Overview of stress, burnout, and self care

The delivery of health care in the United States requires a robust workforce of clinicians who are not only devoted to improving the health of patients and communities but are also committed to the profession, despite the social, emotional, and physical stressors of clinical care. The U.S. health care system, although considered a gold standard throughout the world, is one of the most complex, with many interrelated components, including health systems, community health centers, private clinics, health insurers, home health agencies, pharmacies, and pharmacy benefits managers. The complexities of delivering health care in the United States, the expanded and novel treatment options, and our aging population are likely responsible for the growth in the number of health care professions. Overall employment in health care industry professions is projected to outpace all other occupations and to grow by 18% from 2016 to 2026. The projected growth for physician assistants (PAs) is considerably higher at 37%, whereas the rate for U.S. physicians is projected at 13%. There are many system changes presently in play on how best to improve health outcomes and control costs in the complex, expensive, and inconsistent U.S. health care system. These proposed changes include integrated health information technologies, pay-for-performance systems, chronic disease management, and reimbursement reform. Despite the career growth projections and the exhaustive search for ways to improve the U.S. health system, those on the front line—physicians, PAs, and nurses—bear the increasing burden of both providing care and managing the business of health care delivery. The complexities of providing health care and the business demands placed on clinicians exert a physical and emotional toll on practitioners. The complexities lead to stress, and stress over time leads to burnout. The syndrome of burnout, as defined in 1981 by the Maslach Burnout Inventory, consists of emotional exhaustion, a decreased perception of personal accomplishment, and the loss of empathic connections. The increased interest in burnout has resulted in a greater understanding and amount of research of the factors involved, as well as the tangible and measurable impact that burnout has on clinical care, and thus health outcomes, in the United States. Although most of the literature focuses on physician burnout, it is reasonable to apply these conceptual models to PAs, who work in tandem with medical doctors. Clinician self-care is an emerging trend as a way to prevent or treat the consequences of stress and burnout. There are many self-care strategies currently in play; however, there is little scientific data to guide these practices.

The concepts of wellness and self-care

The term wellness carries many definitions, from the very physical definition of “the absence of disease or disability” to the more comprehensive World Health Organization definition of health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” Indeed, the term wellness should encompass more than simply the absence of illness, distress, or disease. This is an important distinction and definition for PAs who, like physicians, are often trained using a disease-oriented medical model. For the purposes of this discussion, the definition of wellness from Shanafelt and colleagues will be used: “Wellness goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life.”

A major threat to wellness in a clinician is chronic stress and burnout. Although chronic stress and burnout can be considered to be on the same continuum, they are distinct. Short-term stress can be beneficial and provide motivation to accomplish a task or goal. Chronic stress leads to fatigue, overreactive emotions, and anxiety. Long-term stress can contribute to a plethora of negative physical outcomes. Burnout is felt to be one of the consequences of long-term chronic interpersonal stress. Maslach defines burnout as emotional exhaustion, depersonalization and detachment from the job and patient, and a low sense of personal accomplishment ( Fig. 39.1 ). It is characterized by emotional exhaustion, disengagement, blunted emotions, loss of motivation, and hopelessness. Although Maslach’s seminal work remains a widely accepted instrument for the assessment of burnout, a number of conceptual models have followed, each addressing different dimensions of the syndrome. Examples include the Bergen Burnout Inventory, the Shirom-Melamed Burnout Measure, and the Copenhagen Burnout Inventory. Each of these instruments includes exhaustion as a central feature. The negative clinician outcomes associated with chronic stress and burnout include decreased productivity, decreased job satisfaction, depression, relationship problems, substance abuse, and suicide. ^{, , ,} Those experiencing high levels of burnout may exhibit symptoms or features difficult to distinguish from major depressive disorder. Thus, with increasing rates of burnout, it is not surprising that some reports estimate that the suicide rate among physicians is 6 times greater than in the general population.

Components of burnout.

Unfortunately, burnout is prevalent in physician populations, with approximately 50% of physicians reporting symptoms of burnout. Data from physicians suggest that the largest contributor to burnout is excessive workload. This is particularly the case in situations where the clinician lacks control over patient scheduling and where the workload exceeds capacity. Other notable stressors include financial and economic factors (student loans, practice expenses); the burdens of administrative responsibilities; low autonomy; work life imbalance; and setting limits to support balance. Additionally, the traditional culture of medicine suggests that practitioners should sacrifice their own health and wellness in the care of their patients. ^, Limited available data suggest similar disturbing patterns for PAs. For example, specialties with high levels of physician burnout (emergency medicine, primary care, oncology, and palliative and hospice care) report similarly high levels of PA burnout. ^, Despite limited PA specific data, many of the factors that contribute to physician burnout are also present for PAs. Excessive workload, lack of autonomy, electronic medical records and charting requirements, prior authorizations, and other administrative burdens affect all health care providers.

For all clinicians, an ongoing discussion on burnout and wellness is exceedingly important not only because of the impact on the personal health of the clinician, but also because of the effect on the larger health care system and patient outcomes. High rates of clinician burnout contribute to increased health care costs, higher clinician turnover, reduced patient adherence and satisfaction, and poor patient outcomes. There have been widespread calls to add clinician wellness to health care system quality metrics. ^{, , ,} In fact, the “Quadruple Aim” suggests that clinician wellness be added as a fourth essential component to the Institute for Healthcare Improvement’s “Triple Aim” of improving the health of the population while also reducing health care spending and enhancing the patient care experience. Furthermore, this reinforces the idea that clinician wellness should encompass more than simply the absence of burnout; it should also involve true professional fulfillment. ^,

There are multiple models of wellness from other health care disciplines that are applicable to the PA profession. To move beyond the idea that wellness is simply the absence of burnout, an evolving model of wellness incorporates seven domains impacting wellness: physical, emotional, professional or occupational, intellectual, environmental, and social. This model suggests that integration and balance across these domains is essential for well-being. The National Academy of Medicine (NAM) has developed a clinician-focused approach to wellness and identifies seven factors affecting clinician well-being and resilience ( Fig. 39.2 ). Five of the factors are grouped as “external” and contain additional characteristics specific to each category ( Table 39.1 ), whereas the final two factor categories are deemed “internal factors” ( Table 39.2 ). The NAM suggests that each factor must be optimized for an individual clinician to achieve well-being, and clinician well-being is imperative for a successful clinician-patient relationship and ultimately for optimal patient outcomes.

Factors affecting clinician well-being and resilience.

(Adapted from “A Journey to Construct an All-Encompassing Conceptual Model of Factors Affecting Clinician Well-being and Resilience”, 2017 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.)

Table 39.1

External Factors Affecting Clinician Well-being and Resilience

Learning/ Practice Environment	Society and Culture	Rules and Regulations	Health Care Responsibilities	Organizational Factors
■ Autonomy ■ Collaborative vs. competitive environment ■ Curriculum ■ Health IT interoperability and usability/Electronic health records ■ Learning and practice setting ■ Mentorship program ■ Physical learning and practice conditions ■ Professional relationships ■ Student affairs policies ■ Student-centered and patient-centered focus ■ Team structures and functionality ■ Workplace safety and violence	■ Alignment of societal expectations and clinician’s role ■ Culture of safety and transparency ■ Discrimination and overt and unconscious bias ■ Media portrayal ■ Patient behaviors and expectations ■ Political and economic climates ■ Social determinants of health ■ Stigmatization of mental illness	■ Accreditation, high-stakes assessments, and publicized quality ratings ■ Documentation and reporting requirements ■ HR policies and compensation issues ■ Initial licensure and certification ■ Insurance company policies ■ Litigation risk ■ Maintenance of licensure and certification ■ National and state policies and practices ■ Reimbursement structure ■ Shifting systems of care and administrative requirements	■ Administrative responsibilities ■ Alignment of responsibility and authority ■ Clinical responsibilities ■ Learning/career stage ■ Patient population ■ Specialty-related issues ■ Student/trainee responsibilities ■ Teaching and research responsibilities	■ Bureaucracy ■ Congruent organizational mission and values ■ Culture, leadership, and staff engagement ■ Data collection requirements ■ Diversity and inclusion ■ Harassment and discrimination ■ Level of support for all health care team members ■ Power dynamics ■ Professional development opportunities ■ Scope of practice ■ Workload, performance, compensation, and value attributed to work elements

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