Clinician burnout in medical practice represents a significant problem that is exacerbated by the series of COVID-19 pandemic waves. Workplace burnout is characterized as a psychological syndrome involving emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment.(1,2) It is associated with numerous healthcare organizational metrics, including higher physician turnover, lower patient satisfaction, various quality metrics, and decreased productivity.(3) National estimates of physicians experiencing at least one symptom of burnout vary and range from 44% to 66% of U.S. physicians with a financial impact of almost $5 billion annually.(4,5,6)
Key drivers of burnout include systemic factors (e.g., regulatory requirements, payor challenges), organizational factors (e.g., lack of job control, excessive workloads, stressful team dynamics, conflicting metrics, practice inefficiency, leadership, workplace support structures), and personal factors (e.g., change in interest/goals, home situational factors).(7,8) Since many dynamics influence physician wellbeing, the entire healthcare ecosystem (e.g., leaders, health systems, payors, individual physicians, etc.) has the shared task of reducing burnout.
In 2018, Ochsner Health created the Office of Professional Well-Being (OPW) as a resource to help mitigate burnout and promote the well-being of physicians and advance practice providers (APPs). Our work is focused heavily on organizational/systemic factors such as practice efficiency, leadership development, and team-based care strategies. Because system-level changes take time, in addition to our long-range strategy, we concentrated on physicians with more severe burnout who needed immediate support in the form of one-on-one peer coaching.
Personality and Physician Burnout
Unfortunately, there is little discussion and research into personality-based factors that lead to burnout in medical professionals. We imagine this gap exists for various reasons, including the understandable desire to avoid “blaming the victim” and the current consensus that physician burnout is primarily a response to the healthcare system.(8) Nevertheless, research shows that personality factors, such as one’s degree of agreeableness and openness to change, contribute to individual physician burnout symptoms.(9)
We maintain that focusing on individual-level factors is not a deflection of blame away from systems/organizations, but instead provides additional tools to better address physician burnout. Moreover, because systemic factors impacting burnout, given their inherent complexities, take longer to address, individual factors are more easily coachable — particularly if leaders are attentive and skilled at helping their teams.
Professional Experience Program (PXP)
Given the support for one-on-one coaching to improve physician burnout,(7,10) we developed an internal coaching program (Professional Experience Program or PXP) to support physicians who had more significant burnout. In working individually with more than 30 clinicians experiencing moderate to severe burnout in the PXP, we have identified four personality styles or “archetypes.” These archetypes, like all personality styles, have strengths; however, when the person is under considerable stress, these strengths can become liabilities and make a stressful situation even worse.
Consider, for instance, the physician who is detail-oriented. Usually, this is a desirable characteristic because we want physicians to avoid careless errors. Taken to an extreme, obsessiveness can slow down physicians so much that they may have difficulty maintaining a normal workload or focusing on the bigger picture. This is an example of a strength becoming a liability.
Archetype/Personality and Leader Management Strategies
Successful physician leaders know their teams well — what makes them happy, what frustrates them, etc. When a leader begins to sense that a physician is burned out, that leader might ask what burnout archetype or blend thereof do they fit into? Then, based on the physician’s archetype, leaders can select from specific coaching tactics to help that physician address the factors affecting their burnout.
Critically, the four proposed archetypes are not meant to pigeonhole physicians; many may fit into more than one personality type. These archetypes are presented as a conceptual frame of reference to help leaders more easily and quickly help burned out team members (Table 1). Leaders should also know when it is more appropriate to involve behavioral health to support their physicians more intensively.
Type 1: Over-Engaged
The over-engaged archetype is common in healthcare. We all know these people. Over-engaged physicians reflexively say yes and quickly become overextended. Their key needs are to feel valued, successful, important, relevant, and “always part of the solution.” They fear feeling irrelevant, feeling stagnant, not being promoted, and losing value within the group.
Leaders might observe the following behaviors: reflexively saying yes, overestimating the professional consequences of saying no, and being known by colleagues as someone who does too much, resulting in their sense of being overwhelmed and burned out.
The core leader strategy is to help the physician stay engaged for the long term and not burn out too fast. Leaders often avoid having burnout conversations with the over-engaged physician out of fear of upsetting or completely disengaging the individual.
Like any feedback or potentially “difficult” conversation, it can be helpful to start with acknowledging how valued the over-engaged physician is. Remember, they want to feel valued. Next, it is important to ask them if they feel overly stretched. You may say, “How can you do so much? I’d be exhausted!” or “Is your tank near empty?” or “Are you passionate about everything you are involved in right now?”
Note: In this moment, the over-engaged physician still wants you to be impressed with them. If you don’t think the physician is being completely open with you, it is okay to take a risk. You might say something like, “You seem overextended. How can I help us have a safe and open conversation about that?”
When the over-engaged physician acknowledges doing too much, the second part of the coaching conversation must focus on understanding the why. What are they hoping to achieve (a promotion, a specific role, compensation, etc.)? It is essential for leaders to know the answer to this question, and to do so, they may need to ask explicitly about the physician’s goals. This helps them focus on tasks that align with their core goals.
Once you understand their why, the third part of the coaching conversation involves asking them to offload certain tasks. Remind them that saying no to requests will help them direct energy to their goals. Moreover, offloading tasks can be an opportunity for someone else to step up.
Finally, leaders need to check frequently with over-engaged physicians to ensure they are consistently being more reflective before saying yes and cultivating a greater work-life balance as a result of their action.
Type 2: The People-Pleaser
Despite popular culture’s depiction of doctors as overly demanding and assertive, many physicians struggle with facing confrontation and setting limits/boundaries. Key needs for the people-pleasing physician are living in harmony, being liked and well regarded, and feeling helpful and reliable to the team. Key fears include being disliked, facing confrontation, upsetting others, and not being perceived as a team player.
Leaders can observe these people-pleasing physicians doing various things such as not expressing a difference of opinion, avoiding delegation for fear of dumping on colleagues/staff, and preferring to fix someone’s mistake rather than provide corrective feedback. As a leader of people-pleasing physicians, your goal is to help improve their self-advocacy and ability to clearly express their needs. As Brené Brown says, “Clear is kind.”(11)
When leaders approach a people-pleasing physician, they must remember that this archetype tends to avoid confrontation. Leaders may hear “everything is fine” or “I don’t want to rock the boat…” Leaders should foster enough psychological safety for the people-pleasing archetype to ensure an authentic conversation. If you are uncertain of how your message will be received, it may be helpful to say, “This is ‘off the record,’ and I really need your honesty here; nothing is going to upset or surprise me.”
Next, model clear communication by expressing your concern for them and how they seem burned-out to you. To reduce stigma and foster a feeling of safety, you may also share your own burnout experience.
The second task for the leader is to help this physician identify how aspects of their people-pleasing personality contribute to their burnout, but avoid discussing what the physician cannot control.
For example, a physician may say, “I’m burned out because patients want to talk about every problem, and I don’t have enough time.” Help this physician set clear boundaries and expectations during patient visits. When people-pleaser physicians communicate how setting boundaries is impossible with “But, that will make patients angry,” or “My patient experience scores will tank,” your job as a leader is to help them realize that their approach is working against their goal of maintaining a sustainable/joyful medical practice.
Third, the coaching conversation must transition to the leader helping the physician identify one tangible day-to-day practice that increases their comfort with speaking up, setting a boundary, or being clear about what they need. Check in to ensure this goal is consistently being met.
Type 3: The Perfectionist
Perfectionism is highly rewarded in medicine — after all, what patient does not want “perfect” results from their healthcare? The perfectionist physician archetype leverages control over all aspects of a patient’s care and finds delegation and trusting other care team members daunting.
Leaders who coach these physicians are wise to identify key needs of excellence, autonomy, and control. Key fears involve losing control, falling short of internal/external standards, compromising unnecessarily, and failing or making a mistake.
Leaders can recognize these at-risk physicians as those who take overly detailed/long clinical notes, assume tasks other staff should/could do, or say, “Better to do this myself.” Often these physicians are exasperating because no one on the team can live up to their expectations.
Leaders who work with a perfectionist archetype should not tell the physician to “just relax and let go.” Telling someone to relax when they are tightly wound usually makes them feel misunderstood. Instead, leaders must praise these physicians for their standards. Next, they should coach them to recognize how their perfectionism/need for control has clear costs. The goal here is to show that perfectionism and being overly controlling can have diminishing returns, meaning their perfectionism is working against their goals. For example, is that perfect note worth it when the physician does not have time to respond to an urgent patient issue?
Next, with established buy-in, have these physicians identify tasks about which they could be less perfectionistic or tasks they can delegate. Finally, develop concrete metrics to assess their follow-through. For instance, a leader can use data from the medical record to review documentation efficiency or the level of team collaboration.
Type 4: Problem Finder/Cynic
Cynical archetypes are well known. They are excellent at pointing out problems in meetings, saying, “I knew it” when things fall apart, and are quick to perceive negative intentions. Often, a leader’s primary management strategy with the cynic physician is avoidance or sarcasm/humor (“there goes Dr. X spouting off again”). Unfortunately, these physicians are often the most wounded in the group, and management by avoidance typically leads to ongoing problems for the leader and the surrounding team.
Key needs for the cynic physician archetype include self-protection, trust, strength, and transparency. Leaders should understand that these primary needs are rooted in fears, including fear of being let down, fear of being taken advantage of, and fear of being perceived as weak. The physician cynic tends to rant about minor issues, see the worst-case scenario first, assume people have hidden agendas until proven otherwise, and quickly reject solutions after pointing out a problem.
Leaders should first show empathy with cynics even though they initially view these physicians as “difficult” and causing their own problems. Empathic leader behaviors might include arranging initial interactions that establish trust and safety, such as bringing coffee to their office, inquiring about their well-being and listening to their response. The aim is to open a trust bank account, because these cynic physicians have often lost trust in their leader or organization.
Next, it is critical to be authentic and transparent when you are ready to talk to them about burnout. Be clear and concrete (e.g., have a list of examples/behaviors) about how you see their cynicism and how their problem-finder behavior contributes to their burnout. Next, affirm that these physicians have had past experiences that contribute to their cynicism, such as instances when the physician was let down or treated unfairly. This helps them know you “get it.”
Finally, help these physicians recognize that their default cynical/problem-finding attitude may be doing more harm than good by contributing to these negative interactions. Suggest these physicians try to notice positive things staff members do and verbalize the acknowledgment more frequently. Staff will immediately notice the change if the physician does this.
Next, talk to them about how to productively discuss problems or to assess for trust rather than always assuming the worst at the outset. The overall goal is to help the cynics realize that their attitude and perceptions partially contribute to their burnout.
Next Steps for Physician Leaders
Physician leaders struggle to balance two key tasks when dealing with burned-out physicians: projecting enough empathy and responsiveness so team members feel heard and effectively communicating what the leader or organization is doing to address the systemic problem for the burned-out physician.
When considering the personality types described above, physician leaders have a third task to support their team members. This third task is important to quell burnout, and is understandably difficult. Frontline physicians do not want their legitimate organizational problems ignored, and leaders do not want to appear as though they are shifting blame. Leaders must explicitly highlight everyone’s role in mitigating burnout: the leader’s tasks, current/planned organizational work, and the frontline physician’s tasks.
As physician leaders support burned-out staff, transformative moments can occur when a leader coaches over-engaged physicians to offload work or reminds the perfectionist to focus on details that matter. This and similar individual-based strategies are an important element in the wellbeing toolkit. Leaders can help physicians address burnout more quickly and personally. After all, organizationally driven well-being strategies that work today may be irrelevant tomorrow in our rapidly changing healthcare ecosystem.
References
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