Reaching for breakthroughs on burnout​

“I’ll be honest with you—I didn’t recognize that what I was experiencing could be labeled as burnout until recently,” she adds.

Even her commitment to reconnecting with workers, when she sees them stressed, is going to be difficult. Taking the time to ask questions and then listen is the right thing to do. “But when I also have 10 hours of work that I need to do, trying to find time to also have those conversations is hard, to be honest.

“When you’re so short-staffed, and you have this air of every minute counts—because hundreds of samples need to be processed—it does become hard to just have a conversation with somebody,” says Dr. Abbott.

Time (or lack of it) puts everyone in a stranglehold. “It’s an ugly monster,” Dr. Abbott says. “People look around them and say, This person doesn’t put in as much time, or, This person doesn’t have to do this thing that I have to do. We’ve definitely had conversations within the lab about placing blame, and just being kinder to one another. Which is interesting—we’re all adults.”

All of these issues are related, she posits. If someone is spiraling a bit due to the stress of the environment, it’s worth taking the time to talk to them about how their actions are being perceived. “You need to find a way to pull them out of that and have a conversation with them,” even if it feels like there’s no time to talk.

In theory, things should be easier when COVID-19 cases decline. But Dr. Abbott finds that’s not the case. “When we go through a surge, I become hyperfocused on the task in front of me. And when we’re ramping up, people will pull together.” Once the peak has passed, however, “then you’re almost in a free fall. Then people start reflecting on what they had to deal with, again.” She then offers a sobering reflection of her own: “I’m losing more and more people. I don’t know that we’ll make it in the same way through another surge.”

Dr. Abbott also wonders how the profession will make it through the years ahead. The struggle to retain workers was a problem pre-pandemic. How do you support those who remain, who were already tired before the pandemic? “I struggle with the fact that there doesn’t seem to be a lot of concrete answers to this problem.”

She’s discouraged by what she sees as a lack of advocacy for laboratories at a national level. “Why is it that nobody understands what we do? Why aren’t we seen as integral to health care, even after we’ve knocked it out of the park during the pandemic?” And, she asks, why is there no urgency to solve the problem of understaffed labs? “Anyone can see this isn’t sustainable, and yet this has been going on for years.” Both forces “contribute to what at the end of the day we experience as burnout.”

These larger issues are what ultimately made her decide to talk about burnout for this article, she says. “We need to talk about what labs are experiencing currently, and how health care is being changed by the pandemic. And then to make sure, from the laboratory perspective, it’s fundamentally changed for the better, and not the worse.”

“This wasn’t something that I even recognized as being related to burnout,” she says. “But it is.”

This year, microbiology laboratory leaders are pushing to make training, education, and personal goals a top priority for the staff, Dr. Abbott says. “I want our technologists to understand they are critical to health care. I want them to be proud of their profession. And I believe helping them gain confidence in their technical skills and see how quality results translate to positive patient outcomes is an essential element for engagement.”

Dr. Abbott thinks most staff realize she advocates for the lab and them and is “fiercely protective” of both. “But they almost never see that in action,” she says, adding, “We’re looking for ways to get staff out of the lab and into other areas of the hospital and community to promote us.” One example: a day-to-day thanks to others in the hospital. “Our group is service oriented, and we love to eat, so we are baking and buying treats that we’ll deliver to other departments in the hospital.” It gives staff a chance to interact one on one with someone else in the hospital—“to make a connection, saying we are in this together.”

One of the reasons it can be hard to recognize burnout is that the definition is somewhat wobbly.

That can lead to a gap between experiencing and recognizing burnout. Sometimes it takes a period of reflection to absorb what has happened. Dr. Michael Cohen, of Wake Forest, refers to navigating a challenging time earlier in his career, noting, “In retrospect, I probably was burned out afterward.”

He finds the definition created by Christina Maslach, PhD, helpful and in fairly wide use. Symptoms include mental and emotional exhaustion, depersonalization (which Dr. Saint Martin describes as “when we are becoming a little more callous about the work we do”), and personal lack of accomplishment. (“We lose sight of what our purpose is in the work we’re doing,” Dr. Saint Martin says.)

The last stage of burnout is disengagement. When someone is stressed, that person remains engaged (even if it’s demonstrated through anger or tears). “And there is a feeling of overreaction or hyperactivity—something needs to be dealt with right now,” Dr. Saint Martin says. While they may be exhausted, the exhaustion is predominantly physical, and it’s possible to feel refreshed after, for example, a long weekend. “With burnout, the person experiences an emotional exhaustion that cannot be repaired by resting or going on vacation.”

No matter what it’s called, burnout is a problem, Dr. Cohen says. It’s not unique to pathology or to medicine in general. “But certainly heading into year three of the pandemic, it’s a relevant issue.” As part of the CAP project team he and Dr. Saint Martin are leading, the group sent a survey to a subset of CAP members, and results will be reported. He and others, as part of the CAP Policy Roundtable, are also submitting an article for publication that looks at burnout among pathologists, based on data collected from 2019 and 2020.

Quantifying the problem is one step. But Dr. Cohen insists that settling on a definition of burnout is also a necessary step, noting that stress and burnout are two different creatures, with the former not always evolving to the latter.

Viewing the topic through the lens of the pandemic, Dr. Cohen says he regularly sees exhaustion and has since the earliest days. “I don’t get the sense that people are totally cynical and detached from the job, or feeling like they’re of no use.” He suggests “worn out” may be the more accurate descriptor.

That’s not to say people are not burned out, he adds, noting that there are data to suggest that it affects about 35 percent of pathologists—a high number in the absolute sense, though relatively low compared with other specialties.

Dr. Cohen is tasked with helping trainees/house staff develop skills to help ensure their well-being. As part of teaching about wellness and burnout, he helps lead a monthly meeting among residents that’s focused on resilience.

These discussions start at the beginning of residency, “because the data suggest that people who are either new in training or new in practice report the highest rates of burnout.” At the first session every July, the more senior residents share advice on how to navigate their first year.

“What surprises me most,” Dr. Cohen says, “is the level of candor with which residents share some of the challenges they’ve had, and the solutions they’ve found to overcome them.”

While much of this fits under the rubric of stress, he says, stress and burnout are not separate threads. And as others have noted, talking might help reduce stress and thus fend off burnout. It can reduce feelings of isolation, or, as Dr. Cohen puts it, “You’re not the only one experiencing this. It’s not quite group therapy,” he says with a laugh, “but there is value, and some people might have strategies that others can incorporate.”

He, too, looks beyond the personal when thinking about burnout and resiliency. National organizations, such as ACGME, the CAP, the National Academy of Medicine, and others all have large megaphones and need to use them, he says. Below that are the big health systems.

“And then there’s sort of the individual unit—your pathology group or your pathology department,” Dr. Cohen says, followed by individual physicians. “The goal of the project, ultimately, is to see what the CAP might be able to do to help support the individual pathologist.”

That help can’t come soon enough. Like the rest of his colleagues, he’s observed the mismatch between the supply of pathologists and the demand for pathologists. That could drive up salaries. It could also drive up workloads and lead to more burnout.

Mark K. Fung, MD, PhD, professor of pathology and laboratory medicine, University of Vermont Health Network, has a ringside view of residents as they step into the fray. He considers his own early days in practice as he advises them, and finds himself wondering what role mental health issues play in burnout.

Separating the two issues is like separating conjoined twins. “In my mind it’s very blurred,” says Dr. Fung, who is also vice chair for research and a member of the CAP wellness project team. “One swings from one to the other.” Those in medicine, just like anyone in the general public, experience mental health issues, which have been exacerbated by the pandemic. That doesn’t always lead to burnout, Dr. Fung notes, “but there’s a part of my brain that says, ‘Well, they’re contributory.’” It might be possible to compartmentalize mental health from burnout and resilience, he concedes, but he chips away at the wisdom of doing so. “In my mind, burnout is a piece of mental health.”

If health care professionals are reluctant to discuss burnout, talking about mental health is even harder. Says Dr. Fung: “Physicians may be very, very resistant to make it known or to seek help, fearing it will destroy their careers. This was my experience, whether it was reality or perception—that’s what I believed at the time.”

Drawing a border between physical and mental health makes little sense to Dr. Fung, who notes that no one would begrudge a pathologist for seeking treatment for a broken hand: “Better not report that. Better not tell anyone. Better not go for surgery to get my hand fixed. No one would say that about physical health and yet there is reluctance with mental health.”

But medicine’s culture of being strong, independent, and self-sufficient slaps back at those with mental health issues. Dr. Fung, who talks candidly about dealing with anxiety earlier in his career, says, “It took a lot of effort to go seek help for that.”

“Physicians tend to be very reluctant to seek help for fear of being viewed as not a strong leader or not a strong member of the team,” he adds. “And there’s a lot of internal pressure to not share that, or the fear makes you feel like you can’t share that.”

Sharing one’s own story and recovery may help others in similar situations but shouldn’t be used as a cudgel to tell someone to buck up, get help, and get back to business. “Just because it’s my experience that certain resources or approaches were successful for me doesn’t mean it’s going to be your experience,” Dr. Fung says. “But being able to share your own experiences and challenges in private conversations will help others feel more comfortable seeking help—they aren’t suffering alone, that others have experienced this as well and, most important, were able to succeed and thrive in their careers afterward.”

He tries to normalize talking about wellness, burnout, and mental health—and seeking help—when he talks to residents and medical students. “I remind them that they were chosen to be in our program because we have confidence they will be successful. We have everything invested in them to be successful, so why would we not want to help them if they need help? Which I think addresses this fear they have of, I’ll be isolated or abandoned as being defective.”

Dr. Fung sees younger colleagues become more assertive in asking for time off and demarking boundaries between work and life. And he notes that some are fairly candid when talking about the challenges they face, though it’s unclear whether that’s because of their personalities or because of a generational shift. What is clear to him is that two decades ago, those who talked about being on medication or in therapy would not have been ostracized, necessarily, but certainly fewer individuals were willing to discuss such experiences or seek help or were comfortable doing so.

The pandemic might have pushed more people to seek help, but the problem cuts both ways, Dr. Fung says. Physicians might finally be at the breaking point, “which is never a good thing. There’s a tremendous need for physicians to seek help as they need it and not wait until it gets close to catastrophic,” but being able to get help has become harder because of increased demand.

Pathologists might also be experiencing another pandemic pressure, Dr. Fung suggests: Do they feel a certain level of guilt that in the midst of it all, they are not patient-facing? “I think pathologists tend to have a complicated sense of self-identity as a physician,” he says. Some might even feel doubly guilty, he says, for feeling relieved that they’re not patient-facing in the midst of the crisis.

Nevertheless, pathologists are working under tremendous burdens. “The reality is, there’s more work to be done than ever,” he says. The population is aging, bringing with them far more cases for pathologists to sign out. “So when people say, I feel like I’m working harder than I ever did before, and my patients seem to be sicker than they ever did before, the short answer is: It’s true. There are data to explain why you are working harder. This is not your imagination.” And because this is occurring in the midst of the pandemic, it makes it harder for people to step back and say they want to take time off, when everyone else is working so hard, he says.

It’s also true that many feel like they’re working more inefficiently than in the past, he says. “Of course you are. You’re under stress—it’s called the pandemic,” Dr. Fung says.

All of which brings him back to his main point: Seek help. “It’s natural to feel guilty about asking for help when you see everybody else struggling.” Do it anyway. And do it even if, or especially if, you’re a leader in the laboratory.

Dr. Fung urges his colleagues to have “a nice, long conversation about role modeling. You can’t expect others to do as you say if you don’t do it yourself.” If a pathologist burns out, that can lead to added chaos in the group or department, he says, something that’s already in sufficient supply. It makes no sense to be a martyr or a hero—even if the pandemic seems to demand both.

Karen Titus is CAP TODAY contributing editor and co-managing editor.