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13 Articles in Volume 18, Issue #3
Anger Expression & Chronic Pain
Ask the Expert: Should reliance on gabapentin/pregabalin be limited?
Chronic Pain in Children
Considering Comorbidities When Selecting Medications for Chronic Pain Management (Part 1)
Dousing the Physician Burnout Epidemic: An AMA Perspective
Harnessing the Power of Words
Inside ASRA with David Provenzano, MD
Management of Intrathecal Therapies by Interprofessional Teams
Nurse Burnout in Pediatric Pain Management: A Model and Pilot Intervention
Physician Burnout: An Oldtimer’s View
Reporting Metrics, Media Coverage...Letters from the Minds of Peers and Patients
The Case for Slow-Release Anesthetics
The Impact of Pain Practice

The Impact of Pain Practice

Despite being expert providers, physicians often forget to care for themselves.

Editor's Note: In spring 2019, the WHO added "burnout" as an official medical diagnosis to the International Classification of Diseases (ICD-11), defining the condition as: feelings of energy depletion/exhaustion; increased mental distance from one's job or feelings of negativism/cynicism related to one's job; and reduced professional efficacy. PPM has covered this subject from the healthcare provider perspective starting with the impact of pain practice below. See also: the AMA's view and Nurse Burnout.


I have many distinct memories of my early years in clinical practice – among them moments of sheer joy that I was no longer a resident, the good fortune I felt to work with a vulnerable patient population and dedicated colleagues, the sweetness of meeting some of my long-term patients for the first time. If I am truly honest, however, I also remember something darker about those years – my experience with burnout.

One particular image haunts me. I was at a meeting. I have no memory of the topic of discussion, but I do remember feeling like I couldn’t keep my head up; I felt helpless, angry, exhausted, and unsupported. That feeling was, I realized years later, representative of burnout – emotional exhaustion and a low sense of personal accomplishment1 that made it hard for me to function professionally and personally. At the time, my personal and the professional assumptions were that this was my problem to address. Fortunately, I developed strategies to help me recognize and prevent burnout.

Fast forward 20 years. Burnout among physicians is, in the words of my teen, “a thing.” It would seem that none of us are able to open an academic journal, a trade publication, or a newspaper without reading about it. In fact, as I began to write this perspective, I found more than 76,000 articles when I searched “physician burnout,” 17,000 of them published since 2014. Vanishingly few focus on the experience of pain practitioners. Burnout undermines our ability to care for others and for ourselves. It is costly to physicians, to patients, and to our institutions.

When Chronic Pain Patients are at the Core of Care

It is hard to imagine a more challenging situation than caring for someone with chronic pain. These patients are suffering and they have many needs. They may be angry, sad, traumatized, or frantic. Their experience is hard to define and sometimes highly subjective. As their physician, the charge is to reduce suffering and increase function. Yet, there are no algorithms or established guidelines to achieve this; each person has unique challenges and practitioners are challenged by more than one patient’s circumstances. Add to this, the productivity expectations, working in the electronic health record (EHR), and our society’s (legitimate) concerns about opioid addiction.

It is not surprising, then, that in a small study looking at burnout in physicians who care for chronic pain, just over 60% reported emotional exhaustion. Smaller numbers – 37.5% and 19.3%, respectively – experienced high levels of depersonalization and low sense of personal accomplishment.2 While the study was small, and had a very low response rate, one could argue that only pain physicians experiencing burnout answered the survey. Or, one could argue that physicians were tired, over-surveyed, and discouraged, and so chose not to respond at all. Either way, the numbers are consistent with larger studies demonstrating physician burnout rates that exceed 50 percent.3

The Need to Pay Attention to Ourselves

What is a pain practitioner to do? Pull up her bootstraps and look toward retirement? Quit? Go to therapy? Find a new job? Any one of these ideas may work but they are clearly not ideal. If the medical community thinks systemically, there are three questions that need answers in order to effectively turn back the tide on burnout:

  • What can we do to nurture resilience in ourselves?
  • How can we support our colleagues and trainees?
  • What can we do to ensure that our organizations develop an anti-burnout mindset?

On a personal level, it is essential to develop a sense of self-resilience. Each physician needs to recognize his or her own symptoms – and develop strategies to maintain balance. Strategies may be as simple as remembering to pack a lunch, reading nonmedical literature, or taking every minute of allotted vacation time. Other times, something more may be necessary: a close friend or mentor to call, a mantra to repeat (“my schedule is only a suggestion”), and, the ability to reach out for professional help without shame or fear. Whatever the chosen method, caring for oneself may ward off burnout.

Looking Out for Colleagues

Physicians may also reach out and help colleagues with burnout. As healthcare providers, we are trained to observe, assess, and act. Take notice when a colleague needs support, and be generous. Ask coworkers about themselves; help them think through a problem. Approach complex situations with curiosity rather than judgment. In the pain physician study noted herein,2 our junior colleagues suffered the most. Seeking out intergenerational professional connections is not hard and may foster resilience on both sides of the age divide.

Finally, and perhaps most importantly, the medical community leadership and institutions must prioritize burnout prevention and the development of resilience. Valuing both the safety of the patients and the doctors who care for them has led to the most progressive of our institutions actively addressing physician burnout.4 Institutions – and regulatory bodies – must work to think about changing and designing regulations to support patient safety, while avoiding undue burden on the caregivers.

Hospitals and practices must support physicians and patients by investing in highly functional clinical settings that allow physicians to care for patients instead of tending to the computer. Moreover, institutions need to define and reward successful leadership that addresses burnout. In one significant study, every point that a leader improved on a 60-point scale, led to a 3.3% decrease in burnout among clinicians reporting to that leader.5

Making the Hard Choice

Some of these strategies may be complex, while others are fairly basic. All require a paradigm shift for us and for our institutions. Physicians – pain physicians in particular – are incredibly well suited to this challenge. Every day, we come to work, face ambiguous situations with no clear answers, and move toward the development of a plan that is meaningful for our patients and allows them to move forward. We are amply capable of doing this for ourselves and for our colleagues. We have no choice.

Last updated on: May 29, 2019
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Physician Burnout: An Oldtimer’s View
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