Medical and Midwifery Burnout - Part 1
Establishing our place in obstetrical health care can come with a steep price, not the least of which is basic recognition. At times, you can only hope for gratification or peace-of-mind. As midwives, it can be a struggle. Burnout in healthcare has been recognized, and documented, for years. Signs and symptoms include: exhaustion, depression, work-life conflict, diminished joy, physical and mental stress, to name just a few. We do not necessarily experience it to the extent of debilitation, but we all know what it is. And where it comes from.
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Burnout is specific to our coping mechanisms, homelife, and the culture of the workplace. In these next articles on burnout, I am only going to discuss three specific stressors and potential coping mechanisms to consider. In no particular order of significance these stressors are: 1) Fear of Liability; along with associated legal interference. 2) Collegial Sabotage; featuring the predictable perpetrators. 3) Hospital Corporation Apathy and Disrespect; no easy solutions.
How each of us, as individuals, experience career burnout is variable depending on our personalities and employment situations. Prevailing, ugly cultures of care are the most productive for creating high-acuity provider burnout. Career burnout means many things for different providers. It may depend upon several factors:
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- practice setting/culture
- attitudes and management of the corporate entity.
- specific emotional triggers
- family relationships and responsibilities
- money
- respect
- self-worth and status
Occasionally, prior to raging house fire burnout, soon-to-be-burned-beyond-recognition providers may smolder for varying periods of time. Smoldering situations can resemble the following:
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- you're informed by Human Resources that your salary is going to be capped at an unsatisfactory level and, because of your age, and for the remainder of your employment, you will never be paid more (yes, an age and employment discrimination lawsuit that never happened, but should have).
- as a hospitalist CNM, you are asked to deliver a private attending OB's patient. Because this doctor just woke up at home, she will not make it to the hospital in time. You and the patient accomplish a perfect delivery but when the attending finally arrives, instead of thank you, she berates you at the crowded nurses' station for not getting cord gases. ("I always get cord gases! Why don't you know that?")
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- In a money-saving outburst of brilliance, the hospital decided that OB Triage responsibilities should be shared by RNs and CNMs. One role. Two differing levels of provider capability. Only one level (CNM) is legally certified/hospital approved to perform a screening evaluation under EMTALA. Also, one designated salary for two disparate levels of education and scope of practice.
- First year OB residents assigned to "strip rounds"; responsible for monitoring all the EFM tracings on the labor deck. They are beyond clueless, and also documenting their faulty interpretations in the medical record, where your name is found, as well.
- You only feel comfortable talking to the newborn that you just delivered.
- Corporate blackmail (more on that, later).
- Ageism and unkind gossip directed toward older midwives.
- L&D nurses entitled to degrade your management plan for a patient's labor and delivery. In front of the patient.
- You have no idea what day it is.
Fear of Liability
As health care professionals, we have all experienced stressful care situations where a patient (or two) are at high risk of permanent injury or death. For certain areas of practice, these stressful situations are relatively infrequent. For some provider specialties, like OB hospital midwifery, high stress situations may occur every day. Fear of malpractice may hover over midwives' heads each hour that they are engaged with patients.
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Over several decades, obstetrical malpractice litigation has increased significantly. It has been reported that malpractice claims actually peaked sometime in the 1980's, however the amount of claims filed, even today, are described as "epidemic". Fear of litigation can trigger intense, but often unrealistic, fear in providers of healthcare .1
Unfortunately, in litigious medical climates, malpractice lawsuits have greater visibility, especially where millions of dollars are awarded to injured plaintiffs. Permanently brain-injured baby cases, along with shoulder dystocia litigation, are associated with exceptionally high monetary damages and awards. The only reassuring fact to offset the reality of these verdicts, and associated disrupted careers, is that plaintiffs' awards at trial are relatively few.
Cases litigated through the court system reveal that jurors find for defendant care providers far more often than for plaintiffs. Understanding this, however, does not diminish the anxiety and stress that malpractice litigation can inflict on the professionals experiencing it.
Fear of liability is a rational response to work/life stress. Some plaintiffs' trial attorneys are attempting to take advantage of medical provider anxiety and burnout. Random law firms are manipulating consumers to believe, through media advertising, that medical care providers are anxious, burned out, and unable to function at expected professional levels . Although it's hard enough to live with the potential for being sued, attorneys advertising about doctors' and midwives' incapacitating fears and exhaustion in practice are especially aggravating. In addition, these ads encourage consumers to be on high alert for any indication that their providers are burned out, or otherwise diminished in their capabilities to provide competent medical care.
“Good morning Dr. Smith. You look like hell. Are you feeling burned out, today?”
Law Firm Advertising
One medical injury law firm blogs about how the medical industry may be causing malpractice incidents, suggesting that medical professionals are under intense pressure, especially those working in hospitals. One of these law firm advertisements was written during the covid-19 crisis and, on its face, it is not wrong. What may have been exaggerated was an assertion that providers are currently "more burned out than ever", and this has been a problem in America "for a long time". This statement reveals the real intent behind the ad: "Burnout can cause doctors to make critical mistakes".2
A paragraph follows describing a wrong-medication incident that debilitated and caused the death of an elderly patient. It ends with: "You deserve medical staff that is prepared to give you high quality care. If you received substandard treatment at the hospital because of burnout, it was your life at risk.You may be left with worse, not better, health as a result. This is unacceptable". 3
Free legal consultation is offered. "You Pay No Fees Unless We Win!’ 4
Irresponsible and fear-inducing advertisements about professional burnout in hospitals may be productive for the firms who are actively "ambulance chasing". They erode the public's confidence in medical care and create further stress for providers that are working "harder than ever". Law firms with integrity do not stoop to these tactics, relying instead on well-earned reputations for fairness and reason.
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Legal Consciousness
A study done in 2022, explored the association of fear of malpractice and burnout among Chinese doctors. A finding from this study suggested that "Legal Consciousness (LC)" may buffer the effect of fear of malpractice in doctors experiencing burnout. Legal Consciousness is a personal, psychological resource that was found to help an individual deal with fear of malpractice, referring to providers’ willingness to study and apply legal knowledge in medical practice. Understanding aspects of legal proceedings appeared to alleviate malpractice anxiety. Most Chinese medical workers were willing to broaden their legal knowledge and apply it to their medical practice. 5
Practical legal knowledge should be considered for alleviating some fears of malpractice. This does not require earning a JD. Limited knowledge regarding the realities of litigation may be helpful along with assessing your level of diligence, and continually finding ways to improve your practice.
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If you are a care provider suffering burnout, you must seek immediate help. I do not anticipate that all health care entities will be sympathetic or helpful, but they should be informed. Trying to alleviate burnout on your own is not recommended by anyone. There are numerous articles that show burnout to be linked with provider error and the potential for patient harm. 6
1. FEAR OF MALPRACTICE LIABILITY AND ITS ROLE IN CLINICAL DECISION MAKING. Hauser MJ et.al. Mark J. Hauser, M.D.
2. How burnout in the medical industry may be causing malpractice incidents. TLF. The medical Injury Lawfirm. p.2
3. TLF. pg 3
4. TLF . pg 4
5. The association between fear of malpractice and burnout among Chinese medical workers: The mediating role of legal consciousness. Fei Liang, Shu Hu, Youqi Guo. BMC Psychiatry. 2022 May 25;22:358. doi: 10.1186/s12888-022-04009-8.
6. Burnout and Malpractice Litigation. The Sara Charles MD Physician Litigation Stress Resource Center
http://www.midwivesontrial.com