Burnout was first mentioned in literature by Bradley in 1969 as a psychological phenomenon that occurred in helping professions, although Freudenberger (1974) is regarded as the inventor of the term. The term was adopted from empirical research where respondents used burnout as a metaphor to describe a state of exhaustion in which they gradually were drained of energy1.
Patient burnout seems to be a factor we orthodontists seem to be dealing with in this day and age. The prevailing psyche of the patient seems to involve instant gratification. This is a factor which our peers of yesteryear did not have to deal with. What is patient burnout? Why is it of concern to us? Patient burnout is the inability of the patient to deal with the prolonged treatment time required by the duration of treatment due to the effects of emotional exhaustion and a reduced sense of personal accomplishment. This enormously complicates the situation for orthodontists as we may like to proceed with treatment at the mixed dentition stage and the length of treatment may prove to be detrimental to the psychological profile for the patient.
Initially the concept of burnout had been applied to the organizational behaviour of personnel in companies but now it seems to be commonplace in the most professions. The highest proportion of burnout was generally seen in general practitioners. There are multiple studies showing this, one of the most recent being Solowski and Brondt2.
Maslach and Jackson 3 did a study on occupational behaviour and towards the end had a patient base of 1024 individuals. They found that the majority of individuals suffering from burnout were in the healthcare and service industries. They divided burnout based on three factors which were Emotional exhaustion, Depersonalization, Personal accomplishment and there was a fourth optional factor which was Involvement. Females scored higher than males on Emotional Exhaustion, both for frequency and for intensity. On the other hand, males scored higher than females onDepersonalization, both for frequency and intensity. Males also scored higher than females onPersonal Accomplishment, both for frequency and intensity. Interestingly, females scored slightlyhigher than males on the optional fourth factor of Involvement, both for frequency and intensity.
They also said that “Thus, the people in the older age range of our sample may be those who have survived the early stresses of their job and done well in their career.” We can apply this to the orthodontic field by making 2 inferences. Firstly, if the patient survives the initial inconvenience of the fixed appliance eg. Restriction in diet, social stigma etc., the chances of completing the treatment with excellent co-operation is high. Secondly, older individuals may have a better chance at completing the treatment without burnout or even coping with it.
Maslach and Jackson3 also found that with regard to emotional exhaustion the level of education played a part with post graduate students scoring highest followed by those who had completed college followed by those who had not.
One of the earliest mention of patient burnout in orthodontics was by Brezniak and Ben-Yair 4 . Although it had been confined to organizations in previous years they found that it had entered the doctor patient complex and did a study documenting its application to the orthodontic patient.
The orthodontic practitioner needs to view this particular problem from the patients side instead of the jaded viewpoint we are used to seeing. Plotnick and Henderson5 state that providing care to patients with major chronic diseases has its own set of frustrations and sense of futility for the clinician. This is often compounded by unrealistic goals and expectations on the part of the patient and clinician, as well as the tendency of some healthcare providers to assume too much responsibility for problem solving.
If the clinicians fatigue contributes to less than optimal patient care, this deprives patients of their most significant ally. It disrupts the therapeutic alliance for the patient. The clinician needs to overcome these difficulties using all the resources at his or her disposal. The patient’s family is the primary resource to help with the treatment plan and goals.
Vente, Ollf et al6 did investigate the differences between burnout patientsand healthy controls regarding basal physiological values andphysiological stress responses. Measures of the sympathetic-adrenergic-medullary(SAM) axis and the hypothalamic-pituitary-adrenal (HPA) axiswere examined. SAM axis and HPA axis activity was compared between22 burnout patients and 23 healthy controls. SAM axis activitywas measured by means of heart rate (HR) and blood pressure(BP). HPA axis activity was investigated by means of salivarycortisol levels. Resting levels of HR, BP, and cortisol weredetermined as well as reactivity and recovery of these measuresduring a laboratory session involving mental arithmetic andspeech tasks. In addition, morning levels of cortisol were determined. They found that burnout patients showed higher resting HR than healthycontrols. BP resting values did not differ between burnout patientsand healthy controls, nor did cardiovascular reactivity andrecovery measurements during the laboratory session. Basal cortisollevels and cortisol reactivity and recovery measures were similarfor burnout patients and healthy controls. However, burnoutpatients showed elevated cortisol levels during the first hourafter awakening in comparison to healthy controls. Their findings provided limited proof that SAM axisand HPA axis are disturbed among burnout patients. ElevatedHR and elevated early morning cortisol levels may be indicativeof sustained activation. The importance for orthodontists lies in the fact that we know that cortisol plays an important role in bone resorption and remodelling.
Hoover7 did a study on patient burnout in diabetics and concluded that people who live with diabetes always live with unrelieved stress. Throughout the day they have to be in tune with their own bodies in order to anticipate the need for more insulin, more food or more exercise. This can be applied to the orthodontic patient as the patient has to modify their diet to cope with the bonded brackets vs susceptibility to fracture. They have to be in tune with the appliance to know the limits of the stress that can be placed on it. Furthermore they need to get used to the wires in their mouths with the possibility of minor mucosal abrasions due to edges of the wires.
Stenlund8 developed a method for dealing with burnout, Cognitively oriented Behavioural Rehabilitation(CBR). A group of individuals needing therapy is gathered together and a person versed in CBR leads the group. CBR consists of 5 stages 1) education (for example, stress reactions, sleep, affect, medication, the importance of rest in order to recover); 2) awareness of reactions and “self-talk”; 3) development of behavioural/cognitive/emotional skills; 4) spiritual issues and life values; and 5) preparation for return to work. The CBR group reassembled at three, six, and 12 months after the 1-year rehabilitation. Perhaps as orthodontists we can counsel the patient by educating him in greater detail about what we intend to do in each appointment. We can help the patient realize his/her reactions to various treatment options. We can improve the patients behavioural/cognitive/emotional skills through support via family. With regard to life values we can remind the patient of the reasons why they decided to pursue orthodontic therapy. Finally to return and get through the treatment we prepare the patient through a group communication session with the patient and family.
Stenlund8 also recommended the use of qigong (a variant of tai-chi, which is a Chinese art used primarily for exercise, It is very similar to the Indian Yoga exercises ). The program consisted of three parts: 1) warmup movements; 2) basic movements to affect body awareness, balance and coordination, breathing and muscular tension; and 3) relaxation and mindfulness meditation with self-performed body massage at the end.
As we can all see burnout has become a fundamental issue of our time frame. It is not a factor we can escape and so let us try to embrace it and find ways to combat it. Perhaps a modification of the questionnaire developed by Maslach and Jackson can be used to identify patients with burnout and we can begin the counselling procedures before the patient becomes noncompliant and intractable.
1)Ekstedt M. Burnout and sleep 2005 thesis Dept of public health sciences Division of psychosocial and health factors karolinska institute, Stockholm Sweden.
2) Brondt A., Solowski I. Et al.- Continuing Medical education and burnout among Danish GPs- Br. J. Gen. Pract. 2008;58(546) :5-6.
3) Maslach C., Jackson S.- The measurement of experienced burnout- Journal Of Occupational Behaviour. 1981Vol. 2.99-113.
4) Brezniak N., Ben-Ya’Ir S.- Patient burnout – Behaviour of young adults undergoing orthodontic treatment-Stress Medicine,Vol 5, 1989, Pages: 183-187
5) Plotnick L., Henderson R.- Clinical management of the child and teenager with diabetes- JHU Press, 1998
6) W De Vente1, M Olff2 et al.-Physiological differences between burnout patients and healthy controls: blood pressure, heart rate, and cortisol responses Occupational and Environmental Medicine 2003;60:i54
7) Hoover J. –Patient Burnout and Other Reasons for Noncompliance- The Diabetes Educator, 1983,Vol. 9, No. 3, 41-43.
8) Stenlund T. – Rehabilitation of Patients with Burnout- Thesis, 2009, Dept. of Public Health and Clinical Medicine, Umea University, Umea. 35-36
Dr. Yohan Verghese*, Dr. Hemjith Vasudevan, Dr Geo Francis
Dr. Yohan Verghese (I.B., B.D.S., M.D.S., Ph.D.)
Specialist A Orthodontics & Asisstant Professor Orthodontics
GMC Hospital Ajman – GMU