Reaching for breakthroughs on burnout​

Karen Titus

March 2022—Few people want to talk about burnout in health care—at least not publicly.

Take, for example, the response of one laboratory professional, who, when asked to be interviewed for this story, waited several days before ultimately declining. Having his institution associated with the topic, he explained, could fan the flames among colleagues.

“For sure all of us are feeling weary,” he said in an email (quoted with permission). “And I don’t want this in the face of our team members who are chronically short-staffed while seeing large hiring and retention bonuses going to nurses and others at the bedside. Those payouts are choking off access to capital for replacement equipment and causing every non-nursing position to go through a weekly labor committee review,” with finance leaders evaluating all replacement requests based on funding ability and productivity.

“We all have some burnout,” he continued, noting the number of people retiring or trying new careers.

The response ticks many boxes on the aspects-of-burnout list: wrestling with whether to talk about it; strong emotions; money; shortages (of supplies, equipment, staff, maybe tempers); and, finally, a turn toward resiliency and wellness in the face of it all. “Our staff is resilient,” writes the anonymous source, “and they get through the day by supporting each other and doing what is needed for patients and providers. It is actually remarkable to see their loyalty.”

His response also opens the door to further cogitation. Is there a difference between stress and burnout? How do mental health issues fit into the picture, if indeed they do? And is it possible to make it through a pandemic without burning out?

One person who’s not reluctant to talk about burnout is Marisa C. Saint Martin, MD, medical director, OneBlood, a blood center with a large presence in Florida (she’s based in Jacksonville) and other Southeast states. She is also co-leading a CAP project team, under the Council on Membership and Professional Development, to look at pathologists’ well-being. (The other co-leader is Michael B. Cohen, MD, professor of pathology, Wake Forest School of Medicine.)

In fact, burnout has become one of her long suits. (She even became a certified life, career, and executive coach.) “I used to be called much more to talk about transfusion medicine, which is of course my specialty, but nowadays most of my lectures are on the topics of burnout and how to increase resilience. There’s such a need for people to hear this and share some of their stories.” Every speaking engagement, she says, invariably generates several additional invitations to speak to other groups.

The notion of burnout has existed either for decades or millennia, depending on one’s devotion to history and literature.

More recent studies (including an oft-cited one from Mayo Clinic: Shanafelt TD, et al. Mayo Clin Proc. 2015;90[12]:1600–1613) have noted the toll burnout takes on physicians, while other statistics have shown the impact on others in health care, including laboratory professionals.

Subsequent studies have shown the financial costs of burnout. Once hospital administrators, CEOs, and others saw the link between medical errors and burnout, as well as the link between unhappy workers and dissatisfied patients, “they started paying attention,” Dr. Saint Martin says.

Early efforts at measuring burnout led to efforts to help individuals, but often in ways that pushed individuals to fix the problem themselves. In current thinking, burnout is a problem not only for individuals but for the health care institutions that employ them.

The pandemic has dropped a 500-pound barbell onto all this, exposing problems that require a national response. At the same time, it put a spotlight on laboratories, bringing a new kind of recognition.

Experts note that feelings of invisibility can play a role in burnout, as can feeling as though one’s work doesn’t matter. That can be especially true for pathologists and other laboratory professionals, whose face-to-face interactions with patients is limited, Dr. Saint Martin says. “This is a very particular issue for pathologists, because we often feel like we are working behind the scenes.”

The pandemic changed that for the laboratory, at least early on. Suddenly everyone was talking about laboratory testing. Hospital CEOs learned where their lab was located and toured it. Ditto for national and local news outlets. (“I’m not sure a lot of the public understand that the laboratory is run by a physician who is a pathologist,” Dr. Saint Martin notes.) Some pathologists and other lab leaders became close advisors to governors and others who were trying to manage the pandemic response.

The spotlight has since dimmed, but the stress and workload have remained.

“We talk about stress and burnout as being interchangeable,” says Dr. Saint Martin, “but they’re not the same, although chronic stress can lead to burnout.”

That’s what’s happening now, she says. People who are working are working longer hours and handling more cases. “We still have traumas, we still have cancers, we still have sickle cell patients in crisis.” And behind all that is the horrifically high toll of the pandemic: U.S. deaths were nearing 950,000 around the time she spoke with CAP TODAY.

Well before the pandemic, Dr. Saint Martin was developing methods to help residents deal with burnout, lessons she continues to draw on today.

When she lectures about burnout, Dr. Saint Martin says she talks in equal measure about resiliency. “We as humans are naturally resilient, but remaining resilient requires nurturing that innate quality.” The individual techniques to increase resiliency are familiar to many, and each person may have their personal preference, whether it’s going for a run or a walk or doing yoga, meditation, or some other mindfulness exercise. Dr. Saint Martin says more of her colleagues are seeing the need to knit together individual and institutional responses.

While serving as associate program director of the residency program at Loyola University Medical Center, Maywood, Ill. (where she also was an assistant professor, Department of Pathology), Dr. Saint Martin started a wellness program for residents. She also led a group of physicians from various specialties to discuss wellness at nearby Trinity Gottlieb Memorial Hospital.

One thing quickly became clear: While the medical center provided wellness resources (yoga classes, a wellness week with speakers, etc.), the more obvious change came from people simply talking to one another. “When we witness another colleague starting to open up and talking about their feelings of burnout, we realize we are not alone. That connects us to the other person.” Dr. Saint Martin saw a similar dynamic at play in her work with the aforementioned CAP wellness project.

As part of a series of exercises with the residents’ group at Loyola, she asked them to list three things that were positive about the department/hospital, three things that were frustrating, and three things they wanted to change. She then asked them to prioritize the list of what they wanted to change, and to identify what would take the least amount of effort. The initiative had the full support of the department chair.

“We started with the easiest thing,” Dr. Saint Martin says. “And the minute they started seeing these little changes coming, they felt heard, they felt they were part of the team, the residents felt things were finally changing.” (She and her colleagues described this work in Academic Pathology: Saint Martin MC, et al. Published online June 10, 2019. doi:10.1177/​2374289519851233.)

There’s no sign to announce that “George Washington slept here” in the microbiology director’s office at Deaconess Health System, Evansville, Ind. But in the early days of the pandemic, April N. Abbott, PhD, D(ABMM), could have hung a sign of her own. “I basically lived here in the lab,” she says. “So I have a bed in my office.”

She needed it, as she struggled to provide testing at the system’s hospitals in southern Indiana as well as neighboring Kentucky and Illinois. The crisis has passed, in one sense, but in other ways it continues, leaving Dr. Abbott and her colleagues with a different sort of weariness.

She pauses to weigh her words. “When the pandemic first started,” she recalls, “there was this—the only way I can describe it is basically hopelessness on the part of many of us.” The way out, through tests and vaccines, was an impassable route, at least for the foreseeable future.

But neither ample tests nor effective vaccines have brought an end to the misery. While many outside hospital walls have returned to their normal routines, as if the pandemic were over, Dr. Abbott and her colleagues continue to see the true impact of COVID-19 cases. “With the vaccines, we had hope we would come out on the other end of this.” Instead, every new surge adds to the burden, while the volume of non-COVID-19 testing remains high. And with many laboratory employees heading for the exits, those left behind are tasked with processing an unprecedented number of samples. “You get this feeling that it’s never going to end,” Dr. Abbott says.

“We don’t know how it’s going to unfold for the next few years,” she continues. “I’ve been trying to think about how to describe this feeling. It’s an emptiness. Because we don’t know what the next piece is going to be. And there really is no light at the end of the tunnel.”

While the early days brought hopelessness, there was also an unexpected bright spot. The lab was no longer toiling in obscurity—its work had always mattered, but now everyone knew it.

She recalls telling her administration leaders that when the pandemic subsided, she didn’t want things to go back to the status quo, in which the lab returned, Brigadoon-like, to some liminal place, its value seemingly disconnected, once again, from the rest of health care.

But it may be happening already. “We had seen a glimmer of hope that the lab was going to be elevated to be an equal partner in health.” But now that’s flattened out, Dr. Abbott says.

It’s almost a philosophical question: Is it better to not have flown high, to have seen the view from above, if one falls, Icarus-like, back down to earth? “You’ve seen what that looks like, and it’s disappointing to see ourselves falling back again,” says Dr. Abbott.

Staffing had been tight—to put it mildly—for years already, and the pandemic has spurred more departures. Dr. Abbott reports that the microbiology lab is down 7.5 FTE (it currently has about 45 FTE) and has had to send out samples for testing that normally it would be able to perform.

In the molecular lab, there’s been nearly 100 percent turnover since the pandemic began, she says, some of it by design. “We pulled people from other sections of the laboratory when we first built the molecular lab, in case of an event where all of micro, as an example, ended up with COVID. We just didn’t know what things were going to look like. So some people were temporary to begin with.” Nevertheless, it’s a stark marker of the wear and tear on personnel.

Hiring traveling techs has helped reduce the work burden, but it’s added tension. “It perpetuates this sense that the person they’re working alongside might be getting paid 2½ times more—and they might have fewer responsibilities and aren’t planning to stay. It creates a negative feedback loop.”

How do these changes affect Dr. Abbott’s thinking about burnout? “First of all, it’s recognizing that it’s happening,” she says. As she walks about the workplace—within the lab and beyond—she notices colleagues acting out of character. Some are quick to place blame on fellow workers. They may be short with one another. Maybe they’re less willing to pick up extra shifts.

The reason for this change in behavior is obvious to Dr. Abbott. “They’re struggling at the moment with being in the middle of this for almost two years. It’s not because they’re a bad person. It’s the weight of everything that’s happened.” Even wearing masks in the workplace has taken a toll. “It’s hard when you don’t look at a person’s face anymore,” she says; in fact, she has colleagues who came aboard during the pandemic, “and I’ve never actually seen their full face.”

The disconnection is jarring, and Dr. Abbott is determined to address it. “I’m going to make a more conscious effort to pull people aside, say, ‘Hey, let’s go for a quick walk, what’s going on?’ Just have that human interaction.” She’s already done this with a few colleagues, and it’s helped overcome the oddness of, well, everything.

“This person is not the person you were around two years ago,” she says. “You have to try to set up ways to reconnect with people on a more personal level.”

Such conversations imply listening—a skill “that frankly is not in everybody’s wheelhouse,” Dr. Abbott says with a laugh. “We’re just not always good at hearing things from another’s perspective, to listening to how our employees want to be recognized, what helps them to feel valued.”

Sometimes what she hears is predictable. “Everybody wants more money, right?” In her area, she says, some hospitals are offering as much as $10,000 signing bonuses—something her hospital can’t compete with.

Like Dr. Saint Martin, she’s been surprised by other sources of frustration. Some employees wanted changes to their break room, for example—simple enough if someone actually took (or had) the time to fix it.

Behind this lies a harder problem, however. Employees might feel like no one is addressing their problem; at the same time, says Dr. Abbott, she finds it difficult to enlist employees to help solve the problem. It’s not specific to burnout or to the pandemic, but is certainly a close cousin. “We struggle with engagement,” Dr. Abbott says. “We want people to feel engaged in their work every day and to find it fulfilling.”

Is it important to identify these stressors as burnout? Dr. Abbott isn’t sure. “I’m not the kind of person who typically likes to put a label on something, because we all experience things differently. But it may help somebody put a word to it.” In fact, it may even help her—she notes she spent plenty of time thinking about how to encapsulate her feelings before landing on the word “emptiness.” Doing so has helped her see changes in herself in recent years, she says. “Previously I always wanted things to be better, and I would go above and beyond. And now I just can’t find that same drive.”