Tara Riddell is a PGY4 resident in Psychiatry at McMaster University.
Ana Hategan is an Associate Clinical Professor and Geriatric Psychiatrist in the Department of Psychiatry and Behavioural Neurosciences, McMaster University.
Daniel L. Ambrosini is a Barrister and Solicitor in Ontario and an Assistant Professor in the Department of Psychiatry and Behavioural Neurosciences, McMaster University.
Although all healthcare professionals are at risk of experiencing burnout, physicians have especially high rates. A 2019 report on physician burnout conducted via Medscape found that more than 40% of U.S. physicians reported feeling burned out. The precipitants of burnout are manifold; however, increasing bureaucratic tasks, long work hours and disparaging comments from administrators, employers or colleagues have been cited among top contributors. Once present, burnout can lead to
important adverse outcomes including effects on patient care and personal health. As such, rapid identification and remediation is paramount, but law and policy around compensation related to burnout is not clear.
Despite the high prevalence and potential harms, many physicians affected by burnout have been hesitant to seek help. In fact, in a 2019 report, nearly two-thirds of physicians who reported burnout or depression stated they had not sought care for these concerns. While there can be some variation in help-seeking based on specialty, barriers include fears of confidentiality or punitive repercussions should they speak out. Until recently, far from being responsive to the problem, some laws and policies failed to protect vulnerable workers and healthcare professionals, leaving many suffering from chronic psychological stress without remedy.
Despite much debate about the issue of work-related stress and burnout over the years, a key reform took place in 2019 when the WHO clarified that burnout is not a medical condition but rather an “occupational phenomenon” and listed it within the International Classification of Diseases, 11th Revision (ICD-11). According to this classification, burnout is characterized by feelings of exhaustion and depletion, feelings of negativism related to one’s job, and reduced professional efficacy. The ICD-11 defines burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed, and should not be applied to describe experiences in other areas of life. Given this shift in understanding of burnout, attention is now being paid to workplace compensation and insurance, and the role this might play in providing important treatment for those with burnout.
Some workplace compensation boards in North America have responded by developing policies to address workplace stress. For example, as of January 1, 2018, Ontario’s Workplace Safety and Insurance Board (WSIB) has been allowing claims for work-related chronic mental stress, which is psychological distress caused by occupational factors. These legal changes meant workers could now file claims for work-related stress issues.
Under Ontario’s WSIB’s policies, workers can seek compensation for psychological health injuries triggered by either “chronic mental stress” or “traumatic mental stress” in the workplace. Chronic mental stress could occur, for example, where a healthcare professional is the subject of demeaning comments from one’s leader, often in front of other colleagues, and subsequently develops a depressive or anxiety disorder. Traumatic mental stress might arise where a healthcare worker is witness to a severe accident or fatality or is assaulted at work. The expectation is that these changes to WSIB’s policies will likely result in an inflow of claims for workplace chronic and traumatic mental stress. One may believe that the attribution of work in itself and the work environment to the roots of one’s stress may mean implicitly that workplace-related burnout or even illness, is straightforward. But this is not necessarily the case.
Upon further review, the policies in Ontario stipulate that three key criteria must be met before an injured worker can be compensated. The first criterion is a requirement of a formal DSM diagnosis from a healthcare professional authorized to make such a diagnosis. The second criterion is proof of substantial work-related stressors as established triggers for the worker’s chronic mental stress. The third criterion is that the workplace incident (that is, an event or accident) is the predominant cause of the chronic mental stress.
Since burnout is caused by chronic workplace stress, yet is not a medical condition, how would the diagnostic criterion be met in the first place? How would the insidious, cumulative stressful factors be proven as visible causation of the burnout, which we know if untreated can lead to a primary psychiatric diagnosis? Does this diagnostic stipulation risk interfering with secondary prevention efforts designed to mitigate burnout early on?
In Ontario, WSIB’s Chronic Mental Stress policy (15-03-14) provides that “a work-related stressor will generally be considered substantial if it is excessive in intensity and/or duration in comparison to the normal pressures and tensions experienced by workers in similar circumstances.” How will normal stress that is part of the job be fairly and reasonably delineated from that which is in excess of what is to be expected? Might this inappropriately normalize or minimize harmful stressors that are common in medicine, such as mistreatment?
Though most physicians are self-employed and not entitled to protection equal to that of employees, these same questions still apply when seeking to activate their oft-held disability insurance policies. Burnout alone is often not considered a compensable illness. To access disability benefits, then, physicians must exhibit harmful sequelae of persistent and untreated burnout, which usually means experiencing a diagnosable physical or mental illness, which is documented as causing significant disruption to their lives or work performance. Though designed to help physicians restore their health, the current structure of such policies appears to generate further barriers for those who wish to intervene early, and avoid risking graver complications to their well-being and the care and safety of their patients.
This is certainly a rapidly-evolving area that warrants ongoing dialogue particularly given the current status of our healthcare systems and crisis that is physician burnout. Ensuring access to medical benefits for the burned-out physician should not only be a necessity but a legal right, particularly as well physicians help to foster a sustainable profession which positively feeds back to others including the patients they treat and communities they serve. Adequately treating this endemic however, also requires change from a systems level. Employing organizations and institutions must begin to take a proactive and preventative approach, in which they actively strive to improve worker safety and well-being, if we wish to see any meaningful change.