Burnout and Wellness From an Ethics Perspective

Over the last decade, considerable attention has been paid to the association between physician stress, burnout, and medical errors. Many medical schools and hospitals are working to humanize their cultures and encourage wellness behaviors such as exercise, meditation, and taking time to process difficult events.

Despite these welcome advances, little is known about the association between physician stress and ethical errors such as boundary violations and lack of professionalism in the workplace. Medical ethicists working with health care providers who have behaved unethically are aware of the connection between a challenging life event that creates vulnerability and an ethics infraction. The more we understand these vulnerabilities, the better we can address them and prevent ethics errors.

There are few data about the relationship between physician stress and professionalism. One self-report survey study of 2,682 U.S. medical students explored the relationship between symptoms of depression or burnout and instances of professional misconduct (for example, cheating, dishonesty, and unprofessional conduct related to patient care). This study found that students with burnout, but not those with depression, were more likely to engage in cheating or dishonest clinical behaviors and were less likely to hold altruistic views about the role of physicians in society.

Other authors explore the influence of personal and institutional factors that contribute to professionalism in physicians. The personal factors they identify as relevant include personal well-being (including work-life balance, burnout, and stress), individual characteristics (motivation, work ethic, integrity, personality traits), and interpersonal skills (communication, compassion, cynicism, detachment). Some of these qualities are more amenable to change than others: it is easier to improve one’s communication skills and work-life balance and more difficult to alter one’s personality or degree of cynicism.

Although there are many variables that lead a professional to violate an ethics rule, one frequent contributing factor is impairment from stress caused by a family member’s illness (for example, sick child, dying parent, and spouse’s chronic health condition). Some health care providers who have been sanctioned by their licensing board, hospital board, or practice group for an ethics violation tell similar stories of being under unusual levels of stress because of a family member who was ill. In that context, they deviated from their usual behavior.

For example, a surgeon whose son was mentally ill prescribed psychotropic medications because her son refused to go to a psychiatrist. This surgeon was entering into a dual relationship with her child and prescribing outside of her area of competence, but she felt desperate to help her son. Another physician, deeply unsettled by his wife’s diagnosis with and treatment for breast cancer, had an extramarital affair with a nurse who was also his employee. This physician sought comfort without thinking about the boundaries he was violating at work, the risk he was creating for his practice, or the harm he was causing to his marriage.

While physicians cannot avoid stressful events at work and in their personal lives, they can exert some control over how they adapt to or manage that stress. Physician self-care begins with self-awareness, which can be supported by mindfulness meditation, reflective writing, supervision, or psychotherapy. Self-awareness increases compassion for the self and for others, reducing burnout.

Personal self-care activities include regular exercise, sleep hygiene, healthy diet, making time for family and friends, engagement with religious or spiritual life, and time in nature. Professional self-care activities include participation in peer study groups, organizational improvement efforts, team-building activities, and other interactions that build professional networks.

As the practice of medicine grows ever more complex and as the pace of health care delivery accelerates, physicians face increasing stress. That stress may create vulnerabilities to ethical missteps, but it can be mitigated by self-awareness and personal and professional self-care.

The biblical verse “Physician, heal thyself” counsels us to attend to our own flaws rather than criticize those of others. An equally compelling interpretation is that we should focus on our personal vulnerabilities before they lead us to unethical professional behavior. ■