Riding the Waves of Burnout

By Karen L. Chandler

As the COVID-19 epidemic ebbs and flows, burnout among medical professionals is on the rise.

In the second edition of her book, Burnout and Self-Care in Social Work, author SaraKay Smullens, a certified family life educator, group psychotherapist, and social worker basing her private and pro-bono clinical practice in Philadelphia, updates the text’s content with a further enhanced exploration and understanding of burnout.

The wife of Dr. Stanton Smullens, a retired surgeon and former chair of the Pennsylvania Patient Safety Authority, Smullens realizes the effects stressors have on physicians, especially during the onslaught of COVID-19, and acknowledges how any discussion of burnout in doctors has been mainly limited to their professional lives.

“It is essential that burnout warning signs are clearly marked and communicated before lives are destroyed! Wherever burnout originates – personally, professionally, relationally, physically, or societally (or a combination) – it impacts interactively bringing grave danger. When overwhelmed, overloaded, and overburdened by external pressures, when anxiety and exhaustion seem everywhere, the destruction of self-confidence, self-respect, and an inability to connect with others are in the wings.” (Burnout and Self-Care in Social Work, 2nd edition)

While professional burnout remains a topic of concern, Smullens discusses the other aspects of burnout that impact each other and should be examined and recognized: “personal (our inner world capacity to deal with stress); relational (unresolved conflicts in families and in close relationships), societal (the impact of unresolved conflicts played out 24/7 through technology), and physical (our bodies speak to us, offering clues.)”

Smullens describes personal burnout as an upheaval in the cognitive, intellectual, psychological, emotional, or spiritual life, or a lacking in one’s inner world to deal with stress, while relational burnout is based in unresolved conflicts in family or other close relationships and can even affect those interactions that are more distant.

Physical burnout is based in the body’s physiological response to stress and can be evidenced in a multitude of illnesses that may range from sleep disturbances to the common cold, to cardiovascular disease, however, Smullens confirms that no physical symptom should be assumed caused by burnout without the indicated medical evaluations.

New to the second edition of her book is Smullens’ fifth dimension of concern, societal burnout, a state she describes as being “overwhelmed, overburdened, and overloaded by a ‘perfect storm’ of grave, threatening, and unaddressed societal problems,” much like the crisis realized by many physicians working through the COVID-19 pandemic.

Smullens notes that the Medscape Physical Burnout and Depression Report in 2022: Stress, Anxiety, and Anger showed a five-percentage point increase in overall physician burnout, from 42 percent in 2020 to 47 percent in 2021, and an increase in emergency room physician burnout from 43 to 60 percent last year. The report added that most doctors felt that burnout intruded upon most aspects of their lives, with 54 percent feeling its effects to be strong to severe, including in their relationships. The Maslach Burnout Inventory is a source recommended by Smullens for anyone looking for help in evaluating their own experience with burnout.

Gathering over thirty years of clinical experience, Smullens sides with other experts who believe that burnout is a condition separate from depression and while there can be an overlap between the two diagnoses, Smullens explains that many people who believe they are suffering from depression are actually burned out. The World Health Organization officially describes burnout as a syndrome, rather than a psychiatric illness, such as depression, that could carry a stigma. Burnout is evidenced by a combination of reduced personal accomplishment, emotional

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exhaustion, and depersonalization, and can all be brought on by chronic occupational stress.

“Depression caused by loss, rejection, betrayal, connivance can be experienced as a fierce body punch. One may feel blindsided and bewildered as if slats in the floor of an emotional home have disappeared. With burnout the body speaks to us differently: ‘My shoulders, my arms, my being can no longer carry what is asked and expected. My brain feels fried’”. (Burnout and Self-Care in Social Work, 2nd edition)

Smullens writes that researchers have used four attendant syndromes or “wake-up calls” to better explore the tumultuous waters of burnout, and while the complex faces of burnout may overlap, each of the attendant syndromes provides valuable insights into the experience of burnout.

Compassion fatigue is the attendant syndrome that results when medical professionals give until they have nothing left and it highlights the emotional and physical fatigue that many caregivers experience. Compassion fatigue always plays a factor in the other syndromes and indicates a need to take a break for self-care.

Originally defined by Freud, the second attendant syndrome, countertransference, results as a patient’s influence gives rise to a practitioner’s positive or negative subconscious feelings about a significant person from his or her own previous experiences. Smullens advises physicians encountering this syndrome to continually face how they feel about each patient and be aware of how patients trigger past or current emotions.

Vicarious trauma and secondary trauma, considered the third attendant syndrome, results from a medical professional’s direct and frequent exposure to victims of trauma. Smullens notes that caring for patients who became ill or died after a COVID-19 infection may echo a physician’s own personal trauma of watching a loved one in a similar situation, and that processing the resulting emotions with a colleague or other professional can be helpful.

The fourth attendant syndrome is considered by Smullens to be moral distress and injury, an experience felt by medical professionals unable to provide the highest quality of care and healing, a factor in burnout exacerbated by the COVID-19 crisis.

Smullens explains that a key to smoothing the turbulence of burnout is for physicians to move from compassion fatigue to compassion satisfaction, an effort that lessens the grasp of the attendant syndromes and is further helped by employing self-care strategies.

“The goal is to go from compassion fatigue to compassion satisfaction. Key to this is the ability to have boundaries with patients, Yes, physicians care — but empathy is the goal. Empathy connotes boundaries, while sympathy connotes union. Energy and inner resources must be protected for personal lives. Also, those in the medical profession often see themselves as SuperMen and Women, and often extend themselves beyond reason. It is important to be able to protect oneself, to say No and to understand that if we cannot say No, we cannot say Yes, and further, we will be unable to recognize fulfilling options before our very eyes in love, friendship, and work.” – SaraKay Smullens

Self-care in a multi-pronged approach is the way health care professionals can fight back from the grasp of burnout, a condition that has claimed lives as evidenced by rising suicide rates in physicians.

Personal, physical, relational, and societal self-care can work together to create better quality of life for physicians. Smullens confirms the importance of finding a program of strategies and attitudes that speak to each person in a way that is both enjoyable and can become an integral part of daily life, whether it is journaling, learning a new skill, or making a date night with a partner.

Smullens believes that doctors may often forget the power of their own creativity and encourages a renewed focus on making time to devote to a dream, and when one dream does not become fulfilling to seek another.

On the professional front, Smullens notes that some health care institutions are putting together wellness programs for staff to use including such features as recharge rooms and counseling services, and she hopes medical schools will follow suit and teach self-care strategies for students to reduce the risk of burnout.

“All health care leaders in organizations, institutions, and government and industry must prioritize major improvements in settings… Recharge Rooms are a wonderful example. A culture of trust is essential in all healthy settings — someone to go to and process with if overwhelmed. My research shows that anxiety is alleviated when one can speak honestly to one reported to — a sign of a healthy functional setting. In dysfunctional settings, anxiety is imposed from the top, as a control mechanism. People are pitted against each other; one does not know whom to trust.” – SaraKay Smullens

In her book, Smullens tells of the tragic suicide of 49-year-old Lorna Breen, MD, a Manhattan emergency room physician supervisor at a hospital devoted, but ill-supplied, to serve the underprivileged during the COVID-19 pandemic. Breen’s father, Dr. Philip C. Breen, said after his daughter’s death, “she tried to do her job and it killed her.”

Smullens’ personal message to health care professionals is both encouraging and cautionary.

She said, “evidence-based self-care strategies, behaviors, and attitudes, if integrated into your life, will prevent, address, and alleviate burnout. Your body and what I think of as an “InnerSelf Voice” that each of us has, but often ignore, as we push ourselves, will signal when burnout is a threat. Listen!” •

A New, Affordable Model for Medical Practices

Space sharing, also called coworking, has become a popular option for general office work over the last decade but, until recently, has not been available in health care. MedCoShare, as the name implies, has recently opened one coworking facility in Philadelphia, and is about to open another in Marlton, N.J. The company offers doctors and other health care providers flexible space and support services that help independent providers practice on their own terms at a fraction of the cost of setting up a traditional office.

Ronak Vyas, an experienced real-estate agent and broker, founded the company in 2019. Along with partners who include other real-estate experts and health care providers, he created MedCoShare to fill what he saw as a major gap in the traditional office leasing model.

“There are many doctors whose needs just are not met by the typical office lease,” Vyas said, “so I see this as an exciting innovation in the health care office market.” There are many obstacles to starting a practice, including initial expenses, operational challenges and a significant degree of risk, which are neither practical nor affordable for an individual or small partnership. Part-time and short-term medical office space is not part of the traditional leasing model. Health care-space landlords typically require tenants to sign leases ranging from 5 to 10 years, which often include personal guarantees. These spaces then require long and costly fit-outs before a provider can start seeing patients. Setting up an office also requires establishing long-term commitments for cleaning, medical waste removal, support staff and more.

According to one of Vyas’ partners, Gregory Goldmacher, MD, “Many doctors are increasingly unhappy with the lack of autonomy in working for hospitals or large groups, and are considering private practice again, or for the first time, or going part-time as they move toward retirement or shifting family obligations,” Goldmacher said. “Coworking space could provide an ideal option.” Having an affordable coworking space/part-time office to split telehealth and in-person visits would be an effective hybrid practice model, or could give a provider options to see patients in more than one location, one or two days a week in several offices.

Vyas and his partners opened their first location in an outpatient clinic in the Fishtown neighborhood of Philadelphia, an office left vacant by the closure of the Hahnemann hospital system. They started operations in the summer of 2020. In spite of the pandemic, MedCoShare has attracted a variety of health care providers, including specialists in cardiology, dermatology and men’s health, and other types of ancillary providers such as estheticians, massage therapists and more. “Being a new small business owner in the midst of a pandemic, MedCoShare has been a blessing,” said Marybell Rodriguez, a nurse practitioner who performs skin care procedures. “Where else could I start a business, build clients and have a flexible membership with no long-term commitments for peace of mind during the uncertainty?”

In less than a year, the company has filled its first space and is poised to grow. The location in Marlton is scheduled to open at the end of January, and Vyas and his partners are evaluating more locations in King of Prussia. “Our goal is to build locations in the region, develop our support service offerings and then go national,” Vyas said. “We think this will become a popular new practice model across the country, similar to the way urgent care has grown over the last decade.” •

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