Evidence-Based Reviews

How to avoid burnout and keep your spark

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Burnout develops slowly and insidiously; there are no fire alarms, no smoke. It is easy to ignore the warning signs. As psychiatrists, we are at high risk for burnout, and the consequences can be devastating. We have:

  • suicide rates 2 to 3 times higher than those of the general population
  • higher rates of divorce and substance abuse compared with other physicians and non-physicians (Table 1).1-12

Burnout affects 25% to 57% of our profession at any given time,13 yet we seldom address it. Despite vast literature on burnout in family medicine and other medical specialties, psychiatric burnout is grossly under-recognized. It’s as if we aren’t supposed to burn out; after all, aren’t we the experts others come to when they are burned out?

If you think you may be heading toward burnout, we offer practical, evidence-based information to help you:

  • prevent burnout
  • diagnose burnout, “brownout,” and “compassion fatigue”
  • begin to make immediate changes to over-come burnout and reclaim your life.

Table 1

Relative rates of divorce, suicide, and substance abuse among psychiatrists

EventPsychiatristsOther physiciansGeneral population
Divorce*50% (2.7 times risk of other physicians)322% to 24% in internists and pediatricians310% to 20% less than among physicians4
Suicide28 to 40/100,0001 (2 to 3 times rate in general population)May be similar to rate among psychiatrists† Equal rates in male and female physicians12/100,000
Rate in female physicians is 2 to 4 times that of women in general population1,2,5
Substance abuse6-10
Benzodiazepine use (past year)626.3%7% to 16% (11.4% across all specialties)
Lifetime abuse/dependence614.3%7.9%
Alcohol only7.9%4.2%
* Divorce risk across 30 years
† Some but not all evidence indicates psychiatrists have higher rates of suicide than other physicians1,2,11,12

Case: ‘Something in me had died’

I (PB) was 50 years old, racing along, seeing patients 45 hours a week, and keeping a full schedule of teaching and writing. Psychotherapy was my primary training and my love, but monitoring medications for other therapists—without getting to know the patients—had become unsatisfying. My practice group had exploded from 5 mental health professionals to more than 20, creating unexpected stresses and conflicts. At the same time, my marriage was failing.

Increasingly overextended, I lost my good humor. I became irritable and short with everyone, and—worse—I felt resentful and burdened by my patients. Once eager for challenges, I avoided new consults and referrals. Every hour was filled with dread, and I struggled to get through the day. Empty, numb, and miserable, I had burned out but did not realize it. I only knew that something in me had died.

I started fantasizing about retiring from clinical work, but what would I do then? What if this was the end of my career?

Burnout is a ‘heart attack’

Most burnout definitions include three features: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.14 Some writers describe it as a state of mourning: “A grief syndrome due to loss of our dreams or sense of purpose or mission, leading to the experience of emotional depletion…expectations clash with an imposing reality.”15

Burnout represents a loss of meaning. It resembles a “spiritual heart attack,” with “referred pain” that affects our work, our relationships, and our soul. We become members of the “coronary club” (Box 1).16

Box 1

‘Coronary Club’ membership rules
  • Your job comes first; personal considerations are secondary.
  • Go to the office evenings, weekends, and holidays.
  • Never say no to a request; always say yes.
  • Accept all invitations to meetings, banquets, committees, etc.
  • Do not eat a restful, relaxing meal; always plan a meeting for the meal hour.
  • Never delegate responsibility to others; carry the entire load by yourself at all times.

Are you getting close to eligibility?

External causes. Burnout causes include the usual suspects: external factors such as increased paperwork, managed care hassles, lower reimbursement rates, and fears of litigation. In psychiatry, we also face occupational hazards associated with continuous exposure to depressed, violent, suicidal, and personality-disordered individuals.

The “15-minute” medication check is probably the most demoralizing hazard. Pressure from managed care to focus on brief contact with patients only for medication management is dispiriting, resulting in:

  • little time for empathic connection
  • loss of professional autonomy
  • fear of greater liability risk than when we handle psychotherapy and medication
  • fear of lost income if we opt not to accept medication-only referrals.17-21
In a 1998 survey of 100 Manhattan psychiatrists assessing the impact of managed care on their practices, 70% of respondents said they “would not recommend a career in private practice to a graduating psychiatry resident.”22

Internal causes. Approximately 60% of job satisfaction is related to internal determinants: attitudes, beliefs, lifestyle, and coping techniques. Burnout is not simply the result of overwork, underpay, or increasing demands of a changing medical culture. If all managed care hassles disappeared tomorrow—if paperwork went away and reimbursements flowed freely—burnout would continue because it is the loss of a dream. Freuden-berger23 refers to it as a loss of idealism; a loss of expected goals.

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