From the President: Ah, Summer...A Good Season to Readdress Work-Life Balance

There is something about the summertime that promotes appreciation for slower pace and reflection. Whether it’s the cool sand between your toes, an amazing vista after a vigorous hike, or the midmorning laughter of your kids on vacation – these joyful activities help reinvigorate. Reflecting back on 30 summers as an academic pulmonary and critical care physician, I think it may be more important than ever for us to take a moment to contemplate work-life balance in medicine, and, perhaps, our specialty in particular.

We all work hard, and most of us would enter a career in medicine again, and even sign up for the same specialty again. We value the work we do, particularly, the opportunity to improve the lives of our patients and generally find the work stimulating, rewarding, and even exciting. Additionally, we in pulmonary and critical care, and related fields, are accustomed to the stresses of high intensity, fast-pace, high-stakes work, as well as long and often undesirable work hours, including weekends and nights. There are certainly many more individuals in the hospital at night than a decade ago. Additionally, recent years have brought a rapid increase in the proportion of our time working as clinicians devoted to documentation and other non-patient care tasks. All told, the potential for work-related stress is certainly not decreasing.

Individuals who work in the ICU and similar work environments are accustomed to stress. It is part of the territory. To a point, short-term stress can actually be useful, as it tends to enhance focus and efficiency. Burnout, however, is a maladaptive response to excessive stress in the workplace and is characterized by emotional, mental, and physical exhaustion. Classically, burnout is defined as having three dimensions: emotional exhaustion, depersonalization, and diminished personal accomplishment. Importantly, development of burnout in a health-care worker has potential adverse consequences for the individual, the work environment, and our patients. Workers with burnout are more likely to have depression, alcohol and substance abuse, and various health disorders, and, often, leave the profession early. Behaviors of a burned out individual can be disruptive, contributing to staff dissatisfaction and excessive turnover. Finally, burnout has been associated with increased rates of medical errors, lower patient satisfaction, and reduced quality of care. Clearly, preventing and ameliorating burnout is an important target.

There is a growing body of evidence^1-4 that serious burnout is commonplace among ICU workers. From a broad perspective, burnout is more common, and satisfaction with work/life balance less common, among physicians compared with the general population. Not surprisingly, among both physicians and nurses, the ICU as a workplace is associated with higher-than-average rates of burnout. There are now numerous survey-based multicenter studies that indicate approximately one-third to one-half of ICU workers have severe burnout.^1-4 Look to your left. Look to your right. Chances are that one of you has significant burnout.

Particularly noteworthy is a recent online survey of physicians performed by Medscape⁴ in which 52% of intensivists described themselves as having serious burnout – the largest proportion among all 25 medical specialties reported. Perhaps more distressing, intensivists had among the lowest proportion of respondents who described themselves as “very happy” when describing their satisfaction at work and home. Finally, intensivists had the lowest proportion, among 25 medical specialties, of self-described health as “excellent” or “very good.”

We should all be concerned that these findings collectively paint a picture of a specialty at risk. It is important for us to consider why burnout occurs and what can be done about it. Specifically, which individuals are at increased risk? Are there identifiable factors that might be modified to reduce the likelihood of developing burnout? Are there individual and organizational approaches to identify individuals with burnout syndrome and mitigate its effects? Finally, are there opportunities for key stakeholders, including administrators and policymakers, to become better informed as to this emerging epidemic?

Several studies^1,3 have now identified independent, potentially modifiable risk factors for burnout of intensivists, as well as ICU nurses. Common themes have emerged and include the following: (a) the quality of working relationships; (b) end-of-life issues; (c) organizational factors; and (d) personal characteristics. Perhaps the most consistently noted factor is that of interpersonal conflicts, those among physicians, nurses, and patients and family members. ICU physicians and nurses with burnout more commonly described conflict with their colleagues and with the other key members of the ICU team. Suboptimal communication is often at the root of conflict, and there are opportunities for enhancing communications and creating a supportive and trusting environment among ICU health-care workers.

The relationships that physicians and nurses have with critically ill or injured patients, and, perhaps, more commonly with family members, can be highly stressful. Again, promoting understanding and healthy communication proactively can pay dividends in regards to stress mitigation. This ties in with the added challenges of end-of-life situations in which emotions often run high, and calm, thoughtful communication is of critical importance. Surveys indicate^1,3 that end-of-life issues impact our ICU nursing colleagues even more significantly, perhaps in part because of their many hours of direct contact with patients and families at the bedside.

From a unit organizational perspective, studies indicate^1,5 that an excessively heavy work schedule is an important risk factor for physicians. In particular, the number of night shifts per month, and the time since the last nonworking week, were independent risk factors for burnout in one study. In a prospective randomized trial,⁵ a continuous intensivist schedule of 14 consecutive days was associated with higher burnout, greater job distress, and more work-life imbalance than a schedule with weekend cross-coverage. Inclusion of nonclinical work, such as research, teaching, or administrative activities, or work in a different clinical setting, appears to be protective regarding burnout. Unit and practice leaders and administrators have an opportunity to influence scheduling and nonclinical activities to reduce burnout.

Individuals who seem to be higher risk for developing burnout tend to have perfectionist and controlling tendencies, pessimistic views, and an inability to express emotions or to delegate. Individuals with supportive relationships and those who are able to personally manage difficult situations effectively, ie, are “resilient,” tend to avoid burnout more effectively.

Strategies to manage burnout in the ICU focus on prevention, early identification of the individual with burnout, and mitigation of burnout (often employing the same techniques as for prevention). Preventive strategies include both individual and organizational approaches. Individual approaches include awareness and self-monitoring, willingness to accept help from others, lifestyle management, stress management, anger management, “mindfulness,” and development of resilience. Individual approaches are often promoted in an organization setting. Such programs are increasingly used for medical students and residents but must become more ingrained in clinical practice settings.

Organizational approaches include prospective identification and monitoring of worker well-being as a quality indicator, emphasis on teamwork, attention to high stress areas (such as the ICU), deliberate management of the work environment to address overwork, support for a healthy work environment in regards to respectful relationships and communication, and many others.

What can the American College of Chest Physicians do to help alleviate burnout and enhance work-life balance among our members? I’m pleased to report that CHEST is leading an important project conducted by members of the Critical Care Societies Collaborative (CCSC), that includes leaders and experts from the American Association of Critical-Care Nurses (AACN), the American Thoracic Society (ATS), the Society of Critical Care Medicine (SCCM), and CHEST. Key goals of this task force are to raise awareness and set the stage for interventions to reduce burnout in the ICU through publication of a review and call to action in multiple journals; sponsorship of educational sessions at our annual meetings; and development and posting of additional Web-based tools and resources. While critical care workers are certainly aware of the importance and prevalence of ICU burnout, an important aim is to raise awareness among other key groups, including policymakers, administrators, and funding agencies.

In conclusion, please take a moment during this month of August to pause and consider your own work-life balance and how, together, we can enhance not just the health of our patients but also the personal well-being and long productive career among those who care for the critically ill and injured.

References

1. Embriaco NE, Azoulay K, Barrau N et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175[7]:686-692.

2. Merlani PM, Verdon A, Businger G, Domenighetti H, Parggerm H, Ricou B. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184[10]:1140-1146.

3. Poncet MCP, Toullic L, Papazian N, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175[7]:698-704.

4. www.medscape.com/features/slideshow/lifestyle/2013/critical-care#7

5. Ali NA, Hammersley J, Hoffmann SP, et al. Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med. 2011;184[7]:803-808.

There is something about the summertime that promotes appreciation for slower pace and reflection. Whether it’s the cool sand between your toes, an amazing vista after a vigorous hike, or the midmorning laughter of your kids on vacation – these joyful activities help reinvigorate. Reflecting back on 30 summers as an academic pulmonary and critical care physician, I think it may be more important than ever for us to take a moment to contemplate work-life balance in medicine, and, perhaps, our specialty in particular.

We all work hard, and most of us would enter a career in medicine again, and even sign up for the same specialty again. We value the work we do, particularly, the opportunity to improve the lives of our patients and generally find the work stimulating, rewarding, and even exciting. Additionally, we in pulmonary and critical care, and related fields, are accustomed to the stresses of high intensity, fast-pace, high-stakes work, as well as long and often undesirable work hours, including weekends and nights. There are certainly many more individuals in the hospital at night than a decade ago. Additionally, recent years have brought a rapid increase in the proportion of our time working as clinicians devoted to documentation and other non-patient care tasks. All told, the potential for work-related stress is certainly not decreasing.

Individuals who work in the ICU and similar work environments are accustomed to stress. It is part of the territory. To a point, short-term stress can actually be useful, as it tends to enhance focus and efficiency. Burnout, however, is a maladaptive response to excessive stress in the workplace and is characterized by emotional, mental, and physical exhaustion. Classically, burnout is defined as having three dimensions: emotional exhaustion, depersonalization, and diminished personal accomplishment. Importantly, development of burnout in a health-care worker has potential adverse consequences for the individual, the work environment, and our patients. Workers with burnout are more likely to have depression, alcohol and substance abuse, and various health disorders, and, often, leave the profession early. Behaviors of a burned out individual can be disruptive, contributing to staff dissatisfaction and excessive turnover. Finally, burnout has been associated with increased rates of medical errors, lower patient satisfaction, and reduced quality of care. Clearly, preventing and ameliorating burnout is an important target.

There is a growing body of evidence^1-4 that serious burnout is commonplace among ICU workers. From a broad perspective, burnout is more common, and satisfaction with work/life balance less common, among physicians compared with the general population. Not surprisingly, among both physicians and nurses, the ICU as a workplace is associated with higher-than-average rates of burnout. There are now numerous survey-based multicenter studies that indicate approximately one-third to one-half of ICU workers have severe burnout.^1-4 Look to your left. Look to your right. Chances are that one of you has significant burnout.

Particularly noteworthy is a recent online survey of physicians performed by Medscape⁴ in which 52% of intensivists described themselves as having serious burnout – the largest proportion among all 25 medical specialties reported. Perhaps more distressing, intensivists had among the lowest proportion of respondents who described themselves as “very happy” when describing their satisfaction at work and home. Finally, intensivists had the lowest proportion, among 25 medical specialties, of self-described health as “excellent” or “very good.”

We should all be concerned that these findings collectively paint a picture of a specialty at risk. It is important for us to consider why burnout occurs and what can be done about it. Specifically, which individuals are at increased risk? Are there identifiable factors that might be modified to reduce the likelihood of developing burnout? Are there individual and organizational approaches to identify individuals with burnout syndrome and mitigate its effects? Finally, are there opportunities for key stakeholders, including administrators and policymakers, to become better informed as to this emerging epidemic?

Several studies^1,3 have now identified independent, potentially modifiable risk factors for burnout of intensivists, as well as ICU nurses. Common themes have emerged and include the following: (a) the quality of working relationships; (b) end-of-life issues; (c) organizational factors; and (d) personal characteristics. Perhaps the most consistently noted factor is that of interpersonal conflicts, those among physicians, nurses, and patients and family members. ICU physicians and nurses with burnout more commonly described conflict with their colleagues and with the other key members of the ICU team. Suboptimal communication is often at the root of conflict, and there are opportunities for enhancing communications and creating a supportive and trusting environment among ICU health-care workers.

The relationships that physicians and nurses have with critically ill or injured patients, and, perhaps, more commonly with family members, can be highly stressful. Again, promoting understanding and healthy communication proactively can pay dividends in regards to stress mitigation. This ties in with the added challenges of end-of-life situations in which emotions often run high, and calm, thoughtful communication is of critical importance. Surveys indicate^1,3 that end-of-life issues impact our ICU nursing colleagues even more significantly, perhaps in part because of their many hours of direct contact with patients and families at the bedside.

From a unit organizational perspective, studies indicate^1,5 that an excessively heavy work schedule is an important risk factor for physicians. In particular, the number of night shifts per month, and the time since the last nonworking week, were independent risk factors for burnout in one study. In a prospective randomized trial,⁵ a continuous intensivist schedule of 14 consecutive days was associated with higher burnout, greater job distress, and more work-life imbalance than a schedule with weekend cross-coverage. Inclusion of nonclinical work, such as research, teaching, or administrative activities, or work in a different clinical setting, appears to be protective regarding burnout. Unit and practice leaders and administrators have an opportunity to influence scheduling and nonclinical activities to reduce burnout.

Individuals who seem to be higher risk for developing burnout tend to have perfectionist and controlling tendencies, pessimistic views, and an inability to express emotions or to delegate. Individuals with supportive relationships and those who are able to personally manage difficult situations effectively, ie, are “resilient,” tend to avoid burnout more effectively.

Strategies to manage burnout in the ICU focus on prevention, early identification of the individual with burnout, and mitigation of burnout (often employing the same techniques as for prevention). Preventive strategies include both individual and organizational approaches. Individual approaches include awareness and self-monitoring, willingness to accept help from others, lifestyle management, stress management, anger management, “mindfulness,” and development of resilience. Individual approaches are often promoted in an organization setting. Such programs are increasingly used for medical students and residents but must become more ingrained in clinical practice settings.

Organizational approaches include prospective identification and monitoring of worker well-being as a quality indicator, emphasis on teamwork, attention to high stress areas (such as the ICU), deliberate management of the work environment to address overwork, support for a healthy work environment in regards to respectful relationships and communication, and many others.

What can the American College of Chest Physicians do to help alleviate burnout and enhance work-life balance among our members? I’m pleased to report that CHEST is leading an important project conducted by members of the Critical Care Societies Collaborative (CCSC), that includes leaders and experts from the American Association of Critical-Care Nurses (AACN), the American Thoracic Society (ATS), the Society of Critical Care Medicine (SCCM), and CHEST. Key goals of this task force are to raise awareness and set the stage for interventions to reduce burnout in the ICU through publication of a review and call to action in multiple journals; sponsorship of educational sessions at our annual meetings; and development and posting of additional Web-based tools and resources. While critical care workers are certainly aware of the importance and prevalence of ICU burnout, an important aim is to raise awareness among other key groups, including policymakers, administrators, and funding agencies.

In conclusion, please take a moment during this month of August to pause and consider your own work-life balance and how, together, we can enhance not just the health of our patients but also the personal well-being and long productive career among those who care for the critically ill and injured.

References

1. Embriaco NE, Azoulay K, Barrau N et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175[7]:686-692.

2. Merlani PM, Verdon A, Businger G, Domenighetti H, Parggerm H, Ricou B. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184[10]:1140-1146.

3. Poncet MCP, Toullic L, Papazian N, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175[7]:698-704.

4. www.medscape.com/features/slideshow/lifestyle/2013/critical-care#7

5. Ali NA, Hammersley J, Hoffmann SP, et al. Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med. 2011;184[7]:803-808.

There is something about the summertime that promotes appreciation for slower pace and reflection. Whether it’s the cool sand between your toes, an amazing vista after a vigorous hike, or the midmorning laughter of your kids on vacation – these joyful activities help reinvigorate. Reflecting back on 30 summers as an academic pulmonary and critical care physician, I think it may be more important than ever for us to take a moment to contemplate work-life balance in medicine, and, perhaps, our specialty in particular.

We all work hard, and most of us would enter a career in medicine again, and even sign up for the same specialty again. We value the work we do, particularly, the opportunity to improve the lives of our patients and generally find the work stimulating, rewarding, and even exciting. Additionally, we in pulmonary and critical care, and related fields, are accustomed to the stresses of high intensity, fast-pace, high-stakes work, as well as long and often undesirable work hours, including weekends and nights. There are certainly many more individuals in the hospital at night than a decade ago. Additionally, recent years have brought a rapid increase in the proportion of our time working as clinicians devoted to documentation and other non-patient care tasks. All told, the potential for work-related stress is certainly not decreasing.

Individuals who work in the ICU and similar work environments are accustomed to stress. It is part of the territory. To a point, short-term stress can actually be useful, as it tends to enhance focus and efficiency. Burnout, however, is a maladaptive response to excessive stress in the workplace and is characterized by emotional, mental, and physical exhaustion. Classically, burnout is defined as having three dimensions: emotional exhaustion, depersonalization, and diminished personal accomplishment. Importantly, development of burnout in a health-care worker has potential adverse consequences for the individual, the work environment, and our patients. Workers with burnout are more likely to have depression, alcohol and substance abuse, and various health disorders, and, often, leave the profession early. Behaviors of a burned out individual can be disruptive, contributing to staff dissatisfaction and excessive turnover. Finally, burnout has been associated with increased rates of medical errors, lower patient satisfaction, and reduced quality of care. Clearly, preventing and ameliorating burnout is an important target.

There is a growing body of evidence^1-4 that serious burnout is commonplace among ICU workers. From a broad perspective, burnout is more common, and satisfaction with work/life balance less common, among physicians compared with the general population. Not surprisingly, among both physicians and nurses, the ICU as a workplace is associated with higher-than-average rates of burnout. There are now numerous survey-based multicenter studies that indicate approximately one-third to one-half of ICU workers have severe burnout.^1-4 Look to your left. Look to your right. Chances are that one of you has significant burnout.

Particularly noteworthy is a recent online survey of physicians performed by Medscape⁴ in which 52% of intensivists described themselves as having serious burnout – the largest proportion among all 25 medical specialties reported. Perhaps more distressing, intensivists had among the lowest proportion of respondents who described themselves as “very happy” when describing their satisfaction at work and home. Finally, intensivists had the lowest proportion, among 25 medical specialties, of self-described health as “excellent” or “very good.”

We should all be concerned that these findings collectively paint a picture of a specialty at risk. It is important for us to consider why burnout occurs and what can be done about it. Specifically, which individuals are at increased risk? Are there identifiable factors that might be modified to reduce the likelihood of developing burnout? Are there individual and organizational approaches to identify individuals with burnout syndrome and mitigate its effects? Finally, are there opportunities for key stakeholders, including administrators and policymakers, to become better informed as to this emerging epidemic?

Several studies^1,3 have now identified independent, potentially modifiable risk factors for burnout of intensivists, as well as ICU nurses. Common themes have emerged and include the following: (a) the quality of working relationships; (b) end-of-life issues; (c) organizational factors; and (d) personal characteristics. Perhaps the most consistently noted factor is that of interpersonal conflicts, those among physicians, nurses, and patients and family members. ICU physicians and nurses with burnout more commonly described conflict with their colleagues and with the other key members of the ICU team. Suboptimal communication is often at the root of conflict, and there are opportunities for enhancing communications and creating a supportive and trusting environment among ICU health-care workers.

The relationships that physicians and nurses have with critically ill or injured patients, and, perhaps, more commonly with family members, can be highly stressful. Again, promoting understanding and healthy communication proactively can pay dividends in regards to stress mitigation. This ties in with the added challenges of end-of-life situations in which emotions often run high, and calm, thoughtful communication is of critical importance. Surveys indicate^1,3 that end-of-life issues impact our ICU nursing colleagues even more significantly, perhaps in part because of their many hours of direct contact with patients and families at the bedside.

From a unit organizational perspective, studies indicate^1,5 that an excessively heavy work schedule is an important risk factor for physicians. In particular, the number of night shifts per month, and the time since the last nonworking week, were independent risk factors for burnout in one study. In a prospective randomized trial,⁵ a continuous intensivist schedule of 14 consecutive days was associated with higher burnout, greater job distress, and more work-life imbalance than a schedule with weekend cross-coverage. Inclusion of nonclinical work, such as research, teaching, or administrative activities, or work in a different clinical setting, appears to be protective regarding burnout. Unit and practice leaders and administrators have an opportunity to influence scheduling and nonclinical activities to reduce burnout.

Individuals who seem to be higher risk for developing burnout tend to have perfectionist and controlling tendencies, pessimistic views, and an inability to express emotions or to delegate. Individuals with supportive relationships and those who are able to personally manage difficult situations effectively, ie, are “resilient,” tend to avoid burnout more effectively.

Strategies to manage burnout in the ICU focus on prevention, early identification of the individual with burnout, and mitigation of burnout (often employing the same techniques as for prevention). Preventive strategies include both individual and organizational approaches. Individual approaches include awareness and self-monitoring, willingness to accept help from others, lifestyle management, stress management, anger management, “mindfulness,” and development of resilience. Individual approaches are often promoted in an organization setting. Such programs are increasingly used for medical students and residents but must become more ingrained in clinical practice settings.

Organizational approaches include prospective identification and monitoring of worker well-being as a quality indicator, emphasis on teamwork, attention to high stress areas (such as the ICU), deliberate management of the work environment to address overwork, support for a healthy work environment in regards to respectful relationships and communication, and many others.

What can the American College of Chest Physicians do to help alleviate burnout and enhance work-life balance among our members? I’m pleased to report that CHEST is leading an important project conducted by members of the Critical Care Societies Collaborative (CCSC), that includes leaders and experts from the American Association of Critical-Care Nurses (AACN), the American Thoracic Society (ATS), the Society of Critical Care Medicine (SCCM), and CHEST. Key goals of this task force are to raise awareness and set the stage for interventions to reduce burnout in the ICU through publication of a review and call to action in multiple journals; sponsorship of educational sessions at our annual meetings; and development and posting of additional Web-based tools and resources. While critical care workers are certainly aware of the importance and prevalence of ICU burnout, an important aim is to raise awareness among other key groups, including policymakers, administrators, and funding agencies.

In conclusion, please take a moment during this month of August to pause and consider your own work-life balance and how, together, we can enhance not just the health of our patients but also the personal well-being and long productive career among those who care for the critically ill and injured.

References

1. Embriaco NE, Azoulay K, Barrau N et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175[7]:686-692.

2. Merlani PM, Verdon A, Businger G, Domenighetti H, Parggerm H, Ricou B. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184[10]:1140-1146.

3. Poncet MCP, Toullic L, Papazian N, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175[7]:698-704.

4. www.medscape.com/features/slideshow/lifestyle/2013/critical-care#7

5. Ali NA, Hammersley J, Hoffmann SP, et al. Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med. 2011;184[7]:803-808.