Simply telling someone to build resilience is a cop-out. Understanding perception and cognitive fallacies point to better solutions.
“The world in our heads is not a precise replica of reality; our expectations about the frequency of events are distorted by the prevalence and emotional intensity of the messages to which we are exposed.” — Daniel Kahneman
To address burnout, we cannot adopt a one-size-fits-all approach. Cutting hours, building in mandatory breaks, increasing pay, adopting a monthly one-on-one meeting model, or building an office gym can certainly help, but it is a shotgun approach. It will help a few people while missing many others. The magnitude of help will vary as well. If you design a solution to fit everyone, then you design a solution to fit no one.
I propose we look at our perceptions and potential cognitive fallacies — internal approaches — to address burnout.
As a physical therapist in the U.S. healthcare system, I am at the epicenter of the burnout epidemic. I have both witnessed and experienced burnout, which 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 induced by excessive hours worked. We become overextended when we put more into a job than we receive in return. Some people receive immense fulfillment and are energized working 16 hours a day, while others are emotionally drained by part-time roles.
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.” We must also consider factors outside work that can predispose the development of burnout, such as financial stress (student debt), family life, and current events (COVID, social injustice, natural disasters, etc.). These are the factors that hit healthcare workers particularly hard, but they are hardly all-encompassing.
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 perpetuates the notion 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 exacerbate the issue.
To be sure, many of the 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 change in dietary habits, sleep hygiene, and stress management can allow us to better withstand seasons of challenge (such as the current pandemic). But these strategies alone fail to address many of the root causes. Our mental models and thoughts around work can dramatically influence our susceptibility to burnout. My experiences with burnout differed from my colleagues’, both in the development and resolution of the issues.
Logical Fallacies Contribute to Burnout
Perfectionism: Refusal to accept any result other than “perfection.” Perfectionism hampers achievement. It is correlated with depression, anxiety, addiction, and missed opportunities (analysis paralysis).
Solution: Develop clear goals and expectations as a team. Gain perspectives from friends and colleagues. Recognize warning signs and develop strategies to easily discuss potential issues with others. Goal setting and recognition of warning signs fall on all parties.
My Experience: Mixing perfectionism into a stressful job, like an orthopedic residency, is a recipe for disaster. As a former resident who experienced 80-hour work weeks and the stresses of learning how to treat people (one of the greatest challenges healthcare providers face), I can attest to the challenges perfectionism creates. I see it every year in the residents I teach. It has to be addressed early and often. I was able to combat it by frequently redefining goals and reframing “failure” as a growth opportunity.
Avoiding The Gray Areas
Polarized thinking: Also known as dichotomous thinking or black-and-white thinking. It is an irrational mindset that leads to unrealistic expectations. Since there are no gray areas, people often feel frustrated, bitter, and disappointed if an expectation is not met. Either the job expectations or definition of work-life balance met or did not meet expectations.
Solution: Critically assess all variables influencing the issue(s) at hand. Identify and verbalize gray areas.
My Experience: When I did not receive a promotion to area manager within my practice, that could have been viewed as a failure. Instead, I used it as a learning experience and strengthened my relationship with my boss and colleagues. The “failure” catapulted my career and led to the development of my current role, which I would take any day over the job I was passed-up for.
Overestimating Out Abilities
Dunning-Kruger effect: It is common for early-career professions with little experience to overestimate their abilities.
Burnout risk spikes when an individual first understands their lack of ability (falling off “Mount Stupid” into the “Valley of Despair”). It is common to experience a complete reversal in confidence while self-doubt skyrockets.
Solution: Consistent and frequent mentorship and empathy from people around you. Reflect on past successes and failures regularly. Find silver linings in the failures. How can failure or an obstacle help you in the future? Reflecting on successes and receiving praise from others can help someone climb out of the Valley of Despair (where imposture syndrome often lurks).
My Experience: I was king of Mount Stupid as an orthopedic resident. About three months into the program, a patient came into the clinic asking for all her appointments to be canceled. She looked me in the eyes and said, “You hurt me.” I was subsequently flung into the Valley of Despair. How did I crawl out? I owned up to the situation, kept a list of the patients I failed, and made changes in my approach after each one. I read every day and develop a variety of mental models. I try to instill habits of developing a variety of mental models in all my residents from day one.
Weighed Down By Previous Information
Anchoring: When an individual depends too heavily on an initial piece of information offered. For example, expectations set at school can create significant disappointment if they are not met during the early stages of a career (e.g., salary, workload, best practice).
Solution: Strong beliefs, weakly held. As John Maynard Keynes said, “When the facts change, I change my mind.” This is easier said than done but improves with practice. Identify potential anchors early and have conversations with friends and colleagues to determine if and why those anchors may be incorrect.
My Experience: Many new graduate physical therapists come out of school with a variety of expectations. Throughout school, salary, caseload, and workhour anchors are set. It takes time for me and my fellow faculty to remove the anchors. We have to slowly ramp up clinicians and flood the environment with cues, rather than dropping new expectations once and expecting them to stick. The residents who are more adherent to initial anchors often struggle with residency and are more likely to drop out.
Following The Herd
Herd behavior: The tendency for individuals to mimic the actions (rational or irrational) of a larger group. This fallacy is represented in the saying, “If all your friends did [insert ridiculous action], would you?”
Solution: This is when you have to be careful when gathering perspectives from other people. Gain perspectives from people in different situations (employees in different departments or companies, family members, former bosses or professors, etc.) Also, address signs of burnout immediately. Burnout can grow like wildfire, and employees can feed off one another.
My Experience: When you are a new graduate, you lack experience and you are more reliant on your peers and mentors for direction. I was a sponge for information as a new graduate, but I also readily adopted the treatments I saw my mentors using. As I read more research and found some of those treatments to be outdated or inappropriate, I struggled with making changes. Gathering multiple perspectives throughout my career has been helpful, but blindly following the group has led to poor outcomes and made future changes more difficult.
Continuing The Grind
Sunk-cost fallacy: Invested recourses (e.g., time, money, effort) to justify a previous investment of resources, for example, staying in a poor work environment due to investment towards a promotion or built-up incentive (e.g., PTO bank).
Solution: Continuing to work hard, or even show up for work, does not mean burnout is not present. Do not let success at work or promises of future gain be an excuse for experiencing burnout. Yes, there is a time to grind, but limits still need to be set. We can all benefit from an economist’s mindset as described by Kahneman.
My Experience: My wife and I went to Emory and therefore have a mortgage-size amount of student debt (no house included). When my residency director told me much of the information I learned in school was for boards only and should not be used in clinical practice as it was outdated, I was incredulous. I invested time, money, and effort to learn those skills and I wanted to use them. It took time to understand the fallacy in that line of thinking. Learn from the past and have your actions focus on the present and future.
“A rational decision-maker is interested only in future consequences of current investments. Justifying earlier mistakes is not among the Econ’s concern.” — Daniel Kahneman”
Addressing Burnout Requires a Team Effort
Tackling burnout can be lumped into two categories: changing the work environment and building personal resilience. The effectiveness of the strategies within these categories relies on addressing underlying issues.
Simply telling someone to build resilience is a cop-out. Work environments are often changed to fit everyone, not the individual. Without addressing the source of burnout, the individuality of each person, and the ways we interpret our environment, efforts to address burnout will fall short. Addressing burnout falls on all parties involved. It is not the responsibility of any one person. I have both experienced it and seen it in others.
I have found approaching burnout with a team effort and addressing mental models to be the most effective strategy.
Burnout is a complex phenomenon. It takes time to address it. Burnout does not develop overnight, and it cannot be eliminated with a couple of action items in an afternoon. By identifying the influence all parties have and the mental models that influence both risk and resilience, we all can work together to address burnout.