Burnout and Resilience

BJA Education, 17 (10): 334–340 (2017)
doi: 10.1093/bjaed/mkx020
Advance Access Publication Date: 9 June 2017
Matrix reference
1H02, 2H01, 3J02
Burnout and resilience in anaesthesia and intensive

care medicine
Adrian View-Kim Wong BSc MBBS MRCP FRCA FFICM EDIC1,* and
Olusegun Olusanya BSc BM MRCP FRCA2
1
Consultant in Intensive Care Medicine and Anaesthesia, Oxford University Hospitals, NHS Foundation Trust,
Oxford, UK and 2North Hampshire Hospital, Basingstoke, UK
*To whom correspondence should be addressed. Adult Intensive Care Unit, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK. Tel: 01865 220621;
Fax: 01865 222979; E-mail: adrian.wong@ouh.nhs.uk
they work with, and come to treat them in a detached or even

dehumanised way’.1 Individuals often feel a sense of emotional
Key points
exhaustion, indifference, depersonalization, and a lack of desire
• Burnout is a syndrome characterized by deper- for personal achievement.
sonalization, emotional exhaustion, and loss of Stress is related to, but is not the same as burnout (Table 1).
sense of achievement. Stress occurs when the individual’s ability to cope and deal
• The incidence of burnout among medical profes- with demands is exceeded. In controlled amounts, stress allows
an individual to improve his/her performance, while burnout is
sionals appears to be rising, although improved
an intrinsic response to continued excessive stress without
awareness and diagnostic capabilities may be
time or space for recovery.
partly responsible.
Often mentioned and described with burnout, resilience is
• Burnout is associated with significant morbidity defined in the Oxford Dictionary as ‘the capacity to recover
and mortality. The management of burnout syn- quickly from difficulties’. A true clinical definition of resilience
drome involves a multidisciplinary approach, and is lacking, although it has considerable overlap with the con-
a biopsychosocial model may be helpful. cepts of wellness and well-being. Rather than simply being the
• Preventing burnout is feasible. Proactive, multi- absence of burnout, it is considered a state of being able to
thrive in the presence of challenges.2 Like burnout, resilience is
modal techniques beginning early in medical ed-
a complex interplay between the individual, environment, and
ucation, engaging the individual and community
culture.
can be effective, albeit with limited evidence.
• Tools are available for practising clinicians to im-
Prevalence among health care professionals
prove well-being, increase resilience, and reduce
risk of burnout. Although burnout can affect workers from any field, health care
professionals are particularly at risk. With the ever-increasing
workload and demands placed on the modern health care sys-
tem, there is growing concern about burnout among health care
professionals due to its potential to negatively affect the work-
The term ‘burnout’ describes the collection of symptoms and force and also patient care. Doctors reported substantially
signs, both physical and psychological, experienced by individ- higher rates of psychological distress and attempted suicide
uals due to their work. It is defined as the condition where pro- compared with both the general population and other
fessionals ‘lose all concerns, all emotional feeling for the people professionals.3
Editorial decision: April 6, 2017. Accepted: April 6, 2017

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Burnout and resilience in anaesthesia and intensive care medicine
Within health care, there are wide variations in the pub- Individual factors
lished prevalence of burnout within different specialties and
health care groups. Anaesthesia and intensive care medicine Age
are characterized by their high demands (physical and emo- While some studies have suggested an increased risk with age,9
tional) and stress levels. Both specialties deal with long work- more recent data from the UK Practitioner Health Programme
ing hours in high-risk, complex working environments suggests the opposite.10 This is consistent with works from
involving multidisciplinary teams. It is therefore unsurprising both Europe and USA, where age less than 55 years was an inde-
that the incidence of burnout and self-harm/suicide is high. pendent risk factor for burnout. A confounding factor may be
Prevalence rates of burnout from surveys of European anaes- the fact that younger workers have had less professional experi-
thetists are variable, ranging between 6% and 18%.4,5 The rates ence and thus less time to develop effective strategies for deal-
are higher for both critical care physicians and nurses. ing with occupational stress.
Embriaco and colleagues found that almost 50% of critical care
physicians had high levels of burnout symptoms.6,7 A recent Sex
survey from the USA suggests a prevalence of 55% among criti- Females report higher burnout rates than men. Female doctors
cal care physicians, the highest in surveyed medical with young children and good social support, however, have a
specialties.8 lower risk of developing burnout.11
The concept of resilience as a quality for selection is still in
its infancy in medicine. No data are available on the number of Social support/network
‘truly resilient’ doctors. Social isolation at both work and home increases the risk of
burnout.
Coping strategies
Risk factors The availability and type of coping strategies utilized also have
Various factors (individual, environmental, and organizational) a role. ‘Positive’ strategies, such as exercise, meditation, and a
contribute to the risk of developing burnout (Fig. 1). strong social network, are protective. ‘Negative’ strategies, such
as the use of alcohol and illicit substances, are associated with
a higher burnout risk.
Table 1 Stress vs burnout
Personality
Stress Burnout
Personality traits, which are considered to be stable and difficult
Characterized by Characterized by disengagement to change, are important in burnout and psychological distress.
overengagement Individuals with certain personality types may choose high-
Emotions are overactive Emotions are blunted stress occupations, so doctors who choose to pursue a career in
Produces urgency and Produces helplessness and anaesthesia might have personality traits suited for the specific
hyperactivity hopelessness stressful demands of the specialty. People who score high on
Loss of energy Loss of motivation, ideals, and hope neuroticism tend to have an increased susceptibility to their en-
Leads to anxiety disorders Leads to detachment and depression vironment, a tendency to be anxious and insecure with a high-
Primary damage is physical Primary damage is emotional performance drive. This predisposes them towards developing
burnout.
Personal Organizational
ICU environment
characteristics factors
Moral distress
Perceived delivery of inappropriate care
Compassion fatigue
Burnout
Post traumatic stress disorder & Increased rate of

other psychological symptoms Decreased patient job turnover
satisfaction and quality of
care
Fig 1 Causes and consequences of burnout.16
BJA Education | Volume 17, Number 10, 2017 335
Personality testing may be used in selection of trainees/resi- Sense of low personal accomplishment
dents to reduce burnout in future anaesthetists. Hence, strate- This is when the individual feels he/she no longer achieves any-
gies to address these problems can be focused on reinforcing thing remarkable and is wasting his/her time. A feeling of fail-
the coping strategies of the individual. Educational programmes ure and insufficiency indicates diminishing trust in one’s
could be individualized to personal competence and resilience abilities.
and to professional knowledge and skills.
Effects
Organizational/work-related factors
Burnout affects negatively on the individual and can result in
Work–life imbalance reduced quality of patient care, costs related to absenteeism,
Spending more time at work leads to disproportionately less and high turnover of staff.
time for personal interests, family, and recovery.
The individual
Lack of control Burnout has a considerable overlap with mental illness, in par-
An inability to influence decisions that affect one’s job, e.g. ticular depression and anxiety disorders. This can lead to con-
schedule, assignments or workload, and the lack of resources siderable psychological and physical morbidity. In the USA, it is
needed to perform at a satisfactory level can also contribute to estimated that 400 physicians commit suicide each year, with
burnout. burnout thought to contribute to a significant proportion based
on a 1977 study by Sargent and colleagues. It is a predictor for
Unclear job expectations developing depression, absenteeism, substance abuse, and a
Poorly defined roles and objectives are likely to result in dis- decline in working ability.
comfort at the workplace. Physical symptoms may include non-cardiac chest pain, pal-
pitations, shortness of breath, bowel upset, dizziness, and
Workplace/colleague culture and dysfunction headaches. Burnout has been associated with an increased risk
Despite increased awareness and measures to deal with bully- of myocardial infarction and coronary heart disease. It has also
ing within the NHS, it still exists and poses a significant chal- been related to reduced fibrinolytic capacity, decreased capacity
lenge to the well-being of all health care professionals. The way to cope with stress, and hypothalamic–pituitary–adrenal (HPA)
an organization addresses events with poor outcomes can con- axis hypoactivity.12
tribute to the stresses of the individuals involved. Those experiencing burnout may be more vulnerable to
emotional and/or uncontrolled eating with a risk of obesity and
its associated health problems. Trainees who burnout are un-
Symptoms and signs
likely to continue their chosen career and join the consultant
The myriad of physical and psychological symptoms and signs workforce which is not cost-effective for the health care
makes diagnosing burnout a challenge. This problem is further system.
compounded by an affected individual’s reluctance to seek help
for fear of the negative connotations associated with burnout. The patient
Burned-out physicians may be angry, irritable, or impatient. The body of medical literature on burnout has demonstrated
They may seem to treat patients as objects or to be simply significant professional repercussions including decreased pa-
emotionally depleted. They may be frequently absent or seem tient satisfaction, increased medical errors and litigation, and
unable to leave work. the personal consequences of substance abuse and depression.
The clinical symptoms and signs of burnout are often non- Patients cared for by burned-out physicians are less compliant,
specific and can include depression, irritability, insomnia, tired- less satisfied with their care, and may even experience an in-
ness, and anger. The hallmark of burnout is the triad of: creased time to full recovery.13
• emotional exhaustion;
• depersonalization; and The institution
• sense of low personal accomplishment. Burnout has institutional costs; the cost of supporting or replac-
ing a burned-out physician is significant. Additionally, less
Maslach and Jackson1 initially regarded emotional exhaus- quantifiable costs occur when the loss of a colleague disrupts
tion as a reaction to interpersonal demands, depersonalization care teams and work communities. In the longer term, a work
as a coping strategy, and sense of reduced personal accomplish- environment that is rife with burned-out physicians and health
ment as a consequence of non-adaptive coping. care professionals will not be a positive environment to work in
and may struggle to attract the high-quality professionals re-
Emotional exhaustion quired to deliver excellent patient care.
Emotional exhaustion is a chronic state of physical and emo-
tional depletion that results from excessive job and/or personal
demands and continuous stress. It describes a feeling of being Diagnosis
emotionally overextended by one’s work, manifested by both There is some controversy surrounding the diagnosis of burn-
physical fatigue and a sense of being psychologically ‘drained’. out. It is not considered a formal psychiatric diagnosis in the
latest edition of the Diagnostic and Statistical Manual of Health
Depersonalization Disorders (DSM-V). The most widely used tool used to diagnose
This consists of unfeeling and impersonal attitudes and reac- burnout is the Maslach Burnout Inventory (MBI);14 this ques-
tions towards others, particularly people with whom one deals tionnaire consists of 22 items, where the responders are asked
regularly. This behaviour therefore creates distance between to indicate the frequency with which they experience certain
oneself and those who cause discomfort. feelings with regard to their work. Other tools used include the
336 BJA Education | Volume 17, Number 10, 2017
Table 2 List of resources
Support4Doctors
Support4Doctors provides access to a wide range of specialist advice and support for doctors and their families.
http://www.support4doctors.org/
Practitioner Health Programme (London based)
The NHS Practitioner Health Programme is an award-winning, free, and confidential NHS service for doctors and dentists with issues relating
to a mental or physical health concern or addiction problem, where these might affect their work.
http://php.nhs.uk/
BMA support pages
Doctors for Doctors—Confidential, nationwide counselling service for doctors and medical students, provided by BACP-registered counsellors,
available 24/7.
http://www.bma.org.uk/support-at-work/doctors-well-being/about-doctors-for-doctors
Phone: 0330 123 1245
Doctor Advisors—The Doctor Advisor Service runs alongside BMA Counselling giving doctors and medical students in distress the choice of
speaking in confidence to another doctor.
Phone: 0330 123 1245—ask to speak to a Doctor Advisor
Doctors Support Service—Confidential phone and face-to-face support for doctors facing GMC fitness to practice hearings.
http://www.bma.org.uk/support-at-work/doctors-well-being/doctor-support-service
Doctors Support Network
Self-help group for doctors with mental health concerns, including stress, burnout, mood, and eating disorders, with regular meetings around
the UK, a newsletter and an email forum.
Address: Doctors Support Network, PO Box 360, Stevenage SG19AS, UK
Tel. 0870 321 0642
DSN England E-mail: secretary@dsn.org.uk
DSN Scotland E-mail: Malcolm@dsn.org.uk
The Sick Doctors’ Trust
An early intervention programme for addiction, which facilitates treatment in appropriate centres, arranges funding for inpatient treatment,
and provides advocacy and representation when required.
Tel: 0370 444 5163 (24 h)
London Deanery Coaching and Mentoring
A confidential coaching and mentoring service for London’s trainee dentists and doctors and health care professionals in Bands 5–8.
http://mentoring.londondeanery.ac.uk/
E-mail: mentoring@mwl.hrr.nhs.uk
The Couch (doctors.net)
This service is available to doctors registered with doctors.net. There is a forum for mutual support and advice, with the option of anonymous
posting, and a long list of doctors around the UK happy to help colleagues in distress.
http://www.doctors.net.uk
Psychiatrists’ Support Service, Royal College of Psychiatrists
A confidential support and advice telephone helpline for Members or Associates of the College.
Tel: 0207 245 0412
E-mail: psychiatristssupportservice@rcpsych.ac.uk
Royal College of Obstetricians and Gynaecologists Mentoring Scheme
Aimed at obstetricians and gynaecologists who have been experiencing difficulties in relation to their work.
Tel: 020 7772 6369 Email: cdhillon@rcog.org.uk
Association of Anaesthetists support pages
http://www.aagbi.org/professionals/welfare/welfare-schemes
Royal College of Surgeons Confidential Support and Advice Services for Surgeons (CSAS)
This is a confidential telephone service providing a listening ear for surgeons, with further links to appropriate sources of advice and support.
Tel: 020 7869 6030 Email: csas@rcseng.ac.uk
Tea and Empathy- an online peer-to-peer support group. https://www.facebook.com/groups/1215686978446877/ Twitter: @tea_empathyNHS
Copenhagen Burnout Inventory and the Oldenburg Burnout superhuman doctor’ who can cope with and handle everything
Inventory; however, the MBI remains the most widely used and independently is associated with an increased risk of burnout,
validated. mental illness, and suicide.13
Anyone who is experiencing severe symptoms should re-
Dealing with burnout—the 3Rs: recognition, reversal, ceive expert help. All doctors should be registered with a gen-
resilience eral practitioner who will provide a knowledgeable base from
which to seek further help. Occupational Health departments
Recognition are also an excellent initial port of call and handle all enquiries
Maintenance of wellness and treatment of burnout both require confidentially. There is no legal obligation for a struggling doc-
a carefully considered, biopsychosocial approach. tor to inform the General Medical Council.
It is the authors’ opinion that the management of burnout is It is important for individuals to screen themselves, and
not entirely up to the individual. This idea of the ‘resilient people they care about, for symptoms of burnout. UK
Table 3 Summary of interventions
Intervention Aim Example
ICU organization Optimize intensivists’ work schedule Weekend respite, Shift models
Improve work environment Improved design, natural lighting, well-designed relaxation spaces,
comfortable on-call rooms
Change team composition Changing theatre lists, ‘buddy’ systems
Team building and job rotation Planned sabbaticals, varied job plans
Improving work connectedness and Meeting team members socially, ‘fun’ events, Schwartz rounds
psychological safety
Improving sense of value at work Recognizing excellence—‘employee of the month’ schemes,
excellence meetings
Individual—practical Educational programme Well-being seminars
Communication skills Non-violent communication, empathic listening
Relaxation exercise Yoga, Tai Chi
Mindfulness Mindfulness-based stress-reduction courses, online courses, apps
Physical exercise Running, joining a gym
Hobbies Art, music, reading
Individual—personal Personality and coping Emotional intelligence training
Social support Arranging regular meet up with friends, joining new groups,
prioritizing family time
Counselling Formal psychotherapy, informal through a mentor/friend
Practitioner Health Programme has developed a useful screen- Some interventions overlap between personal and environ-
ing questionnaire reproduced below (with permission): ment, for instance; cognitive–behavioural therapy can be of-
fered at the workplace but requires participation of the
1. Has anyone close to you asked you to Cut down your work?
individual.
2. In recent months have you become Angry or resentful about
A recent review assessing these strategies suggested that
your work or about patients?
system-wide strategies may be more effective and long-lasting
3. Do you feel Guilty that you are not spending enough time
than individual strategies. However, this review was limited by
with your friends, family, or even on yourself?
the heterogeneity of the current evidence base. Also, it is
4. Do you find yourself becoming increasingly Emotional, for
recognized that workplaces themselves are incredibly diverse,
example, crying, getting angry, shouting, or feeling tense for
and solutions need to be tailored to the individual’s
no obvious reason?
environment.17
A free online self-test questionnaire, based on the
Oldenburgh Burnout Inventory, can also be accessed through
Resilience
the BMA website.15
Compared with the studies on burnout, which date back to the
1970s, our understanding of the opposite of this, i.e. the factors
Reversal
that keep people buoyant even in the face of dire misfortune, is
The authors appreciate the difficulties and stigma surrounding
in its infancy.
this delicate topic. For those seeking professional assistance, a
As opposed to being a personality trait, recent research sug-
list of helpful resources is available in Table 2.
gests that certain skills (which can be taught and practised to
Strategies to prevent and treat burnout can be grouped into
an extent) can contribute to an individual’s resilience. Some
personal and environmental (intensive care unit/hospital)
simple recommendations include:
strategies.
• Expressing gratitude to people—this generates positive emo-
tions, engages us with others/our workplace, develops rela-
Personal strategies
tionships, and gives us a sense of accomplishment.
Focusing on the health care practitioner, these rely on the indi- • Spending time developing our bonds with friends and
vidual to recognize their symptoms, seek help, and pursue family.
strategies to allow them to manage the symptoms and their • Recording a diary of achievements.
consequences. These include spiritual practices, exercise, medi- • Spending time getting to know oneself. This may involve
tation, and hobbies outside work.16 meditation, coaching, frank discussions with friends and
colleagues, and online resources such as personality testing.
Environmental strategies Identifying one’s strengths and weaknesses in a non-
judgemental fashion may allow one to refine and develop a
These focus on the working environment and are multifaceted.
higher sense of purpose.
Involving unit leaders, hospital administrators, and reaching as
far as government policymakers, these interventions can be A recent systematic review18 identified studies looking at re-
vast and far-reaching. They range from rostering extra staff, al- silience training in doctors and found modest benefits.19,20
lowing adequate rest between shifts, improving workplace These strategies are merely a guide. There are other poten-
communication, and support groups to adjustments in training tial strategies not mentioned here which individuals may find
and credentialing, and improving laws and regulations.16 helpful. Again, we must emphasize that each individual has his
Table 3 gives further examples of such interventions. or her own internal and external point of optimum balance.
A careful, considered, multi-angled approach to well-being, in- There is also help available for those experiencing symp-
volving the individual practitioner and their support network toms and in distress, both locally and nationally. In future,
(e.g. family, friends, social or religious groups, work colleagues, many of these strategies will be built into our medical training
and employer) can lead to a state of sustained vitality. and will be natural parts of a functioning work environment.
It is also important for employers, administrators, funding
It is not the strongest of the species that survive, nor the most intelligent,
agencies, professional societies, academic institutions, patient
but the one most responsive to change.—Darwin
advocacy groups, and policymakers to pay attention to this ‘si-
lent epidemic’ and institute change.
Declaration of interest
O.O. is a founding member of the online, free Tea and Empathy
support group.
A personal story of burnout from one of the authors
MCQs
My wife, a paediatric ST4, started to show some (in retrospect) tell-
tale signs of burnout in 2012. She became very tired, irritable, and The associated MCQs (to support CME/CPD activity) can
lost a lot of her confidence following an unsuccessful attempt at be accessed at http://www.oxforde-learning.com/journals/ by
her MRCPCH clinical examination. subscribers to BJA Education.
Unfortunately, this went unrecognized by all around her, myself in-
cluded, and culminated in a full mental breakdown in 2013.
Since then, we’ve had to make several changes.
Podcasts
1. A sabbatical—we’ve both taken time out of our busy careers. This article has an associated podcast which can be accessed at
2. More exercise. http://dx.doi.org/10.1093/bjaed/mkx020.
3. Spending more time with family.
4. Reconnecting with hobbies. She rediscovered her love of baking
and has since started her own baking business.
References
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BJA Education, 17 (10): 334–340 (2017)

Burnout and resilience in anaesthesia and intensive

they work with, and come to treat them in a detached or even

Editorial decision: April 6, 2017. Accepted: April 6, 2017

Post traumatic stress disorder & Increased rate of

Fig 1 Causes and consequences of burnout.16

BJA Education | Volume 17, Number 10, 2017 335

336 BJA Education | Volume 17, Number 10, 2017

Table 2 List of resources

BJA Education | Volume 17, Number 10, 2017 337

Table 3 Summary of interventions

Intervention Aim Example

338 BJA Education | Volume 17, Number 10, 2017

BJA Education | Volume 17, Number 10, 2017 339

13. Drummond D. Stop Physician Burnout: What To Do When https://www.gov.uk/government/uploads/system/up

340 BJA Education | Volume 17, Number 10, 2017

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