Knowledge Shot: Why we should care for our caregivers

In January 2019, Medscape released their annual National Physician Burnout, Depression, and Suicide report and found that 44% of the 15,000 physicians surveyed felt burned out, that’s a 5% increase from the 39% they saw in their 2013 survey.

Another study by Mayo Clinic researchers found a 9% increase in burnout among physicians from 2011 to 2014. Currently, there are 300 to 400 physicians who die by suicide each year, a rate that’s nearly double that of the general population.

To be honest, even the term ‘burnout’ itself is problematic, because it inaccurately represents these feelings of demoralization, physical and emotional exhaustion often felt by caregivers.

The term ‘burnout’ suggests that individual caregivers are ‘breaking’ as a result of individual character flaws like not being resilient or hard-working enough, rather than as a result of a health care system that is broken and overstretched.

Often the realities of the healthcare system - limited access for the poor, layers of paperwork and bureaucracy, and inadequate time for meaningful conversations contradict the morals and values of the caregivers within that system.

So instead of “burnout” the term “moral injury”, recently suggested by Dr. Zubin Damania, more accurately and honorably describes the demoralization and exhaustion felt by these caregivers.

Based on these reports, the medical community has taken a closer look at exactly how early in a clinician’s training moral injury begins to appear.

The results are not encouraging. A recent review found that around 44% of medical students around the world feel moral injury.

Another review found that 29% of residents had a major depressive episode during training as compared to 8% of similarly aged individuals in the general population.

Similarly, a study of nearly 1,200 inpatient nurses found that the depression rate was 18%, roughly twice that of the general population.

Yet another study found that 20% of employed female caregivers over 50 years old, report symptoms of depression, compared to 8% of their non-caregiving peers.

Furthermore, 72% of family caregivers report not going to the doctor as often as they should, and 58% reported worse exercise habits relative to before they began their caregiving responsibilities.

With the increasing demand for clinicians and caregivers due to the aging population, it’s critical to understand and address the factors that are leading to moral injury and its consequences.

There are at least three consequences we should be paying careful attention to: First, consequences for the caregiver. The moral injury and depression rates among clinicians and caregivers appear to be increasing and can lead to absenteeism, turnover, and even suicide.

Second, consequences for the patient. At the beginning of a flight, the flight attendant always reminds us to “put the oxygen mask on yourself before helping anyone else.” This intuitively makes sense: How can you help anyone else if you’re incapacitated?

Several studies have shown that moral injury and emotional exhaustion are predictors for major medical errors, malpractice lawsuits, health care-associated infections, decreased patient satisfaction, and even patient mortality rates.

Third, consequences for the healthcare system. The effects of moral injury on the care provider and patient lead to consequences for the overall healthcare system.

For example, staff turnover is expensive and can cost health care organizations hundreds of thousands of dollars per provider.

In addition, a study of physicians showed that a 1-point increase in emotional exhaustion leads to a 28% greater likelihood in reducing work hours the following year while a 1-point decrease in job satisfaction lead to 67% greater likelihood in reducing work hours.

The reduction in productivity due to emotional exhaustion at the national level is estimated to be the equivalent of losing seven graduating classes of medical students per year.

In response, the Association of American Medical Colleges has been calling for increased enrollment at medical schools to keep up with demand.

Leading medical organizations such as the National Academy of Medicine and Accreditation Council for Graduate Medical Education are paying close attention to the above issues and, in response, developed an Action Collaborative on Clinician Well-Being and Resilience which is designed to raise awareness and improve our understanding of the issue, and to put forth evidence based solutions to improve caregiver support.

It is encouraging to see how many organizations, ranging from the American Nurses Association to Aetna, have joined the collaborative because the complexity of the problem will require a diverse set of solutions ranging from the individual to the systemic levels.

Focusing on the well-being and resilience of caregivers will have a compounding effect and reap dividends for public health, not only because of improved productivity and quality of care but also because of the diffusion of coping strategies such as physical activity, mindfulness, and healthy eating from caregiver to patient.