08/29/2011 12:17 pm ET Updated Nov 02, 2011

Patient Demands, Frustrations With System Could Lead To Doctor Burnout

TORONTO - Every two weeks for most of the year, Dr. Miriam Salamon meets with a group of other Ottawa family physicians to talk about their emotional experiences related to their practices — a difficult patient, perhaps, or a thorny diagnosis.

While the primary aim of what's known as a Balint group is educational, a means of enhancing the doctor-patient relationship, it offers the side benefit of preventing the buildup of stress that can lead to burnout.

"Doctors really benefit from being able to talk about their own strong emotions that are aroused by patients," says Salamon, who cares for patients from cradle to grave. "And this is really the only place you get to do that in a community of doctors who understand what you're talking about.

"One of the things that (doctors) get from these groups is they really have the opportunity to experience intense emotions, things like feeling helpless and impotent ... And then in the context of a safe, collegial environment you are able to express it."

Such a safety valve could become increasingly critical for physicians and other front-line health providers facing ever escalating patient demands in a system that even now is often unable to deliver timely care. And as the population continues to age, leading to older, sicker patients with multiple medical conditions, those pressures will likely intensify.

As it is, surveys suggest that on-the-job stress and burnout are common among Canadian doctors. A 2001 study of rural family physicians found a self-reported burnout rate of 55 per cent; in a 2008 survey of urban family practitioners in southwestern Ontario, researchers found between 45 and 50 per cent had high scores for burnout symptoms — emotional exhaustion and depersonalization, with a low sense of personal accomplishment.

"Classic burnout is related to stress brought on by factors such as too much paperwork, long waits for specialists and tests, feeling undervalued, feeling unsupported ... difficult patients and medicolegal issues," write the authors of the study published in the journal Canadian Family Physician.

While primary-care doctors may be especially subject to burnout, the condition can affect practitioners in any speciality, and even interns and residents going through certification, says Dr. Michael Leiter of Acadia University in Wolfville, N.S., who has been studying job burnout among health professionals and others in the labour force for 25 years.

Using criteria he calls more stringent than that of most surveys, Leiter estimates that five to 10 per cent of doctors "burn out to the point where it's really having a distressing impact on their lives and starting to take the edge off how well they can perform."

Key markers of the condition are chronic exhaustion — "It's physical, it's emotional. You just can't deal with people anymore, you're all peopled out" — and cynicism or depersonalization, which leads to an emotional and mental disconnect from one's work.

The opposite of being burned out is feeling engaged, energetic and being able to listen carefully to patients' concerns. "It's when you stop believing that this is great work" that a physician is in trouble, Leiter says.

"When people think that 'I'm working in the Canadian health-care system and actually the system's got some huge flaws and the work's not having the impact it should,' that kind of value crisis is just as important in determining whether somebody's going to experience burnout as whether they're overwhelmed by demands."

Dr. Michael Kaufmann, director of the Physician Health Program at the Ontario Medical Association in Toronto, says burnout results from feeling depleted, from giving more than one gets back.

"I'm not suggesting that there is an epidemic or that this is resulting in widespread problems," he says. "I want to avoid the idea that doctors are all toasted and when you're going to see your doctor, watch out, he's not paying any attention to you. I don't think that's true.

"But I do think there is a tendency among doctors in general to put the care of others before their own care, and I think that puts them in a stressful place."

A compounding factor is that many doctors are reluctant to seek help, he says. "They're trained to be in the caregiver role and not the care-receiver role."

Salamon, whose Ottawa doctors "caring circle" is based on a model pioneered decades ago by Hungarian-born Dr. Michael Balint, says physicians also are not trained to express emotions.

"And in fact it's counter-cultural to be reflective," concedes Salamon, who's been in practice for 27 years. "And I think we're only beginning now to realize that medically, in the teaching sector, this is not a good thing."

Worries about stigma and the impact on reputation may also stop doctors on the road to Destination Burnout from reaching out for counselling to get them back on track.

Instead, some turn to alcohol or other substances in a bid to cope.

That was the case for Kaufmann, whose family had a history of alcohol addiction. For him, taking the edge off meant a veritable compendium of prescription opioids and other mood-altering drugs, beginning in medical school and escalating into full-blown addiction while running his family medicine practice in small-town and rural Ontario.

"I wanted to do it all," he recalls of his 14 years seeing patients, working in the local hospital's emergency department and operating room, doing obstetrics and providing community mental health services.

"I covered my own practice 24-7. I didn't believe anybody else could cover my patients as well as I could. And I enjoyed it. I was needed by a lot of people and that suited my temperament.

"But I did not have the skills to withstand that."

In 1986, distraught over neglecting his patients, betraying his colleagues and severely straining his marriage, Kaufmann asked another doctor for help. His colleague gave him the number for the OMA's doctors help line, which led to his being admitted to the former Donwood Institute, where he began to break the chains of substance abuse.

Since 1995, he has headed the program to refer physicians and their families for all manner of health issues, including stress and burnout.

One of the messages he tries to convey when speaking to fellow physicians or medical students is that doctors are human. "I think sometimes we do forget that — doctors forget it and certainly our patients can forget it."

He encourages them to place their own health and emotional needs ahead of or at least on par with those of their patients to avoid being crushed by the weight of unmitigated stress.

"It can take people out of the game, and our human resources are valuable. So it's important to think about being able to work without burning out so we are able to continue to work at the least, and at the most so we can continue to enjoy what we do."

Sheryl Ubelacker, Health Reporter, The Canadian Press