Unique drivers of burnout in healthcare epidemiologists

Whereas physician burnout is classically viewed from the perspective of the doctor–patient relationship, healthcare infection prevention is based on population medicine and epidemiology, rooted in a unique skillset with different expectations and pressures. Healthcare epidemiology intersects clinical medicine, risk analysis, health policy, and administration, and it is closely aligned with organizational quality and safety programs. In many jurisdictions, healthcare-associated infections are publicly reported and tied to hospital financial incentive programs.

The “patient” in infection prevention is the healthcare facility. Hospital epidemiologists bear an emotional burden and responsibility by making decisions and influencing policies that affect thousands of lives daily. Furthermore, although healthcare epidemiologists set policies and guide evidence-based practice, they do not serve as the administrative oversight of individuals and systems. Administrative healthcare leaders set the vision, provide the resources, and empower the action to achieve metrics in quality and safety.Reference Vokes, Bearman and Bazzoli⁶ Without executive sponsorship, no infection prevention program will reach its desired goals.Reference Bearman and Vokes⁷ Keeping leaders engaged is an ongoing challenge, calling into question the alignment of health system values. Frustration ensues when the priorities of hospital administrators do not match the course of action advised by the healthcare epidemiologist. These events can lead to feelings of impotence and conflicting values, which are compounded when infection prevention programs face lack of monetary support, understaffing, and administrations that fail to take safety breaches seriously unless citations by regulatory bodies are potential or real threats.

Issues with depersonalization arise as healthcare epidemiologists speak of “cases” and “rates” of healthcare-associated infections rather than recognize the humans affected by these infections. Depersonalization is potentially dangerous because it diminishes empathy.

Healthcare epidemiologists are not always respected as “real physicians” by medical colleagues, and they are sometimes referred to as the ‘police’ given their roles developing and implementing policies and procedures. For healthcare epidemiologists with no or limited clinical responsibilities, the potential result is a sense of nonmembership in the physician community. For nonphysician healthcare epidemiologists, membership in the physician community is even more challenging. The heavy service component to healthcare epidemiology is generally underappreciated by physician peers and is difficult to balance with academic and clinical responsibilities. This component includes the need to respond to crises and the expectation of influencing the practice of other healthcare workers, particularly physicians. Efforts directed toward healthcare worker behavioral change requires a heavy emotional and time investment, often with disappointing returns. Furthermore, healthcare epidemiologists are susceptible to disagreement from members of the healthcare team and resilience is challenged because infection prevention teams are typically lean in both staffing and resources.

Healthcare infection prevention programs as potential drivers of burnout in other healthcare workers

Infection prevention platforms may potentiate burnout by eroding healthcare-worker autonomy. The growing emphasis on implementation science, mandatory public reporting, standardization, high reliability in patient safety, and pay for performance requires a more active and aggressive role in mechanizing infection prevention best practices. To achieve standardization and reliability, processes must be relentlessly audited and fed back to providers and management.

Commonly assessed infection prevention measures include hand hygiene, patient chlorhexidine bathing, and the use of contact precautions. Preprocedure time-outs and safety checklists are critical components of infection prevention bundles and are subject to audit and feedback. Antimicrobial stewardship programs impact prescriber practice by restriction, prospective audit, and feedback of antibiotic use. Taken together, these measures comprise a growing practice oversight that undermines healthcare-worker autonomy.

Increasing emphasis is now placed on the stewardship of testing, to minimize both overtesting and false-positive diagnosis.Reference Madden, German Mesner and Cox⁸ To achieve greater fidelity in test stewardship, programs are turning to the electronic medical record (EMR) as a point-of-care decision-support tool with forcing functions and hard stops.Reference Keller, Feldman, Smith, Pahwa, Cosgrove and Chida⁹ EMR decision support is also utilized as a facet of antimicrobial stewardship.Reference Madden, German Mesner and Cox⁸ Most physicians have a love–hate relationship with the EMR.Reference Simões, Maia and Gregório¹⁰ The most frequently reported concerns related to the EMR include increased time devoted to nonclinical tasks, less efficient workflow, negative effects on interpersonal relationships, and decreased quality of care.Reference DeChant and Shannon² For many, the EMR is a drain on physician satisfaction that is implemented broadly for greater efficiency, data collection, cost saving, and reductions in medical errors, yet with the significant failure to anticipate the negative downstream effects on workflow overload, meaningfulness, value, and burnout.Reference Wachter¹¹ The incremental impact on burnout of EMR utilization for infection prevention is not known and is worthy of further study.

In conclusion, physician burnout is pervasive and the infectious diseases field is no different, with >50% of infectious diseases specialists reporting burnout. Healthcare epidemiology, as a subspecialty of infectious diseases, is unique given its focus on population medicine, implementation, and healthcare administration. Drivers for physician burnout in healthcare epidemiology may result from challenges in influencing system and population-level practice change. Other concerns include potential health-system value misalignments through understaffing, underresourcing of safety programs, and a perceived lack of respect and support from hospital executives and physician colleagues.

Conversely, infection prevention interventions, policies, time-outs, safety checklists, EMR functions, and decision support mechanisms may serve to potentiate healthcare worker burnout by fostering an erosion of autonomy and a lack of control in patient care. These concerns should not be overlooked and may disincentivize implementation and acceptance of infection prevention strategies.

Further research is needed to assess the drivers of, prevalence of, and potential solutions for burnout among healthcare epidemiologists. In addition, further study is required to understand the perceived impact of infection prevention strategies on healthcare worker burnout, with the ultimate goal of defining optimal infection prevention interventions with minimal collateral damage on wellness. Physician burnout and healthcare infection prevention is an issue with dual implications worthy of greater scrutiny. The well-being of both patients and providers is at stake.