Advocacy as Antidote to Burnout: Perspectives From Intern Year

An antidote is a medication that is taken to counteract a particular poison. Burnout has been described as one of the health care field’s poisons. Christina Maslach and her colleagues at the University of San Francisco developed a widely used burnout inventory in the 1970s. They described burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will” and wrote that it had three key dimensions: exhaustion, depersonalization, and lack of efficacy. Advocacy, as it relates to health care, can be defined as the public voicing of support for causes, policies, or opinions that advance patient and population health. This could also be reframed as intentionally asserting one’s values, dignity, spirit, and will to change circumstances that lead to depersonalization and exhaustion.

In other words, advocacy can be an antidote to burnout.

In the health care setting, advocacy can occur at many levels, including the patient, organizational, and legislative levels. In the era of COVID-19, advocacy is a particularly important skill for psychiatrists to hone, given the unique opportunities to advance policy and regulatory changes that will improve the care of patients with mental illness. Whereas some levels of advocacy require specific knowledge and skills outside the scope of clinical practice, all physicians can engage in patient-level advocacy as a necessary part of their jobs. This means that newly minted physicians can start advocating for their patients on day one of intern year—which may both lessen the impact of burnout on them and set the stage for continuing advocacy throughout their careers.

What does patient-level advocacy look like during the intern year? Here are some examples, as recounted by PGY-1 residents in psychiatry:

• “I was taking care of a patient with vague abdominal pain without a clear etiology. We decided to get a CT angiogram to rule out an abdominal aortic aneurysm [AAA]. The radiology team members initially pushed back because they didn’t think it was indicated. We disagreed and felt a strong sense of responsibility, as thought we were the only ones who could prevent something bad from happening. An AAA was diagnosed. However, the vascular surgery team recommended that we discharge the patient and schedule an elective procedure. We were afraid that his clinical picture was concerning for a dissection and insisted they reconsider, and as a result, the patient was not discharged. Later that evening, he required emergency surgery for an aortic dissection, so it was fortunate that he was still hospitalized. Our team was really proud that we had continued to stand up for our patient, and we were messaging each other after our shift with updates as his surgery was happening. We felt as though we had actually made a difference for someone. The vascular surgeon came to the resident room the next day and told us we were the reason the patient had survived. It was a great feeling. We took extra time to visit him in the ICU, and it was amazing to see him alive.”

  –Anna DeFrancesco, M.D., PGY-1

• “I was taking care of a patient receiving curative whole brain radiation for metastatic lung cancer. She was suffering from low mood, poor appetite, and low energy. I did a lot of research, talked with the psychiatry consultation service, and decided to start a stimulant. When I was presenting my decision on internal medicine rounds, the attending was annoyed that we were starting a psychotropic agent in a confused, elderly patient and told me that we couldn’t blindly follow consultant recommendations. I interrupted him to say that I had worked hard to understand the risks and benefits of this medication in our patient and that I had ordered the medication because I genuinely thought it would improve her quality of life. My attending was a satisfying mix of flustered and impressed, and we moved forward with the medication. The medicine helped my patient start eating again. I initially felt nervous about speaking up, but afterward I felt confident that I could make a difference. It gave me the warm fuzzies and renewed my sense of purpose.”

  –Jacob Eliason, M.D., PGY-1

Intern year can be an exhausting, burnout-inducing experience—or a time of transformational growth during which young physicians find a sense of agency and start down the road to becoming lifelong advocates. In the stories above, the reader can feel the evolution of these interns’ vulnerability to burnout as Drs. DeFrancesco and Eliason experience empathy for human suffering, develop a strong sense of personal responsibility toward healing, work hard to do so, and fear their efforts will be devalued or ignored. They begin to question their own intelligence, competence, and agency. However, these stories do not end with the erosion of their souls due to a deterioration of their values, spirit, and will, but rather with pride, wonder, and a renewed sense of purpose.

For them, advocating for their patients has been an antidote to burnout. This is an antidote they can carry with them throughout their careers as psychiatrists—by continuing to engage in patient-level advocacy, by working within their institutions to promote change, and by advising leaders and policymakers on how to advance mental health care for communities and populations. ■

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or the U.S. government.