From the Editor
I started watching the clock, thinking about how much time is left in my day. That just started getting earlier and earlier. One day, at 8:35 am, I thought: Oh boy, it feels like I’ve been here a while already.
So comments a colleague on his burnout.
More and more, we are discussing physician burnout. But how has the concept of burnout evolved over time? How is it distinct from depression? What are evidence-based interventions? Drs. Constance Guille (of the University of South Carolina) and Srijan Sen (of the University of Michigan) seek to answer these questions in a new review for The New England Journal of Medicine. Though they note challenges, including with the definition itself, they strike an optimistic tone. “Over the past 15 years, progress has been made in raising awareness about physician well-being and improving well-being in specific populations, including physicians in training. There is a clear pathway for investing in and implementing established interventions and developing new interventions to improve well-being for all physicians.” We consider the review and its implications.
In the second selection, Dr. Felix Teufel (of Emory University) and his co-authors explore the treatment of depression in India. In a new JAMA Psychiatry brief report, they drew on a national survey, finding limited care, particularly among those living in rural areas. “Nationwide, 97% of individuals with depression were undiagnosed, and around half of individuals with diagnosed depression were untreated.”
And, in the third selection from Academic Psychiatry, Dr. Ushna Shamoon (of the University of Texas) writes about her medical school rotation in a county jail. She discusses her biases before stepping into the correctional facility. She then describes her connection to an inmate suffering from mental illness. “Though her mind was riddled with psychosis, she was not just a victim of her illness.”
Note: there will be no Reading next week.
DG
Selection 1: “Burnout, Depression, and Diminished Well-Being among Physicians”
Constance Guille and Srijan Sen
The New England Journal of Medicine, 23 October 2024
There is growing concern about the well-being of physicians and the consequences of poor well-being for physicians themselves, their patients, and the broader health care system. Diminished well-being among physicians has been characterized through several constructs, including acute and chronic stress, trauma, moral distress, moral injury, the second victim syndrome, burnout, and depression, and is associated with poor outcomes for physicians and the patients they treat.
So begins a review by Drs. Guille and Sen.
A Brief History of the Construct of Burnout
“In the 1970s, two psychologists, Freudenberger and Maslach, drew from their clinical observations and independently developed the modern concept of burnout. Freudenberger personally experienced and observed among his colleagues the development of emotional exhaustion in response to intensive work to improve the lives of persons in disadvantaged populations amid a difficult and unchanging environment. Maslach similarly observed that people in the helping professions (helping professionals) in interpersonal roles became emotionally drained over time… Freudenberger’s and Maslach’s concept of burnout quickly gained mainstream cultural popularity.”
Physicians and Burnout
“Over the past 15 years, burnout has gained resonance as a term to describe poor well-being among physicians… Physicians often enter medicine to help others but increasingly find that an excessive workload, administrative burdens, and the profit motives of insurance and pharmaceutical companies and health care systems are intractable barriers to improving patients’ lives in the ways the physicians had envisioned.”
That said, they note the problems with the term.
“The use of the term ‘burnout’ to capture a wide range of symptoms has also helped to build community and catalyze collective calls for reform. Even before the term was applied broadly to physicians, however, the lack of consensus on a definition of burnout was a barrier to understanding the prevalence and drivers of distress and implementing effective reforms… The Maslach Burnout Inventory (MBI) was developed, in part, to bring more rigor to the construct of burnout and has become the most widely used tool to assess burnout. However, the ambiguity and definitional problems that impede the colloquial understanding of burnout have carried over to research and to the more formal construct of burnout provided through the MBI. Although the MBI was conceptualized to preferentially capture the effects of workplace stress, nonwork stressors and individual factors, such as personality, contribute to burnout substantially, and their contribution is similar to that for other emotional constructs.”
A Brief History of the Construct of Major Depression
“Along with burnout, the other major construct that has been used to measure physician distress is depression. Major depression is a common psychiatric disorder, characterized by low energy and mood, loss of pleasure, sleep and appetite problems, and thoughts of death. The modern concept of depression originated during the late 1700s with the diagnostic formulation of melancholia…
“The correlation between dichotomous classifications of burnout and depression varies, depending on which definition of burnout is used. However, continuous measures of symptom scores for depression and burnout are highly correlated, which indicates extensive overlap between these constructs. The primary objection to focusing on depression rather than burnout has been the concern that depression is an inappropriate label for most cases of physician distress because prominent symptoms occur in the context of a dysfunctional workplace. Underlying this concern is the implicit assumption that depression, by definition, places the root cause of the problem within the individual, not the environment.”
Interventions to Improve Well-Being for Physicians in Practice
They review several:
- Workload. “Workload should be a primary target in efforts to improve their well-being. For instance, the proportion of physicians reporting at least one symptom of burnout decreased from 45.5% in 2011 to 38.0% in 2020, with the decrease in burnout corresponding to a decrease in work hours.”
- Administrative help. “With the inordinate amount of time physicians spend on documentation, the electronic health record (EHR) is a clear and important target for reducing administrative workload. The use of scribes to reduce the EHR workload for physicians has consistently been found to substantially improve productivity and physician satisfaction.” Clerical support may also be helpful. “A cluster-randomized trial of an intervention that reassigned tasks from physicians to medical assistants, nurses, and physician assistants showed a significant reduction in burnout scores among physicians.”
- Leadership & culture. “Over the past 5 years, many health care organizations have appointed chief wellness officers to improve clinician well-being through changes in leadership and culture.” They note a lack of observational research, however: “because of the elevated risk of confounding and reverse causation.”
- Mindfulness and more. “Many of the studies evaluating these interventions had relatively small samples, lacked active control groups, or did not include follow-up beyond the duration of the intervention, factors that limited the conclusions that could be drawn from the data.” Mindfulness: “meta-analyses of these studies identifying a small but significant positive effect on physician well-being.” A smaller number of studies have considered “professional coaching, keeping a gratitude journal, exercise, yoga, and building social connections among colleagues.” They show “promise.”
A few thoughts:
1. This is an impressive review – concise, lucid in its reasoning, and rich with 74 references – and published in a major journal.
2. Rather than avoiding the controversies surrounding physician burnout, the authors address them directly. “Overall, a systematic review of 182 studies of burnout in physicians identified 142 different definitions of burnout, even though most studies used the MBI. Not surprisingly, the prevalence of burnout reported in the studies varied widely, from 0 to 80.5%.”
3. They considered interventions at both the system and individual levels. Nice – and they move us past the concept of coffee and donuts in the lunchroom.
4. Interested in exploring the topic further? In a Quick Takes interview, I speak with Dr. Treena Wilkie (of the University of Toronto). You can find the podcast here:
https://www.camh.ca/en/professionals/podcasts/quick-takes/qt-june-2019—physician-burnout
The full NEJM review can be found here:
https://www.nejm.org/doi/full/10.1056/NEJMra2302878
Selection 2: “Depression Diagnosis, Treatment, and Remission Among Adults in India”
Felix Teufel, Aastha Aggarwal, Lydia Chwastiak, et al.
JAMA Psychiatry, 30 October 2024 Online First
Substantial care gaps for mental health conditions, a leading cause of morbidity, persist worldwide. However, national-level data to guide health system responses to mental health conditions are scarce, particularly in low- and middle-income countries. Prior to COVID-19, 45.7 million of the 193 million individuals with depressive disorders globally lived in India, the world’s most populous country… To our knowledge, there have been no nationally representative estimates of health coverage for depression in India to date.
So begins a research letter by Teufel et al.
Here’s what they did:
“This cross-sectional study used individual-level survey data from the 2017-2018 Longitudinal Ageing Study in India, which represents all 36 states and union territories of India. Data were collected from April 1, 2017, to December 31, 2018. The sample included adults 45 years or older with data on depression, health care service use, depression diagnosis and treatment, and sociodemographic characteristics. The response rates were 96% for households and 87% for individuals.”
Here’s what they found:
- There were 65 121 participants.
- Demographics. The median age was 57 years and many were men (53.3%); most lived in rural areas (67.9%).
- Prevalence. The weighted prevalence of depression was 8.6%
- Health services utilization. Of all participants with depression, 63.7% had used any health services in the past year.
- Diagnosis & treatment. 3.1% had been diagnosed with depression; 1.6% received some form of treatment (51% of those diagnosed) and 1.0% were in remission (62% of those treated).
- Urban vs. rural. The prevalence of depression was higher in rural areas (9.8%) than in urban areas (6.2%), although health service use, diagnosis, and treatment were lower in rural.
A few thoughts:
1. This is an impressive and important dataset.
2. Wow.
2. Considering those who are untreated in absolute numbers: among 29.6 million middle-aged and older adults with depression across India, 29.1 million remained untreated. (Yes, you read that correctly.)
3. Ouch.
4. One of the problems from a health-systems perspective: many people access care in India but still aren’t able to get treatment – or even a diagnosis.
5. There are limitations; the authors note several, including the self-report nature of the data.
6. The challenges of mental healthcare in low- and middle-income nations have been discussed in past Readings. Recently, for instance, we analyzed a new JAMA Psychiatry study involving 44 primary health centres and nearly 10 000 participants across the states of Haryana and Andhra Pradesh in India. “There were large reductions in risk of depression, anxiety, and self-harm risk with a 3-fold increase in odds of remission (effect size 0.6).”
The JAMA Psych research letter can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2825465
Selection 3: “A Prisoner of Bias”
Ushna Shamoon
Academic Psychiatry, June 2024
Going to jail was not something I planned when I started medical school. However, it was in jail that I appreciated the genius of madness. During my first exposure to a correctional facility, I was escorted up to the psychiatric floor by an officer. I realized this was nothing like my previous third year clerkship rotations. The soft knocks on clinic room doors were replaced with thunderous banging on holding cell doors so that the officer sitting in a control room overlooking the holding unit could hear and see which jail cell door to open so that we may interview the patient. Taking in my surroundings, I was forced to grapple with my own biases. Should I have googled ‘self-defense’ before blindly walking into a jail?
So begins a paper by Dr. Shamoon.
She describes her first contact with a patient. “My first conversation with Ms. T lasted under 60 seconds and consisted of her screaming a stream of profanities until she was escorted out of the room by an officer. Earlier that morning, I heard Ms. T before I saw her.” The author notes her bias: “Walking past her on that first day, she seemed helpless and surely incapable of caring for herself. I would later learn how two-dimensional my perception was.”
“As I spent more time in jail, I learned on her good days. Ms. T was genial and charming. And if candy was involved, the storm clouds that usually shrouded her eyes would part, and a glimmer of the woman she was before the madness would shine through. With lollipop in hand, she relaxed into comfortable conversation with the team. She shared stories about her travels through the south as a Black woman facing homelessness and migrating to Texas from Louisiana after Hurricane Katrina, illustrating how resourceful she had been in navigating the challenging circumstances of her life. The more I experienced Ms. T on her good days, the more I understood her beyond what society may dismiss as a ‘psychotic inmate.’ Our conversations uncovered a quick-witted woman with a sweet tooth.”
She discusses the inmate’s thoughtfulness. “Despite her psychosis, she was remarkably insightful to her circumstances. As her release date approached, I was stunned by her level of comprehension of the chronic and fluctuating nature of her disease and her need for stable and long-term placement. I realized I was witnessing the true dimensionality of a sick mind and all the facets of her psychiatric disease.”
She notes the biases of her fellow med students. “My peers were shocked to learn I had rotated at the jail with many voicing concerns for my safety and inquiring if I had been attacked by an inmate. I was humbled by their surprise and their preconceived notions of what jail must be like which were not dissimilar to my own perceptions before my rotation.”
The paper closes with a comment about candy and care. “In my arsenal of tools to face this challenge, I carry lollipops alongside my stethoscope because sometimes all it takes to rediscover the humanity of madness is some candy.”
A few thoughts:
1. This is a great essay – well written and insightful.
2. The first two sentences are particularly eloquent and worth highlighting: “Going to jail was not something I planned when I started medical school. However, it was in jail that I appreciated the genius of madness.”
3. Should all med students do a rotation in a correctional facility? Should all health professionals?
The full Acad Psychiatry paper can be found here:
https://link.springer.com/article/10.1007/s40596-023-01869-4
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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