Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:
- 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. (World Health Organization, 2019)
Something has never seemed right about this definition.
It’s as though we said myocardial infarctions “result from stress that isn’t successfully managed” … without discussing coronary artery disease.
It took a very ill 10 year old child with perforated appendicitis and Systemic Inflammatory Response Syndrome (SIRS) to make me think about this differently.
As I often do, after my initial visit to the Emergency Room and while waiting for the operating room to get ready, I pulled up UpToDate and PubMed to make sure there wasn’t anything new that might help me take care of this child. As I read, a light bulb went off…
“SIRS is considered a clinical syndrome that is a form of dysregulated inflammation. It was previously defined as two or more abnormalities in temperature, heart rate, respiration, or white blood cell count [29]. SIRS may occur in several conditions related, or not, to infection. Noninfectious conditions classically associated with SIRS include autoimmune disorders, pancreatitis, vasculitis, thromboembolism, burns, or surgery.” (UpToDate, Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis, accessed 7/4/2024)
Which led to an important question….
1. What if burnout is more like SIRS?
If burnout were like SIRS, it could be caused by a variety of etiologies…
SIRS is most often caused by a serious infection. But it can also be caused by trauma (gunshot wounds, car accidents, burns), pancreatitis, burns, inhalation injuries, the “trauma” of major surgery of any kind, transfusion reactions…
What if the same were true for burnout?
What if there were multiple possibilities that could start the cascade from stress to distress?
…and should be understood as the end-stage presentation of a progressive process.
In the case of SIRS from untreated infection, patients who present with seemingly mild symptoms like fever and tachycardia can rapidly progress to sepsis to septic shock to organ failure, and even death.
What if thinking about burnout in the same way could help us understand the progression healers experience from distress to suffering to burnout?
2. The treatment would start with resuscitation (and rapid diagnosis).
Patients with SIRS are hospitalized and aggressively treated with oxygen, fluids, appropriate medications to stabilize blood pressure and antibiotics to treat possible infections. All of this takes place while appropriate exams are being done to find the source of the problem.
What if we approached burnout in a similar fashion? What if, when we first noticed the symptoms ,we provided appropriate “resuscitation” and started looking for specific etiologies?
3. The definitive treatment would be “source control”.
For a patient with SIRS, once we make a diagnosis, we seek to eliminate the source of the SIRS. For appendicitis, we take out the appendix. For pneumonia, we prescribe appropriate antibiotics, and use supplemental oxygen and chest PT as needed.
“Source control” for burnout would be no different. Specific treatments would depend on identifying the specific issue(s) that started the cascade of distress and suffering.
4. Full recovery would require supportive care.
Source control starts the process of healing, but healing is not something we do for or to a patient. In clinical medicine, we facilitate the patient’s ability to heal … and then we support them while they heal.
Burnout should be no different.
I mentioned the need for a good “differential diagnosis” in order to identify the source of SIRS
Which leads to the next important question.
What’s the differential diagnosis for the causes of this syndrome?
I’m sure there are others, but the major categories of insult and injury that I believe should be included in the differential diagnosis of healer distress and/or burnout include:
- Failure to recover from injury (physical, emotional, and spiritual). For example, pronouncing a child dead in the ER and then having to run to clinic because you are now late and patients there are getting angry.
- Moral distress, injury, and outrage. Moral injury occurs when we know the right thing to do, but can’t do it. For example, not being able to perform an important elective surgery or prescribe a needed medication because it is denied by the patient’s insurance.
- Trivializing the sacred nature of healing. For example, the hours spent typing trivial information (for billing) into the EMR.
- Secondary trauma from chronic exposure to suffering or specific traumatic events (like the death of a long-time patient or being sued)
- Horizontal hostility. This is a concept I learned from Joan Halifax in her article The Precious Necessity of Compassion. Horizontal hostility, which is bullying by your peers, is often responsible for nurses leaving nursing, and occurs in all other areas of healthcare as well.
- The structural violence experienced by being marginalized at work and/or in society (racism, misogyny, homophobia, etc)
You’ll notice lack of self-care and insufficient resilience aren’t on this list.
I believe that insufficient self-care is most often a symptom and never the cause of burnout. That being said, I don’t mean to imply that self-care isn’t important. (You can probably tell I think it’s important just by scanning through the other entries on this blog!)
I’ve come to understand that insufficient self-care should be seen as a “comorbidity” for those in the grip of distress, suffering and burnout…similar to how having diabetes makes it harder to recover from physical illness or injury.
As for resilience… There are no human beings more resilient than those who choose to heal. The idea that insufficient resilience causes burnout is just not true. But it is true that this idea has been weaponized by the institutions who employ us to deflect from the real issue; We work in systems that create moral suffering for those who care for the ill and injured.
What should we call this model?
As I began to think more about using SIRS as a way to think about burnout, I realized I needed a name for this concept. I started with “PDS” for Physician Distress Syndrome, which I loved because PDS is my favorite suture. But a good friend, who works as a nurse practitioner, pointed out to me that this wasn’t just about physicians. Good point. She also said, “But you don’t have to change the acronym! You can call it “Provider Distress Syndrome”.
But I never use the word provider.
Everyone who works in healthcare in the United States (and to a lesser extent in the rest of the world) is affected by these issues. It’s too burdensome to list everyone when we are talking about this – but we need a word that describes all of us.
“Provider” is out.
“Clinician” works, but it is too narrow (and too cold).
The only word I’ve come up with so far that works is “Healer”. So for now, I’m using “Healer Distress Syndrome” to describe this model.
By the way, if you recognize yourself as being somewhere on the continuum from distress to suffering to burnout, you are not alone. Every healer I know is currently or has been there.
You matter.
Your work is sacred work.
We need you.
If you are suffering, please reach out to someone and/or seek professional help.
