Nov 092016

Almost half of critical care physicians report symptoms of severe burnout associated with their ICU work, according to a report and "call to action" from the Critical Care Societies Collaborative (CCSC).

Symptoms of severe burnout were highest among pediatric critical care specialists, while 45% of intensivists caring for adults acknowledged severe burnout. Burnout symptoms include exhaustion, depersonalization, and low feelings of personal accomplishment. Almost 90% of ICU nurses had at least one burnout symptom.

With 10,000 critical care physicians and 500,000 critical care nurses in the U.S. at risk for burnout, policymakers and health administrators should give the issue high priority, the collaborative argued in its report.

The Critical Care Societies Collaborative (CCSC) includes the major professional societies in critical care: the American Thoracic Society, the American College of Chest Physicians, the Society of Critical Care Medicine, and the American Association of Critical-Care Nurses (AACN). The collaborative simultaneously published the ICU burnout report in all four societies' journals.

What is ICU Burnout? Definition and Risk Factors

Work-related burnout syndrome is characterized as a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress. (Sound familiar?)

Critical care doctors and nurses may have burnout rates as high or higher than firefighters, police officers, and other high-stress occupations, according to the report.

Risk factors for ICU burnout include:

  • Personal factors common among physicians (unhelpful coping strategies, sleep deprivation, perfectionism, and work-life imbalance)
  • Frequent exposures to end-of-life situations
  • Increasing workload
  • Lack of control over the work environment

Commonly thought of as a late-career development, burnout actually turns out to be twice as common among younger physicians as compared to their older colleagues. Burnout has been described as highly prevalent among residents and fellows in training.

However, there's very little research on ICU burnout syndrome being done today. Hence the call to action (which is also a call for research funding) in the burnout report from the societies.

The report also calls on ICU physicians and nurses to recognize their own risk for burnout and to understand when to ask for help.

Are There Solutions to ICU Burnout?

This report should be applauded for highlighting the problem of burnout in the ICU. Any intensivist who claims to never have felt these feelings needs to be checked for a fentanyl patch. But given the nature of critical care in the U.S. today, it's hard to imagine really reducing burnout risk without major restructuring of critical care training and the ICU workplace itself.

Intensive Palliative Care

Burnout in the ICU doesn't just come from exposure to end-of-life situations. End-of-life situations are stressful, but they can be positive, even spiritually uplifting.

Burnout feelings more often come when care teams feel obligated to perform acts that don't feel like "care" at all -- prolonged mechanical ventilation for patients with metastatic cancer, for example.

A large proportion of patients in U.S. ICUs today receive what could be called intensive palliative care -- end-of-life care that seems futile or unlikely to be in accordance with a patient's wishes. The moral distress that results is probably a major cause of ICU burnout. There's no way to engineer, legislate, or protocolize this tension out of critical care, although it might be possible to train physicians to better manage these interactions and cope with their effects.

Reducing Workloads

Increasing intensivist staffing (say by 30%) might bring workload and stress down to levels sustainable by real people over the course of a 30-year career. But this change would cost more than $1 billion annually, and require large increases in training programs. We're unlikely to see physician groups voluntarily cutting their pay to hire up and overstaff their ICUs. And this would do nothing for the (arguably larger) ICU nursing burnout problem.

ICU Workplace Counseling

All ICU physicians and nurses could be required to attend quarterly counseling sessions with a psychologist specializing in work-related burnout, as a condition of employment. Making it mandatory and normalizing the sessions by having them inside the workplace would show health systems' dedication to their employees and patients and relieve professionals of the barrier to seek help brought by their feelings of pride, invincibility or fear of peer judgment. Those who needed to could attend more sessions outside the workplace confidentially and without stigma. The unavoidable message -- everyone here is a human being who sometimes needs to talk to someone -- might improve the sometimes toxic and dehumanizing culture of critical care medicine.

Assuming 510,000 U.S. professionals received 4 counseling sessions per year at $150/session, the tab would be about $306 million/year. This would be a very doable $54,000 per U.S. hospital per year. (Bigger hospitals would pay more, smaller ones less.) Negotiate that rate down to $100/hour and it's only $36,000 annually per hospital. Do these as group sessions with a psychologist talking with three ICU professionals, and it becomes a rounding error on the payroll and benefits budget of most health systems.

As with any workplace issue, solutions to ICU burnout will only come through real investment -- organizationally and financially -- by large employers and governments. Is it possible to make ICUs a more humane place to build a career? It will be interesting to see if effective strategies -- and the money to fund them -- can be found to support the health and well-being of the professionals providing critical care to more than 5 million people in the U.S. each year.

Read more: An Official Critical Care Societies Collaborative Statement: Burnout Syndrome in Critical Care Healthcare Professionals: A Call for Action. [PubMed]

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Almost half of intensivists feel severe burnout, report says