Burnout in the ICU—What Do We Do Now?*
Not surprisingly, physicians and nurses working in ICUs are among those with the highest rates of burnout (1, 2, 9), including pediatric critical care specialists, in whom BOS was first reported nearly a quarter-century ago (10). In fact, pediatric intensivists may be at particular risk; a Brazilian study found BOS present in 70% of pediatric intensivists, with an odds ratio of 5.7 compared with general pediatricians (11).
At this point, there is consensus that BOS must be addressed (2), but limited information on how it might be prevented or managed. In this issue of Pediatric Critical Care Medicine, Colville et al (12) provide the results of a survey aimed at discovering coping strategies that might be effective against BOS and posttraumatic stress disorder (PTSD) in ICU personnel, including physicians and nurses. Their finding that the strongest association with low scores for BOS and PTSD was self-reported resilience, while interesting, is probably of little help. The observation that strong, resilient people handle stress better is not likely to surprise, nor does it suggest any obvious interventions (7). More intriguing was their finding that certain kinds of coping strategies, such as attending debriefing sessions and talking to senior associates, were associated with lower rates of BOS and PTSD. Particularly in combination with their finding that these most useful strategies were in fact not the ones most commonly employed, these data have implications for interventions going forward (12). Obviously, a major weakness of this study is that it was observational only and did not evaluate whether interventions aimed at increasing the use of such coping strategies might actually reduce the rate of BOS and PTSD.
For the most part, dealing with the stress of working in the ICU, with BOS, and with related issues such as work-life balance, has been implicitly assumed to be the sole responsibility of the individual physician (7, 13). The coping strategies evaluated by Colville et al (12) are of this nature—things an individual might do himself or herself, such as talking to peers or cultivating a hobby. While no possible strategy to address BOS should be dismissed, however, it should be acknowledged that such individual-level strategies are likely not the key solution to this problem. The underlying issue is not that physicians need better coping strategies, but that the ICU as a workplace is sufficiently toxic that half, perhaps more, of ICU physicians manifest a psychological condition simply from coming to work.
If it can be concluded that BOS stems from the working conditions in the ICU, then the problem should be addressed not by teaching physicians how to cope with it, but by improving working conditions.