The U. S. Surgeon General’s Advisory on Burnout, part 1
Burnout of physicians and other professional staff has been the occasional focus of previous articles. Now the issue has become so important that it warranted the issue of an Advisory Report from the U. S. Surgeon General, announced on the internet and in the press. The Advisory Report, titled Addressing Health Worker Burnout: The U. S. Surgeon General’s Advisory on Building a Thriving Health Workforce, is available for download, and runs to 76 pages including references. It is particularly strong in its summary of the current state of affairs, which is the focus of this article.
After acknowledging that working in health care has always been stressful, Dr. Murthy describes the situation before the pandemic.
“But day after day spent stretched too thin, fighting against ever-increasing administrative requirements, and without the resources to provide our patients and communities with the care they need, drove many nurses, doctors, community health workers, and public health staff to the brink. Then came COVID-19.”
He notes that when he talks to staff around the country, they express exhaustion, helplessness, and sadness. Burnout is classically described as a work-place phenomenon where staff have feelings of a high degree of emotional exhaustion and depersonalization, (cynicism,) and a low sense of personal accomplishment at work. It is not a psychiatric condition, although burnout is strongly associated with depression, anxiety, substance use disorders, and suicide.
“While addressing burnout may include individual-level support, burnout is a distinct workplace phenomenon that primarily calls for a prioritization of systems-oriented, organizational-level solutions.”
Many of the previous articles on burnout have focused on individual issues such as improving “resiliency” or “grit.” Considering that getting through a professional education requires both in high degree, it always struck me as an exercise in blaming the victim. Burnout, like battle fatigue, is a normal human reaction to an abnormal situation. The Advisory hopes to make this distinction clear, too.
The report also examines moral distress and moral injury, which can intersect with burnout. “In health care settings, it can manifest when health care workers know the best health care decision to make, but feel helpless and unable to act due to limited resources or circumstances beyond their control.” In my field it is provision of dialysis to undocumented immigrants, but the news is now full of articles involving obstetrician-gynecologists trying to navigate the changed legal environment following the recent Supreme Court decision overturning Roe v. Wade.
The Advisory considers the adverse effects of burnout on the individual worker, the patient, the health care system, and the community. While the list seems obvious, I am still struck by how we have considered staff turnover of 20% or more annually to be “normal.” What is normal is rarely the subject of management attention. I wonder if this report will help change that?
The report includes some useful new data. For instance, the U. S. Bureau of Labor Statistics expects some half million registered nurses to retire by the end of the year, and predicts a nationwide shortfall of 1.1 million individuals. The consulting firm Mercer expects a shortfall of some 3 million people in the lower-wage, lesser licensed health care positions over the next five years. And by the way, there is expected to be shortfall of anywhere from 54,100 to 139,000 physicians in ten years, which does not include the impact of location and specialty mal-distribution. Clearly, given these data, it is not reasonable to expect traditional solutions to staff shortages—re-entry into the workforce and augmentation by locum tenens staff to be effective, since everyone is going to be short.
The impact of “social determinants of health” has received increased attention in both the medical and health care outcomes literature. The Advisory describes the results of a survey of some 1,500 physicians, 61% of whom felt they had no time to address such issues. Perhaps more significantly, when the stress of dealing with the pandemic is considered, the effects were more pronounced in workers of color, immigrants, women, and low-wage positions, particularly those in rural areas or tribal communities. At the very time when outreach to marginalized communities is very important for public health, those people most likely to be successful in inducing change are also most likely to be leaving the work force.
“We must seize this moment to re-imagine and create a health care system where patients, communities, and health workers can all thrive. This will require us to take a whole-of-society approach, one that addresses system-level challenges associated with organizational culture, policy, regulations, information technology, financial incentives, and health inequities.”
The advisory has several specific “immediate” steps. First, protect the health, safety and well-being of all health care workers. Second, eliminate punitive policies for seeking mental health and substance use care. Third, reduce administrative and other workplace burdens to help health workers make time for what matters. Fourth, transform organizational cultures to prioritize health worker well-being, and show all health workers they are valued. Fifth, recognize social connection and community as a core value of the health care system. Sixth, invest in public health and our public health workforce.
The Advisory goes into more detail, some of which we will consider inS later reports. Certainly, the report articulates many of the themes I have stressed here. The absence of public discussion by people makes me concerned it will suffer the fate of most government documents—consigned to the “ash-heap” of history, subject to academic dissection at some distant time in the future when we either did or didn’t make adaptive changes.
25 July 2022
 Current Priorities of the U. S. Surgeon General. Health Worker Burnout. https://www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html
 Murthy V. We Should Care for our Health Workers. USA TODAY, 15 June 2022, p. 7A.
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