Burnout among chronic pain healthcare providers is high.¹˒² Known as a response to repeated exposure to work stress, burnout is marked by emotional exhaustion, depersonalization, and low levels of personal accomplishment.³ Hymen and colleagues found that chronic pain physicians reported the highest levels of burnout compared to other specialty providers, namely those providing acute pain management and pediatric or cardiac anesthesiology,¹ with symptoms reported among pain physicians throughout the US and Europe.⁴˒⁵ What is less known is that provider burnout and stigma can adversely impact empathy, which may impact the treatment process and patient outcomes.⁶
Herein, we review the stressors that chronic pain providers face and demonstrate how a personal yoga practice can help buffer provider symptoms, ultimately, improving the delivery of care.
Why is Physician Burnout So High in Chronic Pain Management?
Many factors have been identified that increase burnout and burnout-related symptoms in chronic pain management providers. First, there are overall higher stressors to treating chronic pain.⁷ Chronic pain treatment requires sophisticated and complex interdisciplinary collaboration, and needs to be tailored to the individual.⁸
These challenges are exacerbated by stigma related to chronic pain, which results in underassessment and underestimation of pain by cliniians.⁹˒¹⁰ Additional challenges include a need for greater provider education (there are no independent pain medicine or pain management residencies) in chronic pain care¹¹⁻¹³ (see also, how gaps in training affect pain management nurses). A survey of 117 US and Canadian medical schools concluded that pain education in North America is “limited, variable, and fragmentary” and that there is a need for more innovative and integrated approaches to pain education.¹⁴
Further, there is a general misunderstanding of chronic pain’s root causes. Unlike other medical specialties where assessment can clearly identify symptom etiologies, a longitudinal study found that scans are not always predictive of chronic pain and do not always correlate with reports of pain and pain severity.¹⁵ Further complicating assessment and treatment is the fact that chronic pain is often accompanied by multiple medical and psychiatric comorbidities, including PTSD and childhood trauma.¹⁶⁻²⁰
The result of complex patient presentations and a lack of tangible “successful” treatment outcomes,²¹ often results in clinicians relying on unhealthy coping, such as depersonalization.⁴⁻⁵ Similar to pain, provider coping strategies such as disassociating from emotions and bodily needs, such as the need for rest, can be helpful in the short term but harmful in the long term, leading to compassion fatigue and reduced empathy.⁶˒²²
Signs of Physician Burnout
Signs of burnout can include:
feeling like you are dragging yourself into work most days
finding yourself repeating the same interpretations/instructions/recommendations
beginning appointments late and/or ending early
dozing off or spacing out during appointments
experiencing a noticeable decline in empathy
compromising your ethical decision making
feeling relieved when patients no show/cancel
not keeping up on reading related to the field of pain medicine
offering self-disclose in ways that do not help the patient
fantasizing about a prior or new job where you feel appreciated
How to Reduce Healthcare Provider Burnout
Healthcare providers are often seen as infallible, all-knowing healers.²³ However, it is important that patients see them as they are – individuals navigating the same human challenges. It is important for clinicians, including those in residency or early careers, to manage their stress response and model healthy coping both for their own well-being and to improve patient outcomes.
Strategies to avoid burnout include:
being involved in your own therapy
using consultations and supervisions regularly
belonging to a professional organization
keeping informed about laws and ethical guidelines
continuing education
educating family and friends about your profession
being involved in non-professional activities
finding ways be a part of and give back to your community
taking time off or go on vacation
diversifying your friendships – hang out with others besides healthcare providers
creating a balance in your life – family, work, fun, etc.
maintaining strict work boundaries – take breaks and lunch, leave work on time, stick to appointment times
considering alternative careers if healthcare no longer feels like the right fit
taking care of yourself – mind, body, and spirit
There are practices one can engage in to help take care of their whole selves and reduce feelings of burnout. Mindful awareness and self-compassion are two malleable, attitudinal factors that have been found to reduce stress and increase well-being. Jon Kabat-Zinn, PhD, founder of Mindfulness-Based Stress Reduction (MBSR, also used in patient care) , emphasizes the importance of providers who present with the “essence” of mindfulness.²⁴ To embody the essence of these mindfulness-based approaches, it is important for clinicians to engage in their own mindfulness practices.
Yoga as a Way to Reduce Stress and Burnout
An ancient Ayurvedic system of medicine, yoga includes physical postures akin to stretching and exercise, mindful meditation, mindful breathing, and attitudinal factors such as nonattachment to things, relationships, thoughts, or emotions. Contemporary yoga practice has been found to be effective for a wide range of physiological and psychological problems. Yoga practitioners reported that yoga improved their energy level and happiness.²⁵ Yoga has also been found to increase self-compassion,²⁶ compassion for others,²⁷ and improvements in overall self-concept.²⁸⁻²⁹
Likewise, yoga has been found to significantly reduce self-reported stress and anxiety.³⁰⁻³² Yoga improves physiological markers of stress biochemically through decreases in cortisol³³⁻³⁴ and increases in the inhibitory neurotransmitter GABA. One session of yoga has been found to increase GABA 27%.³⁵ Increases in alpha:delta brain wave ratio and a reduction in the beta:alpha ratio have also been found.³⁶⁻³⁷ One meta-analysis found that yoga significantly reduced systolic blood pressure.³⁸ Further, there is some evidence suggesting that yoga may positively impact heart rate variability (HRV).³⁹
Personal Yoga as a Pathway to Improving Patient Care
As noted, people with chronic pain also frequently present with prior trauma and related psychopathologies. Trauma histories, especially early attachment injuries, impede patients’ ability to form a trusting relationship with providers. Informed by relational theory, a trusting empathic relationship is arguably the most important prerequisite for the effective treatment of patients who suffer from chronic pain with comorbid trauma. Self-compassion has been found to be related to empathy for others,⁴⁰ of which mindfulness is a required component.⁴¹
Thus, increasing provider mindfulness, a vital component of self-compassion, can increase empathy. Further, if clinicians are self-critical, it will be challenging to model the needed attitudinal factors to patients which is the “essence” that Dr. Kabat-Zinn talks about as an important active ingredient in mindfulness approaches.
Mindfulness appears to moderate the relational outcomes of yoga. One study found that positive relational outcomes of yoga depended on dispositional mindfulness.26 It is important to cultivate mindful awareness prior to a yoga practice. Four factors have been identified in mindfulness practice:⁴²⁻⁴³
being accepting/non-reactive
maintaining awareness of the present moment
describing the experiences
being open/non-avoidant
When pain management physicians present with the four factors of mindfulness and engage in yoga practice, they gain positive emotional, social, and physiological outcomes that help reduce burnout and improve patient relationships. These outcomes allow providers to sit with patients’ distress in an open, accepting, and non-judgmental manner. Clinicians are then able to model distress tolerance and psychological flexibility to patients who, in turn, learn to better manage pain catastrophizing through top down and bottom-up changes.
Basic Yoga Poses to Do in the Office or at Home
This short, 15- to 20-minute sequence can be used by clinicians and patients with chronic pain alike. See a video demonstration from the authors, and a detailed description of the poses follows:
opening meditation, stand in mountain pose to bring attention to the present moment
mountain pose and extended mountain pose – link the breath and movement to bring awareness to the qualities of the breath, repeat 3 to 5 times
half sun salutation, linking breath and movement, repeat 3 times
seated or kneeling cat/cow, repeat 3 to 5 times
final meditation in standing, seated, or lying position, 13 minutes
Mountain Pose
The most accessible yoga pose is the mountain pose; it can be done standing or seated.
Stand with the feet hip distance, draw the navel toward the spine and roll the shoulders back, lifting the chest, with the chin parallel to the ground.
Press down through the feet as if they had roots like a tree, grounding them, while the crown of the head reaches toward the sky, creating space and length in the body.
With a soft gaze or eyes closed, focus on your breathing – noticing the pacing and how much air goes in and comes out, perhaps even placing a hand on the belly and/or chest to better focus on breath awareness.
Extended Mountain Pose
The extended mountain pose is mountain pose with the arms raised.
Continue to bring awareness to the breath.
Align your biceps with the ears, palms facing each other, fingers reaching toward the sky.
Inhale, raising the arms up, following the pace of the inhale.
Exhale, while returning arms back to the side body.
Repeated 3 to 5 times; alternate between mountain pose and extended mountain pose.
It is important to note that the movement follows the breath, so this becomes another way to get familiar with the pacing of one’s breath. Again, this can be done in a seated position if standing is not accessible to the participant.
Half Sun Salutation
Breath awareness is continued in a half sun salutation, where participants are instructed to move from mountain pose to extended mountain pose, to a forward fold, hinging forward at the hips, coming up halfway for a half forward fold, then forward fold again, finally returning slowly back to standing. Each movement is linked with an inhale or exhale. This can also be done in a seated position.
Cat/Cow Pose
Come to a table-top position, on hands and knees if accessible, or seated, which helps increase flexibility in the thoracic spine.
Inhale, rolling the shoulders back and lifting the chest, stretching against the kyphotic curve in the thoracic spine (cow pose).
Exhale, moving the shoulders and back round forward, exaggerating the kyphosis (cat pose).
Repeat 3 to 5 times.
Final Meditation
To finish your yoga session, set, stand or lie comfortably for a final meditation. One can use many different types of meditation, but the following is an example of a mindful breathing meditation that one can use:
“Take your attention inward, focusing on your breath. If the mind is very active, place a hand on the belly and/or chest to draw your attention to your breathing. Concentrate all your attention on the qualities of your breath. Notice how fast or slow the inhales and exhales are. Notice how much air comes in and goes out.
Notice when the mind moves away from the breath. Acknowledge the thought and gently bring your attention back to the breath. Know that your thoughts are not you. You are the observer of your thoughts. Be curious about them.
Gently start to deepen your breathing. Slowly bring your awareness back to the space you’re in. Invite some small movements into the body, then gently blink your eyes open.”
Practical Takeaways
Mindfulness and mindful practices, such as yoga, appear to be an important approach to reduce rates of chronic pain providers’ stress and burnout. Yoga has been found to positively impact emotion, cognition, and physiology through enhanced mindful awareness and non-attachment. Pain management physicians and practitioners are better able to serve patients when they embody mindful awareness and non-attachment. This presence important when treating patients with chronic pain, who often have complex presenting problems and require provider modeling of equanimity and distress tolerance.
Physicians who treat chronic pain report greater symptoms of burnout compared to other specialties. Burnout, in turn, adversely impacts the treatment of chronic pain.
Yoga has the potential to reduce the symptoms of burnout in chronic pain providers and increase attitudinal factors that increase provider effectiveness through modeling non-attachment and acceptance.
Mindfulness is an important prerequisite to the positive outcomes of yoga and may need to be improved prior to beginning a yoga practice.
Yoga can be accessible to most people and does not require a lot of time. It can be done is short, 15- to 20-minute sessions as delineated above.