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.”

“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.