ICU specialists on road to burnout

HIGH stress and burnout rates among intensive care physicians require urgent attention, say experts, citing expanded roles and enhanced societal expectations of clinical outcome among the many stressors affecting this specialty.

Writing in the MJA, Dr Nicholas Simpson of Victoria’s University Hospital Geelong, and Dr Cameron Knott of Austin Health, said that intensive care unit (ICU) physician burnout resulted in consequences for both the clinician and patient.

“Care of the health care provider and quality of patient care are interconnected,” they wrote. “Physician burnout has been associated with lower patient satisfaction, reduced health outcomes and medical error. Burnout symptoms reduce potential ICM [intensive care medicine] workforce capacity through increased sick leave and decreased staff retention.”

A 2008 study found that 80% of practising ICM clinicians experienced psychological stress and discomfort, with many reporting symptoms of burnout, which include emotional exhaustion, depersonalisation and low levels of personal effectiveness.

The authors also noted that evolving trends in the Australian setting – such as greater intensivist coverage and shift work, and an increasingly fractionalised workforce – may exacerbate burnout among intensive care clinicians.

They said that a multilevel strategy – encompassing measures at the individual, leadership and institutional level – was needed to support clinician welfare and ensure a more sustainable workforce.

Dr Simpson told MJA InSight that there had been some efforts in recent years to deal with the high rates of burnout in ICM, but that there had not been a co-ordinated response.

“The evidence suggests that the scale of the problem is worsening,” Dr Simpson said. “Current surveys show the highest rates of burnout symptomatology occurring in critical care physicians when compared to other specialists.”

He said that ICM was a relatively young specialty, so the trajectory of career intensivists was only beginning to be understood.

“There has certainly been a change in the work patterns of intensive care specialists which may contribute: expanded hospital and ward roles, changing community expectations and physically larger ICUs may all play a part,” he said. “The concept of moral distress is being increasingly studied, and the effect that making ethically challenging decisions in high volume may have on individuals.”

Speaking in a podcast, MJA co-author Professor Cameron Knott said that critical care physicians in general experienced a higher rate of burnout than other specialties, but several factors amplified the risk of burnout for intensivists.

“Intensive care … involves complex socio-technical environments where we are often at the interface with end-of-life care, complex decision making involving technology and multiple specialties,” he said.

He added that managing critical patient care in the face of “digital disruption” presented a further stressor for intensive care clinicians.

“We have multiple complex systems managing patient care at the coalface and often many of them don’t operate together … which can create stress and slow patient care at times,” he said.

Dr Mark Nicholls, chair of the Australian and New Zealand Intensive Care Society’s Practice and Economics Committee, said that budgetary pressures from policymakers and hospital administrators were leading to ever greater clinical loads for intensivists.

“Everybody who goes into intensive care loves the job,” Dr Nicholls told MJA InSight. “But, if you have to do clinical work all the time, it can get to you and lead to burnout.”

Dr Nicholls said that the push to a 24/7 intensive care model, which had already been adopted by one Australian ICU, was also likely to amplify the risk of burnout for intensivists. There are studies suggesting that 24/7 intensivist cover does not lead to improved patient outcomes in certain types of ICUs.

In 2017, the Practice and Economics Committee will revisit the 2008 survey to assess current levels of stress and burnout among intensivists.

Dr Nicholls said that the new survey – to be led by Dr Shona Mair – would be an important further step in establishing the true extent of the problem and the factors to be addressed.

“This will be a huge focus for us in the next few years, making sure that, at a unit level, burnout is recognised early, managed appropriately, and people are supported; so people get the leave, have the breaks, and that they are otherwise well supported. Then we need to also be sure that we have proactive processes in place to help prevent burnout,” he said.

Dr Nicholls said that a sustainable, balanced workload might see a physician combine direct clinical contact in the ICU, with clinical work outside the ICU, training, research or quality and safety initiatives.

“Many of us also have responsibilities outside the hospital setting,” Dr Nicholls added. “You need to have a balanced portfolio with your work, and then still have time for family and recreational activities.”

The College of Intensive Care Medicine, in 2016, established a Welfare Special Interest Group to raise awareness of the problem.

Dr Simpson, a member of the group, said that it was important to have an open conversation about a problem that “to our best knowledge” affects most practising intensivists.

“We are developing resources and strategies to help deal with these problems. There are lots of potential areas to target, from a broader societal conversation about goals of care to system support during predictably stressful situations, and individual resilience strategies,” he said. “We think that a lot of the issues we are seeing … are foreseeable, and remediable.”

Dr Manit Arora, associate lecturer at the University of New England and a pioneer in the field of burnout research in Australia, said that while critical care physicians had the highest susceptibility, burnout risk was a concern across all medical specialties.

“One in two Australian doctors are burnt out – it’s an epidemic that’s plaguing our profession,” he said, noting that the rate was even higher at the front line of patient management.

Dr Arora called on the Australian Medical Association or federal government to establish a national taskforce to tackle the problem.

He said that the research focus to date had been on establishing the extent of the problem, but it was now time to look for effective interventions.

“Intensive care and emergency should probably be the first specialties to work on due to the high numbers experiencing burnout in these specialties, and successful interventions could then be rolled out to other areas,” Dr Arora said.

Podcast with Dr Cameron Knott available here.

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