The line that distinguishes depression and burnout from each other is somewhat unclear. But what is certain is that to mitigate these, a significant change in the working environment is needed. This is what Dr. Lisa Rotenstein sought to answer in her study with Dr. Constance Guille, with the aim to create a healthier working environment for healthcare professionals. She joins Patrick Veroneau to dissect her research findings, explaining how understanding the overlapping factors of depression and burnout can help leaders analyze and improve their workplace culture. Dr. Rotenstein also emphasizes how this can transcend into other industries and professions, especially today when most companies are in remote setup and team building is challenged.
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Addressing Depression And Burnout Within The Medical Field With Dr. Lisa Rotenstein
I spent a great deal of my time working with both teams and individuals in the healthcare field. My guest certainly provides a great deal of value, not only for the healthcare field as that’s her background, but I think overall, in terms of there are pieces here that other professions individuals will be able to benefit from as well. My guest is Dr. Lisa Rotenstein. She’s the Assistant Medical Director of Population Health and Faculty Development and Wellbeing at Brigham and Women’s Hospital. She has her undergraduate degree and MBA from Harvard University, and her medical degree from Harvard Medical School. She’s also a faculty member at Harvard Medical School.
Our conversation is going to focus on burnout and depression in the healthcare field, and the work that she’s been involved in. Specifically, we’re going to talk about a research paper that she co-authored with Dr. Constance Guille from the Medical University of South Carolina. Although we’re going to talk about burnout and its relation to depression in healthcare, I do believe this transcends into other professions and areas, the link between the two. In the environment that we’re in where many people are under pressure and stress, that this is a timely article that will provide some resources and some understanding on how you can address this if it’s yourself or if you know somebody else that’s going through this. Let’s get into it.
Dr. Rotenstein, I want to thank you again for taking the time to be on the show. Speaking specifically about a study that you had published in the Journal of General Internal Medicine and title of it was Substantial Overlap Between Factors Predicting Symptoms of Depression and Burnout Among Medical Interns. Although I’m sure it deals with medical interns, I’m sure you would see this in many other places in the environment that we’re in. I was hoping you could talk about the study and what prompted you to design this study in the first place.
Thank you for having me on the show. I have been studying burnout and depression for some time. I became interested in the topic from a business background. I was in MBA training at that time, coming from a medical background. In the medical world, I saw my colleagues, trainees and physicians struggling with burnout with symptoms of depression. At the same time, in my business training, I was learning about how you affect the employee experience of care, how you tailor the workplace to their needs and their motivations. It was a very different lens than we often apply in medicine. I have been studying this over time, including studies in JAMA, showing wide variation in how burnout has been defined. A study showing that more than a quarter of medical students have depressive symptoms. This then led to the study. We were asking ourselves how much of an overlap is there between burnout and depression.We are much more reliant on technology at this point to help us get our work done. Click To Tweet
When we talk about these issues casually, we often talk about depression, having to do with personal factors, things going on in a person’s personal life, as well as their innate skills. We talk about burnout is having to do more with workplace factors. Yet, it’s not very clear from the literature that these are distinct entities. We wanted to answer this question to understand how much overlap there could be between the causes and the solutions. That’s how we landed on the question and I’m happy to go onto the results as well.
It was interesting because one of the pieces that I had read, in terms of the definition of burnout, that there were over 142 different definitions for burnout.
This was the 2018 JAMA study in which we looked across the literature. Our original question was, “What is the prevalence of burnout among physicians?” We found that we could not answer that question because there was so much variation in how burnout was defined. Even amongst studies, you use the Maslach Burnout Inventory, which is the most common instrument for measuring burnout, there were 47 distinct definitions of burnout so it’s hard to compare apples-to-apples. Similarly, it’s hard to then do studies suggesting that you’ve had an impact or that an intervention that works in one place can work in another place because you don’t understand whether you measure the same thing. That was a key takeaway in terms of our limitations.
The other important point is having to do with limitations and studying burnout is that we don’t have the same limitations for studying depressive symptoms. There are standardized instruments for studying depressive symptoms, and these have been validated against clinical interviews which are the gold standard for diagnosing depression. When you think about comparing these two concepts of depression and burnout, there are a lot of differences, even though there might be similarities in how you assess them.
When you talk about the results of this study, what did you find?
We found substantial overlap in the factors that predicted depressive symptoms and symptoms of burnout. We looked among medical interns. What was nice is that we were able to look at them over time. We were also able to ask them questions about personal factors for example, a history of depression, their early family environment, marital status, whether they had children. We also ask them about their workplace experience, including their overall workload satisfaction and their learning environment satisfaction. We found a substantial overlap between the factors associated with depressive symptoms and the factors associated with two of the sub-scales of burnout, emotional exhaustion and depersonalization.
These factors explained a similar percentage of the variation in both depression and burnout symptoms. It told us that these concepts are probably not so different and importantly, some of their contributors or their predictors are similar. What is the takeaway of that? It’s a helpful takeaway in that people are looking to alter work environments to facilitate wellbeing. You don’t have to think about the intervention separately. If you can improve the working environment, if the people you’re catering towards their trainees, if you improve the learning environment, that tells you that you can impact both on depressive symptoms and burnout.
When you talk about the two different components, one is emotional exhaustion, which seems straightforward. When you talk about depersonalization, what exactly does that mean?
Depersonalization has to do with the way you approach your work. The particular subscale of burnout that we used has been created specifically for those people who work with other people. It’s a scale called The Human Services Subscale. The way it applies to medicine and many other jobs that have to do with service, it has to do with how you approach your work and how you feel about your work. Do you have cynicism when you think about the service you provide or the population you’re interacting with? Have you removed yourself from that work emotionally? Do you have decreased empathy towards the people you work with and those you serve?
It’s almost a disengagement.Stop assuming that everybody's reality is the same as yours. Ask people about their realities and try to understand them. Click To Tweet
When we think about this from the standpoint of measuring depression seems to be much cleaner. The research is much more solid in terms of how you do that. From the standpoint of how we can address this, what are some of the things that you would recommend?
I’ll comment on the first point you made and then get to some of the solutions. I agree, based on what we know from the literature and on validation studies that it is cleaner to measure depression or depressive symptoms, and yet that’s not trivial in our society. I think we should make that point upfront. Unfortunately, in many arenas, there is still a stigma. In medicine, there might be licensing ramifications. This is a point of ongoing discussion, even though we now know more about the overlap, and we know that it is more accurate to measure depressive symptoms. The jury is still out on exactly what we should be measuring just because it’s much more than a data question. It’s a question about how society reacts to the results.
In terms of how we address this, I can speak about medicine but I think that the implications carry across to other fields as well. We have learned through studies in the medical field that interventions that impact the workplace are much more likely to affect symptoms of burnout and those that target the individual. What I mean by that is when you think about individual-focused interventions, those might include meditation or resilience training. When you think about interventions that affect the workplace, you might instead think about giving people their time back.
If people provided some service like teaching within medicine, giving them their time back to that and recognizing it. Thinking about schedule modifications that might facilitate better work-life balance, easing people’s interactions with the electronic medical record, and providing them extra support in the workplace. For example, leveraging other members of the team to help provide care. We know that those types of interventions are more effective, and those are what we should be targeting.
I have a lot of work that I do on the healthcare side, working more with nursing groups and smaller groups but things that you talk about are relevant to what they do as well in terms of scheduling a lack of resources that they might have and how that plays into this level of burnout and anxiety that they experience.
These are interventions that are not as simple and they’re harder to enact but they’re incredibly important. The other piece of it is that there has been work showing that if you are going to introduce people to wellness curricula or experiences that you think might decrease their stress or increase their resiliency, you should try not to make those use their outside time. If you’re going to provide yoga sessions, it might not be the best solution for those at 6:00 PM to be tapped onto the end of the workday. It should be integrated in a way that further facilitates work-life balance.
Rather than throw one more thing on top of a day that’s already completely cramped. I’m guessing with the situation that we’re in with the pandemic, this is somewhat timely for you in terms of this article or for those that are experiencing this.
The pandemic has brought up many additional issues and also highlighted issues that were present before but made us more aware of them. The big question now around is, what does work-life balance mean in an era where many people are working from home? How do you define the boundaries there? We are much more reliant on technology at this point to help us get our work done. How do you achieve balance with technology when people are spending many hours a day on Zoom?
Some of the issues that have been highlighted that were certainly present before are the differential impact or prevalence of burnout amongst female physicians and minority physicians. This applies across other fields as well. We know from previous work that female physicians have higher rates of burnout than their male counterparts. We know from previous work that minority health profession students have a lower quality of life and a decreased sense of personal accomplishment. These are important things to bear in mind, especially in light of the pandemic and a new way of working to think about how we ensure that the workplace caters to all people and helps all people thrive.
From the work that I’m involved in, there certainly seems to be a much stronger drive for change.
The curiosity has to be on a few fronts. It has to be asking, not assuming that everybody’s reality is the same as yours, and asking people what their realities are and trying to understand that. Many people have newfound responsibilities of educating within the home and how that affects your workplace. How does that affect your interactions with your peers and then the boundaries you have on your time? Many people have newfound family responsibilities or newfound family stresses. Having a curiosity to figure out what is going on within your workplace and then being creative about supporting that. To your point, we have made strides over time in trying to find solutions to burnout, particularly in the medical world, but some of these we have to rethink.
We know that scribes can be used to help physicians with their documentation burden. What does it mean to use scribes in an era of remote work? We’ll have to figure that out. We know interventions that promote team-based care. The doctors are working as part of close teams with nurses and social workers, and can alleviate burnout and results in better patient care. What does that mean when teams are remote, distributed, and how do we re remake systems to work effectively in this time of change?
There’s such an important piece to understanding our unconscious biases in these situations that we make judgments on people in situations and their experience without understanding what it’s like to be them and to have gone through these things. From a leadership perspective, I see it in healthcare and other industries that I work in. Those in roles where people are reporting to them if they don’t truly take the time to appreciate all of the additional things that have gone on in people’s lives because of this, they will miss an opportunity to engage people. It will increase this lack of trust within organizations and individuals because people are dealing with a lot of different things. Grief has been underappreciated.Successful leaders are those who adapt to the times in a way that is sustainable for the people they lead. Click To Tweet
We’re not done with the change as the key part of it. Change will continue to happen in the ways we work. It will continue to change in the next few months. Gaining that trust through what you’re saying by asking people about their realities are through flexibility and find solutions for new work will be key for helping people buy into the continued changes that will happen over the next months and years.
You wonder on some levels if some of the things that we’ve gone through. These almost seem like dress rehearsals for real change to happen. How do people deal with this?
In healthcare, we have seen changes that would have otherwise taken 5 to 10 years to happen. Telemedicine has exploded, sprouted, and many of the hesitations we had about it, we had to figure them out. It’s a real-time opportunity. The leaders that will be successful are those who adapt to the times in a way that is sustainable for the people they lead as well.
Outside of healthcare, where I see it as well as remote work, people working virtually where many organizations were very resistant to that of, “We can’t do this.” That has been debunked that people can’t work remotely. It’s going to be very difficult for people to try and put that genie back in the bottle.
Speaking of burnout in teams though, how do you keep a pulse on your team in a remote working environment? That has to do with getting things done but also keeping up morale, understanding what people are worried about and how they are viewing the workplace. That is the next frontier. There was a sense early on in this that we’ll do this for a few months and we’ll go back to the old way of working. Many of us realize that it won’t be quite so simple. That will be the next frontier is how do you recreate the great things about previous workplaces in a new way of working when all of us are remote.
That’s something that I hear quite often, especially around this idea of culture, “How do you maintain culture?” I’ve experienced many organizations that will be happy to see the culture that they had to go away if it can because it wasn’t a healthy culture to begin with. I do think there’s an opportunity to rebuild here. From the standpoint of behaviors, especially from what you’re talking about from interventions, it needs to be supported at the very top for this to take hold and individually, “How do I inspire and empower a team?” It will require much more individual touchpoints with people.
What have you heard about building and sustaining culture in this remote work environment?
Everybody is trying to grapple with that. In my humble opinion, culture for one is about behaviors. It doesn’t matter what you say your culture is. It’s how people behave that will determine what that is. From a leadership perspective, if I’m leading a group, it’s going to require much more effort for me shorter doses of having individual connections with people, contact on a more regular basis, and knowing my team that some people need more attention than others remotely. We are doing an assessment. It’s a remote work assessment that allows individuals to answer questions on how they work remotely, a team from a distance dealing with deadlines remotely working under stress. What it allows individuals to look at is, “What are my strengths if I’ve got to work virtually and what are some of the challenges that I’m going to run into?” This can be shared as a team with a manager. It allows people in this new environment to say, “How do we understand what our strengths and weaknesses are going to be here, and how can we play to those?” That’s going to be valuable.
The challenge will be that managers will have to take the time to figure that out. Coming back to where we started, that overlap between burnout and depression in large organizations. For example, within training programs, it’s often hard to get the pulse of such a large group of people. Leaders will have to find ways to do that effectively. If people are going to recognize the changes, they’re making the working environment, learning environment, and keep workers healthy over the long haul, but the long haul of this pandemic, which we’re seeing and continues to rear its head in different ways.It doesn't matter what you say your culture is. How people behave will determine what that is. Click To Tweet
There’s so much data out there at least in regards to belongingness. We are pack animals, and that we need connection. For those leaders who may not have understood this before, the distance creates more of a drive for people needing to feel connected. There’s a sense of purpose to what I’m doing and to the organization that I’m with. Those that are able to identify this and navigate it will be the ones that will be successful in creating a different-looking team.
One of the things we know about medicine that is true in medicine and is true likely in other industries that both drive burnout and then contribute to disparities is that feeling of appreciation and access to networks of power. We know that female physicians are promoted more slowly and less often than their male peers. We know that there are barriers to minority physicians gaining positions of leadership or positions associated with higher prestigious pay. We knew in the previous way of working what some of the barriers were, even though we have not surmounted them. I do think this new way of working presents even more challenges to closing that gap. How do you create the structures that allow you to thoughtfully connect with a variety of members of your team and create connections that allow you to sponsor them and promote them in a way that is equitable? There are perhaps opportunities there now that many of our interactions are over Zoom, which is a more equitable platform. There are a lot to think about there as well in terms of who is reaching out to who and what do some of those more informal connections look like in a time of remote work?
Two behaviors come to mind when I hear that, and it’s work that we’re involved in. One is around congruence, this alignment of what our values are, and do we practice those? The other is around clear expectations. Oftentimes, what we’ve seen within organizations is that there is a disconnect between understanding what is clearly expected either to get to the next level. They’re not clearly defined. If they are clearly defined, they’re not held accountable. Those two things can be a real challenge within organizations.
There’s also a piece of who gets opportunities and who learns about opportunities through what it means. That will be redefined in our time of remote working potentially in good ways but also in unfortunate ways. We all have to be thoughtful about that as another facet of this pandemic and how it affects the careers of a diverse workforce.
I would agree completely with that. I had this conversation around organizational values. Oftentimes, when people hear that, they roll their eyes thinking, “The values.” Why? It’s because people don’t feel as they’ve had any sense of creation of those values is part of this process. If we want to start having real equity, it’s time to pull out those values and hold people accountable to those. “Here’s what we say as an organization that we stand.” That’s the organization’s compass to be able to make decisions to say, “Is this behavior now in line with what we state as our values?”
What actions do you have to take in a time of remote working to make sure that you ultimately act in congruence with your values? That takes a little bit more planning than it would have in a time of in-person work.
Values are something that needs to resurface as something that is real and not just something that was nice to put together on our website or in our employee handbook, but they mean something.
There’s great opportunity for that in the setting of the pandemic. We have changed the ways we work, and we have had to think long and hard about what we care about and the implications on our society. It’s a real opportunity to re-examine values for organizations from healthcare to every organization imaginable.
Without question, I do think that this is a period of time where people have been pushed in ways that they said something needs to change here like, “I’m not going to do this.” The biggest concern that I would say is that you will have more people quit and stay, than quit and leave their organizations if things don’t change. As we finish up here, based on your research, if the reader might be in the healthcare field and they are dealing with this, what would you recommend to them?
The biggest takeaway is to think about your work environment. There are undoubtedly many personal factors that play into both burnout and depressive symptoms. We know that the work environment affects burnout. We know that changes in the work environment can improve burnout and the work environment has changed. To have a healthy workforce, we have to be willing to re-examine. We have to examine what are people’s new ways of working. What does the new workplace look like? To make changes in a time of constant change, that’s hard but it’s necessary. We know that the costs of burnout are real. In healthcare alone, we know that burnout is associated with worse patient outcomes with decreased quality of care with increased turnover of employees. This is an issue with real economic and health consequences. It’s one to take extremely seriously.Distance creates more of a drive for people needing to feel connected. Click To Tweet
There are many different levels of implication here that I think are important to look at, whether it’s the hospital’s financial health and the patient’s health, there are impacts all along the way here. I appreciate you taking the time to speak about the research that you have done. It’s important for us to understand how we address this. Thank you for that.
Thank you for taking the time. I would be happy to talk to the readers about these issues. The best way would be by email, Lisa.Rotenstein@Gmail.com.
Thank you for your time. Good luck with all that you’re doing. Thank you for putting this together to be able to help those that need this.
About Dr. Lisa Rotenstein
Asst Medical Director, Population Health and Faculty Wellbeing, Brigham and Women’s Hospital