Strategies to Mitigate Secondary Trauma and Compassion Fatigue

Educational Objectives

The goal of this program is to improve strategies for minimizing secondary trauma in physicians. After hearing and assimilating this program, the clinician will be better able to:

1. Identify the symptoms of secondary traumatic stress in physicians.
2. Recognize conditions in the workplace that contribute to high rates of burnout.
3. Implement organizational strategies to combat burnout.

Summary

Secondary trauma (ST): stress resulting from helping or wanting to help a traumatized or suffering person; may occur from a single interaction with a patient; vicarious trauma (VT) occurs over time, from witnessing the pain and suffering of others; VT is associated with negative changes in the clinician’s view of themselves, others, or the world at large caused by repeated empathetic engagement with the trauma-related emotions of patients; repeated exposure to ST has psychologic, cognitive, and interpersonal effects and may cause compassion fatigue; may produce anxiety, isolation, avoidance, mistrust of others, cynicism, maladaptive coping strategies, compulsive or addictive behaviors (eg, substance abuse); characterized by, eg, emotional and physical exhaustion, diminished empathy or compassion; may lead to burnout, which is a constellation of factors including emotional exhaustion, depersonalization, and reduced sense of personal accomplishment

Symptoms of secondary traumatic stress (STS): clinicians experience, eg, include sleep disturbances, appetite disturbances, fatigue, irritability, headaches, gastrointestinal issues, cardiac symptoms, sexual dysfunction; self-isolation, decreased job performance, and trouble meeting personal commitments also may be seen; psychological effects include feelings of sadness or grief, over-rumination, struggles with concentration, memory issues, and increased sensitivity to violence; ST, if left untreated, is associated with, eg, anxiety, post-traumatic stress disorder (PTSD), substance abuse, depression, thoughts of self-harm

Prevalence of STS: in a study by Warren et al (2013) two-thirds of surgeons self-reported secondary stress; ≈10% reported higher degree or severe symptoms; 20% met the criteria for PTSD in all 3 domains (ie, intrusion, avoidance and arousal); surgeons who care for trauma patients may have increased levels of burnout

Studies on burnout: a survey from Medscape taken in 2021 of 13,000 physicians in the United States showed an increase in average physician burnout rates from 42% to 47% over 1 yr; the rate for emergency medicine (EM) physicians increased from 43% to 60%; high rates were reported by other physicians involved with trauma care, compared with other specialties; ≈50% of intensivists, anesthesiologists and surgeons reported burnout; Jackson et al (2019) found trauma surgeons to have a rate of 30% and rate of PTSD of 17%; Brown et al (2021) found a rate of 61% for trauma surgeons, and 57% of surgeons expressed dissatisfaction with their work-life balance; another survey found a rate of 51% among trauma surgeons, which was the highest of any specialty; Afonso et al (2021) surveyed ≈4000 anesthesiologists and found 59% are at high-risk for burnout and ≈14% met criteria for burnout syndrome; risk for EM physicians has been reported to be from 40% to 90%; other professions — nurses reported higher rates than EM physicians; rates for police officers are comparable to physicians

Contributing factors: 60% of respondents specified charting, paperwork, and bureaucratic tasks; ≈40% mentioned lack of respect from administrative colleagues or other staff; ≈30% of physicians reported work hours, salary and computerization issues; SS in combination with financial and clinical pressures, and fatigue, may lead to burnout; common risk factors are, eg, fatigue, excess workload, long hours, excess administrative stress, lack of support systems, struggles with work-life balance; specific risks may be associated with medical specialty; eg, anesthesiologists may struggle with lack of personal connections with patients and their families, or lack of continuity of care; Elkbuli et al (2020) found female gender to be the strongest predictor of burnout, with an odds ratio of ≈20%; other predictors included hours worked per wk; clinicians who worked 70 to 79 hr/wk increased their risk 49-fold; 30 to 34 yr old trauma surgeons were at the highest risk (36%) for thoughts of self-harm

Effects of burnout: >50% of the respondents to the Medscape survey reported severe symptoms that impacted their lives; two-thirds reported burnout negatively affected their personal relationships; burnout is associated with increased risk for, eg, cardiovascular complications, diabetes, obesity, substance use, depression, suicide; burnout is a cause for attrition of physicians; may also be contagious within a group or institution; a meta-analysis by Al-Ghunaim et al (2022) found burnout increased risk for medical errors; physicians with high emotional exhaustion scores had higher rates of medical errors; increased depersonalization scores did not effect the rate of medical errors

Strategies to counter burnout: wellness programs should consist of a variety of personal resilience and organizational programs; strategies for mitigating burnout may be created for individuals or on the level of institutions; prioritization of self-care is beneficial; social support (eg, education on STS, reduction of bureaucratic work, peer support networks, optimization of work-life balance) minimizes isolation; 50% of physicians report using exercise to counter burnout; self-care methods also may include sleep, healthy eating and listening to music; potentially damaging habits reported by physicians were, eg, isolation, unhealthy eating, alcohol and drug use

Resilience: the process of adapting to stress over time; results from the intersection of protective factors and threats; strongly associated with, eg, self-reflection, competency, confidence in one's abilities, optimism, social support; 43% of trauma surgeons reported to Brown et al (2021) satisfaction with their work-life balance; more leisure and personal time at home (by, eg, leaving work early) and participating in hobbies were most associated with satisfaction with work-life balance; flexibility of starting times (for attending to personal needs) did not have a significant effect on satisfaction; surgeons who exercised, followed a healthy diet, and slept ≥7 hr per night had higher rates of work-life satisfaction; using less allotted vacation time produced lower satisfaction scores; claiming emotional supports and satisfaction with one’s personal life was associated with satisfaction at work

Additional ways to decrease burnout and compassion fatigue: mindfulness — based on the Buddhist practice of meditation; consists of four tenets, ie, regulation, body awareness, emotional regulation, and changing the perception of self; focuses on awareness of the present moment; reactivity and stress are minimized; practices include deep breathing and conscious awareness of individual muscles through intentional relaxation; journaling and focusing on one single stream of thought may produce mindfulness; additional techniques — cultivating gratitude, practicing self-compassion and empathy; cultivating relationships enhances interpersonal connection and combats isolation; organizational changes — modifications to working hours, clinic or emergency room workflows, or reduction in bureaucratic workload may reduce burnout

Changing the health care model: Fischer et al (2020) analyzed the development of personal and institutional resiliency in the medical system, for the purposes of facilitating professional growth, enabling personal accomplishments, and reducing burnout; physicians and systems should move towards work-life integration in order to preserve values of humanism and goal-focused care; medicine permeates all aspects of life and personhood; excessive standards and protocols in health care practice may devalue individuals and degrade the personal accomplishments of physicians; physicians must regain leadership roles in health care systems to align patient, provider, and institutional goals

Institutional strategies: organizations may implement practices to promote self-care (eg, encouraging the use of allotted vacation time, limiting required overtime, allowing time for illness, granting family and medical leave, promoting continuing education); damage from VT may be countered by providing avenues for hope (eg, opportunities for patient outreach, education and advocacy); organizations must provide a safe working environment and educate about ST and VT; peer support systems should be instituted; physicians have reported that additional time, money and autonomy from their employers decrease burnout; lighter patient loads, more manageable work schedules, and hiring additional support staff may help clinicians achieve a better work-life balance and find the time for self-care

Barriers to progress: ≈40% of physicians are aware of programs for managing stress, but ≦60% would participate in services if they were offered; the culture of health care is a potential reason for declining services; many physicians who self-identify as having burnout or depression do not seek treatment; physicians may feel that they can deal with the symptoms without professional assistance; declining services because mistrust of the system is more concerning; physicians may not accept services because of the stigma associated with seeking help; state licensing commissions may ask for histories of mental health treatment; potential judgement by colleagues may affect decision making; in a study of EM physicians, surgeons and anesthesiologists, Zhang et al (2020) found that involvement in adverse patient events, medical errors, legal action, substance abuse issues, illness and interpersonal conflicts were the primary drivers in seeking assistance; <10% of respondents stated that burnout would prompt them to seek assistance; major barriers to seeking support are stigmatization, lack of confidentiality, and lack of time

Comprehensive wellness programs: dynamic and multidisciplinary programs are able to reach a diverse workforce; Balch et al (2011) found dysfunction within care teams and issues with leadership; physicians may require additional assistance with, eg, liability, responsibility, academic promotion; nurses may require more support for mistreatment by other team members and for moral distress; clinician education should be emphasized; organizations should have programs to decrease work-related stress and strive for technological improvement (eg, electronic health records)

Trauma informed care (TIC): seeks to reduce potentially traumatic aspects of patient treatment; beneficial for patients and providers; clinicians who provide TIC may see, eg, reduction in burnout, improvement in equity

Peer support: provision of timely, confidential psychologic first aid and emotional support to colleagues after adverse events; a 3-tiered peer support model was developed by Scott et al (2010); tier 1 includes colleagues connecting with one another following an adverse event; tier-2 support involves crisis management, interventions, peer support, mentoring, and team debriefs provided by team members who have received additional training (in, eg, second victim symptomatology, peer support fundamentals, one-on-one interventions); support may be individually directed or broadened to group settings; tier-3 support is offered by trained professional counselors; a variety of medical institutions have created peer support systems since the COVID-19 pandemic; Schwartz rounds — focus on social, emotional and psychologic perspectives; compassionate care is emphasized; found to decrease caregiver stress, reduce burnout, and enhance cooperation in health care environments; anesthesia peer support program (University of Chicago) — ≈50% of program activations were related to perioperative mortality, 20% involved perioperative cardiac arrest, 10% involved difficult airway management, and 7% were for other perioperative morbidities; 12% were related to other issues (eg, anxiety, depression, suicidal ideation); one-third of cases were related to level 1 trauma; >50% of activations were trainees; 76% favorable response rate based on evaluation of 90 interventions

Readings

Afonso AM, Cadwell JB, Staffa SJ, Zurakowski D, Vinson AE. Burnout rate and risk factors among anesthesiologists in the United States. Anesthesiology. 2021;134(5):683-696. doi:10.1097/ALN.0000000000003722; Al-Ghunaim TA, Johnson J, Biyani CS, et al. Surgeon burnout, impact on patient safety and professionalism: A systematic review and meta-analysis. Am J Surg. 2022; 224(1 Pt A):228-238; Balch CM, Shanafelt TD, Sloan JA, et al. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558-568. doi:10.1097/SLA.0b013e318230097e; Brown CVR, Joseph BA, Davis K, et al. Modifiable factors to improve work-life balance for trauma surgeons. J Trauma Acute Care Surg. 2021; 90(1):122-128. doi:10.1097/TA.0000000000002910; Elkbuli A, Kinslow K, Boneva D, et al. Addressing burnout among trauma surgeons. Am Surg. 2020;86(9):1175-1177. doi:10.1177/0003134820945264; Fischer NA, Persaud MA, Tsai MH, et al. Physician disrupt thyself: building individual and institutional resilience. Anesth Analg. 2020;131(4):1308-1312. doi:10.1213/ANE.0000000000005016; Jackson TN, Morgan JP, Jackson DL, et al. The crossroads of posttraumatic stress disorder and physician burnout: a national review of United States trauma and nontrauma surgeons. Am Surg. 2019;85(2):127-135; Medscape. Physician Burnout & Depression Report 2022. January 21, 2022. Accessed July 11, 2022. https://www.medscape.com/slideshow/2022-lifestyle-burnout-6014664; Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233-240. doi:10.1016/s1553-7250(10)36038-7; Shanafelt T, Trockel M, Ripp J, et al. Building a program on well-being: Key design considerations to meet the unique needs of each organization. Acad Med. 2019; 94(2):156-161. doi:10.1097/ACM.0000000000002415; Warren AM, Jones AL, Shafi S, et al. Does caring for trauma patients lead to psychological stress in surgeons?. J Trauma Acute Care Surg. 2013; 75(1):179-184. doi:10.1097/ta.0b013e3182984a7d; Wei H, Kifner H, Dawes ME, Wei TL, Boyd JM. Self-care strategies to combat burnout among pediatric critical care nurses and physicians. Crit Care Nurse. 2020;40(2):44-53. doi:10.4037/ccn2020621.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Dalton was recorded at the 2022 Virtual Webinar: Trauma Anesthesia and Resuscitation Conference, held on March 12, 2022, and presented by the University of Chicago Medicine, Department of Anesthesia and Critical Care. For information about upcoming CME activities from this presenter, please visit cme.uchicago.edu. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

AN642901

Qualifies for:

ABA MOCA, Trauma

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.