Thursday Review: “Disenfranchised Grief and Physician Burnout”

Grief for Patients and for Physicians

It’s easy enough to agree that grief is a part of a physician’s work. It goes without saying that a profession dealing with life and death has to come to terms with the loss of a patient. When I first picked up Dr. Deborah Lathrop’s article, I expected her discussion to revolve around how that kind of grief — the loss of a patient — can lead to physician burnout. Lathrop, however, widens the scope of the idea of grief to include not just the loss of life, but a loss of how a physician understands their role and the practice of medicine.

Lathrop begins the article with a list of changes in physicians’ work in the last two decades. This list neatly summarizes what physicians have told me are the biggest issues facing their own understanding of how they practice medicine:

• The trend from running a private practice to becoming employees (changes in authority, level of autonomy, role, responsibilities)
• Implementation of electronic health records
• Trend toward team-based vs physician-visit–based care and the rise of a midlevel practitioner presence
• Insurance product refinement (pre-authorizations, panel size changes)
• Increasing regulatory and administrative aspects
• Evolving credentialing requirements

These changes, she goes on, while incremental, have been continuous, and taken en masse, have required adjustments in how we practice medicine. Since grief is a response to loss, any time we go through changes or adaptations, there is the potential for grief.

This sense of loss is especially potent in the identity of a healer. Physicians view themselves as the holder of unique knowledge, manifesting itself in the professional title which embodies hard-sought training, ethical mandates, and knowledge-based authority. There is a profound blow to personal identity when that authority and knowledge is shifted from an autonomous healer to an employee racing to keep up with organizational demands. There is a loss of identity when that authority shifts from being the primary source of a patient’s healing to a second opinion, subordinate to symptoms checked online and the latest drug advertisement.

In this series, we’ve discussed a calling to medicine and an alignment of personal values with organizational demands. Lathrop’s discussion makes it clear that these changes in organizational demands are not merely organizational issues. The changes in a physician’s responsibilities affect the physician’s experience, and thus the patient’s level of care. The idea of grief gets to the heart of it: if a physician loses a part of the experience of healing they had had or thought they were going to have, there is a loss and a grieving process.

All of this is connected to burnout for the simple reason that grief takes energy.

Worse than using energy to grieve is the use of energy not to grieve:

At work, Emotions and feelings are discounted, discouraged and disallowed, and therefore all losses are disenfranchised in the workplace.¹ Additionally, physician loss is underacknowledged due to limited collegial exchange, the hierarchical nature of the medical milieu, and concerns about career consequences (e.g., being labeled as disruptive or a whiner).

This is disenfranchised grief, that is, grief that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported.²

We’ve discussed how the coping techniques used by medical students to succeed during their education can contribute to burnout later. Lathrop confirms this, in the context of grief:

Medical training’s historic “hidden curriculum” often required of trainees an initial loss of autonomy, sense of mastery, sleep, outside interests, etc, and cultivated the use of such defensive strategies. Mid- and late-career physicians now increasingly hear the skills and nonclinical qualities promoted within that training system deemed obsolete, eroding acknowledgment of developed acumen and bringing to question the personal opportunity costs of their acquisition. Reflecting on the impact of sacrifice can be painful, and evaded through defensive techniques. In this way, physicians may suppress or minimize the recognition of their losses, which further complicates the experience of grieving.

Lathrop also adds another layer to that discussion, adding that physicians face a long lead time between entering medical school and being able to work independently. Dissonance may develop between the expected role and regard a physician held before entering the profession, vs. one’s current experience.

Grief, Burnout, and Resiliency

There are two main organizational attempts to decrease burnout, according to Lathrop: decreasing physician workload and physician resiliency training.

The emphasis on decreasing physician workload is usually done in the name of efficiency, which can have unintended consequences:

For example, using nurse practitioners potentially decreases highly valued elements of work such as continuity with established patients, control of patient care plans, and revenue (if high RVU/time-expenditure visits are siphoned off). Meanwhile, the physician acquires supervisory tasks, for which compensatory adjustment or other rewards (mentoring, scheduling flexibility, etc) may be insufficient. Further, physicians may interpret this as a sign that their extensive training, board certification, and experience are not as valued as their (risk-incurring, supervisory) signature. This again can undermine physician integrity, and sets up the dynamic for loss and grief.

Lathrop claims that attempts to increase physician resiliency can further disenfranchise physicians’ experiences. On the one hand, she cites 6 different studies, stating that evidence in the literature is insufficient to support that stress-reduction/mindfulness techniques are effective against physician burnout. On the other hand, promoting resiliency training implies a personal failing on the part of the physician.

The meta-analysis done by Lee, et al. concluded that it was more effective to remove “constraints” than to add “drivers”. In other words, removing stressors from a physician is more effective than adding positive or relaxing activities. This corroborates Lathrop’s assertion (citing Maslach) that evidence points to occupational burnout being a consequence of system processes,³ rather than any personal shortcoming.

When done well, resiliency training emphasizes that a physician already has all of the necessary mental tools and emotional capacity, but isn’t utilizing them effectively. This is the point Gazelle, et al. make in their discussion of professional coaching for physicians. In other words, doctors are already incredibly resilient.

Lathrop backs this up:

In fact, physicians have already demonstrated their high resiliency through successful completion of their medical education and training and some argue it is actually the high level of physician resiliency which has allowed system processes to become ripe for occupational burnout!

In other words, yes, doctors have incredible resiliency. If they weren’t already extremely resilient, their changing professional roles, diminished autonomy, EMRs, a constantly shifting insurance landscape, etc., etc., etc., would have collectively pushed physicians to the brink long ago.

The lesson from Lathrop’s article, in view of all of the other work we’ve been discussing, is that burnout can’t be solved solely by a change in individual attitude and thinking. No attempt to relieve burnout, though, is complete without turning disenfranchised grief into acknowledged grief. What’s more, an open grieving is a good place to start if we want to help physicians:

Suffering physicians could benefit when they acknowledge changes in their work environment incur loss, chose to address any pain from hidden grief, withdraw emotional energy from earlier professional expectations, and reframe their professional future.⁴ Meeting this challenge may require accessing resources or addressing personal and/or professional conflicts from which doctors have traditionally shied away. Most of all, as in all grief, physicians will need to accept that their losses are real—and permanent.

…

Each organization will have to weigh the cost of ameliorating such unintended consequences. In the meantime, we must give the utmost respect and care to the consideration that physicians are potentially grieving, while upholding their professional role.

Sources

The article reviewed: Lathrop, Deborah. “Disenfranchised Grief and Physician Burnout.” Annals of Family Medicine 15, no. 4 (2017): 375–78. https://doi.org/10.1370/afm.2074.

¹ Stein, Alexis Jay, and Howard Robin Winokuer. “Monday Mourning: Managing Employee Grief.” In Disenfranchised Grief: Recognizing Hidden Sorrow, edited by Kenneth J. Doka, xvi, 347. Lexington Books, 1989. ↑

² Doka, Kenneth J. Disenfranchised Grief: Recognizing Hidden Sorrow. Lexington Books, 1989. ↑

³ Maslach, Christina, and Michael P. Leiter. The Truth about Burnout: How Organizations Cause Personal Stress and What to Do about It. Jossey-Bass, 1997. ↑

⁴ Doka, Kenneth J. Disenfranchised Grief: Recognizing Hidden Sorrow. Lexington Books, 1989. ↑

Featured Image attributed to Reddit user NickMoore911, whose Reddit and Imgur accounts have apparently been deactivated.