Navigating COVID-19’s Lessons on Burnout

How has the pandemic affected wellbeing and engagement in the workplace?

Feeling burned out? You are not alone. When the COVID-19 pandemic shuttered businesses and sequestered employees at home, wellbeing plummeted to lows not seen since the Great Recession of 2008.1 Only 46.5% of Americans described their lives as “thriving” in April 2020, a 15% decline from before the pandemic. By December, these rates had rebounded slightly to just 48%.1 Clearly, the stress and worry of 2020 continued to take its toll.

But rather than becoming distracted and listless, workers remained highly engaged at work, with employee engagement rates hitting record highs in 2020 and ending the year 1% higher on average than 2019.1 Gallup has studied the relationship between wellbeing and engagement since 2009 and described COVID workplace data trends “truly like nothing Gallup has ever seen.”1 Traditionally, its research suggests wellbeing and work engagement have a reciprocal, additive effect on one another. When rates for one go up or down, the other tends to follow in lockstep. An employee who feels needed and valued tends to be more engaged with work and experiences a greater sense of wellbeing. In this way, engagement and wellbeing work together to stave off burnout.

In 2020, however, engagement and wellbeing split from their usual partnership. Wellbeing certainly suffered, but workers remained highly engaged. Employees pitched in and pivoted because they were “united under a shared sense of purpose,” according to Gallup’s 2020 study.1 As many businesses closed for good, many individuals were just grateful to have jobs, even as their sense of wellbeing was threatened. They showed incredible resilience, but high levels of resilience can only be maintained for so long before it gives way to burnout. COVID-19, it seemed, had created a unique kind of burnout, one that has not abated. Two-thirds of workers say burnout has increased due to the pandemic, according to a February 2021 survey conducted by Indeed, an online job search site.2

As businesses recover, everyone is scrambling to adapt to the new normal. Burnout has always been a problem for employers, especially since there tends to be a stigma around it. Employers may balk at giving workers the option to slow down productivity. If it is not clearly defined and accepted in the workplace, employees may alternatively seek treatment for burnout’s secondary symptoms of mood, anxiety, or physical effects (Table).

While 91% of workers in 2019 felt their employers should express more care over their mental health, only 26% have sought out professional help. Additionally, 20% of those who do not take advantage of workplace mental health services say they fear it will negatively impact their careers.3 Perhaps the shared experience of COVID-19 will change this perspective. After getting a taste of flexible work schedules, many employees and employers are looking to make more changes to support a healthier work-life balance. 

Psychiatrists, psychologists, and other mental health professionals can play a critical role in these discussions, both in helping workers adjust to the new normal and in advising businesses on how to provide support. The irony, however, is that medical professionals tend to experience high workplace burnout rates themselves. As we work to heal burnout in the workplace, it is important to heed our own advice and avoid the same pitfalls as our patients.

What Is Burnout?

Burnout is described as emotional and physical exhaustion brought on by prolonged periods of stress.4 The World Health Organization (WHO) describes it as, “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”5 Mentally, burnout is experienced as a feeling of overwhelming exhaustion, cynicism, and detachment toward one’s job; a feeling of ineffectiveness; and a lack of accomplishment.4 Physical symptoms include fatigue, body aches, headaches, gastrointestinal symptoms, appetite changes, increased susceptibility to common infections, and sleep disruption.6

In the workplace, common causes of burnout include lack of control over things like schedule, workload, and assignments; unclear job expectations; dysfunctional workplace dynamics, such as an office bully or a micromanaging boss; extremes of activity, such as job monotony or chaos; lack of social support, either at work or in one’s personal life; and work-life imbalance. Risk factors include a heavy workload and long hours, feeling little to no control over work, and struggles with work-life balance. Certain professions, such as health care, are particularly prone to burnout.7

The term burnout was coined in 1974 by clinical psychologist Herbert Freudenberger, PhD, while he volunteered in a free clinic in New York City. It was a slang term common among the clinic’s patients who were addicted to drugs, but Freudenberger used burnout to describe the exhaustion many clinic volunteers felt from the excessive demands placed upon them.8 Social psychologist Christina Maslach, PhD, took Freudenberger’s work a step further and studied burnout across the entire spectrum of employment. She is considered a pioneer in the field. She coauthored the Maslach Burnout Inventory (MBI), which has been the most widely used metric over the past 40 years to measure job burnout. Her work guided the WHO’s decision in 2019 to include burnout in its International Classification of Diseases (ICD) as “a syndrome associated with chronic workplace stress that has not been successfully managed.”5

Burnout Studies

The vision of a haggard parent often paints the clearest picture of what burnout looks and feels like. For mothers in a 2018 study, burnout involved an underlying current of fear. This could include feelings that they were not good enough, a fear of giving up control over things, or a discontinuity of sense of self.9 Burned-out mothers often did not want to be around their children, developed an aversion to everyday chores, felt like they were working on autopilot, and had thoughts of either killing themselves or abandoning their children. This led to feelings of distress, self-hate, loneliness, shame, and guilt.

Even before the pandemic, burnout was experienced by two-thirds of full-time employees, according to a 2018 Gallup survey of 7500 full-time employees. Burned out employees were 63% more likely to take a sick day, 23% were more likely to visit the emergency departments, and 2.6 times more likely to find another job.10

The effects of burnout are not limited to the workplace. It often spills over to affect relationships with family and friends. When supervisors are critical of employees who are also mothers, these women tend to be harsher toward their children as well as more withdrawn.11 Burnout also tends to increase rates of alcohol and substance abuse. One 2012 study, for example, found that surgeons experiencing burnout were more likely to have alcohol abuse or dependence issues. This was especially true for surgeons who reported a major medical error 3 months prior.12 Plus, burnout is a predictor of 12 somatic diseases, which include coronary heart disease, headaches, respiratory diseases, and mortality under the age of 45 years old.13

Medically, there has been some debate whether burnout is simply a form of depression or anxiety. After all, there are similarities and overlap among the conditions. An individual who is burned out, for example, often looks and acts like they are depressed. One meta-analysis included 69 studies on burnout and depression, and 36 studies on burnout and anxiety. It found that while burnout and depression were associated with each other, they are 2 different constructs that share common characteristics and likely develop in tandem.14 A commonly acknowledged difference between the 2 is that burnout is specific to workplace situations, whereas depression can crop up in any given circumstances, with or without triggers or stressors.

These findings were similar to burnout and anxiety. The analysis also noted that studies using MBI as a measurement for burnout (about half) generally resulted in better results and found a lower association between burnout and depression or anxiety.14

Burnout Among Physicians

While all occupations have the potential for burnout, individuals who work in health care—especially physicians—are particularly prone to it. Physicians tend to work in a culture of self-reliance and independence, and it is common for them to feel they cannot show any sign of weakness. As a result, they are often the least likely to seek treatment for mental health issues. Psychiatrists experience their own unique form of burnout, one that comes from stretching themselves to help people gripped by mental illness.

One 2012 national study found that burnout among physicians—especially frontline workers—occurred at an “alarming” rate, with 45.8% of physicians reporting at least one symptom.15 Cumulative changes to how health care is provided, documented, and reimbursed have over time contributed to a “chronic imbalance” on physicians, according to a National Academy of Medicine report. Unmanageable work schedules, administrative burdens, distractions and interruptions, inadequate technology, encroachment on personal time, and moral distress were all credited for creating this burnout. For physicians, the consequences of burnout include occupational injury, problematic alcohol use, risk of suicide, and career regret. For patients, consequences include increased risk of safety incidents and malpractice claims, poorer quality of care, reduced satisfaction, and ineffective communication with clinicians.16

The health care community’s familiarity and acceptance of burnout is likely fostered during medical school, when the importance of self-care quickly takes a back seat to the demands of exams. A systematic review in 2013 noted that at least half of all medical students reported burnout while enduring the rigors of their education.17

Psychiatrists are particularly vulnerable to burnout, generally due to their work environment, personality and appraisal styles, the support they receive, and their personal levels of resilience. A 2007 article in World Psychiatry notes the powerful range of emotions psychiatrists experience as they “use themselves as tools” to treat patients.18 These can include the need to rescue patients, feelings of failure if treatment is not effective, feeling powerless against illnesses, and a fear of becoming ill themselves. Long hours, dealing with difficult and hostile patient relatives, poor work-life balance, and managing suicidal or homicidal patients were the most common causes of burnout among psychiatrists. And yet, despite this, psychiatrists have consistently scored high in job satisfaction surveys.18 This could be due to their commitment and passion in their work or a simple acceptance that burnout and exhaustion are just part of the job. 

Psychiatrists and other mental health care professionals are now preparing to deal with the fallout of COVID-19. But to be effective, they will need to treat exhausted patients without falling prey to the trap of burnout themselves. Although burnout can be a risk factor for suicide, data suggests that suicidal risk is connected more with underlying mental illness, such as a depression and anxiety disorder. A 2019 cross-sectional study of 1354 physicians found that burnout was not directly related to suicidal ideations. It was, however, directly related to medical errors made by physicians.19 But there are other studies that suggest otherwise. A 2011 report on surgeons indicates burnout and depression were independently associated with suicide ideation. In fact, suicide ideation had an adverse relationship with all 3 areas of burnout: emotional exhaustion, depersonalization, and low personal accomplishment.20

The issue of physician burnout and suicide recently came a head during the height of the COVID-19 pandemic when 2, possibly 3 immigrant medical residents at Lincoln Medical Center in New York committed suicide. Colleagues said these doctors were under enormous pressure to perform without complaint, and were worried they might get fired and lose their visas.21

Burnout in COVID-19’s New Normal

As COVID-19 marches through 2021, its unpredictability continues to keep everyone on their toes. According to an International Wound Journal article, “the response to COVID-19 is a marathon, not a sprint.”6 Some businesses died during COVID-19, others reopened with caution, and still others are optimistically launching as new ventures. But all employers will need to approach the new normal of the modern-day workplace with thought and care. 

Employees may not be ready to let go of the work-life balance they discovered through flexible work conditions. They do not want to return to spending long hours commuting to and from work. They may welcome the trust and independence that comes with remote work and be eager to prove they deserve it. Others, however, may thirst for the structure and company of working in an office. They may find it difficult to disengage from work at home, or they may prefer in-person team building opportunities that teleconferencing simply cannot provide. There is no one-size-fits-all solution, and employers would do well to study what led to the high levels of engagement in 2020.

Remote workers, for example, experienced the highest levels of stress and worry, but they also happened to be the most engaged. Work infiltrated their personal lives just as much as it provided a life raft to stay focused amid COVID-19’s constantly shifting reality.1 Engagement took a sharp dip after George Floyd was killed in May 2020 and the nation experienced heartbreak, uncertainty, and social unrest. Perhaps as a coping mechanism, workplace engagement then jumped in June to a record-high rate of 40%.1 Clearly, work plays a large and important role in our lives and identity.

When the WHO recognized burnout as a syndrome in 2019, it promised to develop evidence-based guidelines on mental wellbeing in the workplace. Its member nations are set to implement the ICD revisions by 2022. It will be interesting to see what those guidelines are and how they will incorporate COVID-19’s lessons on burnout.

Concluding Thoughts

Talking about and treating burnout is the responsibility of everyone on the corporate ladder. Employers set the tone by openly discussing burnout and by training their workforce to identify its early signs. While many businesses regularly review engagement rates, employee wellbeing should also be assessed. This is especially true for mental health professionals. Psychiatrists need to acknowledge that the very nature of their job makes them at high risk for burnout. Most professional medical organizations have resources for recognizing and treating burnout among psychiatrists and physicians.

We must lead by our own example if we are to facilitate open conversations about workplace burnout. Speaking up and creating outlets to get treatment makes us true advocates in the lives of our family, friends, colleagues, patients, as well as ourselves.

Dr Parmar is a double board-certified adult and child psychiatrist with Community Psychiatry based in Newark, CA.

References

1. Wigert B, Agrawal S, Barry K, Maese E. The wellbeing-engagement paradox of 2020. Gallup. March 13, 2021. Accessed July 30, 2021. https://www.gallup.com/workplace/336941/wellbeing-engagement-paradox-2020.aspx

2. Threlkeld K. Employee burnout report: COVID-19’s impact and 3 strategies to curb it. Indeed. March 11, 2021. Accessed July 30, 2021. https://www.indeed.com/lead/preventing-employee-burnout-report

3. Ginger. 2019 workforce attitudes toward behavioral health. Ginger Anuual Report. 2020. Accessed July 30, 2021. https://go.ginger.io/final-report-workforce-behavioral-health-2019

4. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-111.

5. World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed July 30, 2021. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

6. Queen D, Harding K. Societal pandemic burnout: a COVID legacy. Int Wound J. 2020;17(4):873-874.

7. Mayo Clinic staff. Job burnout: how to spot it and take action. June 5, 2021. Accessed July 30, 2021. https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642

8. Reith TP. Burnout in United States healthcare professionals: a narrative review. Cureus. 2018;10(12):e3681.

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15. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-85.

16. National Acadmey of Medicine. Taking action against clinician burnout: a systems approach to professional well-being. October 2019. Accessed July 30, 2021. https://nam.edu/wp-content/uploads/2019/10/CR-report-highlights-brief-final.pdf

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19. Menon NK, Shanafelt TD, Sinsky CA, et al. Association of physician burnout with suicidal ideation and medical errors. JAMA Netw Open. 2020;3(12):e2028780.

20. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.

21. Gartland M. NYC doctor suicides raise concerns about treatment of resident physicians at Bronx hospital. New York Daily News. July 17, 2021. Accessed July 30, 2021. https://www.nydailynews.com/new-york/ny-suicides-residency-lincoln-medical-center-south-bronx-20210718-eiq3tepxxbcwdacip3au4624m4-story.html