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“Be More Resilient” Is Not Enough:

Our mental complexity influences our susceptibility to burnout.

“The confidence that individuals have in their beliefs depends mostly on the quality of the story they can tell about what they see, even if they see little.” — Daniel Kahneman in ‘Thinking, Fast and Slow’

This is not going to be another article about the prevalence of burnout. We already know it is pervasive. Google ‘burnout’ and you will receive 89,700,000 results. We are not short on content addressing burnout. So, what new information can we add to the mix?

I am going to propose addressing cognitive frameworks we use as individuals that contribute to the development and maintenance of burnout. Our mental complexity can influence our susceptibility to burnout.

You will often hear of or read about the need to build resilience. This is certainly a strategy that can be used, but it will fall short if our cognitive frameworks are not addressed first. Why? Resilience strategies will simply be a band-aide. Sure, some strategies may be a set of armor, but a breaking point still exists. As the Coordinator of an Orthopedic Physical Therapy Residency Program and former multi-clinic manager, I can attest to the inadequacy of the resiliency strategy in isolation.

Resilience is an Incomplete Strategy

Burnout is a multifactorial issue that cannot be resolved by changing work hours, increasing awareness, or exclusively building resilience. Focusing on these factors in isolation sends the message that people lack mental fortitude. We either need to ease up on work demands or build mental toughness. These messages can be shame-inducing and worsen the issue.

To be sure, many of the traditional approaches used have merit. An excessive workload can be an issue and developing resilience — not simply telling someone to buck up — can reduce burnout risk. Building resilience through lifestyle changes in dietary habits, sleep hygiene, and stress management can help people better withstand seasons of challenge (such as the current pandemic). But these strategies alone fail to address many of the root causes of burnout. Our mental models and thoughts about work can dramatically influence our susceptibility to burnout.

To begin to have an understanding of these cognitive influencers, we need a foundation in what burnout is first. This overview will be brief.

Brief Review of the Basics: What is Burnout?

Burnout is characterized by emotional exhaustion, cynicism, and ineffectiveness in the workplace, and by chronic negative responses to stressful workplace conditions. Emotional exhaustion is the depletion of emotional resources and feelings of being overextended by work. This is not only a result of excessive hours worked. We become overextended when we put more into a job than we receive in return. Some people receive fulfillment and are energized working 16 hours a day, while others are emotionally drained by part-time roles. We are all different. A personal experience of one person cannot be attributed to the masses.

The World Health Organization identified consistent evidence that “high job demands, low control, and effort-reward imbalance are risk factors for mental and physical health problems.”

Our careers possess seasonality. We may be able to grind during a residency program or when gunning for a promotion, but then we need opportunities to throttle down later, perhaps when starting a family. In the short term, throttling down can be accomplished through a vacation or letting a couple of projects go. For medium or long-term solutions, it may mean taking a lateral move to a new department or a step down in role and responsibilities.

If the workload is not managed — recognizing workload is relative — cynical attitudes towards work may develop. This results in mental distancing and eventual reduced personal efficacy — meaning you feel less able to accomplish personal goals. It is difficult to contain cynical attitudes and a reduction in personal efficacy. These emotions can easily spread between colleagues as we relate our personal struggles to those around us.

Burnout stifles healthy professional growth, impairs personal and social functioning, overwhelms cognitive skills, and even functions of the body (e.g. neuroendocrine systems). We see distinctive changes in the anatomy and functioning of the brain. While reversible, it is still concerning. These changes lead to the following:

  • Reduced efficiency and energy

  • Lowered levels of motivation

  • Increased errors

  • Fatigue

  • Headaches, muscle tension, GI problems

  • Irritability, Increased frustration

  • High levels of stress and anxiety

  • Suspiciousness; cynicism

  • Trouble sleeping

  • Feelings trapped — lack of control

  • Alcohol, substances to cope

  • Feelings worried about work when not at work

  • Loss of interest — Apathy

Having laid the foundation of what burnout is, let’s look at the influence our mental complexities can have on experiencing and addressing burnout.

Experience Improves the Complexity of Our Mind

“Intelligence is not only the ability to reason; it is also the ability to find relevant material in memory and to deploy attention when needed.” —Daniel Kahneman in ‘Thinking, Fast and Slow’

Mental complexity determines how we perceive the outside world and make decisions. The variety of response options and their effectiveness are influenced by our perspectives, concepts, and vocabularies. As our mental complexity grows, our ability to understand the outside world and control our response to it grows as well. Differences in mental complexity among two people can lead to two different responses to the same rigors and circumstances. Mental complexity alters our burnout risk.

Mental complexity is divided into three categories. Note how they are a progression in complexity:

  • The socialized mind: An individual is shaped by the definitions and expectations of their surrounding environment. They align with and are loyal to their perceived identity. They are reliant on others to guide decision-making. (most susceptible to burnout)

  • The self-authoring mind: An individual is able to take a step back and take an outside perspective to evaluate situations and make choices. They are able to take stands, set limits, and create boundaries that align with a personal belief system. They seek new information and perspectives but are resistant to information not personally sought out.

  • The self-transforming mind: An individual can step back and reflect on the entire situation, including a personal belief system or code of conduct. They seek all possible perspectives. They value and are wary of any particular stance or belief, regardless of the source. They can maintain multiple views on a particular issue and do not project one over the other. (least susceptible to burnout)

As you read through those categories, where would you fall? What about your colleagues? Mental complexity develops over time. While mental complexity correlates with age, experience plays a role. Simply becoming an executive and earning the company gold watch does not guarantee you possess a self-transforming mind and are immune to logical fallacies and burnout, but experience does provide additional perspectives and opportunities to learn from past actions.

As someone who has predominantly worked with students and early career professionals, I have met a higher proportion of clinicians who fall in the socialized mind category, followed by self-authoring and then self-transforming. I would imagine my experience is shared by most managers and educators, especially in healthcare.

A new survey indicates the current average age of burnout is 32. I’ll let that sink in. I was 26 when I finished my residency and was the youngest in my class. At age 32, many physicians are still in residency and many academics are still completing their doctorate. Burnout is surfacing before careers are starting. Burnout is higher in residents than non-residents

Studies show burnout starts as early as graduate school and worsens in post-doctorate training. In one study, the age group with the highest prevalence of burnout among physicians was 55–64 years old. The > 65-year-old group was the least prevalent. (source)

Most early-career professionals will fall in the social-mind category. They are more dependent on their environment and their personal identity. Do you see how the mantra of “suck it up” or “build resilience” won’t work? It fails to address the issues of the environment. It sends the message that the employee is a failure and is simply not trying hard enough. To address burnout, we must identify the work environment and understand how people perceive themselves in that environment.

Putting Complexity Into Action

We can’t treat all people the same and we can’t design all “fixes” for burnout to fit individuals universally. Shotgun approaches may show overall improvements, but many individuals will fall through the cracks (or gapping fissures). Instead, we need to first identify all the potential factors contributing to burnout and how they are interpreted. This has become a routine exercise in the Residency Program I teach.

Our Orthopedic Residency program is rigorous — I completed it myself and consider that year one of the most challenging of my life. We challenge new professionals to stretch their mental models and question their current beliefs. We layer on a variety of assignments designed to develop well-rounded clinicians. All this occurs while the clinician is wildly inefficient at most tasks (treatment, documentation, ‘adulting’).

An early-career professional with a socialized mind will be heavily influenced by what they believe others want to see and hear, such as the faculty of a residency program or boss. Someone with a socialized mind is less likely to speak up when they are experiencing early signs of burnout. Group-think takes hold. They may rationalize that they need to “pay their dues” or “everyone experiences this” or “don’t be ‘that guy’”. To address burnout, we need to take a team approach.

This is where I have a choice, along with my fellow faculty members. We can play the “suck it up and build resilience card” or we can recognize the unique challenges each individual faces. We choose the latter.

We assign each resident a clinical mentor and a faculty coach. We conduct 30/60/90 check-ins, weekly mentoring sessions, and monthly coaching calls. As a faculty, we review which clinicians are struggling during our monthly meetings and develop individual action plans to help. Lastly, we build flexibility into the program to make adjustments as needed.

A clinician with 15 years of experience and a self-authoring mind may not need the same array of safety nets. They create limits and seek help when needed. It is important for both leaders and individuals to recognize where they are on the mental complexity continuum. We then personally need to be aware of the signs of burnout as recognizing them in others is far easier than in ourselves.

Our biases and perspectives change our perceptions of a situation. We are less cognitively busy when assessing someone else than we are when assessing ourselves. Recognizing signs doesn’t fall exclusively on the manager, as recognizing and bringing awareness to potential burnout falls on everyone. We need to be able to help each other out and not hope a manager recognizes potential issues.

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