Improving physician well-being: lessons from palliative care
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* Leeat Granek
* Sandy Buchman

KEY POINTS
*   Physician burnout is a problem worldwide.

*   Dealing with patient death is one factor associated with burnout in physicians.

*   Palliative care principles include practising compassionate leadership, addressing suffering, working on interdisciplinary teams and not seeing patient death as a failure.

*   This ethos of palliative care teams may help other physicians deal with the emotional stresses of their work.

The well-being of doctors has become a primary concern of medical associations globally, and for good reason: physicians, on the whole, are not doing well.1 One relatively unexamined factor related to physician burnout is coping with patient death. Treating patients at the end of their lives, and coping with patient death, can undoubtedly cause stress, including burnout, but little research has documented this relationship empirically. One medical discipline deals with death more often, and much better, than most others: palliative care. There are aspects of palliative care — not seeing death as failure, working on interdisciplinary teams, practising compassionate leadership, developing competencies to address suffering — that can help physicians in other disciplines cope with these stresses and help reduce burnout.

Poor physician health has personal, professional and economic consequences. Recent research shows that more than half of doctors report symptoms of burnout,1 a condition linked to lower quality of care, medical errors and poorer patient satisfaction. Moreover, burnout can decrease work satisfaction and lead to mental health distress and poor self-care among physicians.1 One Canadian study estimated that burnout among physicians costs the health care system $28 million per year.2

Causes of poor physician health are complex and multifaceted. They include large patient volume, insufficient resources at work, poor workplace management and difficulty balancing work and home life.1 One promising but relatively unexamined factor related to physician ill-health is the impact of patient death on health care professionals. In one study, both qualitative and quantitative data corroborated the finding that the emotional impact of numerous patient deaths influenced burnout in oncologists.3 In a recent survey of oncologists, high levels of burnout, coupled with high levels of grief symptoms, were shown to increase emotional distress, suggesting that dealing with patient death contributes substantially to distress among certain physician groups.4 Research conducted among other practitioners has yielded similar results: pediatric nurses’ grief over patient death was positively correlated to burnout.5 There is a dearth of research to tell us whether coping with patient death may influence burnout among physicians in other specialties. However, evidence suggests that most health care professionals do not receive training on how to respond to their feelings about patient death and the emotional challenges of providing end-of-life care.6

A well-conducted survey of French palliative care physicians found a lower prevalence of burnout in this group than previously noted in other specialties.7 A nationally representative survey of Portuguese palliative care and intensive care professionals found that the latter were more than twice as likely to have burnout than those in palliative care.8 One explanation is that palliative care physicians are trained to cope with the emotional challenges of patient death. An online survey of Spanish palliative care professionals found that the ability to cope effectively with patient death was negatively associated with burnout and positively associated with quality of life.9

To be sure, palliative care is a unique specialty and there are a number of factors that may contribute to differences in burnout rates, including patient volume and administrative burden. Moreover, the death of a patient in palliative care is anticipated. The death of patients who were expected to recover may be more challenging. Nonetheless, there may be lessons from palliative care that could improve health outcomes for other health care professionals, particularly in the context of patient death.

Palliative care physicians may have better health outcomes for several reasons. Patient death is not viewed as a personal failure, so palliative care physicians are less likely to have burnout, depression or stress when patients die. Palliative care physicians tend to work on cooperative interdisciplinary teams, which has proven to promote better outcomes for physicians,8 who may feel less isolated and solely responsible for making life-and-death decisions about their patients. Furthermore, teams are nonhierarchical, and all members share an understanding of human suffering throughout the treatment trajectory, allowing them to process grief and loss in an open, supportive, compassionate and nonjudgmental way.

Practising compassion is integral to providing palliative care. Often, unbeknown even to themselves, palliative care physicians use this skill in taking a compassionate leadership10 approach to caring for colleagues. This involves noticing suffering in others, interpreting and responding empathically to that suffering, taking compassionate action to alleviate it, and creating a culture of caring and mutual support. Palliative care physicians are also trained to develop competencies in addressing and alleviating suffering in all its domains — physical, psychosocial and spiritual — potentially making them more comfortable dealing with their own suffering. Physicians are humans caring for other humans. They must acknowledge that they also suffer and are deserving of the same compassionate, person-centred support provided to patients.

More research is needed to evaluate whether all physicians can effectively incorporate these aspects of the provision of palliative care into the day-to-day care of patients, to lower the risk of burnout. We believe that the ethos of palliative care teams has the potential to improve the well-being of physicians, and in the process, potentially reduce burnout in the wider medical profession.

## Footnotes

*   **Competing interests:** None declared.

*   This article has been peer reviewed.

*   **Contributors:** Both authors contributed to the conception and design of the work, drafted the manuscript, revised it critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

*   **Disclaimer:** Sandy Buchman is the President-Elect, Canadian Medical Association and was not involved in the editorial decision-making for this article.

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