Burnout: A Closer Look at Integrative Medicine Strategies

Elaine Cheung, PhD; Ania Grimone, MS, LAc, CH, CPCC

The intensive care unit (ICU) is a busy, complex, and demanding work environment in which physicians, nurses, and other healthcare staff are routinely confronted with human suffering, patient morbidity and mortality, complex ethical decision-making, and difficult conversations with patients and their families. Professionals working in such high-stakes and high-stress environments are particularly vulnerable to developing burnout, a multidimensional response to chronic job-related stress, characterized by a low sense of personal accomplishment (e.g., loss of enthusiasm, fulfillment, zest, and creativity), emotional exhaustion (e.g., feeling overwhelmed, stressed, tired, lacking energy), and depersonalization (e.g., selfcriticism, doubting one’s self-worth, loss of confidence).^1–3

Indeed, rates of burnout tend to be particularly high among healthcare professionals working in the ICU, with recent estimates suggesting that approximately half of critical care physicians and one-third of critical care nurses have burnout.^4–10 Burnout is associated with increased rates of alcoholism, strained personal relationships, and poorer physical health in physicians.^11–14 Beyond personal consequences for the individual, burnout has also been linked to poorer-quality patient care, including increased medical errors, and lower patient satisfaction with care.^13,15,16 These findings highlight a need for early intervention and preventive efforts targeting burnout in medicine.¹⁷ This article highlights three approaches that critical care professionals can use to prevent and manage burnout in the ICU: 1) positive emotion coping skills, 2) acupuncture, and 3) herbal medicine.

Indeed, rates of burnout tend to be particularly high among healthcare professionals working in the ICU, with recent estimates suggesting that approximately half of critical care physicians and one-third of critical care nurses have burnout.

Positive Emotion Coping Skills
Many medical centers have begun offering wellness programs to address burnout among their staff.^18,19 Most of these programs focus on targeting negative emotional constructs such as stress, depression, and anxiety (e.g., mindfulness-based stress reduction, cognitive behavioral stress management).^18,19 However, a growing body of evidence suggests that positive emotion plays a uniquely important role in fueling resilient responses to stress.^20–24 Moreover, positive emotion has been found to increase humanistic motivation in physicians and may help them derive greater meaning and professional satisfaction from their work.^25–29

Our team at Northwestern University has developed a multicomponent, positive emotion coping skills program that targets increasing positive emotion as a pathway to reduce stress and burnout. This program involves providing a “toolbox” of eight empirically supported skills for increasing the frequency of positive emotion experienced in daily life: 1) positive reappraisal, 2) noticing positive events, 3) capitalizing on positive emotion, 4) gratitude, 5) mindfulness, 6) personal strengths, 7) self-compassion, and 8) compassion toward others. This theory-based program has demonstrated feasibility, acceptability, and preliminary efficacy for improving psychological adjustment across a number of groups experiencing high levels of life stress, including women with advanced cancer, people recently diagnosed with HIV, people with type 2 diabetes, and caregivers of patients with dementia.^30–33 Recently we have tailored this program specifically to physicians and
medical trainees.

The positive emotion coping skills taught in this program may help address burnout in healthcare professionals through differentially targeting the three dimensions of burnout: low sense of personal accomplishment, emotional exhaustion, and depersonalization. Specifically, the skills of noticing positive events, capitalizing on positive emotion, gratitude, and compassion toward others can target a low sense of personal accomplishment lost enthusiasm) by training healthcare professionals to attune themselves toward the small, positive moments in medicine that can help them sustain a sense of meaning and satisfaction in their work. In addition, the skills of positive reappraisal and mindfulness can target emotional exhaustion (lost energy) by helping them cope more effectively with daily hassles and stressors, which can free up bandwidth to tackle larger goals and challenges. Finally, the skills of self-compassion and personal strengths can target depersonalization (loss of confidence) by helping them recognize their unique personal strengths during moments of stress or failure and to respond to these moments with compassion rather than self-criticism and perfectionism. These positive emotion coping skills can be easily infused into the busy lives of healthcare professionals working in the ICU. For instance, they can incorporate quick (one- to two-minute) mindful breathing exercises as they wash their hands throughout the day, or spend five minutes each evening reflecting on three good things that happened to them that day.

Acupuncture
Acupuncture involves stimulating strategic points of the body (“acupoints”) by inserting extremely thin, filiform needles into the skin. Acupuncture has been found to be an effective intervention for reducing stress and treating other conditions that are aggravated by chronic stress, such as fatigue, high blood pressure, irritable bowel syndrome, and sleep disturbance.^34–38

Whereas a disadvantage of acupuncture is that it typically involves regular, repeated visits to a clinic, which may be difficult to integrate into healthcare professionals’ lives, acupressure is an allied intervention that, because it is self-administered and easily learned, does not require repeated visits to a clinic.³⁹ Acupressure draws from the same principles as acupuncture, but involves applying manual pressure on relevant acupoints for a minimum of two minutes per point. One acupoint that is particularly relevant for stress reduction is HT7, located at the wrist crease on the radial side of the flexor carpi ulnaris tendon, between the ulna and the pisiform bones.

Another allied intervention that is easy to integrate into healthcare professionals’ lives is auricular acupuncture, which involves placing small magnets on specific acupoints of the auricle. The Shenmen acupoint, which is situated on each ear at the apex of the triangular fossa, is a common target for reducing stress. Auricle acupuncture on the Shenmen acupoint has been found to be helpful in calming the mind and alleviating stress, pain, anxiety, insomnia, and restlessness.3 Notably, auricle acupuncture has been found to reduce stress, anxiety, and burnout in healthcare providers.⁴⁰

Herbal Medicine
Herbal medicine, including traditional Chinese adaptogenic herbs and formulas, may also be used to help people manage the physical manifestations of stress and burnout. Herbal supplements that have been found to be beneficial for reducing stress and fatigue include ginseng (Panax ginseng), eleuthero (Siberian) ginseng (Eleutherococcus senticosus), holy basil (Ocimum tenuiflorum), astragalus root (Astragalus membranaceus), schisandra (Schisandra chinensis), licorice root (Glycyrrhiza glabra), rhodiola (Rhodiola rosea) and mushrooms such as Cordyceps, reishi, shiitake, and maitake.^41–45 Although these herbal supplements can be obtained over the counter without a prescription, it is important to be mindful of the potential adverse side effects and interactive effects that these supplements may have with prescription medications. We recommend consulting an herbalist before initiation of herbal supplements.

Summary
Three approaches that critical care professionals may use to prevent and manage burnout in the ICU are: 1) positive emotion coping skills, 2) acupuncture, and 3) herbal medicine. These quick, convenient, and relatively inexpensive strategies can easily be integrated into the busy lives of healthcare professionals and may help people cope more effectively with the stress of working in the ICU. 

References
1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
2. Maslach C. Job burnout: new directions in research and intervention. Curr Directions Psychol Sci. 2003;12:189-192.
3. Wang SM, Kain ZN. Auricular acupuncture: a potential treatment for anxiety. Anesth Analg. 2001 Feb;92(2):548-553.
4. Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. A Critical Care Societies Collaborative statement: burnout syndrome in critical care health-care professionals. A call for action. Am J Respir Crit Care Med. 2016 Jul 1;194(1):106-113.
5. Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007 Oct;13(5):482-488.
6. Colville GA, Smith JG, Brierley J, et al. Coping with staff burnout and work-related posttraumatic stress in intensive care. Pediatr Crit Care Med. 2017 Jul;18(7):e267-e273.
7. Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007 Apr 1;175(7):698-704.
8. Guntupalli KK, Fromm RE Jr. Burnout in the internist-intensivist. Intensive Care Med. 1996 Jul;22(7):625-630.
9. Embriaco N, Azoulay E, Barrau K, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007 Apr 1;175(7):686-692.
10. Johnson-Coyle L, Opgenorth D, Bellows M, Dhaliwal J, Richardson-Carr S, Bagshaw SM. Moral distress and burnout among cardiovascular surgery intensive care unit healthcare professionals: a prospective cross-sectional survey. Can J Crit Care Nurs. 2016;27(4):27-36.
11. Goldberg R, Boss RW, Chan L, et al. Burnout and its correlates in emergency physicians: four years’ experience with a wellness booth. Acad Emerg Med. 1996 Dec;3(12):1156-1164.
12. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012 Feb;147(2):168-174.
13. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002 Mar 5;136(5):358-367.
14. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011 Jan;146(1):54-62.
15. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev. 2007 Jul-Sep;32(3):203-212.
16. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006 Sep 6;296(9):1071-1078.
17. Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002 Sep 25;288(12):1447-1450.
18. Finkelstein C, Brownstein A, Scott C, Lan YL. Anxiety and stress reduction in medical education: an intervention. Med Educ. 2007 Mar;41(3):258-264.
19. MacLaughlin BW, Wang D, Noone AM, et al. Stress biomarkers in medical students participating in a mind body medicine skills program. Evid Based Complement Alternat Med. 2011;2011:950461.
20. Folkman S. Positive psychological states and coping with severe stress. Soc Sci Med. 1997 Oct;45(8):1207-1221.
21. Folkman S, Moskowitz JT. Positive affect and the other side of coping. Am Psychol. 2000 Jun;55(6):647-654.
22. Moskowitz JT, Folkman S, Acree M. Do positive psychological states shed light on recovery from bereavement? Findings from a 3-year longitudinal study. Death Stud. 2003 Jul;27(6):471-500.
23. Bonanno GA, Moskowitz JT, Papa A, Folkman S. Resilience to loss in bereaved spouses, bereaved parents, and bereaved gay men. J Pers Soc Psychol. 2005 May;88:827-843.
24. Moskowitz JT, Epel ES, Acree M. Positive affect uniquely predicts lower risk of mortality in people with diabetes. Health Psychol. 2008 Jan;27(1S):S73-S82.
25. Estrada CA, Isen AM, Young MJ. Positive affect improves creative problem solving and influences reported source of practice satisfaction in physicians. Motiv Emot. 1994 Dec;18(4):285-299.
26. Duarte J, Pinto-Gouveia J, Cruz B. Relationships between nurses’ empathy, self-compassion and dimensions of professional quality of life: a cross-sectional study. Int J Nurs Stud. 2016 Aug;60:1-11.
27. Gleichgerrcht E, Decety J. The relationship between different facets of empathy, pain perception and compassion fatigue among physicians. Front Behav Neurosci. 2014 Jul 11;8:243.
28. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA. 2005 Mar 2;293(9):1100-1106.
29. Thomas MR, Dyrbye LN, Huntington JL, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007 Feb;22(2):177-183.
30. Cohn MA, Pietrucha ME, Saslow LR, Hult JR, Moskowitz JT. An online positive affect skills intervention reduces depression in adults with type 2 diabetes. J Posit Psychol. 2014 Jan 1;9(6):523-534.
31. Moskowitz JT, Hult JR, Duncan LG, et al. A positive affect intervention for people experiencing health-related stress: development and non-randomized pilot test. J Health Psychol. 2012 Jul;17(5):676-692.
32. Cheung EO, Cohn MA, Dunn LB, et al. A randomized pilot trial of a positive affect skill intervention (lessons in linking affect and coping) for women with metastatic breast cancer. Psychooncology. 2017 Dec;26(12):2101-2108.
33. Moskowitz JT, Carrico AW, Duncan LG, et al. Randomized controlled trial of a positive affect intervention for people newly diagnosed with HIV. J Consult Clin Psychol. 2017 May;85(5):409-423.
34. Kim SB, Choi WH, Liu WX, Lee NR, Shin TM, Lee YH. Use of pupil size to determine the effect of electromagnetic acupuncture on activation level of the autonomic nervous system. J Acupunct  Meridian Stud. 2014 Jun;7(3):122-132.
35. Takahashi T. Mechanism of acupuncture on neuromodulation in the gut—a review. Neuromodulation. 2011 Jan;14(1):8-12.
36. Huang H, Zhong Z, Chen J, et al. Effect of acupuncture at HT7 on heart rate variability: an exploratory study. Acupunct Med. 2015 Feb;33(1):30-35.
37. Mayor D. An exploratory review of the electroacupuncture literature: clinical applications and endorphin mechanisms. Acupunct Med. 2013 Dec;31(4):409-415.
38. Yu JS, Zeng BY, Hsieh CL. Acupuncture stimulation and neuroendocrine regulation. Int Rev Neurobiol. 2013;111:125-140.
39. Hmwe NT, Subramanian P, Tan LP, Chong WK. The effects of acupressure on depression, anxiety and stress in patients with hemodialysis: a randomized controlled trial. Int J Nurs Stud. 2015 Feb;52(2):509-518.
40. Reilly PM, Buchanan TM, Vafides C, Breakey S, Dykes P. Auricular acupuncture to relieve health care workers’ stress and anxiety: impact on caring. Dimens Crit Care Nurs. 2014 May-Jun;33(3):151-159.
41. Panossian A, Wikman G. Evidence-based efficacy of adaptogens in fatigue, and molecular mechanisms related to their stress-protective activity. Curr Clin Pharmacol. 2009 Sep;4(3):198-219.
42. Chan SW. Panax ginseng, Rhodiola rosea and Schisandra chinensis. Int J Food Sci Nutr. 2012 Mar;63 Suppl 1:75-81.
43. Cropley M, Banks AP, Boyle J. The effects of Rhodiola rosea L. extract on anxiety, stress, cognition and other mood symptoms. Phytother Res. 2015 Dec;29(12):1934-1939.
44. Liu CH, Tsai CH, Li TC, et al. Effects of the traditional Chinese herb Astragalus membranaceus in patients with poststroke fatigue: a double-blind, randomized, controlled preliminary study. J Ethnopharmacol. 2016 Dec 24;194:954-962.
45. Das SK, Masuda M, Sakurai A, Sakakibara M. Medicinal uses of the mushroom Cordyceps militaris: current state and prospects. Fitoterapia. 2010 Dec;81(8):961-968.