Healthcare needs an expanded vocabulary for what clinicians experience.
Pre-pandemic, healthcare had its lowercase burnout and uppercase burnout.
Uppercase burnout is the textbook term, coined in 1974 by American psychologist Herbert Freudenberger, PhD, for the stress and exhaustion felt by those in service professions that makes it tough to cope. In 2017, CEOs of the nation's most prominent health systems categorized burnout among physicians as a public health crisis and outlined an 11-step response. In 2019, the World Health Organization finally included burnout in its International Classification of Diseases, describing it as "a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed." Uppercase burnout is both a condition and a studied, well-known public health threat, like driving without a seatbelt.
Lowercase burnout is more personal, ubiquitous and messy. Pre-pandemic, it was the status quo, with 42 percent of physicians reporting that they were burned out before COVID-19 spread to the U.S. In 2014, 54 percent of physicians experienced burnout, with those in general internal medicine, family medicine and emergency medicine hit hardest.
Pre-pandemic, lowercase burnout was the daily grind: The documentation, prior authorizations and two hours clicking away on an EHR for every one hour with patients. The reduced clinical hours and turnover that culminated in more than $4 billion in annual costs and a doubled likelihood of patient safety incidents. Lowercase burnout was the daily, unaddressed manifestation of exhaustion, cynicism and feeling ineffective. It was the tough days that led to bad weeks that led to foggy months.
When COVID-19 first hit U.S. hospitals, lowercase burnout was already alive and well.
In an age where websites load in 1.29 seconds on average, it can be confounding when our language does not catch up to our circumstances. If clinician burnout was a public health crisis pre-pandemic, then what is it now? Is "burnout" even the right word for what America's medical professionals are experiencing?
Beyond that one word
Slapping the term "burnout" on a range of conditions might have gotten healthcare from there to here. At the very least, the term and attention paid to it allowed us to focus on the mental well-being of the medical workforce. But to best convey and communicate clinicians' experience now, leaders and organizations need expanded vocabularies, strategies and resources.
In conversation with physician and health system leaders, a variety of terms were put forth to describe what clinicians have experienced since the pandemic began, including fear, anxiety, overwhelm, moral injury, fatigue, feeling out of character, loss of control, frustration, anger, dismay and disillusionment.
A number of analogies were also used to describe what this new brand of struggle feels like. One described it as being slammed underwater by a wave, topsy-turvy, unable to see anything but white. Another described it as trying to start a fire in a soaking wet environment short on oxygen.
One compared it to an endless marathon. "As we get to the 24th mile of the 26.2 mile race, the finish line keeps moving back," said Kate FitzPatrick, DNP, RN, chief nurse executive officer of Jefferson Health. "It's that level of mental exhaustion, physical exhaustion. It's just 'overwhelm.'"
What sets this experience apart?
"The reason that 'burnout' doesn't apply that well is that there are a myriad of forces that lead clinicians to feel a variety of emotions, including being undervalued, being frustrated, perhaps being fearful, and being overextended. The emotion might get placed in a bucket of burnout, but there are different factors depending on the circumstance," said Gregory Kane, MD, chair of the department of medicine and the Jane & Leonard Korman Professor of Pulmonary Medicine at Thomas Jefferson University Hospital in Philadelphia.
It's more than prior authorizations or EHR clicks. Fear, moral injury, invalidation and isolation are just a few of the distinctive facets of many clinicians' experience since the pandemic began.
Fear
The intensity of fear alone that physicians, nurses and staff experienced around COVID-19 distinguishes their experience from pre-pandemic burnout. Exacerbating it was a national shortage of personal protective equipment and variation in organizations' responses and policies.
"Fear is relatively new during the pandemic," said Jonathan Gleason, MD, executive vice president and chief quality officer for Jefferson Health in Philadelphia. "And it wasn't just fear for your own safety. For many of our folks, they were talking about the safety of their kids or a parent who lives with them. In healthcare, we work a lot of long hours and a lot of nights and weekends. So there is a little bit of guilt all of us have about being away from our families so much. Then you add to that the ability to harm them — that part of it is unique and beyond burnout."
Inefficacy and moral injury
Compounding clinicians' fear and anxiety about the airborne transmission of COVID-19 was their proximity to the immense and relentless damage inflicted by the virus on poor communities and communities of color. In the first six months of 2020, 53 percent of all in-hospital deaths from COVID-19 were among Black and Hispanic patients, according to research from Palo Alto, Calif.-based Stanford Medicine. (The U.S. Census Bureau estimates that Black people make up 13.4 percent of the U.S. population, Hispanic people 18.5 percent and white people 60 percent.)
Preexisting conditions were often blamed for the disparate morbidity rates among white people and people of color, sidestepping how racism is a preexisting condition itself in America. Healthcare professionals see its unjust, downstream effects every day. When the nation watched footage of police officer Derek Chauvin killing George Floyd with a knee to his neck May 25, 2020, long-standing inequities in healthcare became intolerable. "Racism and anti-Blackness in our country's structures and medical systems can be seen as clearly as the footage of Mr. Floyd's life being taken," physician and public health leaders wrote in Health Affairs. "They warrant immediate reform."
"Burnout might be one thing," said Kelly Cawcutt, MD, associate medical director of infection control and epidemiology for Omaha-based University of Nebraska Medical Center. "But there perhaps may be more moral injury being faced by working in a system that is broken, has not been equitable, has not been inclusive, hasn't necessarily maintained the level of fairness and justice and the attributes you're taught when you go to medical school about what it means to be a physician and to care for everyone and provide that best level of care you can."
Invalidation
Many clinicians' raw emotions were met with performative gestures (clapping but not masking), toxic positivity, and reductive suggestions to take a walk, yoga class or deep breath.
"From a physician standpoint, pre-COVID, one of the things that was extraordinarily frustrating was the workload burden that frequently led to burnout," said Dr. Cawcutt. "What frequently happened was so much advice of, 'Oh you just need more self-care. You should sign up for a yoga class.' Well, my individual yoga has nothing to do with the system that is starting to fail and overstretching us where we can't do our jobs the way we need to."
When leaders, managers or colleagues responded to new emotions and experiences with good intentions but the same menu of pre-pandemic solutions, healthcare professionals felt worse. This was exacerbated when the national sentiment split, with widespread celebration of "healthcare heroes" turning into politicized resentment, sneers at healthcare's calls for masking and safety, and the pitting of public health against economic viability.
"You go from being 'heroes' to the flip of that — the people who are causing the problem, the reason there is a problem, the reason the economy is failing. It's very hard to manage that kind of flip-flop," said Dr. Cawcutt.
Isolation
Healthcare professionals couldn't turn to their familiar outlets for stress, which is something they shared with much of America throughout the pandemic. Quality time with family and friends or rejuvenating workouts at the gym were not widely accessible.
But something more unique to healthcare professionals' experience is deceptively obvious, yet incurs its own emotional toll: How little they have been able to fully emote and see one another's faces for a year-plus. Don't misunderstand — masking is a must in healthcare organizations. But its necessity doesn't negate its unintended consequences.
"A component of this that I think adds another layer of complexity is interacting with patients in full PPE," said Dr. FitzPatrick. "Some of those emotions were lost because we lost key parts of our body in how we emote. The basic emotion of happiness, smiling or showing warmth — you can't do it in ways you normally would. It's hidden by the PPE we are still wearing."
Are your managers and leaders ready for this?
At Jefferson Health, CEO Stephen Klasko, MD, and numerous senior leaders at the system are working to expand the way Jefferson responds to exhaustion and struggle among its 32,000 associates.
So far, more than 2,500 Jefferson staff across all levels of the system have undergone psychoeducation, including training on coping skills to support personal and collegial well-being. Some within that group also received formal training on an evidence-based mental health support methodology. Jefferson is just getting started. Leaders plan to expand the number of colleagues who receive these resources and opportunities to strengthen emotional support skills.
Because one thing that became clear at Jefferson is likely true at most health systems nationwide: Managers didn't know what to do or say when a team member said they were struggling.
"The hardest thing we've found when we encounter well-intentioned managers is they have been very forthright in saying, 'We just don't know how to talk about this. We know we're at a critical intersection, but we don't know what to say,'" says Michael Vergare, MD, former chair of psychiatry and human behavior with Thomas Jefferson University and Sidney Kimmel Medical College in Philadelphia. "That's led us to develop more training for them and services to help them become a bit more sophisticated psychologically so we can observe along the way and intervene earlier."
While managers might feel especially hamstrung responding to others' emotional hardship on the job, they are one small part of a wider, long-standing culture in medicine that has rewarded and upheld perfectionism, excessive hours and little vulnerability. This is nothing new: Physicians and healthcare professionals have grown up in this culture for decades, each with their own war stories that hardly promote well-being. Medical school may be the last time introspective conversation or questions about how they're doing are commonplace.
"There is a whole repertoire of ways to talk that even I am still learning, but we don't regularly build that into our work processes," says Dr. Vergare. "When you add to that a personality that is hyper-serious, concerned and perfectionistic in everything they do, we're talking about a perfect storm."
More than word choice
As COVID-19 cases steadily decrease in the United States, it's tempting to think healthcare professionals' exhaustion will naturally subside, too. Maybe it will, to some degree. But the mental and emotional effects of the pandemic are going to be with us for a long time. And it's not as though pre-pandemic rates of burnout are an especially attractive destination to rebound to.
Naming distinct emotions or experiences helps diffuse their charge and gives us a say in what we do with them. Hospitals and health systems are at a tipping point. Attitudes, language and responses to suffering among their own will either expand and evolve, or stay narrow, stuck in pre-pandemic thinking wherein "burnout" is the diagnosis for every less-than-great emotion. Who wants to work in the latter?
Burnout isn't always the right word. Ask your people what is, and why.
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