Averting Burnout in Pediatricians: Understanding the Intersection of Workload and Meaning of Work

In their article, Uong et al¹  describe a decrease in burnout rates among pediatric faculty at a tertiary care children’s hospital during the initial coronavirus disease 2019 (COVID-19) surge in April of 2020. The authors measured burnout via the 22 item Maslach Burnout Inventory ∼1 month before the surge (survey time 1), during the surge in April 2020 (survey time 2), and then again in September after the surge (survey time 3). In addition to the Maslach Burnout Inventory, the authors included questions on personal and professional information through the Areas of Worklife Survey, which is used to assess 6 key organizational areas of the work environment that affect burnout. Despite a COVID-19 surge with pediatric faculty deployment to care for adults and an increase in COVID-19 pediatric patients, there were no changes in faculty burnout rates during the study time period. The authors found burnout rates ranged from 20% to 26% across the 3 survey times and there was actually a decrease in the emotional exhaustion subscale scores at survey time 2, which was administered during the surge. Additionally, when they explored components of the Areas of Worklife Survey, there was an improvement in the workload and fairness domains when comparing survey time 1 (presurge) to survey time 2 (during the surge), which did not change when analysis was modified to separate inpatient and outpatient providers.

This finding is notable, given the extreme stress that many providers must have experienced during the initial COVID-19 surge, especially if deployed to care for patients outside their normal expertise and/or caring for patients suffering from an illness that was poorly understood at that time. Many studies on burnout have explored the contribution of stress to burnout; however, we recognize that the etiology of burnout is multifaceted and influenced by both internal and external factors. In a recent national study, the Pediatric Resident Burnout-Resilience Study Consortium followed pediatric residents over 3 years and found that stress, sleepiness, dissatisfaction with work–life balance, and recent medical error were each independently associated with an increased risk of burnout.²  Undoubtedly, many of these factors were exacerbated and experienced by the faculty during the COVID surge, which should have theoretically led to increased burnout rates. However, the lack of change in burnout in these physicians across the 6 months of the study period prompts us to explore other factors that may have influenced burnout and stress experienced during the COVID-19 surge by this group.

One possible explanation for these burnout rates can be found when we look at the typical emotional response of a community during a national disaster. In this well documented pattern, early in a disaster the community first goes through a heroic and honeymoon phase characterized by “altruism…community bonding…optimism.”³  This response, particularly regarding burnout among health care workers during a pandemic, aligns nicely with previous literature that reveals that enhanced meaning of work is associated with less burnout.⁴  Meaning of work has been defined as the intersection between (1) work that distinguishes oneself as “worthy” and brings an individual closer in alignment with how they perceive themselves, (2) work that is significant or done in service of the greater good, and (3) work that brings an individual into “harmony with other beings or principles.”⁵  As such, working on the front lines during a pandemic, although likely leading to increased stress, can also provide a countervailing greater sense of meaning of work for many physicians. One must also take into account that this study was performed on pediatric faculty who, although some were deployed to care for adults and/or cared for children with COVID-19, were generally not as affected as internal medicine faculty, given the disparate impact that COVID-19 had at that time on adults versus children. Given this difference, one can speculate that the lower pediatric volumes generally seen in the initial stages of the pandemic may have offset some of the changes in coverage and high acuity patients who may have been experienced by pediatric faculty. This consideration is further supported by measures of workload in the study. Workload has been defined as a key component of the work environment that contributes to burnout,⁶  and, in this study, workload was lower at survey time 2, during the COVID-19 surge, than at survey time 1. Whether this result is reflective of a perception of workload, given the general mindset during that time, or actual workload, remains unclear.

For those individuals studying burnout, this is a key finding that should inform future interventions and studies in which researchers are looking to mitigate the impact of burnout in health care professionals. Although workload has already been a target of several burnout interventions in trainees, the Accreditation Council for Graduate Medical Education duty hour restrictions implemented in 2003 were not associated with any discernable decline in burnout in these trainees. Measures to address workload and modify its effect on physician stress and burnout have proven to be complex interventions, and it is not clear that effective methods to address the burden of excessive or unpredictable workload have been devised. Standardized methods to quantify and characterize workload for physicians would facilitate these efforts.

Recently, there has been more literature supporting the need to better highlight meaning of work in health care.^4,7,8  The common theme identified through this literature is the importance of involvement in direct patient care, intellectual engagement, respect, and community.^7,8  Perhaps we can tie what we know about working during the initial stages of the COVID-19 pandemic with the definition of meaning of work and what has been hypothesized to contribute to meaning of work in medicine. One could argue that there was no time like the initial stages of the pandemic when the medical community was more respected, felt a greater sense of community, was intellectually challenged and stimulated, and was engaged directly in patient care that was important and meaningful. The question then is this: how do we distill these phenomena and incorporate these forces into health care generally and on an ongoing basis? Methods to facilitate these approaches will be an excellent area for future study; one example is how Bayer explored meaning of work and its relation to burnout using the Work and Meaning Inventory in pediatric residents a few years ago. In this cross-sectional study of pediatric residents at a single center, there was strong correlation between meaning of work and decreased levels of burnout.⁴  Future efforts to examine this relationship in other specialties and, moreover, develop specific interventions aimed at improving meaning of work for physicians should be a fruitful area of exploration.

Finally, the intersection of the effects of workload on physicians’ ability to retain and be energized by meaning of work will require more nuanced investigation. We know that meaning of work does not simply increase as workload declines; in fact, oppositely aligned associations (more good workload equaling more meaning of work) may be operant in many situations. Although absolute workload will be an important value, the physician perspective on the workload is likely to be the most important factor. We can imagine interventions that focus on the ability of physicians to better share work, rely on other team members during high stress periods, seek breaks and opportunities to recharge amid heavy clinical loads, and align more intense work with greater internal and external rewards as areas for further exploration. Similarly, meaning of work is all about the perspective of the health care professional, and interventions that focus on physicians’ perspectives of their work should be an area of focus. Efforts to explore the interaction of workload and meaning will be important because workload is unlikely to be minimized in the future and methods to develop and maintain resilient and effective physicians and other health care professionals will be even more vital for our society.

Let the efforts and investigations continue!