Feeling Burned Out? You’re Not Alone

By Denny Watkins
June 14, 2024 | SPRING 2024 ISSUE

The worst day of Amanda White’s nursing career came in June 2020, shortly after the first devastating peak of the COVID-19 pandemic.

Death rates had been on the decline in the last 2 months, but around 800 people were still dying daily from COVID in the United States. Dozens of patients were coming through the ICU each month at UPMC Memorial Hospital, where White had worked since 2017.

“Out of everyone that came to us, like 90% of them died,” White said. “Every day, I knew I was going to have to see a lot of people die.”

In the ICU, White attended to patients with COVID on respirators to help their breathing as their lungs grew inflamed and filled with fluid. Before coming into each room, White routinely donned a full surgical gown and gloves. The N95 filtration mask she wore was such a precious commodity that she used the same one every day for weeks. The hospital would collect them, clean the dirty masks, and redistribute them. At one point, White recalled, hospital administration sent an email asking women not to wear makeup to work because it made cleaning the masks more difficult.

On this particular day, White was walking through the ICU corridor when she noticed a patient with COVID rousing from sedation and pulling on her breathing tube, separating the plastic piece connecting the tube to the ventilator.

As White pulled on her personal protective equipment, she remembered thinking the patient would likely suffocate before she could get into the room. But if she walked in unprotected, she would expose herself to an active case of COVID, which meant, at best, a 2-week quarantine afterward and risk of infection.

The nurse decided to step in without protective equipment, reinsert the breathing tube, and help put the patient back under sedation. White had just returned to the ICU after 8 weeks of maternity leave following a cesarean delivery. She knew the consequences of her decision.

“Then I went outside, and I called my husband from the parking lot,” White said. She told her husband, who is a nurse in a long-term care facility, that she’d have to swap houses with her father-in-law for the next 2 weeks to quarantine while the two men cared for her 2-month-old son.

She also made a decision about the future of her career as an intensive care nurse. “That was the day I decided to get out.”

Running on empty

White is far from the only health care professional to transition to a lower-stress career path in recent years. A 2023 survey by the National Council of State Boards of Nursing estimated that roughly 100,000 nurses have quit the profession since 2021, with another 610,388 nurses planning to leave because of stress, burnout, or retirement by 2027.

According to a study conducted in 2020 by the American Medical Association, nearly one in four physicians planned to leave their practice within the next 2 years.

More alarmingly, the suicide rate among physicians is estimated to be 1.44 per 100,000, according to a 2019 meta-analysis in PLOS One, outpacing the suicide rate in the general population by 16%. The same study also found that physicians in internal medicine made up the greatest proportion of suicides, at 16%, which was more than psychiatrists at 11% and surgeons at 4%. What’s more, the risk of suicide among physicians is significantly higher in the US compared with the rest of the world.

The World Health Organization defines burnout as an “occupational phenomenon”—not a medical condition—characterized by exhaustion, cynicism related to the job, and diminished effectiveness as a professional.

Betrayed by the system

In her 2023 book, If I Betray These Words: Moral Injury in Medicine and Why It’s So Hard for Clinicians to Put Patients First, psychiatrist Wendy Dean, MD, argued that what’s driving doctors and nurses out of the health care industry is not just burnout, per se, but the regulations, policies, and cost-cutting measures preventing practitioners from caring for patients the way they are trained to do.

Wendy Dean, MD

Ultimately, as Dr. Dean described it, the mental health crisis facing health practitioners is a failure of institutional culture. “Burnout is a demand-resource mismatch,” Dr. Dean said. “Moral injury is an experience that’s based in betrayal, which is often unintentional.”

Brad, a 38-year-old former nurse who did not want his last name publicized, felt the pressures of profit earning at two separate clinics where he worked more than 4 years. He said that “moral injury” accurately described the frustration and depression that led him to leave nursing in 2023 for a new career in technical writing.

The pandemic created a financial ripple effect across the health care industry. While emergency rooms and ICUs were inundated with patients with COVID-19, other specialties saw patients drop off as they postponed checkups and elective surgeries. Once patients started returning, some clinics compensated for lost revenue by putting extra demands on their staff.

“I didn’t feel like I was making a difference,” Brad said. “I felt like I was just there to make people money. And if I’m going to work to make someone else money, I can do that at any job.”

Private equity investments in hospitals and clinics began before the pandemic and are still ongoing. In 2012, private equity acquired 75 physician practices, but that number ballooned to 484 deals financed by private equity in 2021, according to the American Antitrust Institute.

Although revenue often increases at medical facilities acquired by private equity, it often means an increased workload for staff and diminished patient care.

Passion for the profession—not the paperwork

“Burnout during COVID was a different flavor than now,” said Gabriel Bosslet, MD, FCCP, an ICU physician and Professor of Clinical Medicine at Indiana University. “Now we have mostly corporate administrative burnout.”

Gabriel Bosslet, MD, FCCP

Irene Hsu, MD, felt continually frustrated with the business side of medicine throughout her 15 years as a pediatric ophthalmologist. “I actually loved being a pediatric ophthalmologist,” she said. “I really enjoyed the interactions with the family, and the kids are just adorable.”

At the three ophthalmology practices that she worked at after completing her fellowship, Dr. Hsu often found her role in pediatrics, where she performed strabismus correction surgery, undervalued compared with surgeons who specialized in cataract removal, which can generate more revenue. Even in a relatively small physician-owned practice, where decisions were made collectively, high-value surgeries took precedence over spending time with patients.

“You can’t push kids through your rooms because they’re kids, and you want to spend time talking to families who have concerns,” Dr. Hsu said. “It’s like comparing apples and oranges.”

Dr. Hsu reached her limit in 2021 while waiting 9 months for her new medical license after moving from the West Coast to the East Coast. “I just decided that I didn’t want to do it anymore because of all this administration,” she said.

She took her knowledge and skills to a large medical insurance company, where she keeps regular hours and feels valued as the company’s only on-staff ophthalmologist who reviews claims.

Working in insurance also gave Dr. Hsu a new perspective on the financial pressures that trickle down to patients waiting to find out if their insurance will cover a particular medical procedure.

“On a grand scale, there’s only a certain pool of money for these procedures,” Dr. Hsu said. “Canada and England probably shell out even less for the investigative or experimental stuff.”

Burnout without borders

While the profit motive has the most significant impact in the US, where private insurance and large corporate ownership of hospitals is the norm, physicians in countries with government-funded health care see similar rates of burnout.

A 2022 study estimated that burnout rates among physicians across 41 European countries were as high as 43%. Doctors in France went on strike in 2022 to demand better working conditions and fees, doctors in Germany went on a 1-day strike in 2023 to protest excessive bureaucracy, and, in the United Kingdom, nurses went on strike in 2022 and junior doctors went on strike in 2024 asking for better salaries.

“Universal health care won't be the sole solution,” Dr. Dean said. “When we're looking across all these different cultures and across all these different countries that have different payment systems, what we are seeing is that the experience is the same, but the drivers are different. So the solutions will have to be tailored to the drivers.”

The big picture issues affecting burnout are systemic, and addressing them will likely require a significant governmental and societal effort to reduce the unnecessary mental burdens on health care workers. However, Dr. Dean points to the recent Federal Trade Commission ruling banning noncompete contracts as proof that reform is possible—if enough people demand it.

“Speak out, but never alone,” Dr. Dean said. That means finding other physicians who share your concerns—whether it’s at your own institution, a small nonprofit, or a bigger medical association—and leveraging that collective voice to make changes in government regulations or hospital policies.

Filling the void

Some hospitals have adopted compassion rounds, which are presentations and talking sessions that help health care workers open up about the emotional toll of their work. More than 800 hospitals worldwide use Schwartz Rounds, which are monthly forums where both clinical and nonclinical staff discuss the emotional impacts of their work.

“Our membership expanded a lot during the pandemic because people wanted that kind of community,” said Beth Lown, MD, Chief Medical Officer at The Schwartz Center for Compassionate Healthcare. “They wanted that ability to share what they were experiencing with people who knew what it was like to be there taking care of patients and families, what it was like to be afraid for your own family going home.”

Beth Lown, MD

Compassion rounds can give a significant boost to the people who participate. A 2023 study in England found that attending Schwartz Rounds cut down measures of poor psychological well-being from 25% to 12%, compared with a drop from 37% to 34% in people who did not participate.

Unplugged and offline

Other physicians have adopted more personal strategies to manage the mental burdens of the job. Dr. Bosslet’s email signature, below his many titles and professional affiliations, includes a friendly note in a bold, bright red font: “I do my best not to email on weekends and after 5 p.m. (I am not always successful).”

It’s part of Dr. Bosslet’s conscientious efforts to maintain a healthy separation between work and home life. He has to respond when he’s on call, of course—but a separate clinical messaging system handles those inquiries. Email is where he sees those nonemergent issues that sap attention and mental energy.

“The email signature works,” he said. “I don't find myself making dinner with my 14-year-old daughter, then checking an email that I didn't need to see and having it completely ruin my night.”

Dr. Bosslet began to take the risk of burnout more seriously after another physician and good friend committed suicide in 2016. He began practicing mindfulness—a wellness cliche but a useful one—to be more aware of the source of his emotions and to recognize and acknowledge those emotions in patients and their families.

“There's a role for understanding our own cognitive processes and trying to separate our emotional reactions to our thoughts from the content of those thoughts themselves,” Dr. Bosslet said. “It will touch every aspect of your life: your relationship with your spouse, your kids, your parents, your brothers and sisters, your coworkers, the patients that you care for—everyone.”

The need for more than mindfulness and reflection

While individual actions might work in the short term, if hospital leaders and owners fail to make significant changes to how they approach patient care and caring for their employees, it seems likely that the exodus of doctors and nurses from health care will likely continue.

White, the former ICU nurse, isn’t sure if anything could have compelled her to stay in nursing. Although her coworkers were supportive through the difficulty during the peak of the COVID-19 pandemic, management often wasn’t on the ICU floor, and leadership seemed absent entirely. “They did offer a lot of money,” White said. “[But] they didn’t do a lot of staff appreciation. We didn’t get kudos or meals—not that it matters. For Nurses Week, we didn’t even get a gift.”

White quit the ICU floor at UPMC Memorial soon after her quarantine ended and took a nursing job at a public school that specializes in children with developmental disabilities.

Along with three other nurses, she provides daily care for children with seizure disorders, autism, cerebral palsy, and other genetic conditions. White works regular school hours, which gives her time at home with her son, who is now 4 years old and has been diagnosed with Duchenne muscular dystrophy, a life-shortening disease.

“I don’t think I would go back,” White said. And in that, she’s not alone.