Expert Conversations: Addressing Burnout and Promoting Well-Being

​​​​​​In this podcast, Seppo T. Rinne, MD, PhD, and Lakshman Swamy, MD, MBA, talk about burnout in pulmonary critical care medicine, including compassion fatigue, the financial burden of burnout, ways to manage burnout, and promoting well-being.

Additional Resources:

Seppo T. Rinne, MD, PhD, is a pulmonary and critical care physician and a health services researcher in Boston, MA.

Seppo T. Rinne, MD, PhD, is a pulmonary and critical care physician and a health services researcher in Boston, MA.

Lakshman Swamy, MD, MBA, is a pulmonary and critical care physician at Cambridge Health Alliance in Boston, MA.

Lakshman Swamy, MD, MBA, is a pulmonary and critical care physician at Cambridge Health Alliance in Boston, MA.



Jessica Bard: Hello everyone, and welcome to another installment of Podcast360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360 Specialty Network. There is a high rate of burnout among critical care clinicians, especially during the COVID-19 pandemic.

Doctors Seppo Rinne and Lakshman Swamy are here to speak with us today about their respective research on burnout and promoting well-being. Dr Rinne is a pulmonary and critical care physician and health services researcher.

Dr Swamy is a pulmonary and critical care physician at Cambridge Health Alliance. They're both based in Boston, Massachusetts.

Thank you for joining us today. Can you please talk to us about what's going on right now in pulmonary and critical care medicine in the context of burnout? What are contributing factors to burnout?

Lakshman Swamy, MD, MBA:

Maybe I can start by kind of defining what burnout is and that'll give us a place to start. I actually really like the WHO's definition of burnout, which squarely places it as an occupational phenomenon. This is really a disease of the workplace. This is chronic workplace stress leads to burnout, and then what is the burnout that comes from that. It is feelings of being really depleted or emotionally exhausted, feelings of cynicism or distance from one's job, feeling disconnected, and feeling like you're not achieving kind of personal accomplishment, feeling like you are not being efficient or effective in your work.

I'll say that this is an important point to stop and say, externally, none of these might appear to be evident. Many of your colleagues might say, "Oh, look, you look so energetic. You're doing all these procedures in the ICU, and you're accomplishing all these things in your academic life," or whatever. That's not necessarily reflecting what we're talking about with burnout. It's really what that individual is experiencing.

It's, again, these feelings of emotional exhaustion, of depersonalization, disconnection, and a sense of just not achieving the goals that you're aiming for. That's kind of where we started with this definition of burnout. And what I'll say is that from a pretty large body of research that Seppo can comment on more, we already knew that there were pretty high rates of burnout across ICU staff, especially ICU nurses we studied, but I think it's not hard to imagine that it's true.

We have literature showing this for intensive care physicians as well. I think it's across the whole staff. That was before COVID. I think after COVID hit, and I'm sure Seppo can comment on this in greater detail, I would just say that there's burnout that was really pushed to the limit, and there's probably a lot more going on than burnout as well.

Seppo T. Rinne, MD, PhD:

Selection of data did a really good job of encapsulating definition of burnout and some of the manifestations of that. What I would say in our research group, we oftentimes think of contributors or drivers of burnout in three major categories. It is what is your work, how much you work, and where you work. All of those factors have been impacted by COVID. And as Lakshman mentioned, there were trends even of prior to the pandemic. Some of that related to how the delivery of care has shifted.

You can see going back many years ago, a hundred years ago, there was a very different practice. We had these doctors carrying around their doctor bags going to house to house, and that approach to medicine has shifted so that now we have these large organizations that have changed the dynamic of how people deliver care. One element is what is the clinician's autonomy? What is their ability to practice care they want the way they want to practice?

And how is that now institutionalized in a way that leads them sometimes powerless to be able to practice the care they want to practice? EHRs, the electronic health record, have also influenced how we interact with our patients, how we interact with our colleagues. Now we sometimes feel slaves to this entity that's driving our day-to-day practice. Again, all of that predated COVID. When we think about COVID and these 3 major drivers that I've identified, where you work, what you work, and how much you work, all of those have been impacted, especially in critical care.

We notice that what is your work, now we're dealing with this very difficult disease that sometimes we're not able to treat effectively, and that contributes to an entity called moral distress, when you're not able to provide the care that you feel is ethical and appropriate for a patient. Morally appropriate. There are some patients where I would like to cure them. I want to do whatever I can to help them and get them to a point where they're able to breathe on their own and get out of the hospital.

Despite those hopes and wishes, we don't have the treatments oftentimes available to get them to that point. How much your work has changed, I can say for myself, I'm primarily a researcher, and I've been pulled to do a lot of clinical work during the pandemic. And that's just me. I see my colleagues really burning the candle on both ends to try to their home lives, their clinical time, and whatever other aspects of the jobs that they have. And then where you work has changed too.

It's been a dramatic shift where there are some simple things like we all wear masks as we go around, that's certainly appropriate. It's necessary for patient care and for safety, but it impacts our interactions. Our interpersonal interactions at work have been dramatically impacted by COVID. We've talked a little bit about the major organizational and clinical changes that have happened over decades, and then how in the past two years a lot of those changes have been really accelerated by COVID.

Lakshman Swamy, MD, MBA:

Let me just put a little bit of flavor to that. I think the last point of the place in which we work, our colleagues, our relationships, it means so much more than... and in some ways, maybe I even took it for granted. Pre-pandemic, we would have... If it was a holiday or a birthday or something in the ICU, there would be a huge celebration, right? It was like everyone would bring in food. The nurses are really driving all of this, but the whole staff is kind of a part of it. There's such a celebratory atmosphere, despite what's going on in the unit, despite if it's the dark day in the unit.

The relationships we had were so close. We knew each other. We knew what was going on each other's lives. We were spending time outside of work. After a night shift, you'd go to get brunch with your colleagues. All of that has just went away overnight, and it has really not come back because of COVID. I think for some of us who've been in the same institution for a while, we still have those relationships, although they are fraying, and they're under lot of duress.

But I can tell you, I switched institutions during the pandemic, and that was also really hard to meet all these new people without that social infrastructure.

Jessica Bard:

Yeah, absolutely. I think a lot of that makes a lot of sense. We talked a little bit, especially in the beginning about what is burnout. If we want to get a little bit deeper and kind of talk about what is not burnout, what is it not, I know you had mentioned that sometimes it's not always evident that someone is burnt out. Talk to us a little bit about that.

Lakshman Swamy, MD, MBA:

I can start, and I'm sure Seppo will have a lot to add here that'll be valuable. First of all, burnout is inflicted by the workplace. I think largely a sort of litmus test for burnout can be, if you're removed from that workplace, do you get better in some way? I think when burnout is really severe, it doesn't happen that quickly. But still, the burnout should be driven by the workplace and by those three factors. And if you take away all three of those factors, the burnout should be largely resolved.

I think what we can see now is that the pandemic has inflicted on all of us, but I think especially in a unique way in the intensive care unit, it has inflicted different kinds of harm that go beyond workplace stress. I'm not going to be surprised when we see more literature showing actual PTSD. PTSD and burnout are not the same thing, and I think we're going to start seeing that. I think we're going to see more than just compassion fatigue.

I think we're going to see extremes of this that really go beyond burnout. Seppo, I'm sure you have some updates and thoughts about that.

Seppo T. Rinne, MD, PhD:

Yeah. I think you do a good job, Lakshman, of highlighting that burnout is a work-related phenomenon, work-related stress, and really an overwhelming work-related stress. I think of it similar to how I think about sepsis. Sepsis is this dysfunctional response to an insult, being an infection. Burnout is a dysfunctional response to work-related stress. Not all work-related stress is bad. Sometimes we have stress that is appropriate and we manage in the context of a patient crashing or certain deadlines that help us drive productivity.

But when it gets to a point where we're really dysfunctional, where we're not able to manage appropriately, where it feels overwhelming, that's where it becomes burnout. Again, what is it not what? What is not burnout? Burnout is not other mental health disorders. Lakshman noted things like PTSD, anxiety, depression, those can be related, but they're not the same thing.

Lakshman and I did a study once asking about drivers and solutions to burnout. One of the most telling thing­­­­– this was based on program director's responses– is when we asked about solutions. One of the solutions was retirement, and that's totally true. You take away work and you take away burnout. Now, that is not a sustainable solution for our health system at large to encourage people to retire or reduce their workload to address burnout. We need people to show up to treat patients.

We need to think about other ways to address burnout beyond limiting work or taking away work. And maybe we can get into talking a little bit about some of those solutions.

Jessica Bard:

Yeah, absolutely. Do you want to just get into some of the solutions now?

Seppo T. Rinne, MD, PhD:

The core concepts that we've already kind of brought up, the drivers of burnout being where you work, how much you work, and what is your work, we can think about solutions within each of those as well. I'll start with workload, how much you work, because that is, I think, the largest driver of burnout. I did a study where we examined the relative contribution of different factors impacting burnout and weighted them to see what is the biggest driver, and perceived workload was undoubtedly the biggest driver of burnout.

When we think about solutions to burnout, again, reducing your workload or reducing your work hours and retiring is one solution on an individual level, but it doesn't work for a health system. We have to think about ways to limit the perceptions of driving workload. If we think about the health system as a machine, then one of the most valuable parts of that machine is the clinicians. And yet, we oftentimes think of them, reduce them to cogs in the machine and not recognize if you take those out, the machine doesn't work.

If we can conceptualize that value as inherent to the individuals who contribute to the system, then we need to be able to drive them in a way or support them in a way that doesn't overwork them. A lot of us are under RVU productivity pressures. If we can recognize that as sometimes harmful, or just acknowledge that we need to incentivize more than penalize people's workload, I think that's critical. One is workload and having an appropriate workload, and that is a solution that needs to happen on the organizational level.

It has to happen on a health system level, our health care system in the United States needs to recognize, we need to value physicians more than drive them to productivity. The other things like work environment, there are cultural changes. Lakshman started to talk about how COVID has impacted the culture of a health care system. I think we need to acknowledge that, especially as we want to support our colleagues and the clinicians doing the work. How do we create a positive culture?

A lot of that starts with leadership and I think leaders oftentimes set the tone of a work environment. We need to work with leaders to get them aware of these issues, acknowledging issues of burnout, and searching for solutions that will support clinicians. Some of that can be things like improving communication, improving team building, showing respect for clinicians, showing clinicians that they're valued. There's a whole host of business literature on how that can happen.

We've talked about workload, how much you work, where you work, and then what is our work? Oftentimes we can't change that. We're still going to be doing critical care medicine, but there are ways, there are elements of our work that we need to rethink. One of those is the electronic health record (EHR). We have electronic health records that are designed for billing purposes. They're not designed to support care delivery.

Oftentimes clinicians and physicians have very limited influence on how those EHRs are designed and how they are implemented, and we need to think about ways to transform technology to work for us rather than the other way around.

Lakshman Swamy, MD, MBA:

Let me layer in a little bit there, because those are some really powerful points. I think one, it brings up one of the... This is a direct quote that one of the pulmonary and critical care division chiefs wrote in one of our papers, "The demands placed on us far exceed the supports provided for us to meet those demands." I think that sums up so much of this where the workload is excessive, it's excessive, and I think clinicians really for feel like they're being treated like widgets and ground down.

I think the problem is, is that it's a really shortsighted way to approach medicine. I think it's challenging because labor is such an issue today more than ever. But if you don't work with people to give them the kind of work that they can manage and sustain over time, you're going to lose them. The costs to replacing a physician are enormous. A million dollars to get probably a pulmonary critical care physician replaced. Somehow that's on a different line in the balance book than actually working to retain the physician.

I don't really understand that. But much of what we feel from leadership is a really shortsighted approach, asking for more and more volunteerism to cover surge teams. That's a strategy that really shouldn't have lasted past the first surge of 2020, and yet we still see that in play. I think there is a lot of responsibility that leadership has here. I've seen the gifts that nurses get on Nurse Appreciation Day. It's shocking. It's kind of like you devalue the work by giving people these sort of trinkets.

That genuine appreciation and the relationship with leadership is really powerful. I think the advice I would give is to get out there. Medicine is happening at the bedside, so appreciation should happen there too. I think that the workload actually can be changed in other ways too that are not within our control. For example, the experience of the work we provide, I don't know, vaccination would do a lot to change that, right?

If we had more widespread vaccination, the experience of delivering care for a critical care physician would be radically different. I think there's a lot of actual society level interventions that if they're not in play to a good enough extent, that really impacts the direct experience of providing care and receiving care in the ICU.

Jessica Bard:

Let's talk more about the research. Can you please give us an overview of the research titled “Professional Societies' Role in Addressing Member Burnout and Promoting Well-Being” and what were the objectives?

Seppo T. Rinne, MD, PhD:

Yeah. This was a study that I led that was a critical care collaborative across critical care societies. We did a mixed-method study where we included surveys, interviews, and really documentation of artifacts, including websites and other materials that professional societies had to understand what is really the role of professional societies in addressing burnout. Because oftentimes the conversation starts with what's an individual role or what's the solutions that target the individual in.

I think that's perhaps where we really started as burnout was initially... We were becoming more aware of burnout and the challenges of burnout. The kind of knee-jerk response was to figure out how do we solve that on an individual level. More and more recently, we've recognized the importance of the organization and how to address things at the organizational level. But even that does not acknowledge the entire societal responsibility and the culture of healthcare in the United States and elsewhere.

We looked at how do we go beyond those individual and organizational solutions to look at professional society responsibilities? What we found was that responding to the burnout and promoting clinician well-being is a moral imperative. We heard that from numerous different professional societies that this is not something that we can ignore. Recognizing that we all have responsibility to address burnout, there are some key things that professional societies can do.

Some of that is setting the tone and the culture around burnout, acknowledging that it's a problem, stating with societal statements and leadership statements that this is something that we take seriously and we need to address, supporting different policies, supporting research into burnout, all of these things are things that professional societies can drive how healthcare response to the burnout crisis. For a practicing clinician, it's the awareness that this is not your fault. This is not an individual problem.

This is how healthcare is delivered in the United States. It may be related to some of the organizational policies. And more importantly, it may extend beyond that to figure out how we address this at the national level.

Jessica Bard:

Do you want to talk a little bit more about the roadmap and recommendations, or do you think you covered it pretty well there?

Seppo T. Rinne, MD, PhD:

They're all pretty intuitive. It's things like, again, acknowledging that it's a problem, creating some cultural change around it locally, supporting innovation, those types of things that I think have probably been covered.

Jessica Bard:

Well, overall, why should we care? What are the dangers of burnout? Compassion fatigue, financial costs. Let's talk about some of those.

Lakshman Swamy, MD, MBA:

The reasons to care about burnout have really never been more obvious, more evident. I'll tell you that the number one reason why at every American should care about clinician burnout today is that we are hemorrhaging clinicians. ICU nurses have, I don't know, never been in greater need and people are leaving. People are leaving. I think the physicians are feeling the same pressure and asking themselves, for example, why am I still in this institution?

Why I here instead of somewhere else, when I could go somewhere else and potentially have a better balance of my work life? I think everyone's feeling the same pressures today of kind of reprioritizing their lives and saying, "Maybe I should be spending more time with my family. In what ways could I have a better work-life balance?"

I think those pressures are real for everyone, but in the ICU, the other side of that is being really aggressively pushed to work many, many hours with very, very sick people, many of whom have preventative disease from COVID and facing also kind of, honestly, not really being appreciated by society. This is all the sort of environment that we're coming into already being burned out, and then having, as Seppo described, all the factors that drive burnout be kind of ramped up so much. When we lose ICU clinicians, it's a huge loss to the community.

It's a huge loss of investment. It's going to lead to huge recruitment costs for healthcare organizations. And all of that is, I'm just speaking now about the financial side, it's enormous. It is enormous and really can't be ignored. But when it comes to the individual patient, the last thing you want is to need an ICU doctor and an ICU nurse and to be stuck in an emergency room for hours or days on end waiting to get the care that you need and deserve. And that's what happens when you let burnout run unchecked.

Seppo T. Rinne, MD, PhD:

Yeah. I agree. I would say maybe even more fundamentally, we should care because it's the right thing to do. Part of practicing medicine is caring for patients and caring for each other. It was Hippocrates who said, "Wherever the art of medicine is loved there is also a love of humanity." We need to be able to recognize that not only for our patients but for ourselves and for our colleagues. As we think about these changes, the changes are not easy.

They involve changes that address not only our own individual lives, not only our organization but again, going beyond that and recognizing a lot of the cultural changes that need to happen in medicine. Culture is not easy you to change, but it's necessary that we do.

Jessica Bard:

Speaking to clinicians, what are personal ways to manage burnout?

Lakshman Swamy, MD, MBA:

We want to start anytime we talk about personal strategies to mitigate burnout, you want to start by saying, this is not about victim blaming, because many clinicians are facing that from their institutions, from their leadership, that you're burning out because of you. That's not true. That being said, I think there are a lot of things that individual clinicians can do to improve their own experience. And unfortunately, a lot of this is, I'm saying now that I didn't say before, COVID.

Because before COVID, we were really hammering on we need to fix these systemic organizational issues, which are still the main root cause here. But I think what we've seen in the past years is a real sense of abandonment that many clinicians feel. That these systemic things are not changing. I think at that point, you have to say, "Well, what can we do to help out our colleagues? If you've got to do something yourself, what could you do? "

I have a couple of points that I think can help. I think, first of all, if you can't get the time protected, it's really impossible to do a lot of this, so you have to find the time and space to do this. It is so important, even though it doesn't feel like it is, to take care of your physical health and to have your own doctor, your own primary care doctor. I can't tell you how many times I have let my own medical conditions, my asthma, I developed dermatitis in the ICU in my hands from being in the ICU washing my hands all the time.

My hands were just getting more and more raw and it was more and more painful. Finally, I saw a dermatologist and it just got better within days because of the recommendations they gave me. It just made my life so much better in the ICU. No one else was going to do that for me. I think there are some things we can do to prioritize our physical health. I'll say this too, I think that at this point, after being through this much pandemic in the ICU, I can say kind of unreservedly that I think every intensive care clinician benefits from seeing a therapist.

Previously really hesitated to say that because I don't want to say that this is your problem, but working with a therapist helps you exist in a terrible toxic world of being in an ICU during a pandemic. It doesn't make those things go away, but I think there's a real mental health crisis out there and we are in the heat of it. It might even take a long time to find those resources. I would just get going and get it on the books. And then when the time comes, see how it goes, because I think that it actually saves lives at this point.

Jessica Bard:

What would you both say are the overall take-home messages from our conversation today?

Seppo T. Rinne, MD, PhD:

I would say that burnout is a crisis, and it's a crisis that we need to address. We've talked about some potential solutions to that, and we've talked about how we need to go beyond the individual solutions and recognize the organizational interventions that need to happen, the change that needs to happen on a societal level. In talking about how to address this for the audience, some of us are, again, practicing clinicians who may not be overseeing large healthcare systems.

Seppo T. Rinne, MD, PhD:

I think keeping this conversation going, not letting this fall off and saying that maybe it's the responsibility of the leadership and we'll just wait for them to change. It's our responsibility to continue to bring this up and demand some of that change and work together. I think, again, professional societies can be one avenue where we start to influence that change.

Lakshman Swamy, MD, MBA:

I would say in addition to that, it's challenging. One of the things I get really worried when I see is when you expect the victims to do the work and to fix the problem. But on the other hand, I think that it's evident that leadership really doesn't understand what the problems are and how to fix them. I think there's a balance here where for clinicians, we really need to be more vocal. We can't sort of suffer in silence, are the victims of burnout. We need to speak up so that leadership understands what's happening.

Because a lot of the time, the way they're finding out is when people leave. I think actually to give all of our leadership at all the various levels in a healthcare institution some credit, I think they know there's a problem. They want to do something about it. I have a feeling at many places they'll be open to hearing from you. Again, I would be cautious if they're just going to say, "Well, great. I'm glad you know all about this. You should fix it."

But on the other hand, we do have to use our voices and we have to make it clear what we're going through and what we need.

Jessica Bard:

I want to thank you both for being on the podcast and for your work and your research and your advocacy. Thank you again.

Seppo T. Rinne, MD, PhD:

Thank you for having this podcast.

Lakshman Swamy, MD, MBA:

Thank you.