By Christina Hernandez Sherwood

Avir Mitra, MD ’15, experienced his first bout of burnout during his emergency medicine residency at Mount Sinai Beth Israel Hospital in New York City. His intern year was so overwhelming — even compared to the rigors of medical school — that his social life tanked and his hobbies, such as producing radio journalism, fell by the wayside. Plus, there was the imposter syndrome: “People are calling you ‘doctor,’” Mitra says, “but you don’t know what’s going on.”

Time and experience eased that early burnout for Mitra, who is now an assistant program director for the emergency medicine residency at Icahn School of Medicine. Yet the feelings resurfaced when he felt bogged down by the bureaucracy of medicine, when he’d spend late-night hours charting, not for his own benefit or his patients’ well-being, but to satisfy the coding department. “There’s so much red tape. There’s so much stuff you have to do that doesn’t serve anyone except for the powers that be,” Mitra says. “Those types of things over time lead to burnout.”

Then came COVID-19.

In the beginning, Mitra says, some physicians in emergency medicine were energized by the sense of purpose that came from fighting a pandemic on the front lines. “Our specialty was kind of elevated in status because of it,” he says. Also, the influx of sick patients required an all-hands-on-deck approach that eschewed burdensome administrative tasks.

Soon, though, as the COVID-19 crisis worsened, Mitra says hospital policies seemed to change almost daily, with doctors maskless one shift and donning full personal protective equipment the next. The level of paranoia — Oh my god, I touched this table and this table touched this glove, so now I’ve got to change this glove and I’ve got to wash this table, but I have to use a new glove to do that… — was maddening. There was no one to look to for guidance, Mitra says, because no one had experienced a situation like this before. “COVID took burnout to another level,” he says. “The stakes were very high. The uncertainty was so high.”

Physicians face nearly twice the risk of burnout compared to other professionals.¹ Though doctors reported roughly the same rate of burnout before and during the COVID-19 pandemic (42% in Medscape’s most recent burnout report²), certain specialties — critical care, rheumatology and infectious diseases — fared worse in 2020. But the pandemic also thrust the longstanding problem of physician burnout into the national spotlight.

“Prior to COVID, the meaning and connection that people got out of taking care of patients was routinely stripped away in favor of making more money, relative value units, regulatory environments, guidelines, metrics — all these things that weren’t why we all went into medicine,” says Carol Bernstein, MD, a psychiatrist who in 2003 was a fellow in the College of Medicine’s Executive Leadership in Academic Medicine program for women. “That created this burnout crisis before COVID hit. The upside to COVID, such as it is, is that it really put these issues front and center... It was burnout on steroids.”

As the world begins to emerge from the pandemic, health care leaders, policymakers and even doctors themselves are devoting funding and resources to initiatives to combat physician burnout and promote wellness. Major hospital systems are installing “wellness champions” to focus on employee well-being. Unused COVID-19 patient overflow tents are being reimagined as self-care retreats where doctors can recharge during shifts. And the Dr. Lorna Breen Health Care Provider Protection Act, introduced in the U.S. Senate last year and named for a New York City emergency medicine physician who died by suicide in April 2020, aims to improve mental health and prevent burnout among providers.

“I don’t know that you can be in medicine and dealing with people who are seriously ill and dying, and say that there’s never going to be burnout,” says Bernstein, vice chair of faculty development and well-being at Montefiore Medical Center in the Bronx. “But we need to have ways to counteract it, to get recharged again.”

Burnout has three key dimensions: “overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness or lack of accomplishment,” according to a June 2016 article in World Psychiatry.³ For a physician, Bernstein says, burnout might look like sleeping through a shift, objectifying a patient as “that gallbladder,” or even feeling like their work has no meaning. Physicians who experience burnout are more likely to report a recent medical error.⁴

(An important distinction: burnout is not the same as depression, Bernstein says, though the terms are often used interchangeably and the symptoms can look similar. Burnout is an individual response to a systemic issue, she says, while depression is a medical condition. And, unlike with depression, feelings of burnout should ease with rest and relaxation. The conditions can coexist, but it is depression in physicians — not burnout — that has been linked to suicide.⁵)

For some, burnout can start as early as medical school. That might be due to the qualities medical schools select for in students, says Donna Sudak, MD, MCP ’80, professor of psychiatry and vice chair for education at the College of Medicine. “We often choose relatively perfectionistic, hyperresponsive people to be physicians,” she says. Then, these highly motivated young people — who were perhaps accustomed to being at the top of their class — find out just how much they don’t know. “When you’re less secure in your abilities, it’s much harder to have a sense of meaning and purpose in your work,” Sudak says. “There’s more anxiety about what you’re doing.”

The demands only intensify and, as Mitra learned, residency schedules are unforgiving. In 2003, the Accreditation Council for Graduate Medical Education limited resident duty hours to 80 hours a week — still twice the length of the average professional’s workweek. The load is often seen as a badge of honor, Sudak says. “People don’t think about the human toll of that over time,” she says.

When Robyn Tiger, MD, MCP ’91, trained as a radiologist, she learned an integrative approach to patient care by reviewing cases in a reading room filled with other providers. But, while in medical practice, the field changed with the digital age. “It became reading cases, dictating into a Dictaphone, in a dark room nine to ten hours a day without much interaction,” Tiger says. “The emphasis started to turn to quantity instead of quality.”

Over time, Tiger developed severe physical and mental health issues — migraines, gastroesophageal reflux, numbness in her hands and feet, even suicidal thoughts — and feared she had a debilitating disease. She was exhausted and burned out, and visited a variety of specialists to no avail. The breaking point came when Tiger noticed she was making mistakes in her personal life: arriving at the wrong terminal for a flight or packing her children’s lunches in the wrong backpacks. “I was terrified. If I’m doing these things, am I messing up at work?” she says. “I didn’t have any lawsuits against me or anything like that. It was just my thought that I needed to do something... I started at that point to look outside of traditional medicine.” Tiger found relief at a beginners’ yoga and meditation class. Her feelings of anxiety, imbalance and lack of control reversed.

Eventually, as Tiger continued her yoga and meditation practice, all of her physical and mental health symptoms subsided. But despite seeing such remarkable changes in herself, Tiger was skeptical. “As a doctor, my left brain was saying, ‘What is the physiology behind all this?’” she says. Tiger dove into the medical literature, amassing a stack of research documenting the benefits of yoga and meditation in relieving chronic stress.

When her radiology practice downsized in 2012, Tiger left her part-time position to pursue her new passion. She became certified in yoga therapy and meditation, as well as life coaching, and started a wellness business. She taught free yoga classes for people recovering from cancer and military veterans, two of the patient populations she realized needed help to relieve their stress. All along, Tiger also helped her physician colleagues deal with burnout, but she decided to finally formalize those efforts after losing three doctor friends to suicide. “I felt it was my obligation to create programming for physicians to help them relieve their suffering,” she says.

In 2020, Tiger created StressFreeMD, a self-care education practice specifically designed for physicians. Along with private coaching, she offers online programming, including quick, evidence-based stress management lessons to accommodate doctors’ busy schedules. Physicians can earn continuing medical education credit, she says, by simply learning to care for themselves. “This is really important information that we never learned in medical school, that we never learned in internship or residency or fellowship or medical practice,” says Tiger, who lives with her family in Asheville, North Carolina. “We have these innate superpowers that can essentially control how we’re feeling in any given moment. We just need to learn how to use them.”

Sharrón Manuel, MD ’13, PhD, an assistant professor in the Department of Obstetrics and Gynecology at Texas Tech University Health Sciences Center El Paso, says self-care, in the form of exercise, helped her handle the toll of the COVID-19 pandemic. When she found herself snapping at her husband and daughters due to work stress, Manuel turned to weight training, on-demand workout videos and her new Peloton bike. “I just realized how important self-care was,” she says. “I’m trying to get some exercise in, if not daily, then at least three to four times a week.”

Self-care is an important antidote for burnout, Sudak says, citing the value of sleep, healthy eating, rest, gratitude and exercise. But focusing too heavily on the individual can make people feel blamed for their own burnout, she adds. “It’s important to acknowledge that workplace issues have got to be fixed,” Sudak says. “The best evidence suggests that what works is changing systems.”

Health care leaders should look at the burnout crisis as a chance for quality improvement, Sudak says. “We can make sure physicians are assessed, and we do focus groups and we figure out what about their day-to-day work life is unacceptable to them,” she says. “Then have somebody who’s willing to brainstorm: How can we fix that?” Are there ways, for instance, to get colleagues working together more efficiently? To fix redundancies in the electronic medical record? To hire a virtual scribe to ease the burden on physicians? To hire someone to manage physicians’ email while they’re on vacation? To create systems for repeated tasks? To better support doctors when a patient dies? To root out bullying and microaggressions? To support underrepresented doctors? These questions are typically handled by an organization’s wellness champion.

Sudak, with Wei Du, MD, MS, professor and academic chair of psychiatry at Drexel, is spearheading an effort to install a wellness champion at every Drexel clinical site and affiliate hospital. As a variety of wellness initiatives are deployed throughout the Drexel system — there are mandates for wellness programming at the graduate level for both residents and faculty, for instance — these champions would share their information about burnout, screening, mitigation efforts and more to the larger community.

As General Psychiatry Residency program director at Tower Health-Brandywine Hospital, Sudak instituted Wellness Wednesdays, one didactic day each month featuring a community wellness activity, such as an evening book club. The Tower Health Wellness Committee also organizes educational, recreational and community-building events throughout the year. The committee recently released four webinars on topics including burnout and self-care, Sudak says, that are meant to spark discussions and action plans among small groups of colleagues.

This kind of community-building initiative is another way to mitigate burnout, Bernstein says. Encouraging conversations among colleagues can help, she says, even just using the first few minutes of a weekly meeting to ask coworkers how they’re doing. “A sense of a collective, shared experience, and building community, and a sense of value and meaning and purpose in what we do,” Bernstein says, “will counteract the effects of burnout.”

As for Mitra, the emergency medicine physician in New York, he’d like to see hospitals take cues from Google — whose campus he once visited — by offering employees comfortable seating, places to mingle and snacks. Mount Sinai Beth Israel is one of the institutions where a COVID-19 patient overflow tent has been transformed into an employee relaxation center. The tent has couches, a screen showing a roaring campfire, and even an electric piano, where Mitra once performed “Piano Man” accompanied by an internal medicine doctor on the ukulele. “The thought was so heartwarming,” he says. “Little things like that go a long way. Burnout has been going on for a long time, before I ever got into medicine,” he says. “But COVID brought it to the forefront, and now there’s funding behind addressing it.”