A Viktor Frankl for the healthcare system

Gustavo Tolchinsky

“For only to the extent to which man commits himself to the fulfilment of his life's meaning, to this extent he also actualizes himself.” 

Viktor Frankl

Recently, in a meeting about the health of physicians, Dr. Clare Gerada, responsible PHP caring program for NHS doctors, commented on something that had never crossed my mind... How is it that we continue accepting that the Declaration of Geneva, which emanates from the Hippocratic Oath and was ratified in 2005 by the World Medical Association in France, keeps stating that "we (doctors) promise to consecrate our lives to the service of humanity"? Such a load seems unaffordable in these terms, but seeing the conditions in which we work, gives us the feeling that sometimes we are paying with a large part of our lives practicing as doctors.

We all have very clear that the patients should be in the centre of the healthcare system and our attention, and must receive quality care, adjusted to their values ​​and in organizations integrated in the community.

In the same way that in the previous post I had explained that the doctor has to be “fit to practice” to be able to give a good care and I wrote about the Caring Programme  for sick doctor, in this occasion I would like to focus on the burnout or burned-out professional.

More than 40 years ago the phenomenon of burnout in work environments began to be studied, initially described in workers in prisons but, mainly, in those devoted to serving people. The commitment to meet the needs of others with intense interpersonal contact has lots of positive aspects, but also secondary effects, especially in environments where there are limited resources, such as healthcare systems, but also in educational and others.

Burnout, as defined by Dr. Christina Maslach, is a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job. The three dimensions that draw it are:

• The emotional exhaustion, out of confrontation with a burden seen as excessive and the lack of personal or professional resources to face it.
• Depersonalization, which often characterized by cynicism, it’s, perhaps, the most genuine manifestation of burnout.
• The ineffectiveness, the perception by the professional that his action is futile in the organization or in front of the patients.

Burnout has become "epidemic" everywhere. Experts point out that it’s associated with more errors, worse health outcomes and increased costs. Therefore, and considering there is more than 40% or even up to 50% of burnout in medical profession, depending on the publication that we consider, and it’s increasing, we cannot have an efficient and safe health system unless we get rid of all these professionals burnouts.

At the other end of the line, we have professionals who are committed, motivated, with what is called engagement, characterized by a series of factors that make them resistant to most adverse situations in the professional environment.

Therefore, the therapeutic approach of burned-out professionals as ones who have a disorder seems reasonable. In short, you could think that burnout is a problem of the professional himself. In that case, we could say we have on the one hand qualified professionals and on the other hand those who are not suitable for the health system.

But nothings are not so simple, there is a lot of scientific literature about burnout and although it’s true that there are factors that can be attributed to professionals, it wouldn’t make sense that we bring this discussion here. We bring here for several reasons, but for one in particular. The path of each person who chooses to dedicate him or herself to medicine is not simple or short and, in addition, it’s expensive. In the first place, it takes many years to "manufacture" a doctor and, therefore, we cannot afford to waste them easily. In second place, the current situation confronts us with a wave of chronicity and complexity and a changing medical demography, with changes in values ​​and professionals who will work in a system inherited from a model that has become obsolete. It’s the perfect storm and, if we don’t have good leaders in the profession who know how to read these factors and move towards a practice that makes sense for both patients and professionals, we will end up like the Titanic, sinking before we know why, thinking that the system supports everything.

But being burned-out is not a disease, although in many countries it’s intended to be established as a diagnosis in order to recognize the right of the worker to take sick leaves or even ill-health pension. Dr. Maslach warns us that being burnout is just a symptom, not the disease; it’s the fever, not the infection. The Maslach Burnout Inventory (MBI), the tool currently used to measure burnout, is the thermometer, but it does not tell us why we have fever.

Caring programmes, wellness promotion, or support services for burnout professional allow those professionals to face their personal situation. But who is putting the effort and the time to recover from burnout? It’s the burned-out professional himself. Is burnout perhaps a problem of personnel selection or of lack of correct training? At present, the evidence resulting from research in this field shows us the issue is in the mismatch of worker with workplace in the organization, and this is composed of different elements:

1. The workload: the load perception assumable. When work overflows and forces you to give up other tasks that you consider important or even your personal time.
2. The feeling of control: the existence of mechanisms to influence the organization of work.
3. The recognition/reward: the reinforcement of a certain behaviour, no matter if it’s economic, social or institutional reduces the vulnerability to burnout.
4. The community: the relationship of employees with other people at their job, either of friendship or of good climate of professional relation, is capital.
5. Fairness or social Justice: in many ways, the unfair treatment of professionals or patients can cause an emotional and physical detachment from work.
6. The values: aligning the values ​​of the organization and professionals is important, especially when it comes to healthcare professionals. The values ​​shared by the team enhance it but, on the contrary, when they are not shared, they generate exhaustion and cynicism.

Therefore, it’s the organizations responsibility - perhaps even before focusing on the patient- to line up the values ​​of the profession, of professionals and the organization in order to prioritize measures that give meaning to the work we do day after day for the community, for our patients and with our patients. It must be valued, even if it’s just by explicitly expressing gratitude for the work done and treating the professionals in a fair way that helps to keep the balance of the relationships in the team. It can be done by setting goals with the participation of the team which they can control throughout its’ implementation.

So, although support for professionals who are already burned-out is necessary and its’ valued as positive, we cannot forget that the solution - both for the system and for organizations, services and teams - lies in leadership.

The paradigm of acute disease has disappeared, and chronic disease, frailty and dependence have come to stay in a health system that was not designed for this and with professionals who have not all been trained to face them. And all this "an uphill struggle" and it is hard for us to overcome it.

Even agreeing that the cause of burnout is a mismatch between the worker and his job, I want to point out that there’s also a mismatch between undergraduate training and the reality of healthcare, between the inherited model and the necessary model, among the expectations society have of the medical profession and what we really are, in fact, able to achieve, which is quite a lot. In this “cocktail”, we must be aware that the medical culture where we store the vision of what the healthcare system is, and mainly, what practicing medicine means has become obsolete. The need to establish a right care culture must be linked to a new culture of professionalism that helps us have common reference points, cultivated from undergraduate period, shared with the society and we grow in out organizations. And, above all, a culture that gives meaning to our actions.

Without aiming to be exhaustive, I list some blog entries referring to the topics that I have discussed in this post and there, perhaps, you’ll find more in depth explanations.

- Right Care: focusing on the attitude
- How to involve doctors in transforming the health system
- Leadership: difficulties and challenges