pick one thing today,” Ms. Leddy concluded. “Integrate one thing into your day because one thing makes a huge difference down the road. You will build off this. Your brain loves this stuff. It wants this stuff, and it will build off it from there” (Figure 1).

Figure 1

Integrate one thing: The power of a one-degree shift.