Defeat and Its Toll on Well-Being

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Of the three dimensions of burnout, a sense of ineffectiveness at work (or decreased personal accomplishment, according to Maslach’s framework) is perhaps the most complex and least well-understood (1). Nonetheless, feeling competent in one’s work is a feature shared by most models of workplace motivation. One of the most popular is Ryan and Deci’s self-determination theory, in which competence is considered one of three basic psychological needs, alongside autonomy and relatedness (2). (You may have heard a slightly modified version of this theory in Daniel Pink’s work, in which he refers to the three needs as mastery, autonomy, and purpose.) Even some of the more task-focused motivational frameworks, such as Hackman and Oldham’s job characteristics model, still recognize the critical interplay between the work being done and how well one is doing it (3).

Although feeling defeated at work has major implications for any career, there are at least two factors that may explain why it has such a pronounced effect on health care professionals (4). First, the many screens to entering a career in health care select for individuals who persevere in the face of adversity. For example, the path to practicing medicine involves getting accepted to medical school (which itself requires high levels of achievement in high school and undergraduate studies and doing well on standardized exams), passing several additional standardized exams during medical school and in postgraduate training, and completing several years of residency training; those pursuing a specialty area must complete several additional years of fellowship training and obtain board certification in their area of specialty.

Evidence of a persevering mindset among health care professionals can also be observed in other ways. For example, in studies characterizing the StrengthsFinder profiles of student pharmacists and pharmacy residents, results indicate that over 40% have the Achiever theme in their top five strengths (5,6). According to the descriptions provided on the Gallup website, Achievers are individuals who “have a great deal of stamina and work hard…. [who] take great satisfaction from being busy and productive.” Approximately 41% of the students in our program also have Achiever in their top five strengths, suggesting that high levels of perseverance are fairly consistent among students pursuing a career in pharmacy.

The second factor for why ineffectiveness at work may be particularly problematic for health care professionals is that these individuals are then thrown into an environment where defeat is the norm, as the challenges they face are complex and often beyond their control. For one, health care is notoriously deficient in the resources necessary for routine care. This may seem surprising given the ubiquity of cafes, water features, and other elements designed to make health care facilities look nice, but units are frequently understaffed, overworked trainees misrepresent their time in order to avoid workhour violations, and a significant amount of unpaid administrative work is often done on evenings and weekends (7,8).

It may also be difficult to find wins in day-to-day practice. Disease is increasingly more complex, and few disorders can be cured entirely. In certain practice settings, clinicians may never see the full fruits of their labor, such as when a stabilized patient is transferred out of the emergency room or intensive care unit, only to be replaced by one that needs immediate attention. It is therefore no wonder that burnout among these specialties approaches 50%. Worse yet, improvements in some disorders may paradoxically worsen outcomes in others. For example, advances in the management of acute myocardial infarction have led to increases in survival, but also the number of patients who go on to develop chronic heart failure.

Even if a patient’s medical problems can be improved substantially, a complicated web of social determinants await to further thwart one’s efforts. Recommending that a patient reduce their risk of stroke by eating healthier or exercising more is rendered useless if the patient lives in a food desert or in a neighborhood where it is unsafe to exercise. These and related issues are explored further in a piece by Elizabeth H. Bradley and Lauren A. Taylor in The New Yorker, and a link to burnout has been proposed in a recent commentary in the New England Journal of Medicine (9).

So why highlight these issues? This post may seem somewhat dire by placing a focus on defeat, but the point of it is to describe some of the complex systemic factors that may contribute to burnout, and why health care professionals may be especially susceptible to it. According to the conceptualizations proposed by Maslach and other experts, burnout is more commonly the result of organizational factors such as those described above, and not individual failings, such as a lack of perseverance or mindfulness about work (1). Asking individuals to meditate or perform other exercises may lead to short-term improvements in symptoms but they fail to address the underlying problems that cause burnout in the first place. To borrow from the pathophysiologic model with which health care professionals are most familiar, strategies to address burnout should not just treat its signs and symptoms – they should also treat the underlying disease.

References

  1. Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annu Rev Psychol. 2001 Feb 1;52(1):397–422.
  2. Ryan RM, Deci EL. Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemporary Educational Psychology. 2000 Jan;25(1):54–67.
  3. Hackman JR, Oldham GR. Motivation through the Design of Work: Test of a Theory. Organizational Behavior & Human Performance. 1976 Aug;16(2):250–79.
  4. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600–13.
  5. Yee GC, Janke KK, Fuller PD, Kelley KA, Scott SA, Sorensen TD. StrengthsFinder® signature themes of talent in pharmacy residents at four midwestern pharmacy schools. Curr Pharm Teach Learn. 2018 Feb;10(1):61–5.
  6. Janke KK, Farris KB, Kelley KA, Marshall VD, Plake KS, Scott SA, et al. StrengthsFinder Signature Themes of Talent in Doctor of Pharmacy Students in Five Midwestern Pharmacy Schools. Am J Pharm Educ. 2015 May 25;79(4):49.
  7. Drolet BC, Schwede M, Bishop KD, Fischer SA. Compliance and Falsification of Duty Hours: Reports From Residents and Program Directors. J Grad Med Educ. 2013 Sep;5(3):368–73.
  8. Dyrbye LN, Shanafelt TD, Sinsky CA, Cipirano PF, Bhatt J, Ommaya A, et al. Burnout Among Health Care Professionals: A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care [Internet]. National Academy of Medicine; 2017 [cited 2018 Jul 22]. Available from: https://nam.edu/burnout-among-health-care-professionals-a-call-to-explore-and-address-this-underrecognized-threat-to-safe-high-quality-care/
  9. Eisenstein L. To Fight Burnout, Organize. N Engl J Med. 2018 Aug 9;379(6):509–11.

 Image credits: adapted from Perseids, again by John Fowler (CC BY 2.0)

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