This is a reflection piece on the challenge of answering this simple question, asked so many times a day, “How are you doing?” While this is usually asked in passing, the true answer to this question is increasingly complex for health care workers as the pandemic wears on.
I will be presenting “Burnout: Soul Loss & Recovery in Health Care” at this free virtual international symposium sponsored by The Doctor as Humanist, McGraw Hill, Sechenov University, and Universidad Anáhuac México.
This is a talk that I prepared for Seattle University’s 13th Annual Giving Voice to Experience Conference, “Maintaining a Soulful Approach to Psychological Research and Practice: Swimming Upstream in a Technological Society.” It was to have been on 3/7/20, but it was cancelled as Washington state began shutting down due to the COVID-19 Coronavirus. I thought that I could at least get it out there through my blog. The conference will likely be rescheduled in the future, but until then, I’ll release these slides out into the world. We need to come up with creative ways of sharing information and creating community in these times when we cannot gather together. As my friend Suzanne Richman recently said, “Technology is the new architecture of how people gather.” She says the idea is not her’s, she was paraphrasing a talk by a Rabbi she heard on Martin Buber.
This is the title of a poster presentation that my good friend, Gary Orr, and I presented at the Australasian Doctors’ Health Conference in Perth, Australia, November 22nd, 2019. This conference takes place every two years, rotating through the Australian states and New Zealand. Here is a screen shot of the whole poster, it is a bit difficult to read in this format, so I’ll break down the elements and type them in below the poster…
THE GIFT OF BURNOUT: INITIATION INTO BECOMING A HEALER
David R. Kopacz, MD, ABPN, ABIHM, ABoIM, Puget Sound VA, University of Washington
Burnout could be a predictable rite of passage that occurs several times throughout the education and practice of being a doctor. It is part of the initiation into becoming a healer.
We should not aim to prevent burnout, but rather to expect it and plan for how to create healing inner and outer environments to support doctors through the burnout phase of initiation into becoming a healer. Currently there is a failure of moral leadership in health care institutions, resulting in moral injury (1,2) and burnout with rates upward of 50% of physicians.
This poster provides a new view of burnout, re-examining it as a process of transformational learning and initiation into the archetype of the wounded healer. We will examine the process of finding strength and compassion in our wounds and discuss how we can develop a system of mentorship that guides and supports those going through the initiatory wounding of burnout. Gary will show how the path of a healer sometimes leads out of clinical care and into larger challenges of reinventing one’s self and the effects of design on health.
The World Health Organization has recently defined burnout as an “occupational phenomenon.” (3)
• feelings of energy depletion or exhaustion;
• increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job;
• and reduced professional efficacy
Symptoms of burnout have been reported in over 50% of physicians (4,5). Much of the literature on burnout, implicitly or explicitly, focuses on deficits, deficiencies, or negligence of self-care of the clinician. Individual suffering is marginalized and responsibility for addressing burnout is placed upon the individual. Yet there is a growing realization that burnout is a consequence of a mismatch between the professional values and ideals of physicians and institutional demands that require physicians to compromise their values and ideals – some have begun to call this moral injury. An initiation perspective depends on the availability of elders to communalise and contextualise suffering and yet our institutions marginalize the human and silences the elders.
Burnout as Initiation
We can view burnout as a necessary step for us to grow as healers rather than a pathology to be avoided. The problem then shifts from the individual experiencing burnout to the professional community whose job it is to guide and support the burnt out clinician to become comfortable in suffering rather than to eliminate or minimize discomfort and suffering. Initiation is a form of transformational learning, which does not seek to restore a previous state, but rather the transformation of the individual, leading to a new and expanded identity.
Rather than blame the victim or search for deficits — shift to narratives of transformation and healing.
Intentional Suffering – approaching suffering rather than avoiding (6)
Hero’s Journey – Joseph Campbell (6)
Feelings of being fragmented, apathy, lack of joy in life; the inability to make decisions; the inability to feel love for others or receive love from another, often resulting in the sense of being emotionally flat-lined. despair, suicidal ideation, addictions, and depression (8)
Transformational Learning & Education – Jack Mezirow,(9) Richard Katz (10)
Burnout as moral injury
Outer Environments of Burnout / Healing:
Poor physical environments
High levels of clinical demand
High staff turnover
High staff sickness and absence
High levels of violence
Poor personal control over day to day scheduling of calender
Poor clinical leadership and evidence of bullying, undermining of the professionalism of the practitioner
Discrimination which was dismissed by leadership
While we can view burnout as a necessary step in the growth as healers, the problem then shifts from the individual experiencing burnout to the elders of institutions and professional communities whose job it is to guide and support the wounded clinician through the initiation process. We know how to use suffering for growth, Indigenous communities have been doing this for millennia, the question is: Can our institutions and professional organizations create the ritual space for elders and sufferers to do the work of transformation, or will there continue to be failure of moral leadership?
If there is a failure of moral leadership, moral injury will be the result – where physicians are put in institutional situations in which there is cognitive dissonance between professional values and institutional priorities. If we look at recommendations on treatment for moral injury, we see the importance of community, interpersonal connection, reconnecting to meaning and purpose and reconnecting to positive aspects of identity. (11)
Lived Experience of Burn Out and Personal Reflections
Personal Reflections on Moral Injury
Finding oneself constrained in a system that is not able to reflect on its failings can lead to stagnation of the system. Then, when the incoming senior comprehends the moral failings of the system’s leadership, and then calls the leadership to account, but the leadership fails to stand to account. The incoming
senior individual becomes scapegoated, victimized, marginalised, and ostracised. If there is a lack of Elders within the service and subsequent of the Silencing of the Elders, many of whom had a personal over-identification with the service. This failure of moral leadership leads to a lack of elders within the system, and those that are there, are silenced. There are then consequences for the institution
Science – Evidence-based Reductionism
All too often, an evidence-based reductionism can lead to dehumanisation of the process of intellectually comprehending the psychodynamic underpinings of such human behaviour. This can lead to the process of devaluing an individual’s unique experience and expertise, and the individual becomes scapegoated, victimized, marginlised, and ostracised.
Institutional vs. Individual Values
Burn-out takes place when the individual is not able to reconcile the conflict between their own value system and that of the institution.
Economic vs. Individual Values
The trend of chasing multiple KPI’s as proxy measures of care, removes the process of individual’s being treated as individuals, resulting in increased stress in the work place. For example: the KPI of time to transfer from ED, can lead to rushed decision making in order to meet the KPI, rather than allowing a sensible treatment approach to take place, and safer discharge planning processes to be put in place. Increased time to be able to clearly create an effective discharge plan, can lead to an improved out for patient and staff – can there can be cost savings for the service.
Healthcare environments outside of well resourced centres are often characterized by poor standards of the physical environment. Working in a poorly maintained environment has an impact on both staff and patients. There are multiple Issues of OH&S; impacting staff and patients contibuting to increase violence and aggression in the healthcare space, leading to high staff turn over and increased risk of burn out. People are less likely to respect a poorly maintained environment.
These can be a helpful mechanism of independent external review and recommendations, but the impact can be limited depending on invested interests and potential issues of Elders having been silenced by higher failings of moral leadership. Grass Roots activism and lived experience groups can be a helpful alternative source of raising issues within a service.
Leave your job
Leave medicine – this was the choice that Gary made
Institutions need to Change:
Institutions need to expect burnout, and create workforce and job planning that takes account of such.
There is an opportunity for institutions to create working practices that encourage doctors to create portfolios that include variety in both clinical, leadership, academic and teaching opportunities. Create healing & supportive circles/communities of elders to support working through burnout.
There is a requirement to shift from prevention to developmental career guidance, and institutions need to take moral responsibility for contributing to burnout.
It is possible that institutions and professional organizations are incapable of morality and compassion, because those are human traits—the responsibility of the institution is to organize humans and create space and support for humans to provide moral guidance and the human wisdom of elders.
The fact that we cannot heal the wounded healers is an indictment of our current health care institutions and professional organizations and calls for a refounding and reorganization of the way we do medicine.
We recognize that a crisis of the individual healer is a crisis of the system.
We have allowed institutional economics and protocolised flow charts to replace human caring and moral leadership.
Our institutions have lost focus on the care in health care—no longer caring for their staff or creating
institutional spaces for the care of the patient.
Questions and Reflections:
Is this conference (ADHC) capable of caring for the souls of those who are caring for the souls of others?
Is the ADHC an organization that inspires hope, helps us find meaning & purpose, and cares for those who burnout?
Is a doctor merely a human form engaging in an AI process?
Do we have caring elders in medicine capable of guiding the younger generations through burnout and through initiation into becoming a healer?
Does Health Care still care about Caring?
What is the Economic toll of Burnout – for the individual; for institutions?
Are $’s more important than people?
Does the desire to care predispose one to burnout?
Are concepts about machines & economics good models for caring for the soul?
Are health care workers expendable equipment?
How does an institution take moral responsibility for the wounds and suffering of its workers?
How does an institution undertake reflection?
How does an institution undergo refounding?
Can we create healing circles of elders to guide physicians from wounded to wounded healer?
Remedies & Remediations
Recognizing burnout as the disorienting first step of transformation
Finding Your Soul (soul retrieval)
Re-envisioning Your Calling (reconnecting to your healing vision)
Finding Your Self (the counter-curriculum of re-humanization) (12)
Finding Your Tribe (mentors and guiding elders)
Finding Your Bliss (what brings you joy?)
Starting a Revolution (compassion revolution resources) (12)
4. Dzau, VJ, DG Kirch, and TJ. Nasca, M.D. “To Care Is Human — Collectively Confronting the Clinician-Burnout Crisis,” New Engl J Med, 378(4), January 25, 2018.
5. Shanafelt, TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015; 90: 1600-13.
6. Kopacz, David and Joseph Rael. Walking the Medicine Wheel: Healing Trauma & PTSD. Tulsa: Pointer Oak & Millichap Books, 2016.
7. Moore, Robert L. The Archetype of Initiation: Sacred Space, Ritual Process, and Personal Transformation. Xlibris, 2001.
12. Kopacz, David. Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. Washington DC: Ayni Books, 2014.
This presentation was submitted as a workshop using the suffering of burnout as a process of initiation into becoming a healer however, it was accepted as a poster significantly limiting experiential and healing components.This highlights the challenge of working positively with burnout – institutional limitations interfere with the proper functioning of human beings
“It can be helpful to see the circle path of the hero’s journey as the healer’s journey, the path that we take through our lifelong medical education. For the true healer, this is not a journey we make just once, but periodically we embark on exploring new depths of the suffering of the world, reaching deep into ourselves to find new resources for healing to bring into our work and world.“
“Burnout as part of the healer’s journey: I have been thinking of burnout in this way. Maybe burnout is a necessary step for us to grow as healers. There are intrinsic elements in our work that change us, working with illness and death. When we get “infected” by our work, we incubate until we can find a cure and healing path. There are also extrinsic elements of burnout, such as institutional pathologies and frameworks. In modern times, healing has been regulated and institutionalized, and institutional economic and organizational demands are sometimes at odds with the demands of healing. We must continually work to reconcile the essence of our work as healers with the daily reality of the institution.”