The UK is not short of healthcare scandals which in turn lead to reports that catalogue clinical failures often associated with callous and unprofessional behaviour. Jeremy Hunt speaking at the Kings Fund in 2012 put his finger on the issue when he said 'In places that should be devoted to patients, where compassion should be uppermost, we find its very opposite: a coldness, resentment, indifference, even contempt. Go deeper and look at the worst cases like Mid Staffs and Winterbourne View, and there is something even darker: a kind of normalisation of cruelty where the unacceptable is legitimised and the callous becomes mundane.' Yet most clinicians start their career with the best intentions and are often altruistic in their outlook. So how can things go so terribly wrong?
As regulators it is important to ask what culture is created by some of the actions taken with the intention of protecting patients. In 2015 we published a series of three papers* examining the impact of complaint procedures on doctors. We found high levels of moderate to severe anxiety and depression as well as suicidal ideation for all types of complaint procedure, particularly those involving referral to the General Medical Counicl (GMC). We found doctors who had been involved in complaints procedures were very likely to practise medicine defensively, meaning that they hedged (e.g. overprescribed, over referred, over investigated) or practised avoidance (e.g. abandoned procedures early, avoided difficult patients or surgery). This behaviour is clearly not in the interests of patients and adds significantly to healthcare costs. Furthermore this contributes to the blame culture and fear that permeates both the NHS and other healthcare systems. This ultimately does not help in relation to burnout.
What is burnout?
First of all we need to define what burnout is. The WHO defines it as a syndrome conceptualised as resulting from chronic workplace stress that has not been successfully managed. It has three dimensions:
- emotional exhaustion,
- depersonalisation, and
- reduced professional accomplishment.
Of the three, depersonalisation manifests as negative, callous, and cynical behaviours; or interacting with colleagues or patients in an impersonal or unprofessional manner.
Critically it is associated with an inability to express empathy or perhaps grief when a patient dies. Emotional exhaustion sounds familiar to all of us, but it is particularly prevalent when people are forced to devote excessive time and effort to tasks that are not perceived to be beneficial (examples of this might be struggling with poor hospital IT and patient records, inappropriate bureaucracy, or aspects of appraisal).
To understand the size of the problem we carried out a survey study that was sent to all obstetricians and gynaecologists in the UK. Over 3,000 clinicians (response rate of 55%) completed a validated instrument to measure burnout (the Maslach Burnout inventory), an assessment of defensive medical practice and answered questions about wellbeing. Alarmingly, we found 43% of trainees and 31% of consultants met the criteria for burnout. Clinicians with burnout were approximately four times more likely to practise defensively. Doctors with burnout were three to four times more likely to report depression, anxiety and anger/irritability. One in 16 doctors with burnout reported suicidal ideation.
Interestingly when we published this paper, it was the Sun newspaper that put two and two together: 'Researchers from Imperial College London warn one in three maternity doctors are struggling with burnout….. The findings follow the revelations last week that dozens of babies and several mums died amid major failings at a hospital trust. In the biggest maternity scandal in NHS history, blundering doctors, midwives and bosses worked unchecked in a "toxic" culture at Shrewsbury and Telford Hospital Trust for 40 years.' I think the journalists at the Sun were absolutely right to make this association.
Let’s discuss a little more about why burnout matters. I think we have seen above some of the impacts on individuals. For the individual clinician there is an increased likelihood of alcohol and substance abuse, broken relationships/divorce, depression as well as suicide. For institutions it is associated with decreased quality of care and an increase in medical errors, decreased patient satisfaction, poor professional behaviour, decreased professional effort and increased staff turnover. In a large systematic review on burnout nearly every study examined showed an association between burnout and patient safety incidents, lack of professionalism and low levels of patient satisfaction. Risk factors for burnout include unrealistic expectations, being a young adult with an idealistic worldview, lack of control, heavy workload, understaffing and a variable work schedule. These read rather like the job description and traits of a junior doctor.
What are the solutions?
What are the solutions? I think the report by Professor Michael West and Dame Denise Coia outlines many of these. Several key themes are important including introducing mechanisms for doctors to influence the culture of their healthcare organisations and decisions about how medicine is delivered, and improving working conditions including work schedules and rotas. In addition, the creation of supportive teams, ensuring organisations have a nurturing culture, and tackling workload are of paramount importance. This is hardly 'rocket science', and it is disappointing that these requirements need to be pointed out to organisations that purport to specialise in caring for people.
The UK is not an outlier by any means in terms of burnout and its effects. In the United States in 2017, the National Academy of Medicine (NAM) launched the Action Collaborative on Clinician Well-Being and Resilience, a network of more than 200 organisations committed to reversing trends in clinician burnout. The NAM was so alarmed they described burnout as a healthcare emergency. They estimated the societal costs of burnout in the USA each year amounted to $4.6 billion. It is well worth looking through some of the resources that the NAM has created by visiting their website.
Of course, everything I have written relates to what was happening before the SARS-CoV-2 pandemic. In a large survey study on UK doctors carried out by the BMA some of the qualitative answers given by doctors perhaps speak more eloquently than data:
'Seeing people dying, receiving and breaking bad news, no socialising outside work to refresh and recharge – all these factors increased the level of anxiety and depression'
'I signed up to be a doctor. But my family didn’t choose this career path, I feel like I’ve forced the risk on them and I can’t get away from the guilt,'
'I am frequently tearful about all those who have died; continuously fearful of contracting Covid and secondarily infecting my family.'
How the experience of working through the pandemic impacts on the medium to long-term wellbeing of clinicians is a major concern.
Unfortunately institutions more often than not position burnout as a personal responsibility and mistakenly offer stress management workshops, individual training in resilience or similar initiatives as the only solutions. This fails to grasp the importance of implementing organisational strategies to deal with the problem. Some of these are usefully summarised in a review by Tate Shanafelt, who is the chief wellness officer (CWO) and associate dean at Stanford medicine. It is also worth quoting how he sees his role: 'health care CWOs must focus primarily on improving their organizations' work environment and culture, not on developing individual-level interventions, such as personal resilience, mindfulness, and self-care offerings. The goal of this work is to address what is wrong with the practice environment, not to make individuals better able to tolerate a broken system.'
Given the clear association between burnout and the quality and safety of patient care, I would argue that it should be compulsory for institutions to measure levels of burnout and other metrics of staff wellbeing down to individual department level. This should be used as a measure of quality of care alongside other outcome measures. Regulators should take a keen interest in this data when judging the behaviour and actions of individuals, who are often victims themselves of a toxic and unhealthy culture.
Professor Tom Bourne is Chair in Gynaecology at Imperial College London, Hon Consultant Gynaecologist at Queen Charlottes and Chelsea Hospital and Visiting Professor at KU Leuven Belgium. He is director of early pregnancy research at the Tommy’s National Centre for Miscarriage Research. He is President of the International Society for Ultrasound in Obstetrics and Gynecology and the UK Association of Early Pregnancy Units.
Personal webpage: https://www.imperial.ac.uk/people/t.bourne
Summary of links and references used in the blog:
- https://www.gov.uk/government/speeches/28-november-2012-jeremy-hunt-kings-fund-quality-of-care last accessed 4th March 2021
- *Bourne T, Wynants L, Peters M, et al. The impact of complaints procedures on the welfare, health and clinical practise of 7926 doctors in the UK: a cross-sectional survey. BMJ Open 2015;5:e006687. https://bmjopen.bmj.com/content/5/1/e006687
- *Bourne T, De Cock B, Wynants L, et al. Doctors' perception of support and the processes involved in complaints investigations and how these relate to welfare and defensive practice: a cross-sectional survey of the UK physicians. BMJ Open 2017;7:e017856. https://bmjopen.bmj.com/content/7/11/e017856
- *Bourne T, Vanderhaegen J, Vranken R, et al. Doctors' experiences and their perception of the most stressful aspects of complaints processes in the UK: an analysis of qualitative survey data. BMJ Open 2016;6:e011711. https://bmjopen.bmj.com/content/6/7/e011711
- Burnout, well-being and defensive medical practice among obstetricians and gynaecologists in the UK: cross-sectional survey study. Bourne T, Shah H, Falconieri N, Timmerman D, Lees C, Wright A, Lumsden MA, Regan L, Van Calster B. BMJ Open. 2019 Nov 25;9(11):e030968. doi: 10.1136/bmjopen-2019-030968. https://bmjopen.bmj.com/content/9/11/e030968
- https://www.thesun.co.uk/news/10422581/burnout-doctors-babies-at-risk/ last accessed 4th March 2021
- Panagioti M, Geraghty K, Johnson J , et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis. JAMA Intern Med 2018;178:1317–30.doi:10.1001/jamainternmed.2018.3713
- https://www.gmc-uk.org/about/how-we-work/corporate-strategy-plans-and-impact/supporting-a-profession-under-pressure/uk-wide-review-of-doctors-and-medical-students-wellbeing last accessed 4th March 2021
- https://nam.edu/initiatives/clinician-resilience-and-well-being/ last accessed 6tMarch 2021
- https://www.bma.org.uk/bma-media-centre/personal-impact-of-the-covid-19-pandemic-on-doctors-wellbeing-revealed-in-major-bma-survey last accessed 6th March 2021
- Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Shanafelt TD, Noseworthy JH. Mayo Clin Proc. 2017 Jan;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004.
- The Health Care Chief Wellness Officer: What the Role Is and Is Not. Ripp J, Shanafelt T. Acad Med. 2020 Sep;95(9):1354-1358