Posted on June 5, 2019 at 6:31 PM
by Craig Klugman, Ph.D.
Last week, the World Health Organization (WHO) re-defined workplace burnout as a syndrome consisting of “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.” The change still does not define burnout as a medical problem and it is not new since it appears in the International Classification of Diseases version 10 as well. What it does is provide a focus on the increasing stress that we face by jobs that demand more time, effort and productivity while giving us less in return.
Consider a new report on physicians in the UK that finds decreasing salaries, gender disparity in pay, an increase in the number of hours per week spent on paperwork (vs. seeing patients), and pressure to use more technology. The result is dissatisfaction with staffing levels and workload. Almost 40% of UK physicians would choose a different career if they were starting their professional lives now. One-third are considering leaving the UK to practice elsewhere.
In the U.S., the pressures are similar though one can add the burden of staggering medical school loans. Seventy-five percent of medical students graduate in student loan debt with a mean debt of $196,520 (median $200,000), and 83% owing at least $100,000. While UK physicians are concerned about spending 1/3 of their time on paperwork, their U.S. colleagues spend 2/3 of their time on it. Fifty-four percent of U.S. physicians qualify as having burnout. Physician burnout is estimated to cost U.S. health care $4.6 billion in physician turnover, and reduced hours.
If health care providers are in a structure where they cannot take care of themselves and there is little support to help, then how can we expect them to help everyone else?
The stress epidemic extends beyond just practicing physicians. Consider that 1 in 3 university students worldwide are now struggling with their mental health. A new book argues that today’s university students have an “inordinate amount of anxiety”. Nearly half report feeling hopeless and 85% report feeling overwhelmed with all they have to do. Many of these students arrive on campus under treatment for mental illness and when faced with having to take care of themselves for the first time, they are less adherent and face new stresses on their own.
On top of this, the U.S. is experiencing an outbreak of loneliness. Sixty-two percent of college students report feeling lonely. Twenty-two percent of U.S. adults report feeling lonely, isolated, or lacking in human connection. Even our zeitgeist and national politics may be making us feel worse. An American Psychological Association survey found that 66% of Americans feel that the nation’s direction is a source of stress and 57% cite the “current political climate “as causing stress that includes “worry, tension, irritability, headaches, insomnia,” and GI upset. A report from the Canadian Broadcast Corporation (CBC) shows an increase in “Trump Anxiety Disorder” that reflects a “collective anxiety” many Americans are experiencing.
The effects of burnout and stress are real. Robert Sapolsky, a Stanford behavioral biologist (and a former professor of mine) explains in Why Zebras Don’t Get Ulcers that the kind of stress that is part of the modern condition is the body’s response to “psychological and social disruptions”. Our bodies have limited ways to respond to this stimulation and overstimulation—basically releasing hormones that cause our flight or fight response. In the short term, this can be an adaptive behavior (especially in the savannah when being chased by a lion). But over the long haul, chronic stress takes a toll on our health: fatigue, increased risk of diabetes, cardiovascular damage, peptic ulcers, growth inhibition, reproductive disorders, reduced immune system, memory loss, and even the rate at which we age.
Proposed responses to these stressors focus on what we, as individuals, can do for ourselves: Turn off the news; take walks; breathe; do yoga; ignore what you cannot do anything about; pursue therapy; take anti-anxiety meds. These approaches suggest that stress is endemic and all we can do is learn how to deal with it. By putting the onus on the individual to treat and survive the effects of stress, we ignore the cause of the problem: structural injustice in a system that increasingly makes personal and professional lives incompatible with human health.
Consider the old business adage, “Do more with less.” When I worked as a tech journalist in the 90s, whenever someone left the editorial room, instead of hiring a replacement, the publisher simply gave a strong employee the workload of the person who left. By the time I left, after only a year in my position, I was responsible for the work of 3 people. Consider that one of the measures of economic growth and success is “productivity” —getting more work out of the people you have. And for all that additional work, we are actually earning less money than ever before. Despite a low unemployment rate, wages haven’t effectively moved in nearly 40 years unless you are in the top 0.01% on the socioeconomic ladder.
In our personal lives, we are increasingly isolated as well. Smartphones and tablets have decreased our face-to-face interactions.Marriage rates are at their lowest in U.S. history and we no longer join social organizations (political parties, unions, houses of worship, unions, social clubs). Part of the reason seems to be related to our increased use of technology—we spend more time with our faces glued to a screen than interacting with one another. For many people, their cell phone is their most significant relationship. Another reason, the stress that comes at us from all parts of our world make us disengage and hide away from others.
What has not been well explored is how do we change the structural issues that have created a society that requires us to be in a stress state all the time. This is not about turning off my cell phone two hours before bed or meditating for 20 minutes a day. This about a society that has broken our biology and then expects us to individually try to cope. How can we have empathetic and compassionate health care providers when the system is rigged? Withdrawing from others is the only way we can survive the onslaught.
Adding humanities to health professions education is not going to change this either. Having physicians read poems and nurses writing narratives might help in the short term, but on the long road, we need more. We need to change the system instead of trying to use the humanities as band aids.
To change a system requires that we come together. Change of a system requires that we not retreat into our personal screens and tiny houses, but that we learn to re-connect with other human beings for face-to-face interaction. We need to change a society that demands a flight or fight response 24 hours a day/7 days a week. France made a good start when it passed a law making it illegal for employers to email their workers after hours. Stress is a social determinant of health. Loneliness should be a social determinant of health. And bioethics should be working more on these basic issues of human flourishing.