key: cord-010515-6klurh6a authors: Houtrow, Amy title: Addressing Burnout: Symptom Management Versus Treating the Cause date: 2020-05-01 journal: J Pediatr DOI: 10.1016/j.jpeds.2020.04.068 sha: doc_id: 10515 cord_uid: 6klurh6a nan Over the last decade, burnout among physicians and other health care providers has received considerable attention. What is the optimal way to address what appears to be a growing pattern of burnout among pediatric providers, subject to administrative and productivity burdens, while they care for pediatric patients, who themselves often have expensive and complex, multi-system diseases? What is the best path to wellness for providers? In this volume of The Journal, Hente et al consider one solution. They report a pilot study of 24 providers in the Cincinnati Children's Hospital Medical Center cystic fibrosis clinic who took part in six mindfulness-based, cognitive therapy sessions in order to assess the efficacy of this therapy to reduce stress and improve provider well-being. After the intervention, participants had improvements in empathy, depersonalization, perspectivetaking, perceived stress, anxiety, negative affect, and resilience. The research team undertook this intervention due to the high risk of burnout for their interdisciplinary team. 1,2 Symptoms of burnout classically include malaise, fatigue, frustration, cynicism and inefficacy. 3 The personal, health system, and financial costs of burnout are substantial. 4 In a baseline evaluation, prior to initiating the mindfulness intervention, the cystic fibrosis interdisciplinary team endorsed numerous stressors and scored in the average range for work-related stress. The researchers should be applauded for their use of numerous validated tools and the length of time for follow-up in this study. Demonstrating sustained benefits at 15 months is impressive. As in this pilot study, many of the efforts to address burnout focus on techniques to reduce stress or improve resilience. 5, 6 Mindfulness has been associated with positive impacts for health care providers, so this intervention was logical to pursue. 6, 7 That said, what is more important is addressing the underlying reasons health care providers experience burnout in the first place. This approach would be akin to treating the disease itself, rather than just treating the symptoms. To treat the disease effectively, we should recognize that burnout in health care has an important cause: moral injury. 8, 9 As defined by the Syracuse University Moral Injury Project, moral injury is "the damage done to one's conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one's moral beliefs, values, or ethical codes of conduct." 10 Although much of the research in the area of moral injury is conducted with war veterans, there is a growing emphasis and a body of literature that frames the experience of health care providers in terms of moral injury. 11,12 Health care providers have a fiduciary responsibility to their patients. 13 We are taught how to advocate best for our patients' needs by uncovering disease and providing effective treatments using shared decision-making techniques. This responsibility is deeply ingrained in us, and we have given over our lives to this work. When health care providers cannot act in accordance with our moral obligations to our patients, profound psychological distress can result. 12, 14 It is morally distressing, for example, to have increasing clinical productivity standards coupled with additional administrative tasks that infringe upon the patient-provider relationship. 8 Repeatedly, health care providers face circumstances when they cannot provide optimal care because of a malalignment with the values and objectives of the health care environment in which they work. 8 Symptom interventions, such as mindfulness training, are valuable and can play an important role in the management of clinician distress, but a shift to addressing the root causes is truly necessary. 8 Focusing on burnout suggests that the health care provider has the problem and that the locus of intervention should be at the provider level. 11 The implication is that health care providers who experience burnout (over half of us) are not mindful enough or not resilient enough. 1, 9, 15 It may seem insulting to many health care providers to be told that their distress is their weakness and that their symptoms can be adequately addressed with meditation or mindfulness. 11 It should be distressing when care of patients is hindered by increasing work expectations make providing that care effectively nearly impossible. Health care providers are in a double bind that no amount of "goat yoga" will fix. Of course, working day in and day out under unfavorable circumstances severely challenges our ability to fulfill their ethical commitments to provide the best care. 14 In the immediate short term, we should that the moral injury crisis in health care will worsen. In light of the COVID-19 pandemic, health care workers have faced knowing that they must do what they can with limited and depleted resources. 13 The basic essence of moral injury for a health care provider is going against what is known to be the right and just thing to do because of circumstances beyond their control. We have seen this moral injury play out in real time during this pandemic. 12, 16, 17 Health care providers are putting their own health (and subsequently their families' health) at risk when treating patients without proper personal protective equipment. Health care providers are overwhelmed while watching patients struggle and having so little to offer them. Health care providers are emotionally exhausted holding the hands of dying patients without their family members at the bedside because of the infection risk. Health care workers suffer when the public health response is inadequate. The souls of health care providers are hurt when capacity is exceeded and people die because of it. Looking toward a future when COVID-19 looms less large, it will be imperative to focus on fixing what is broken in the way we deliver health care. Optimizing population health and the health of individual patients will require attending to the misaligned goals of health care providers, health insurers, hospital administrators, regulators, and the public. In the realignment of health care, patients' needs should be the top priority and everything that does not facilitate the achievement of improving the health, functioning, and well-being of patients and populations should reconsidered. 9 Although mindfulness practices, relaxation techniques, exercise, and the like will still have a role in the management of burnout, what we really need is collective action to promote clinician well-being that helps health care providers carry out their lives' work--to provide the best possible care to the patients and communities whom we serve. 14 Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Metaanalysis Beyond Burnout -Redesigning Care to Restore Meaning and Sanity for Physicians The staff burn-out syndrome in alternative institutions Estimating the Attributable Cost of Physician Burnout in the United States A mindfulness course decreases burnout and improves wellbeing among healthcare providers The impact of mindfulness-based interventions on doctors' well-being and performance: A systematic review Systematic Review of Mindfulness Practice for Reducing Job Burnout Clarifying the Language of Clinician Distress The Moral Injury Project Reframing Clinician Distress: Moral Injury Not Burnout COVID-19 and experiences of moral injury in front-line key workers The Toughest Triage -Allocating Ventilators in a Pandemic To Care Is Human -Collectively Confronting the Clinician-Burnout Crisis Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between Clinician Wellness During the COVID-19 Pandemic: Extraordinary Times and Unusual Challenges for the Allergist/Immunologist Supporting the Health Care Workforce During the COVID-19 Global Epidemic