Issue link: https://beckershealthcare.uberflip.com/i/1393415
34 POPULATION HEALTH 34 CEO / STRATEGY Stop calling everything 'burnout' By Molly Gamble P re-pandemic, healthcare had its lowercase burnout and uppercase burnout. Uppercase burnout is the textbook term, coined in 1974 by American psychologist Herbert Freudenberger, PhD, for the stress and exhaustion felt by those in service professions that makes it tough to cope. In 2017, CEOs of the nation's most prominent health systems categorized burnout among physicians as a public health crisis and outlined an 11-step response. In 2019, the World Health Organization finally included burnout in its International Classification of Diseases, describing it as "a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed." Uppercase burnout is both a condition and a studied, well-known public health threat, like driving without a seatbelt. Lowercase burnout is more personal, ubiquitous and messy. Pre-pan- demic, it was the status quo, with 42 percent of physicians reporting that they were burned out before COVID-19 spread to the U.S. In 2014, 54 percent of physicians experienced burnout, with those in general in- ternal medicine, family medicine and emergency medicine hit hardest. Pre-pandemic, lowercase burnout was the daily grind: e documenta- tion, prior authorizations and two hours clicking away on an EHR for every one hour with patients. e reduced clinical hours and turnover that culminated in more than $4 billion in annual costs and a doubled likelihood of patient safety incidents. Lowercase burnout was the daily, unaddressed manifestation of exhaustion, cynicism and feeling ineffec- tive. It was the tough days that led to bad weeks that led to foggy months. When COVID-19 first hit U.S. hospitals, lowercase burnout was al- ready alive and well. In an age where websites load in 1.29 seconds on average, it can be confounding when our language does not catch up to our circum- stances. If clinician burnout was a public health crisis pre-pandemic, then what is it now? Is "burnout" even the right word for what Amer- ica's medical professionals are experiencing? Beyond that one word Slapping the term "burnout" on a range of conditions might have gotten healthcare from there to here. At the very least, the term and attention paid to it allowed us to focus on the mental well-being of the medical workforce. But to best convey and communicate clinicians' experience now, leaders and organizations need expanded vocabular- ies, strategies and resources. In conversation with physician and health system leaders, a variety of terms were put forth to describe what clinicians have experienced since the pandemic began, including fear, anxiety, overwhelm, moral injury, fatigue, feeling out of character, loss of control, frustration, an- ger, dismay and disillusionment. A number of analogies were also used to describe what this new brand of struggle feels like. One described it as being slammed underwater by a wave, topsy-turvy, unable to see anything but white. Another described it as trying to start a fire in a soaking wet environment short on oxygen. One compared it to an endless marathon. "As we get to the 24th mile of the 26.2 mile race, the finish line keeps moving back," said Kate FitzPat- rick, DNP, RN, chief nurse executive officer of Jefferson Health. "It's that level of mental exhaustion, physical exhaustion. It's just 'overwhelm.'" What sets this experience apart? "e reason that 'burnout' doesn't apply that well is that there are a myriad of forces that lead clinicians to feel a variety of emotions, in- cluding being undervalued, being frustrated, perhaps being fearful, and being overextended. e emotion might get placed in a bucket of burnout, but there are different factors depending on the circum- stance," said Gregory Kane, MD, chair of the department of medicine and the Jane & Leonard Korman Professor of Pulmonary Medicine at omas Jefferson University Hospital in Philadelphia. It's more than prior authorizations or EHR clicks. Fear, moral inju- ry, invalidation and isolation are just a few of the distinctive facets of many clinicians' experience since the pandemic began. Fear e intensity of fear alone that physicians, nurses and staff experienced around COVID-19 distinguishes their experience from pre-pandemic burnout. Exacerbating it was a national shortage of personal protec- tive equipment and variation in organizations' responses and policies. "Fear is relatively new during the pandemic," said Jonathan Gleason, MD, executive vice president and chief quality officer for Jefferson Health in Philadelphia. "And it wasn't just fear for your own safety. For many of our folks, they were talking about the safety of their kids or a parent who lives with them. In healthcare, we work a lot of long hours and a lot of nights and weekends. So there is a little bit of guilt all of us have about being away from our families so much. en you add to that the ability to harm them — that part of it is unique and beyond burnout." Inefficacy and moral injury Compounding clinicians' fear and anxiety about the airborne transmis- sion of COVID-19 was their proximity to the immense and relentless damage inflicted by the virus on poor communities and communities of color. In the first six months of 2020, 53 percent of all in-hospital deaths from COVID-19 were among Black and Hispanic patients, according to research from Palo Alto, Calif.-based Stanford Medicine. (e U.S. Cen- sus Bureau estimates that Black people make up 13.4 percent of the U.S. population, Hispanic people 18.5 percent and white people 60 percent.) Preexisting conditions were oen blamed for the disparate morbid- ity rates among white people and people of color, sidestepping how racism is a preexisting condition itself in America. Healthcare pro- fessionals see its unjust, downstream effects every day. When the na- tion watched footage of police officer Derek Chauvin killing George Floyd with a knee to his neck May 25, 2020, long-standing inequities in healthcare became intolerable. "Racism and anti-Blackness in our country's structures and medical systems can be seen as clearly as the footage of Mr. Floyd's life being taken," physician and public health leaders wrote in Health Affairs. "ey warrant immediate reform." "Burnout might be one thing," said Kelly Cawcutt, MD, associate med- ical director of infection control and epidemiology for Omaha-based University of Nebraska Medical Center. "But there perhaps may be more moral injury being faced by working in a system that is broken, has not been equitable, has not been inclusive, hasn't necessarily main- tained the level of fairness and justice and the attributes you're taught when you go to medical school about what it means to be a physician and to care for everyone and provide that best level of care you can."