Beyond burnout: Lasting effects of COVID-19 on physician mental health
By: Edwin Kim, MD, MRO
Burnout is an issue familiar to medical professionals long before COVID-19. But the added stress of treating patients during a pandemic has made a huge impact on physician well-being around the country.
According to Maslach and colleagues, who first developed the Maslach Burnout Inventory, burnout is a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment. In studies of both physicians-in-training and practicing physicians, rates of burnout symptoms now have been shown to exceed 50 percent (West et. al).
As we enter another month of COVID-19, there are still many unknowns and physicians are at risk of experiencing an additional stressor related to their workplace. More importantly, we are anticipating a number of medical professionals on the frontline experiencing traumatic stress. Left unchecked, the traumatic experiences of working in emergency rooms, hospital wards, or intensive care units can manifest as severe trauma/stressor related disorders including acute stress disorder (ASD) or post-traumatic stress disorder (PTSD).
The diagnostic criteria for ASD and PTSD overlap; however, ASD is diagnosed within the first month after exposure to the trauma. A PTSD diagnosis cannot be given until symptoms have lasted at least one month. While rates of ASD and PTSD vary based on the traumatic experience, survivors can show rates of ASD anywhere between six and 33 percent within one month of the trauma.
While we don’t yet know if there is a correlation between the workplace phenomena and mental disorders, we can rest assured that post-traumatic stress in addition to an environment conducive to physician burnout can increase a medical professional’s risk for diminished function, dysfunction and distress. Left unmitigated, the effects of either burnout or trauma/stressor-related disorders, such as ASD or PTSD, jeopardize the well-being and safety of physicians in the workplace and at home.
Similarities of burnout and PTSD
In the 11th Revision of the International Classification of Diseases (ICD-11), burnout is characterized by feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy. While burnout is not yet classified as a medical disorder, signs associated with burnout include feelings of sadness and apathy, or frustration and irritability, which can mimic psychiatric illness.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), common signs of acute or post-traumatic stress include negative mood, altered sense of oneself or surroundings, and efforts to avoid reminders of traumatic events. Other signs of PTSD include risky or destructive behavior, overly negative thoughts and assumptions about oneself or the world, exaggerated blame of self or others for causing the trauma, negative affect, decreased interest in activities and feeling isolated.
It is important to note that burnout and post-traumatic disorders may share similar signs and symptoms. Both the occupational stress syndrome and mental disorders can present with poor concentration, sleep disturbance, mood change, irritability or low frustration tolerance, outburst, and a sense of depersonalization or derealization (losing sense of oneself or one’s environment, respectively). Finally, problematic substance use can be comorbid with either burnout or post-traumatic stress.
Determining the difference between burnout and PTSD
While ASD and PTSD by definition occurs after exposure to a traumatic event, a red flag for post-traumatic stress is the persistent re-experiencing of traumas in form of nightmares, flashbacks, or emotional and physical reactivity to traumatic reminders.
Symptoms such as hypervigilance, exaggerated startle response, and persistent exaggerated self-blame about events raise concern about the presence of a traumatic/stressors-related disorder.
Furthermore, the depersonalization or derealization one experiences occurs or is heightened when confronted with the trauma or reminders of the events (i.e., people, places, conversations, activities, objects, situations).
What to do if you think you have burnout
If you are concerned about burnout, then evaluate your options as suggested by the Mayo Clinic. First, determine whether you can work with your supervisors to change contributing factors thought to contribute to burnout. These include an inability to control scheduling decisions, work assignments or adjust workload. Clarify job expectations and your specific role within the treatment team or organization. Lastly, identify any dysfunctional workplace dynamics.
It will be important to seek support from colleagues, family and friends. Actively prioritizing self-care in the form of relaxation, exercise and sleep can help balance the stressors of work and achieve balance with your personal life. The practice of mindfulness meditation can be a strengthening exercise in your resilience. Finally, consult with professionals if the above initial steps do not alleviate the stress.
What to do if you think you’re suffering from post-traumatic stress
Research shows that trauma-focused cognitive-behavioral therapy, a type of individual psychotherapy, is an effective, first-line treatment for both ASD and PTSD.
Consulting with a mental health professional will help determine whether therapy or medications can be useful in alleviating the symptoms. It is important to seek consultation or evaluation sooner than later because delaying treatment can prolong the duration of symptoms. Most importantly, keep an open mind and be kind to yourself.
How to seek professional help after you identified the signs or symptoms of either burnout or traumatic stress
What matters most in this situation is not necessarily distinguishing between burnout and ASD or PTSD yourself. Rather, understanding the potential risk and remaining aware of possible signs and symptoms can help change the trajectory of the distress. Both stressors can operate independently or co-exist, exacerbating each other.
The next best step if you have concern about any emerging signs of burnout or PTSD is to reach out to a mental health professional. This can be through a trauma-informed counselor, therapist, psychologist or psychiatrist who specializes in working with medical professionals. If you are part of a larger organization, then some viable options include inquiring with your Employee Assistance Program (EAP), designated Wellness Officer, or Wellness Committee or Group. Another good resource to find a mental health professional is by referring to the behavioral health coverage included with your medical insurance.
Don’t let social distancing protocols deter you from seeking care. For the time being, most clinicians are offering virtual or telemedicine visits which occur mostly by phone or HIPAA-compliant videoconferencing platforms (remember to ask when inquiring about services).
The Pennsylvania Physicians’ Health Program (PHP) can also help physicians and other medical professionals, including trainees, physician assistants and dental professionals, by connecting individuals with a list of clinicians in their area who can help assess, diagnose and treat negative symptoms related to the aftermath of the current pandemic. To learn more, you can contact the PHP at (800) 228-7823 or visit www.foundationpamedsoc.org/physicians-health-program/physician-burnout-resources.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.
Department of Veterans Affairs and Department of Defense. (2017). VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. Washington DC: Author. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/ptsd/
Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual, 3rd ed. Palo Alto, CA: Consulting Psychologists Press, 1996.
West, CP, Dyrbye, LN, Shanafelt, TD. (Mayo Clinic, Rochester, MN; and Stanford University Medical Center, Stanford, CA, USA). Physician burnout: contributors, consequences and solutions (Review). J Intern Med 2018; 283: 516– 529.
World Health Organization. (2018). International classification of diseases for mortality and morbidity statistics (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/129180281