Alan S. Wolkenstein, MSW

Burnout among physicians, especially mental health specialists, is multifactorial. However, the key elements to burnout seem to be external obstacles as well as internal limitations. External constraints include lack of administrative support and systems that discourage deeply emotional connections between psychiatrists and patients by demanding high numbers of patients per hour for 15-minute medication checks. Internal or intrapsychic limitations include personality, ego strengths, emotional defenses, and professional experiences.

For purposes of this analysis, let us define burnout as an inability to care for and about those who come to us for help-with erosion of compassion, empathy, and deep caring as symptoms. These three feelings of a fully engaged physician will not return without strategic interventions.

Role of difficult conversations in burnout

Difficult conversations play a significant role in the development of burnout. It comes as no surprise that giving and sharing “bad news” is a heightened and deeply emotional example of a difficult conversation. We will focus on the process and professional dynamics of dynamics of difficult conversations and sharing the bad news, for they are in reality dependent and interdependent. Let us decode their dynamics, their effects on us, and strategies for professionally using our responses with patients/families to reduce the possibility of burnout.

For a few moments, reflect on these questions and think about how you may answer them:

• What do you believe are some of the dynamics of difficult conversations?

• What surprises you most about difficult conversations?

• Why is it so important to explore, understand, and facilitate difficult conversations, especially if we feel uncomfortable in doing so?

• Do you have a sense that the possibility of burnout may be enhanced by lack of training in reflection, supervision, and mentoring?

Sometimes, conversations are difficult because:

• Everyone has an opinion-whether verbalized or not.

• The stakes are frequently very high for each participant.

• No one feels comfortable emotionally, sometimes even physically, engaging in these meaningful conversations.

• The history of earlier conversations shows they were generally unsuccessful, unrewarding, and futile in accomplishing any objectives.

Once we fully understand and appreciate the nuances of difficult conversations and feel less guarded about them, we can be free to visualize-with guidance and mentoring-how to improve them:

• Visit your intended outcomes-what will they be like, what will they sound like, how will you carry yourself?

• Explore previously uncomfortable conversations in order to seek ways to reduce your discomfort and to apply these techniques to the current discussions.

• Always think about the silences between your words and the words of others.

No one can guarantee success, but the options are not favorable: to merely repeat the past hoping for a better outcome or to do as Homer Simpson does, simply be unable to make an effort to change the dynamics.

Difficult conversations between physicians and patients contribute to and are an interdependent part of the phenomenon of burnout. Physicians, especially psychiatrists, who are not well schooled, sufficiently trained, and mentored in understanding and negotiating difficult conversations will be seriously affected by such discussions. What is it about difficult conversations that make them so troublesome?

Dr Brown has been a psychiatrist for over 25 years. He is described as a compassionate and caring physician. Recently, he was called to the bedside of a 68-year-old man who was told by his oncologist his cancer is untreatable. Dr Brown briefly spoke with the patient about what he was experiencing after having been told this news and then suddenly left. “I just didn’t feel anything towards him; no empathy or even compassion.” He found himself in a stairwell seemingly unable to understand his lack of feelings. Dr Brown began to realize after this encounter that the “good” in him had been slowly draining away.

As empathy is heart-based and must be renewed to remain within a physician’s psyche, the healer component of physicians is also heart-based and therefore is a necessarily renewable resource. Difficult conversations require empathy and the healer component, but neither can flourish within the unfavorable parameters of current health care systems. Psychiatrists well-trained in the psychological sciences and skilled in psychotherapy will find themselves disillusioned, and as disappointed as their patients, when constrained by the psychiatric systems. This is a certain prelude to burnout as their healing qualities simply cannot be utilized in patient care.

The concept of giving and sharing “bad news” to patients and their families is always difficult. There are few professional interactions that create more anxiety, worry, and deep concern than telling someone unpleasant and painful news. I believe that such conversations, without a supportive environment, can enhance the chances of burnout.

My experience is that students, residents and, often, seasoned practitioners may fear these discussions. This fear is pervasive enough to prevent them from reflecting on and learning the skills, techniques, and attitudes necessary to present this material in a compassionate and empathic manner. Most of us, untrained in the real-time dynamics of this encounter, believe we are poorly prepared and lack good role modeling in how to conduct such a potentially highly emotional discussion. No wonder we shy away from doing so, or seek others to do so, or present the findings in a nonempathic manner devoid of compassion. In my years of educating physicians, nurses and allied professionals, medical students, and graduate medical residents, I found that the preconceived methods of teaching and sharing knowledge about this topic never seemed helpful to them.

I realized that such highly prescriptive, over-verbalized, and over-intellectualized lectures, discussions, and even role-playing were less than helpful. The sessions were emotionally under-experienced with few faculty-educators venturing into examining and sharing their feelings, emotions, and innate responses to such deeply charged discussions. In their presentations, they never got to their own limbic systems-the very place where emotions are generated and stored, memories are built, and real and meaningful learning occurs-and so the learners were never really taught what I am sharing right now. They could not or would not go from an intellectual level to a deeper and more intense personal-emotional level of education. 

 we think during these discussions, being 

 how to express these feelings is the only real way to be therapeutic, compassionate, and empathic with those we are responsible for serving. Unfortunately, this was never part of their methodology of education.

What has been helpful is to provide examples of difficult conversation starters such as:

• “I am so sorry to tell you this.”

• “I am saddened by this information.”

• “This is difficult for me to share with you.”

• “Come, let us sit together and talk.”

In addition, it is important to consider the following in terms of our own feelings and attitudes:

• One must be fully “in the moment” in these discussions. The need is there for personal efforts at psychological depth by the physician to be successful.

• We must try to permit ourselves to feel the experience and not deny our personal feelings. Being and remaining “objective” works quite the opposite. Burnout is in many ways contingent on such misguided objectivity.

• Empathy and compassion do not imply the loss of or lack of professional standards and boundaries.

• To feel, to be aware, to accept one’s feelings as appropriate and legitimate, and to share when appropriate will keep us from burning out and be able to get and remain “in the moment” with those who come to us for care.

From my clinical experience of interviewing over 200 patients and their families who heard “bad news,” they remember less of what they heard and more about how they felt. In other words, they described feelings of loneliness, isolation (even though there were others in the room), and fear. These three feelings would awaken them in the night as uninvited guests, unheralded and unwanted. I was also told the “bad news” and would wake up with these feelings surrounding me. They eventually left, and the task was to create a new life as each of the 200 patients had to do the same.

I share this with you because you do the best you can in emotionally tough and challenging circumstances. Try to begin with how you feel and then move to the information. You will be compassionate and empathetic if you do so, for you will be initiating the process of their learning to accept and cope with their new reality.

Your patients will be confronted with the need to learn about different hospitals, various systems of health care, a host of different physicians and caregivers, and how they might now perceive their spirituality and even their relationship with God. It is a time of significant change for them. For you, it is about being with them, caring about them, sharing how you feel, and being open and compassionate.

 If you do so, you will thrive and grow as a person and as a professional.

Lastly, when we reflect on difficult conversations and giving and sharing “bad news,” it is important to remember that we sometimes feel we haven’t done enough-only to realize later that we have done all we can. If you look at and assess yourself in challenging experiences in your training and practice, you will move from a cognitive/intellectual level to a more emotional and almost soulful level, a place where real learning occurs that will last your entire career-a career that is hopefully devoid of burnout and its consequences to ourselves and to those whose care we are responsible for.

 is Clinical Professor of Family Medicine (Ret.), University of Wisconsin School of Medicine and Public Health, Wolkenstein and Associates, LLC, Mequon, WI. 

 is an editorial board member and regular contributor to 

. He was a tenured Professor at the Medical College of Wisconsin in Milwaukee. Currently, Dr Moffic is focused on three major advocacy initiatives: physician burnout, climate change, and Islamophobia. The authors report no conflicts of interest concerning the subject matter of this article.

 This manuscript was edited by Angela G. Gentile, MSW, RSW.

1. Wolkenstein AS, Wolkenstein ME. Using reflective learning in graduate medical education and practice. 

Articles

Few professional interactions create more anxiety, worry, and deep concern than telling someone unpleasant and painful news. Without a supportive environment, such conversations can enhance the chances of burnout.

Alan S. Wolkenstein, MSW

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Difficult Conversations: The Case for Physician Burnout