Matrix of Clinician Distress - Part 7 Conclusion
Recap, Key Takeaways, and Some Recommendations (Including "Rethink Burnout, ASAP!")
Yes, the 7 part Matrix of Clinician Distress series ends here. But the work has just begun!
If you’ve read the preceding six articles, you’ll see that I got more intrigued about the nuanced complexity of distress the more I delved. What started out as a two-page recap of a conversation with an investigative journalist writing for The Guardian doing a piece on burnout, compassion fatigue and moral injury amongst clinicians in the context of COVID turned into a mini-book! And I’m glad it did. Because it forced me to reexamine the utility - even the very validity - of the burnout construct.
That’s a hell of a number isn’t it? After all these years striving to bring attention to the rapidly emerging problem of physician burnout (I spoke on it at the AMA conferences in 2002 and 2004, based on MY burnout in the mid ‘90s !), and now healthcare institutions and national associations are finally saying “yes, burnout is a problem, let’s address it.” And I’m now suggesting we toss the burnout concept out?
I’m afraid I’m cursed with contrarian genes and a distinct resistance to go with the flow. And therein probably lies the key theme to my life story.
The matrix of clinician distress is a much more expansive concept. It's like an amorphous cloud comprised of a whole slew of watercolor blotches. And the burnout occupational stress syndrome is only one component blotch within it.
When clinicians start manifesting exhaustion, feeling disconnected from the work, and feeling a loss of effectiveness or diminished productivity either in quality or quantity, one always thinks of burnout. After all, these are the hallmark (Maslach) criteria.
Burnout Has Become a Catchall Term
But burnout has become a catchall term. And multiple other stress syndromes share similar symptom presentations.
A Representative Multi-Syndrome Scenario
Here’s a scenario, somewhat more complex than the one I shared in the 1st article of the series.
Imagine a physician client is seeking your guidance because s/he is grappling with fatigue and losing interest in their field of work, and their quality performance is lagging. They just can't mobilize themselves to snap out of it. And that worries him greatly. They share with you that they took a great risk to even make this appointment. Of course, you're thinking from the outset "sounds like they're pretty burned out.”
But in their initial meeting with you, they also share that they recently witnessed a traumatic death of a young patient and are having nightmares about it. And you learn that they are also having considerable anxiety and sadness due to marital and financial strain. And then they tell you that they’ve just been named in a wrongful death malpractice suit. You learn, almost in passing, that they recently lost a dear colleague to COVID.
And while you thought to yourself that things can't possibly get any more stressful, they tell you that their department chair is “concerned about them” and is ordering them to go to the medical board-affiliated PHP because of their lack of focus and negative attitude.
It would be understandable if you thought this was simply too unrealistic, too much bad stuff happening in such a compressed period of time. But talk with any therapist or coach about the physicians and nurses they work with as clients and you will find that this is not such an unrealistic scenario at all.
The Problem with Burnout - The Term Is Overly Inclusive
Burnout has unfortunately become a catchall term for all clinician distress. But as we saw in the series, clinician distress can result from many different causes and may in fact represent many discrete syndromes.
But with this over-inclusiveness, remedies for burnout are doomed to fail simply because they're not addressing the multiplicity of components that have erroneously been put into the burnout bucket.
Burnout may be an inadequate if not essentially flawed construct.
In fact, and I recognize that this is probably not politically correct, “burnout” itself may be an inadequate if not essentially flawed construct.
Burnout is an occupational stress syndrome which is defined by its manifestations and affected populations, not by its causality. That makes it different from other types of stress syndromes that are related to a specific precipitating event or a stressor. For example
With grief, the precipitating event is loss.
In the syndrome of post-traumatic stress disorder, the precipitating event is a psychologically significant traumatic event.
In the syndrome of litigation stress, the stressor is being a defendant in malpractice litigation.
But while burnout is broadly defined according to its symptomatic manifestations in three domains – energy, connection, and efficacy, it doesn't point to the stressors causing one's burnout symptoms.
As I gave thought to this, I recognized that, as clinicians, we're dealing with a variable mix of concurrent stress syndromes but they're all being grouped together under the broad heading of “burnout."
In the scenario above, can you identify the likely syndromes present? Read it out loud to yourself or a friend and see how many you pick up.
If you named four or more, you’re pretty astute!
We start with possible “burnout classic” just on the reported symptoms, but we then hear elements of PTSD. And there’s significant personal life stress. And litigation stress. And grief from loss of a colleague. And on top of that, stress from being thrust into the maw of the medical regulatory therapeutic complex (MRTC).
What We Covered In Our Matrix of Clinician Distress Series
We've explored a wide range of syndromes that constitute what I am newly referring to as the matrix of clinician distress.
We’ve covered burnout, compassion fatigue and moral injury (part 2); grief, acute traumatic stress and PTSD (part 3), the clinical mood disorders revolving around the primary emotions of sadness and anxiety (part 4); malpractice litigation stress and medical regulatory system duress (part 5); and stress from discrimination and the bully culture of medicine (part 6).
It’s been a lot to take in, I’m sure.
(As one non-medical friend summed it up after finishing Part 1 “gajeesh, that’s weighty stuff, Kernan!” I hated to break the news that she really ought to dose up on Prozac before wading in to Parts 2-6. Who but the most somber reader wants to hear that?!)
But there’s no other way to convey this – that’s the reality of what’s going on. There’s no soft-sell on this. No tweet, no one-paragraph post, no cute “don't worry, be happy" jingle is going to be able to put a happy face on this intensifying matrix of distress.
The sooner we see it, and realize its immensity and ramifications, the more capable we’ll be to systematically address it. But we’ve first got to see it, name it, and acknowledge its immensity.
As we’ve seen, these syndromes individually are each of major consequence. And they’re not mutually exclusive. And they not only can but do co-occur.
I suspect it's more often the case that a clinician may be grappling with multiple stress syndromes. And they’re often interrelated in a causal chain like a serially exploding fireworks display.
In fact, there’s quite a commonality of symptoms amongst the syndromes, and that can make them difficult to tease apart, especially if one hasn't listened carefully to the clinician’s narrative containing references to the stressors.
A clinician’s complex presentation is customary; it’s a melange of cumulative symptoms coming from concurrent syndromes.
Addressing one stress syndrome without addressing or at least naming the others leaves the distressed clinician feeling that they’ve not really been heard, that their situation has been incompletely identified. As a result, their overall distress is not able to be resolved satisfactorily. And the longer that one's distress is not sufficiently relieved, the more intense it may become. Distress is like an avalanche that gains speed and size as it continues. It eventually overwhelms.
Multi-syndrome Illness Complexes
This notion of complex illnesses is nothing new in medicine; multi-syndrome illness complexes are common in medicine.
When someone comes in to the emergency room after a major accident, they almost always have multiple things going on. They may have a head injury and a hemorrhaging stab wound, and they may be in respiratory or cardiac distress.
There is no one simple intervention that fixes all of these. The sum total is a person with multiple trauma critically affecting multiple organ systems. Not accurately identifying and addressing all of these thwarts effective intervention and could even doom the entire stabilization effort to failure.
The distress matrix is remarkably similar to the concept of multiple trauma. The only way you can work with it is to address its multiple components. Just as the term "multiple trauma" it is not per se a diagnosis and is simply a term of art telling you that the patient's presentation going to be compound and complex by nature and that you need to be prepared, so too the clinician distress matrix.
“For every complex problem, there is always one simple solution - and it’s nearly invariably wrong.”
In consulting it's often said that “for every complex problem, there is always one simple solution - and it’s nearly invariably wrong.” The lure of simplicity is a great one. Now, occasionally, but most often for relatively straightforward issues, one tweak can do the trick. However, the risk of employing simple approaches to complex problems is not just that the approach did not work. It’s that the recipient of the interventions - the patient, the group - becomes weary and wary while their distress and distrust increase.
Therefore, it's crucial that the therapist/coach have a full understanding of these various syndromes and how to tease them apart and help provide effective relief, recognizing that sufficient space and time needs to be afforded to accomplish this.
As we saw from the scenario above, the reality is that the clarity of these issues in the actual client encounter is often not that straightforward. Those of us who do this work – therapists, coaches, counselors – know the complex presentation of many people and how difficult it can be to make sense of what's causing their distress. And be assured, if it’s difficult for us as professionals who specialize in this work, imagine what it is for the clinician client who’s experiencing such distress. They can't be expected to figure it out because it's not in their knowledge domain. And besides, their headspace is so jammed with distress and their energy show sapped that they don't have the mental RAM space to disentangle it. That's why they're seeking help.
Why Do Anything For Clinicians In Distress?
“Why should YOUR problem be MY problem?”
It’s as if to say “you’re a grown-up; you ought to be able to handle this. Look, everybody else is!” Of course, there are numerous flaws in this, not the least of which is that everybody else is doing fine; they aren’t.
But, presuming that’s the gist of an organizational leader’s sentiments, there are abundant reasons why any organization employing clinicians ought to aggressively address clinician distress.
If any group of people you lead is experiencing distress, your task is to recognize that on your radar and promptly strive to identify and explore the distress and do something about it. Why? Not simply because distress is a form of pain and causes an undesirable quality of life, but because it is affecting the well-being and performance of your people. That group of people is not - or soon will not be - performing as you need them to perform and as they want to perform.
Apart from the frequently cited cost of recruiting and retraining a clinician, and they are indeed considerable, let me add a less utilitarian and more humanistic, clinician-centric perspective.
In the case of physicians, they may have sunk a quarter-million dollars into their medical school education. Given that they had to prepare to enter medical school, they had four years of college pursuing the arduous pre-medical track which probably already cost a hundred thousand dollars. After getting their MD or DO degree, as part of their necessary apprenticeship in the knowledge and skills of clinical medicine, they endured four or more post-graduate years of apprenticeship training in their desired specialty, a program of work and study that more resembles an indentured servitude in exchange for learning. The lost income from those years is considerable.
But more importantly, experientially, here we have a physician who has effortfully acquired a wealth of specialized knowledge and skill and has entered into a specialty altruistically wanting to help humanity by using those talents to treat human illness. And now, because of a multiplicity of forces, s/he is hobbled by distress and can't effectively do the work they set out to do. In effect, they are disabled, not able to perform their work in the way that they want to perform. Considering here their subjective experience, i.e. their own severely diminished quality of life and thwarted professional fulfillment, we've got to recognize that these fine people are experiencing extraordinary psychological distress.
But I fear too many watch passively, perhaps indifferently, while an increasing number of clinicians are suffering. However, I can only believe that that indifference is based in unawareness of their plight.
We Are Squandering Our Rare Resources
Many don't realize that the pipeline to produce such clinicians is very limited. And yet the need for specialized healthcare resources is only going to increase with longer life expectancy, even more so because of the complex medical problems inherent in an aging population.
The healthcare system, leaders and clinicians, and coaches and therapists, all need to develop a solid and shared understanding and approach to remedying clinician distress and fostering their, as well as overall organizational, well-being. If we don't do this, the distress will continue. It will increase by its very nature. That’s the nature of unresolved illness.
And in not addressing it effectively, our negligence will have directly caused increased attrition. Inevitably, and likely sooner than later, we will have a full-blown healthcare personnel crisis. We will be losing, if not hemorrhaging, deeply good, genuinely caring people who are highly intelligent and well-trained, and devoted to patient care – the very people you want in the roles they are serving. And incidentally, they too want to continue to serve in these roles. After all, that's why they devoted the extraordinary time and effort to undertake their profession in the first place. They are a rare and treasured resource; they are not simply expendable “provider units" who can be replaced like blown fuses.
If we – healthcare leaders, therapists, coaches, organizational leaders – do come together to address this, we have the opportunity to restore and strengthen a healthy culture of medicine that not only fosters clinician well-being but also creates a thriving workplace culture. And a thriving culture beneficially impacts the quality of one's work and overall staff excellence and of course promotes more favorable patient outcomes.
Key Takeaways - What Can WE Do?
1) Stop normalizing burnout and distress as a way of life to be expected in this profession.
Considering the bully culture of medicine, evidence suggests that we’ve become so used to living in distress, we’ve normalized it as part of the physician’s identity.
2) Knowledge and awareness of the distress matrix are key.
We need to acknowledge the reality and magnitude of clinicians’ distress and its complexity.
It’s not just ‘burnout.’ Cumulatively, it’s distress. It’s suffering.
Clinicians who are grappling with these multi-layered syndromes are not just “burned out.” They are in distress; they are suffering. And unrelieved suffering devours our psychic reserve.
It’s vital that the helper – be they a mentor, a coach, a therapist, or a counselor – have a full awareness of these various syndromes so that they know what they need to be listening for. As in any syndrome, you have to further dig based upon what your suspicion is. But before you dig, you have to have an understanding of what you're digging for.
Healthcare organizations and the entire healthcare system need to comprehend this complex matrix which itself, preliminary as it is, may still not capture the full picture of clinician distress. Without understanding this complex matrix of distress, one can only expect to have continued distress and fallout from that.
3) Stop framing distress as a deficiency of coping
Stop labeling distress as insufficient coping – it is actually coping resource depletion.
If you look at a population of people - in any group, in any system - if you have only one person who is having distress and everyone else is going along hunky-dory, then you're dealing with a rare outlier of an otherwise healthy functioning organization. Whatever the cause, that person does need help in finding resources to resolve their distress.
However as you begin to see more and more people within your workforce population who are having distress, you need to recognize that these are not outliers. Just as though it were an environmental-caused illness like contaminated water, your task is to definitively determine what's causing it and remedy it.
4) Stop pathologizing distress
We need to stop pathologizing the human experience of distress. Just because it’s a pain-filled mood state doesn’t mean it’s a mental illness, though severe or prolonged distress can lead to illness.
Rather, it’s the composite degree of stress that devours all coping and overcomes all resilience that is pathological. Stress ultimately wears down your reserves and you start to develop symptoms as a result of those diminished reserves And those symptoms can have significant disabling impacts on all aspects of your life – work, personal, social and intrapsychic.
The Good News About Distress
Distress is itself a form of emotional intelligence. It's like the pain of a sprained ankle. The pain is there not simply as an annoyance or a byproduct of swelling. It’s telling us that something’s awry. It's sending a signal that something needs to be done to repair the injury and that meanwhile, the ankle is not to be used in the customary way. Pain is conveying critically important intelligence.
So too, by preventing us from operating in our customary healthy manner, distress is informing us that one or more things are out of kilter.
5) Recognize that complex things like multi-syndrome distress take time to sort out
We need to afford clinicians - and the helpers - that time
Therapists and coaches, we need to approach this like complex trauma just as in the emergency room example above. We need to develop a comfort with both complexity and uncertainty.
If we're treating the individual client –and I use “treating” in a general way – we need to have in mind the array of concurrent syndromes that may be occurring. Likewise, if we are a change agent or a system leader, we do need to understand that there is an array of things that may be going on concurrently and we need to approach this like a complex multi-trauma illness.
And just as in the ER, our task is to rapidly understand the full array of what's going on and to determine what can we best do to help stabilize and begin repair.
As importantly, once we understand this and help the clinician articulate and then name these various component syndromes in their distress matrix, our task is to help them prioritize their approach.
6) Provide abundant support and guidance in deepening emotional intelligence and developing self-mastery.
Both as a psychiatrist and a physician coach, as well as from my own distress matrix, I’ve found that one of the biggest things that devours your psychological reserves and immobilizes you is not the stressor situation itself nor the challenge of having multiple stress syndromes concurrently. It’s the relentless whittling down one’s reserves to exhaustion that leads to hopelessness and despondency.
Clinicians’ difficulty in coping with overwhelming stress is not a personal deficiency state.
Validating the immensity of their distress, we must help them in understanding themselves, in deepening their emotional intelligence, and in mastering psychological self management. Our approach needs to be one of positivity and not pathology. We need to help articulate that the stressors that they are up against are in fact inordinate and that their difficulty in coping is not a personal deficiency state. In essence, our core tasks are to validate, and help name the territory, and equip them with the tools to navigate these most tumultuous seas so that they can find their way through these seemingly overwhelming circumstances.
7) Especially for coaches, therapists and counselors …
Therapists and coaches have different expertise, different perspectives, and different approaches to work and life challenges.
While generic approaches to stress management such as meditation, mindfulness, yoga etc. are perfectly fine in their own right, they don’t substitute for in-depth reflective work and systematically processing each component of one’s distress matrix.
Because coaches and therapists take markedly different approaches to help clients, they each may feel that their expertise is limited in addressing some of these discrete syndromes. So they may tend to take a limited approach or simply not address the components they're not comfortable dealing with. And that is ultimately a disservice to the client.
It is likely that neither field is fully capable of addressing each of these syndromes in the ways that are needed.
Generally speaking, coaches lack a sufficient understanding of the psychological components of illness and its often debilitating impact on one’s work and personal life.
Taking the all too common coaching path of simply helping them sidestep all of this and look at a new career or a new job setting is not going to address the complex of underlying distress. Sure, taking a soldier out of battle and putting them at a desk job away from the front does lessen the chance of further combat injury; but it doesn't do anything to address the existing injuries, PTSD, and grief. Nor does it change the systemic problems that are causing it.
Conversely, therapists tend to delve more deeply into symptoms, and psychodynamics, and feelings, and too often lack a pragmatic approach toward ensuring that the client moves forward and out of the morass.
And therapists with a prescriber’s degree, such as an MD/DO or mid-level, may be inclined to put everything into a clinical syndrome diagnostic bucket such as “depression” or “anxiety” or some variant of those, and then prescribe medication for that newly diagnosed syndrome. While that medication may or may not help with some of the symptoms – if a clinical syndrome is in fact present – it is unlikely to address these other syndromes that are presenting such as grief and PTSD etc.
Get more training in these syndromes. Coming together around a shared understanding of this distress matrix and broadening your professional scope can help eliminate the inherent limitations of these diversely talented helpers.
Make yourself known as a trusted, knowledgeable referral resource. Reach out to healthcare organizations who employ these physicians and offer your services; make it known that clinician distress is what you specialize in and that you offer your services with utmost confidentiality.
Connect with other coaches and therapists and organizational leaders who are doing this work.
8) For healthcare organization leaders …
Recognize that the distress matrix is greater than burnout alone.
Get out of the mindset that “your problem is not my problem” because a) its smug indifference doesn’t help, and b) your workforce’s distress IS your problem.
Recognize the urgency to act.
Get knowledgeable guidance on how best as an organization to approach remedying clinician distress.
Refer to coaches and therapists who have expertise in these matters and promise strictest confidentiality.
Actively create/co-create and otherwise host and enable programs for clinician recovery and wellness.
And … continuously show concern and understanding - “walk the talk.”
9) And last but certainly not least - for clinicians experiencing distress from any one or more of these syndromes
Get help – safely; seek out safe therapist/coaching referrals from knowledgeable others. Exercise extreme caution in receiving any assistance from PHPs.
Work on deepening your emotional intelligence.1
Get active in changing some aspect of the healthcare system that you believe is fueling clinician distress and preventing clinicians from getting the help they need.
It’s understandable that the act of being wounded puts you into a victim mindset. While getting help yourself, try to turn your ordeal into a life lesson in self-mastery. This is pivotal in getting out of the harmful victim mode no matter how valid that victimization is.
Connect with others who are also grappling with burnout and distress.
At all costs, maintain hope and vision, and persevere. The world needs your talents and compassion.
Hold on to faith that you can and will find a way to navigate this awful period of distress. At all costs, maintain hope and vision, and persevere. The world needs your talents and compassion.
Build self-preservation prophylaxis. Tell yourself that at no point is suicide an option.
Make a pact with yourself and those who love you. Remind yourself repeatedly that at no point is suicide an option and why that is the case. Build-in this self-preservation prophylaxis so that you can especially return to it should you find yourself in a profound nadir of despair. Recognize that a system that stresses people to the max and doesn’t allow them to get the care they need is a screwed-up system. It’s like a relentlessly demanding narcissistic partner who devours all your goodness and demands more, indifferent to your needs.
Clinical healthcare is not the only professional track. If this system is so screwed-up and causing you so much pain and it doesn’t seem workable, recognize it’s the system that’s not workable, not you. It doesn’t matter whether others see what you’re going through. It doesn’t matter whether other people seem to be coping just fine (most are not). The reality may be that for any number of entirely valid reasons not due to your deficiency, the pain from the distress may be so intense that your job, your chosen career, working in your organization or anywhere in the field of healthcare may simply not be workable. Do not use up precious energy trying to convince others of that. You either get the help you need for your distress and the system accommodates you in that effort, or not. You can't fix it yourself. It may be time to move on despite all the money and effort you’ve put into it. And be assured, there is a growing community of physicians who have done so successfully. It seems terribly unfortunate that it must come to that. But sometimes a rapacious system itself may need to feel the pain before it acts.
Enlarging our frame from a burnout occupational stress syndrome to that of a matrix of clinician distress may at first glance seem more daunting than the current approach which equates all of clinician distress with burnout. Rather, I believe it simplifies it. It makes the challenge more manageable. If you can develop safe pathways for coaching/therapist assistance and appropriately treat/counsel the component stress syndromes, this would make that which is termed “burnout” so much more remediable.
If you’re in the pre-burnout phase of burnout that I term “weardown,” and then you experience psychological trauma and are grappling with PTSD, addressing the PTSD component is going to remove that added distress from one’s overall distress matrix. Yes, you’ll still need to deal with the weardown, and savvy organizations and specialty groups ought to be aggressively confronting this. (If they’re not, it’s another signal that you may not be in a system that wants to attend to your overall distress, burnout or otherwise.)
Does this make sense? I’d love to hear your comments. Perhaps we could have an open Zoom call amongst interested people where we can flesh this out further.
You can take deep breaths until you’re giddy and meditate until the cows come home, but these diverse syndromes are not going to magically evaporate.
At the risk of death by reiteration, I hope it’s clear now that if you’re dealing with some degree of burnout, AND you add on top of that ANY combination of compassion fatigue; moral injury; grief, PTSD; a clinical mood syndrome like depression or anxiety; the hostile and career-threatening medical regulatory apparatus; and malpractice litigation stress, the customary burnout antidotes, marginally effective as they are already, are not going to do diddlysquat to improve the distress picture, erroneously bundled as burnout. With no slight intended to wellness practitioners, you can take deep breaths until you’re giddy and meditate until the cows come home, but these diverse stress syndromes are not going to magically evaporate.
I hope the challenge of understanding clinician distress as a matrix and how it relates to the epidemic of burnout is clearer than it had been previously. Is the pathway clear? No, but I hope this exploration has helped chart the territory to make it more so.
Let me again share with you that I write this not from a lofty, removed theoretical stance. I know every one of these syndromes, not just from their theoretical perspective. I’ve experienced most of them, some quite intensively. I know their complexity. I know what is it to try to navigate through them. I know, for me, how crucial it was to strive to tease them apart, asking almost obsessively “what IS this that I’m experiencing?”
I love being a physician and its entire arena of study and healing. I’m humbled to be a member of this deeply honorable profession. And it worries me greatly that a coalescence of forces from many directions is bearing down so immensely on our field of work, our calling, burdening if not crippling so many devoted clinicians and driving them out of their chosen profession.
Thoughtfully understanding the matrix of clinician distress and finally recognizing the necessity to help our clinician workforce heal, we will be more empowered to craft a sustainable healthcare system for all. But that sustainability MUST BE especially mindful to take care of the extraordinarily talented and dedicated clinicians who provide that care.
I so want us to be able to identify and fix what is ailing us as a profession. So that we can do the work of healing without it making us ill and miserable and forcing many talented clinicians to leave the profession out of insoluble distress. So that we can do the work of healing that we love and are good at, that we've been called to do, and that people so desperately need.
If I can be of assistance in your efforts at understanding and tailoring effective approaches to clinician distress, please let me know.
Your comments and your sharing this series will be most appreciated.
p.s. if you didn’t know, this entire series is also available as a podcast on this very same Physician Interrupted Substack platform. Simply go to the Physician Interrupted main page and go to the podcast tab in the uppermost header.