On Clinician Burnout

These last few weeks as we come closer to UK launch of O.S.L.E.R., I’ve been reflecting on what it is exactly we are trying to achieve. Co-working alongside AI makes medicine faster, smarter and kinder, spending more time connecting with the patient, and far less time typing on keyboards. We spend a lot of time with nearly every level of the healthcare system finding out what their problems are, from nurses to CFOs to government and everyone in between. While their responses vary wildly, the one universal problem on everyone’s mind: clinician burnout.

What is ‘burnout’? I’ve worked as a clinician for sixteen years, founded a charity dedicated to healthcare workers wellbeing and been burnt out personally at least twice in my career, but I’m still not sure I could fully characterise it. I think the best definition I’ve found is this:

“What started out as important, meaningful, and challenging work becomes
unpleasant, unfulfilling, and meaningless.”Maslach et al

Easier than trying to academically define is to describe what it actually feels like.

I’ve been burnt out twice in my career that I remember.

The first time was about ten years ago. We used to do seven days in a row of on-call shifts (13 hours a day), and on the very last day the night doctor didn’t turn up. Without any other cover, I had to do the night shift as well – a 26-hour shift. One day later, I was back on the wards on a normal shift, a cumulative sleep deficit in the tens of hours, sitting in the office at about 3pm. Exhausted, kind of numb, waiting for the clock to just get to 5pm so I could go home and finally rest.

A nurse rushed in to the doctor’s office – “I need help; this patient’s saturations have dropped to 90%”. This usually means a real emergency. This is as important, meaningful and sometimes as challenging as it gets. And I remember just staring blankly at the ward sister for what seemed like a minute. Knowing all of this. And simply saying “Could you find someone else?”. Luckily, a colleague of mine at that moment was walking in to the office and took one look at me and went off with the nurse. No harm done. And I had sufficient insight to know I should go home early. With a few days off, and a holiday not soon after, I was quickly back to normal. But to this day that numbness still frightens me. For a moment, a genuine life or death situation just felt so pointless.

The second time was much worse. I started a new role in an extremely high pressure environment with very little support. The work was brutal, and unrelenting. The bosses were unsupportive at best. This was chronic burnout and made me dread going to work, dread any interaction with anyone to be honest. I remember just feeling incredibly isolated – so very far away from anyone. Paranoid about every interaction, it spiralled over months. I felt like leaving, and to be brutally honest, not just leaving my job. It felt impossible to separate my work identity from my person identity (common to many professionals especially doctors). This was another type of burn out. It took a long time, some external help, lots of exercise, and really a change of hospitals, to get back to normal.

Why does burnout happen? Why are clinicians so vulnerable to it? I’ve reflected a lot on this. I think there’s a few elements:

  • Moral injury – knowing you can and could be doing more for patients, but are obstructed from doing so. This could be the system pressures, the physical requirements of the jobs (long hours, nights) or the digital systems that now take up 30-40% of clinicians time.
  • Constant exposure to distress– most clinicians will deal with death, grief, life-changing diagnoses, births, miscarriages, breakdowns and more, every single day. The Life events with a capital L that happen to an individual a handful of times in a lifetime, are exposed to a clinician every single day. System pressures exacerbate that. I remember doing a medical registrar shift where we admitted nearly 60 patients in 12 hours – A&E was so busy I could only find a literal linen cupboard to quietly tell a family their mum with terminal ovarian cancer was now in obstructive renal failure and dying. Grief, for anyone with a shred of empathy, is a really hard emotion to not participate in, even a little.
  • Isolation – increasingly, especially post-COVID, clinicians feel they are suffering alone. Where once they felt part of and appreciated by society (which really helped – as corny as the clapping was, as an ITU COVID doctor at the time it genuinely brought tears to my eyes) there is now a sense of apathy, even outright hostility sometimes, towards healthcare services from some segments of society.
  • Exhaustion – the workload is ever increasing, staffing is actually relatively decreasing as many decide to leave, and this creates an ever increasing burden on the staff that are left behind.

Burnout isn’t unique to the UK, far from it. Clinician burnout has been reported in nearly every country in the world, and worsening near universally in the past decade or so. Why?

  • Patients are getting older
  • Patients now survive conditions they previously didn’t, which is good. But this means that now the survivor population is sicker and multi-morbid
  • Healthcare is more complex as a result – with more interventions, scans, medicines
  • Healthcare is therefore more expensive
  • We haven’t innovated in any direction – workforce, technology, system – sufficiently to actually change the way modern healthcare systems were originally set up nearly one hundred years ago

The result? Burnout. Up to 1 in 2 clinicians now show signs of burnout, even pre-Covid. 40% of UK clinicians are considering leaving the profession in the next 5 years. This worsens the load to bear on those left behind, and so the vicious spiral continues.

So what is the solution?

  • I can tell you what isn’t – training more staff. Not because this isn’t the right idea, but simply because the long lead times (five years for nurses, ten for doctors) mean that this won’t solve the problem now, and those new staff will be training alongside a worsening demographic trend meaning the same result when they arrive.
  • Also what isn’t; ‘resilience’ training. I won’t say much more about that.

In my view, the only logical answer is technology +/- system change. Likely one will lead to the other and back again. Our goals at TORTUS with our AI agent are pretty simple:

  • Step 1: Use AI to give clinicians more time, by taking away all the busy work (e.g. documentation, ordering, information finding, scheduling, follow up). This is the ‘cognitive load’ of practicing medicine in the digital era.
    • Goal number one: “the clinician doesn’t routinely touch the computer any more”
  • Step 2: Use AI to give clinicians ‘cognitive support’, adding knowledge bases from national, local guidelines – not just clinical but also operational knowledge.
    • Goal number two: “the clinician never has to look anything up ever again”
  • Step 3: Send the AI home with the patient – explain diagnoses, collate information, care navigate.
    • Goal number three: “Every patient is an expert patient, informed and capable of self-care and self care navigation”

Lastly, I think a lot about burnout as a CEO of a fast-moving start-up. I work longer hours now than I ever have I think, and I do those same hours pretty much every day. But I don’t feel burnt out at all – quite the opposite. I think the difference is autonomy. Whatever I can or cannot do in a day definitely weighs on my mind, but it’s all fully within my power. The autonomy is intimidating at times, but far different from the days when I couldn’t control when or where I worked or what the workload was. And for that I’m truly grateful. I don’t think we have all the answers, we certainly can’t solve population demographics or large scale system dysfunction, but where we can relieve the suffering of our colleagues using current and future technology, we will.

Why? Because the fundamental unit of every healthcare system in the world is the clinician-patient interaction. Every pathway, every decision, every treatment, intervention, flows into and out of that bottleneck. Burnt out clinicians can’t provide the best care they are capable of. In any healthcare system that problem then downstream, creating worse outcomes for everyone.

The bottom line: it serves us all to care for those who care for us.

Dr Dom Pimenta

NB: If you’d like to see what we are up to at TORTUS with our AI agent, O.S.L.E.R, you can check it out here.