Work, stress and burnout

President Ronald Reagan had famously said: "It's true hard work never killed anybody, but I figure, why take the chance?" As it turned out, he was rather prescient: During the bubble economy of the late 1980s, a number of Japanese corporate executives actually died from overwork in what was subsequently termed karoshi. But even if overwork does not kill, it can cause wide-ranging problems.

At this year's World Economic Forum in Davos, Switzerland, the Organisation for Economic Cooperation and Development (OECD) highlighted the issue of stress in the workplace. In the United Kingdom last year, nearly half a million people were off work for mental health reasons, while more than 8 in 10 working Americans reported being stressed at work, with more than half reporting being less productive because of stress.

"This is something that can be addressed and treated," said OECD Secretary-General Angel Gurria while noting regrettably that this is "not yet embedded in the awareness of managers".

The Straits Times last week carried the findings of a study by the Health Promotion Board (HPB) on more than 8,000 Singaporeans. It reported that one in four workers admitted to being "highly stressed". Rather surprisingly, 94 per cent said they are coping "reasonably well". This is presumably based on self-reporting. Without any objective assessment on how well they are actually coping, it is difficult to establish the veracity of this rather optimistic claim.

There is certainly a sizeable body of studies that have shown the heavy toll on health resulting from work stress: Workers who are unhappy are at higher risk of heart attacks, other heart diseases, depression and other ailments.

What would have been interesting, but was not revealed (or not elicited) in the HPB survey, is the association (if any) between stress and the hours of work, and whether any particular profession might be more vulnerable.

Cult of overwork

In an article in the New Yorker in January this year, American journalist James Surowiecki described what he called "the cult of overwork".

He cited a Harvard Business School survey of 1,000 professionals that found that 94 per cent worked 50 hours or more a week, and almost half worked in excess of 65 hours a week.

He puzzled over this trend of overwork since it has been amply established that long hours produce diminishing return on productivity and quality.

To a certain extent, the long hours are part of an expression of a culture of machismo, where relentlessly putting in hours of overtime is seen as producing a tough and dedicated worker.

"Working 15 hours a day doesn't just demonstrate your commitment to a company; it also reinforces that commitment," said Mr Surowiecki.

"Over time, the simple fact that you work so much becomes proof that the job is worthwhile, and being in the office day and night becomes a kind of permanent initiation ritual."

That sort of machismo is also common in the field of medicine, where long hours are the norm. Until recently, with the imposition of a limit on the number of working hours for doctors in training, a frenetic pace of work with long hours and sleep deprivation were commonplace. The cherished and time-honoured sentiment was that the experience of going through a baptism of fire in the trenches of frontline medicine was a rite of passage that would forge and test a doctor's mettle and character.


Research in the past decade in the West has shown that burnout (which comprises that combination of emotional exhaustion, detachment and a low sense of accomplishment) is widespread among medical students and trainee doctors.

When that happens, they also lose the capacity to empathise with their patients. They are also more vulnerable to unethical and unprofessional behaviour such as lying and cheating.

But burnout is not confined only to fledgling doctors. In a 2012 paper in the Archives of Internal Medicine, researchers in America found that senior doctors, including those with decades of practice, are just as vulnerable to burnout. Of the more than 7,000 US doctors surveyed, almost half complained of burnout.

Related research suggests that burnout in the medical profession has dire consequences. These include increased risk of medical errors, poorer quality of care given to patients, and doctors abandoning medicine altogether. They are also more likely to have relationship problems, alcohol abuse and suicidal tendencies.

There is no single cause of burnout. It might have something to do with the way that the nature of medical practice has changed. The explosion of information (not necessarily knowledge), the skyrocketing health-care costs, the involvement of third-party payers, the raising expectations of patients, and the increase in lawsuits have made medicine far more complex - and stressful.

Doctors today have to cope with all that as well as with heavy patient volumes and onerous administrative burdens that cut into the time they can spend with each patient. The embrace of information and communication technology in the field of medicine is inevitable. It has created a work environment with no boundaries in which most doctors are electronically connected and available almost all the time, with no respite from work and from one another.

Status and the loss of control

The work of British epidemiologist Michael Marmot might provide some insight into why some doctors suffer burnout.

Professor Marmot, who studied more than 10,000 British civil servants in Whitehall in 1985, found that the lower a person is placed in the socioeconomic hierarchy, the worse is the person's health - after taking into account differences in smoking, diet and access to health care. He called this phenomenon the "status syndrome". Those at the lower rungs of the hierarchy suffer from chronic stress because they have a lesser sense of control over their fate. High status work, on the other hand, tends to be associated with greater control and better health.

In the case of the medical profession though, status does not seem to matter. Instead, burnout happens across a swathe of the profession.

More important is the sense of a loss of control. During the course of training and the actual practice of medicine, one thing after another happens, producing a cumulative effect. At some point, it all spins out of control. And at the same time, there is that constant erosion of the ideals and values that motivated doctors take up medicine in the first place - leaving them exhausted and disillusioned.

So what might be needed - other than the usual strategies of personal stress reduction and resilience training - is to enable doctors to have a sense of better control. They need help to identify what they value, and connect with what is most meaningful in their work.

Search for meaning

Work, for most of us, is a crucial and indispensable part of our life, whether we like it or not. Some might see it as a drudgery to be endured, while others feel trapped and stymied in an organisation or system that seems oppressive and soul destroying.

In these situations, economist Albert O. Hirschman says that people would do one of two things. In his book entitled Exit, Voice And Loyalty published in 1970, he notes that they can either leave or stay put and protest.

But there is, perhaps, another thing that can be done - they could attempt to derive some meaning from work.

The work that most people do is - unless it is illegal or morally reprehensible - intrinsically honourable and almost certainly serves some social good. It would be good if we could try to reclaim that sense of meaning in what we do and consciously remind ourselves of that amid the messiness, frustrations and heartaches.

Sigmund Freud, the father of psychoanalysis, was asked once what makes people happy. His reply was: "Love and work."

The writer is the vice-chairman on the medical board (research) at the Institute of Mental Health.

This article was published on May 16 in The Straits Times.

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