Physician burnout & depression with Dr. Srijan Sen

May 31, 2023

[Edited for grammar and clarity by CAMH]

Running time: 21:47 [Intro music]

David Gratzer: A recent CMA survey suggests that a majority of Canadian physicians are experiencing high levels of burnout. 53%. It’s nearly a doubling of the number of doctors who felt that they were going through burnout when the survey was done back in 2017. How do we understand burnout and are we conceptually making a mistake by distinguishing burnout from depression?

Welcome to Quick Takes. My name is Dr. David Gratzer. I’m a psychiatrist here at CAMH. And on this podcast, we have a special guest, Dr. Srijan Sen. Dr. Sen is director of the Depression Centre at the University of Michigan. He’s also a professor there of both depression and neurosciences. He’s a prolific author and has written on burnout, including for the New England Journal of Medicine. Welcome, Dr. Sen.

Srijan Sen: Thank you for having me.

David Gratzer: First things first: you’re not a Canadian, and I’m assuming you’re not a member of the Canadi- an Medical Association, but are you surprised by these survey results?

Srijan Sen: I’m not surprised by the high levels of burnout and the effect of the pandemic. And the results are largely similar to results seen in the US and results on physician well-being across the world. So it’s alarming, but not surprising to me.

David Gratzer: There’s so much more interest in this topic than there has been previously. In a recent New England Journal of Medicine perspective that you’ve written, you talk about in 2020, there were ten times the number of published scholarly articles as there were 20 years before. What are your thoughts?

Srijan Sen: Yeah. There’s really been an explosion of interest in physician well-being and particularly burnout, sparked for a number of different reasons. In general, I think the increased attention both among clinicians on the ground, among policy experts and researchers, is a good thing. I think what we need to do is to make sure that all that attention is moving in the right direction and moving us to a healthier workplace.

David Gratzer: And that’s where I think you disagreeing with some. In particular in the distinction perhaps between burnout and depression itself.

Srijan Sen: Yes, I think that’s where we can do better. I think burnout with the increased attention, both in the literature and in normal conversation, has become a loose term that means different things for different peo- ple. I think that’s made it harder in terms of research to make progress. One example I cite in the piece, and pulling back to a previous review we did, that out of 182 studies looking at burnout there were 142 different definitions. So different researchers are talking about different things. And I think in colloquial discussion it’s even broader. And as we talk about very different things, it’s hard to make progress until we agree on a defini- tion. So I think that’s where some of my problems with burnout start.

David Gratzer: Are we confusing burnout, perhaps with some things that are normal and some things that are really mental illness on the other side of the spectrum, like depression?

Srijan Sen: I think so. I think burnout and depression, and this is talked about quite eloquently by Dr. Maslach who’s composed many of the most used burnout scales, that burnout should be measured as a continuous measure from slight symptoms of burnout to very severe burnout. And I think on the lower end of the spec- trum, those are relatively normal symptoms that it would be impossible to go through life without experienc- ing. And on the more severe end it’s a critical problem. I think depression also, as psychiatrists we know that there’s a spectrum from mild depressive symptoms, and many of our scales are written like this, to moderate and severe depressive symptoms with risk for suicide. One of the problems, and one of the sources of the many definitions of burnout, is deciding where on that continuum we decide to call someone “burnt out” and many studies do that in different places and some at a very mild end and I think that causes part of the confu- sion.

David Gratzer: Do you think part of the issue itself is the term “burnout” and how it developed over time?

Srijan Sen: I think so. And I think there’s people more expert than me, but the history of how the term came about, and came about to apply to physicians is really interesting. I think it’s become and was sort of concep- tualized as a way to capture the emotional distress and problems that come specifically from the work envi- ronment and from us as clinicians, from our experience in the clinical environment, and distinguishing that from symptoms that arise from other parts of life. I think in practice the research shows that, at least the burnout inventories that have been developed so far, are not successful in specifically capturing the emotional distress caused by the workplace and distinguishing it from the home environment and other sources. We try to break down how much of burnout is due to home, due to work, due to other sources, it has the same sort of breakdown between individual factors, workplace factors as depression and anxiety. And conceptually, that fits with my experience as a psychiatrist, that’s really hard to figure out where symptoms are coming from, the source, and with some patients we never do and it’s particularly hard to do through a checklist questionnaire. So I think sort of how burnout emerged and was conceived was a reasonable idea, but I think the literature shows it’s not being fully successful in capturing work-specific symptoms. But despite that, it’s grown into the general understanding among clinicians and among the public is that burnout is capturing work-related symptoms.

David Gratzer: You’ve made mention of Maslach of course. She’s the one who came up with the Maslach Burnout Inventory, which does seem to have overlap with depression and depression scales. No?

Srijan Sen: Yes, a lot of overlap in particularly the core parts of the inventory really overlap strongly with depression, both in how people score on them, but also the sources and the work factors that drive it. I think high scores on burnout among physicians is clearly driven largely by the workplace. But so is depression. And I think that’s the key that you know in work we’ve done in others that the depression rates rise about fivefold once people enter the medical profession in the US and Canada and across the world. And that’s not happen- ing because people are changing, it’s because of the clinical environment. So, I think in physicians it’s pretty clear that burnout and depression track very closely together and have very similar causes.

David Gratzer: So let’s pivot because we’re practical and we’re not just thinking about a definition for the sake of a definition, obviously, but we’re thinking about some of our colleagues who are struggling. What does this mean in terms of designing health systems or even designing hospital programs?

Srijan Sen: In our October article in the New England Journal on work hours and depression, we found that the training physicians working 80, 90 hours plus a week had three times the depressive symptom rate as individuals working 45 hours or less. And no other factor had as much of an impact on depression. And so in preventing depression among training physicians, focusing on work hours is critical. I think there’s other factors we can identify, and the field has identified, to target in preventing depression in physicians in different career stages and different specialties. And I think more broadly, we also know from the literature in the general population important factors that are critical in preventing depression, including psychotherapies, but also, you know, adequate sleep and the right type of sleep and timing and exercise and social connection, and bringing all those to bear to help physicians and preventing creating a healthier workplace where we can prevent depression and improve well-being among physicians is possible. And I think bringing to bear what we know about depression can help us get there.

David Gratzer: Dr. Sen, conceptually, we often think about depression as being the individual experience and burnout as being related to the system. You find that an artificial divide?

Srijan Sen: Yes, I find that to be an artificial divide. That’s not at all supported by the evidence that in physi- cians and in particular the rate of depression goes dramatically up as people enter the profession. And in physicians, both burnout and depression are clearly driven by the environment. So emphasizing depression is not putting the blame at all on the individual, but helping us bring more tools to help the individual and help the professional get healthier as we move forward.

David Gratzer: So pivoting our thinking away from quote unquote burnout and thinking about mild, moderate and severe depression and the spectrum: is part of the issue the culture of medicine itself? When I was in training, we frowned on people who took days off. No one really got sick, and certainly no one had a mental health problem. Except, of course we did. Now I trained around the time dinosaurs roamed the earth. So things have evolved a bit, but maybe not profoundly. What are your thoughts?

Srijan Sen: I think, yeah. I think the culture of medicine is there and you know, it has positive parts to it but definitely has that negative aspect of making it really difficult to talk about mental health and glorifies a certain type of physician and I think getting away from that and realising that prioritising our own mental health and those particularly of our colleagues is good for us, but also good for our patients. There’s so much evidence that we’re better physicians when we’re healthy and make less errors, provide a higher level of care. I think there’s some evidence that it’s changing. In our longstanding study of first year physicians, interns, about three or four times as many get treatment for depression than did 15 years ago. So, it’s getting better. It’s getting better at a much higher rate among women physicians than men physicians and getting better among non-surgeons than surgeons. So there’s still pockets where there’s still a lot of stigma and there’s still there’s a clear generational difference. I think continuing to improve on stigma and talking about mental health, is important and we’re making progress. But there’s still more to do there.

David Gratzer: It’s kind of ironic, isn’t it? Many of our colleagues are very eager to talk about depression with their patients, certainly as psychiatrists, but absolutely obstetricians, family doctors, general surgeons. I was talking with an intensivist the other day who was asking me about what he could read because he wants to understand more psychiatry because he thinks it’s relevant to his field. And yet when we talk about mental health care for our colleagues and for ourselves, stigma still exists and in fact might be quite strong in certain pockets within our larger community.

Srijan Sen: Yeah, I think that’s definitely true. And I think, you know, a lot of the practice I do is with other physicians and it’s almost universal that the first part of the conversation I have is about doctor and their symptoms and feelings and me educating on sort of how common they are. And most people come in feeling like they’re the only ones struggling or having these negative thoughts or strong feelings and even sometimes suicidal feelings and feel like all their colleagues are going through the day perfectly happy, taking perfect care of their patients, writing beautiful notes, going home, cooking a wonderful dinner, then going for an eight mile run and getting perfect sleep and just realising how much everyone else is struggling in this current work environment that we’re in, struggling is the norm if we’re aware of what others are going through and that we’re going through this together, it’s much easier. And I think the younger generation is getting closer to that than older physicians. But overall, I think the more conversation we have, the better.\

David Gratzer: We’ve built up some programs for physicians here at CAMH and credit where credit is due, it’s Dr. Tajirian and Dr. Wilkie. I haven’t been involved, but I’m a big fan. And one of the things they’ve done is build up peer support, allowing people to talk with their peers, certainly not with the people with the fancy titles - they might hesitate - and there is a literature on that. I wonder if we’re returning back to concepts that appear dated and have fallen by the wayside but might still be relevant. There’s an article in a recent CMAJ, Canadian Medical Association Journal, talking about why doctors’ lounges might be appropriate and talking about some hospitals that have added them. What are your thoughts?

Srijan Sen: Yeah, I think that’s worth exploring and I think ways of increasing communication do sort of making medicine less rapid, less harried are worthwhile. I think it’s important to do research on all these things and identify what the drivers are. I think doctors’ lounges are a good thing. I think there is a temptation for some health systems to invest in easier or cheaper options. Not that lounges are cheap, but they’re proba- bly cheaper than cutting everyone’s hours by 20%. And so I think we need to be open to different and cre- ative approaches. But look at this in a rigorous way. I think we need a lot more research. But my read of the literature right now is that workload is the primary driver of poor well-being. And really serious efforts to improve well-being will really need to tackle that. There’s lots of different ways we can do that and making the workday a little bit less over-filled and stressed and giving people a time to relax in a doctor’s lounge is proba- bly part of it. But I think there’s other things we need to do as a field to really make progress.

David Gratzer: Working 120-hour-week, but being able to put your feet up at the doctor’s lounge isn’t neces- sarily panacea, fair. You’ve talked about workload and one thing that comes up in the literature repeatedly is the EMR and frustrations around the EMR. Is that ironic? The EMR was supposed to make life easier two clicks and the patient can get the blood work you want. And yet consistently doctors report burnout being tied to EMR.

Srijan Sen: Yeah, I think the ERM is not lived up to what it was sold as or what we expected initially. I think it’s added frustration in different ways and made doctors even more stenographers and recording what happened instead of focusing on what we became doctors to do and help patients. I think reforming the EMR is critical. I think doing it in a way that really does reduce tasks and reduce workload is what we should focus on. And I think one way, and it’s probably different in different specialties, but the one way the EMR has added work is that it’s accessible all the time and accessible from home. And that’s created a whole new set of documenta- tion burdens that that maybe weren’t there in a previous generation. So finding a way to rein that back in is important. And there’s little pockets of innovation showing some success there. But bringing that to the broader population of physicians will be critical.

David Gratzer: Dr. Sen it is a tradition here at Quick Takes that we add a rapid-fire minute at the end. Are you ready?

Srijan Sen: I think I’m ready.

David Gratzer: That didn’t sound too confident! Are you ready? All right. We’re going to put a minute on the clock. Dr. Sen, what’s a research question you’d like to see answered?

Srijan Sen: What are the right number of hours for physicians to work to get the care patients need but still stay healthy?

David Gratzer:What makes you hopeful?

SrijanSen: The new generation of physicians are so bright and have, I think, values that will serve medicine really well. So, the new students and training physicians and young physicians make me hopeful.David Gratzer: What keeps you up at night?

Srijan Sen: Um. A lot of things! But I think both among physicians and broadly the general population about how stress is affecting us and whether we can come up with ways to really have healthy lives in terms of our well-being. How to get there is one of the things that does keep me up at night.

David Gratzer: And at the buzzer, one last question: Dr.Sen. If a colleague of ours approached you and said that she or he felt they were going through burnout, what advice would you give based on your read of the literature and your own research?

Srijan Sen: I think talking with others and understanding how many people are going through this and then getting professional help, but also figuring out what what’s driving it and trying to take some of the simple steps we can to get better.

David Gratzer: Dr.Sen, we appreciate your time and we really appreciate your expertise. This is a big topic, a timely topic. And I think your work and your research and your advocacy, frankly, are very important.

Srijan Sen: Thank you. And thanks so much for having me.

[Outro:] Quick Takes is a production of the Centre for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at CAMH.ca/professional/podcasts.

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