Turning tides in doctors’ wellbeing: from individual resilience to systemic responsibility
Time for turning tides in doctors' wellbeing: we should be focusing on systemic responsibility rather than placing blame on the individual.
A popular way to respond to increasing workloads and pressures in healthcare has been to put responsibility on the individual to ‘build resilience’ and ‘manage stress better’ to avoid burnout, but is this fair? How about taking a systemic approach to modifying the working environment and associated pressures; isn’t it at least as much a responsibility for the employer as it is for the employee? The General Medical Council thinks so in it’s newly published report on doctor’s wellbeing, entitled ‘Caring for doctors Caring for patients’.
Burnout is a term which could be used to push responsibility back onto the individual. There are several different ways to conceptualise it: as a response to a lack of autonomy in and connection to one’s work; or putting in prolonged effort for not-enough reward, leading to a gradual depletion of enthusiasm and energy for the work, for example. The phenomenon tends to be insidious in onset and is often not noticed by the sufferer or by others until late in its course, if at all.
A recent Lancet editorial which discusses the concept of physician burnout in the context of health systems highlights the recent trend towards a more systemic, rather than individualistic, way of viewing burnout in doctors.
The article points out the worrying statistic that burnout is reported to affect more than 50% of practicing physicians in the US, and that similar patterns are being reported in the UK and China.
It can be, paradoxically, the most resilient people who experience burnout, by virtue of their ability and/or willingness to withstand long periods of deprivation of one kind or another. There is no blame implicit in this statement; this is multifactorial and driven by many different factors, depending on each individual’s experience of life to that point. But, it does highlight a falsehood in pushing yet more responsibility onto individuals to up their game when they may already have given far too much of themselves and are, therefore, already relatively deprived.
The deprivation may be in terms of work satisfaction, having basic needs met, getting positive feedback, and any other combination of a large number of positive and sustaining factors.
The RCPsych Bulletin, one of the journals produced by the Royal College of Psychiatrists, recently published a paper entitled Personal resilience in psychiatrists: systematic review. Although the title of the paper implies the exploration of responsibility on the part of the individual, the conclusion is that interventions at a workplace level are likely to be the most helpful, rather than those focused on the individual.
When the support network, which includes support within the workplace itself, is lacking, unavailable, or actually negatively impacting the doctor’s sense of self, this can have a detrimental effect on that doctor’s ability to perform their role as a carer of others. This state may be endured for some time before the individual runs out of resources within themselves due to a lack of replenishment from the support network.
As a profession, medicine, and more widely healthcare, has to face up to the fact that doctors and their colleagues are only human and require the same basic needs to be met as any human being . A useful way to conceptualise this is to be found in Maslow’s hierarchy of needs; physiological needs are fundamental to be met before moving up to the next level of need – this means providing doctors with places they can rest, eat and drink. Next in the hierarchy is safety – the safety of knowing that you have colleagues whom you can rely on to help out when the going gets tough.
Once these two needs are met, then a sense of belonging can be allowed to develop and flourish. Above this is self-esteem and self-actualisation – the doctor is now in a secure and supportive enough environment to be able to get satisfaction from their work and to work at the highest possible standard. Using this hierarchy, it is easy to see how a lack of basic provisions can affect the doctor’s ability to work effectively, and to gain the satisfaction needed to provide a buffer against the demands of the work.
In a profession where basic needs are often unmet, particularly when the provision of both practical and emotional support is eroded, the drip-drip of frustration builds up over time. The task of finding compensatory sources of satisfaction and succor becomes gradually more difficult, and can prove to be impossible. This is when burnout rages unchecked in a unhelpfully amplifying feedback loop.
Doctors are leaving the profession in unprecedented numbers in the UK, as in other countries around the world . There is a need to maintain and re-grow the healthcare workforce rather than see it dwindle. The urgency of retaining doctors has sparked more thought around the subject and, now, the new set of recommendations from the GMC.
The medical profession in the UK and elsewhere is starting to actively acknowledge and intervene to meet the needs of doctors through taking a more systemic approach. With this advance comes hope that medicine as a career will be able to sustain itself through adversity and will continue to contribute to the health and wellbeing of all of us.
Laura Allison
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