Provider Burnout, in the Flesh

Two months ago, I truly felt that if a student opened a nursing textbook to the few pages on “burnout”, my picture would be there. I am a nurse practitioner in a busy general neurology practice, with a sub-specialty in Multiple Sclerosis. I am efficient, have good time management skills, and do my best not to run late. I usually have a speaking engagement two nights per week after clinic, and once a week I teach yoga to people living with MS for my nonprofit organization, oMS Yoga. I have a busy, full life, and while these extracurricular activities certainly take away from time for rest and rejuvenation, I love to do them. Educating peers and patients comes natural to me, and teaching yoga to people living with MS is one of the best things I have ever done in my medical career. Sounds great, right? Well, a month ago, I took an unpaid leave of absence from my practice. You might ask, then, what happened?

Burnout Defined

• A long-term stress reaction resulting in depersonalization, negative attitudes, emotional exhaustion, feelings of decreased personal achievement, and lack of empathy. (from the AMA module, “STEPSforward: Preventing physician burnout, http://www.stepsforward.org)
• By the inventors of the Maslach Burnout Inventory: “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.” (Christina Maslach)
• Burnout results in decreased care and professionalism, increased errors, lower patient adherence and satisfaction, and increased rates of substance abuse/suicide/intent to leave practice.

Do Patients Cause Burnout?

Well, sure, there are certain personality types that can eat away at a health care provider: the person who refuses every option for treatment presented by you and many other providers and continually says, “No one can help me”; the “woe is me” personality, or as I call it, the “Eeyore” (think Winnie-the-Pooh), who usually does not want to dismiss the sick role; the person who comes in armed with information from Google University, looking for an argument… the list goes on and on. But, if you are armed with a healthy personality and a healthy sense of humor, these people just become little potholes in the day. You cruise over them, and forget they happened. Two months ago, I was finding it much harder to cruise over them. I felt like I was getting whiplash every time I hit a pothole.

Does the System Cause Burnout?

Well, sure it does! We don’t get reimbursed as well as we used to, and certainly not for time spent in care and concern of a patient and their family. We get monitored for checking specific boxes, documenting things that may be irrelevant to a case, and making sure we send in a prescription electronically, even if the patient doesn’t need one. We spend countless non-reimbursable hours filling out step edit forms, writing letters of prior authorization, and trying to get physicians on the phone to get appropriate studies approved for patients. Even older medications require prior authorization. Blue Cross and Blue Shield of Florida has a six-page form to get PT approved for some of its plans. We learn how to play in a sandbox that doesn’t have the right tools, that doesn’t support us, so that we can adequately care for our patients. Some days, it feels like swimming while holding a 100-pound rock.

Then There is the EMR

I come from the earliest part of the electronic generation, having entered nursing in 1998. I adapt easily to electronic changes, but that does not mean that I like them (I still use write in an old-fashioned planner). It does not mean electronic tools support me. Most of us went into nursing and medicine to care for patients. A large part of care is looking a person in the eye, establishing a connection and rapport, and sharing humanity with patients. The EMR has taken away from this time as we make sure to double cross our T’s and dot our I’s, and code correctly. That connection with patients, if one is not very skilled in communication, becomes a thin tight rope to walk as we peck away at keyboards.

And I haven’t even mentioned the shortage of nurses, and of certain physician specialties, adding to increased demands and workloads.

A study published in Archives of Internal Medicine in 2012 (172(18): 1377-1385) by Shanafelt TD et al., based on the Maslach Burnout Inventory, revealed that over 40% of physicians report at least one symptom of burnout, and that having a higher level of education (such as an MD or DO degree) correlated with increased burnout. The American Medical Association has actually created a series of modules to help physicians learn to be resilient, and to prevent burnout, in the face of today’s rapidly changing health care delivery system (see http://www.stepsforward.org).

According to the Erickson & Grove, who published an article on burnout in Nursing World (2007, 13(1)), younger nurses are more likely to experience burnout and less likely to seek out measures of self-care. Burnout is associated with greater negative feelings towards ones job, and a greater likelihood of leaving the profession. According to a 2001 American Nurses Association (ANA) staffing survey, nurses report leaving work feeling “exhausted and discouraged (50%); “discouraged and saddened by what I couldn’t provide for my patients” (44%); “powerless to affect change necessary for safe, quality patient care." In spite of this, for the 13^th year in a row, nurses ranked highest in a 2014 Gallup poll asking Americans to rate the most honest and ethical professions.

Burnout among ARNPs takes on a slightly different form, as we are not necessarily dealing with a nursing shortage, so to speak, but rather a shortage of resources. In busy clinical practice, there may not be a medical assistant, or a clinic nurse, for every provider. ARNPs often take the brunt of the paperwork for disability forms, prior authorizations, and step-edits, not just for their own patient base, but for that of the physicians for whom they work…because, well, they are “the nurse.” Sanjay Gupta, MD, references Linda Aiken, PhD, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. Dr. Aiken notes that nurses tend to underestimate the time needed to recover from stressful clinical situations. In the American Nurse Today (2012, 7(4)), Gessler and Ferron also report the electronic medical record and patients who diagnose and treat themselves by Google as additional issues contributing to burnout.

What Are the Warning Signs?

According to Dike Drummond, MD, warning signs include not being able to recover on your days off, or simply during your non-working hours; feeling cynical, sarcastic, or negative towards patients; and the tendency to see your work as valueless/meaningless.

What Do You Do About It?

Self-care needs to become a priority. What else is going on in your life such that you cannot recharge? What are you doing TO recharge? For example, are you investing time in unhealthy habits that actually make you more tired and can cause depression, like alcohol overuse? Can you start small? For example, five minutes a day of non-professional reading, deep breathing, prayer, or meditation? I have always admired my boss for leaving the office everyday at lunch. He remains with a positive attitude and a light outlook. He lets go, rejuvenates, and re-engages. If that is not possible in your clinic, can you shut the door for five minutes in the middle of the day?

Take a look at your nutrition. Do certain foods make you feel bad? Work them out of your diet. Add in physical activity. Find an activity that you enjoy. Take competition out, unless you thrive in that environment. Enlist the help of your support system to uplift you: friends, family, church community, exercise community. Consider counseling, acupuncture, massage. Just say no. Make yourself a priority; say yes to your priorities, and no to things that get in the way of your time for renewal each day.

What happens when you ignore the warning signs? There are several possibilities. Continued stress, unhappiness, and eventual illness as a result are just a few. Then there are addiction, accidents, medical mistakes. In my case, I recognized the warning signs, and had to literally step out. I couldn’t find my way out of the labyrinth at home. I had a bad feeling that, if I did not take steps to slow down, something would do it for me…an accident, an illness, something undesirable. I took a financial risk, a career risk, a month away from my practice, and left the mainland US. A little more than halfway in, I can see much more clearly my worth, the importance of incorporating renewal daily, and, fortunately, how much I love what I do. I’ll be ready to return. My days will look different. I have already turned down two potentially exciting speaking engagements so that I am sure to have weekends at home, and I am not tired before the work week even starts. I am practicing the art of “No”.

Anthony de Mello said, “Life is a banquet, and the tragedy is that most people are starving.” Dig in. To your life. You will be a better person for it, for yourself, your family, your friends, your staff, your colleagues, and your patients.