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The Triple Aim Revised: Financial Shock, Burnout and Imposter Syndrome

The pandemic has revised the Triple Aim framework of health care. The simultaneous triple pursuit of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care is currently not possible. With widespread forced lockdowns, we are unable to provide the optimal patient care experience, the health of the population is declining (limited access, postponed procedures, delayed vaccinations, etc). And while wage reductions and furloughs for health care workers are reducing health care costs, this further compromises the other two aims.


Where does that leave us physicians? We are teetering on the precipice of our own well-being. We have stepped up to the plate to serve because it is ingrained in our very being. Our altruistic selves have come forward, and we have been slapped back by COVID, by leaders decisions beyond our control, and our resilience is wearing thin. The truth is I am tired of flexing, helping, working and thinking. Four weeks into this crazy adventure (it’s not quite a nightmare in my region) and I am exhausted. We try to lift each other up and encourage one another. We acknowledge each other’s sacrifices and we have genuine concern about one another’s emotional, physical and mental health. But, are these enough to prevent a worsening burnout crisis in coming months, especially now that financial strain is added to the mix?


The Self-Worth Challenge

In medicine we are relatively immune from wage reduction. The current income loss most health care workers are experiencing, in order for their employers to keep afloat, undermines our sense of self-worth and may create feelings of inadequacy and a sense of “not being good enough.” At the beginning of this crisis, in my workplace, we were told to reduce patient numbers in our clinics. We dutifully triaged patients who needed to be seen and those who we felt could wait a few weeks. I was dismayed at having to compromise care in this way. Then, when deep wage reductions occurred, my perspective now included feeling devalued and angry.


Reality Distorted

I’m slightly embarrassed to say in my moment of anger over my salary decrease I experienced 9 cognitive distortions. Cognitive distortions are ways that our mind convinces us of something that isn’t really true. These inaccurate thoughts are usually used to reinforce negative thinking or emotions — we tell ourselves things that sound rational and accurate, but really only serve to keep us feeling bad about ourselves.


When I felt devalued and anger about the pay reduction I unwittingly filtered and magnified the negative details of the pay cut without considering any positive aspects of the reduced hours such as increased family time. I overgeneralized and jumped to the conclusion that my pay cut reflected my value to the institution. I engaged in catastrophizing the situation by imagining worse future pay cuts and possible job loss (my anxiety about this is has not completely resolved). I personalized the issue by thinking my administrators did this to me on purpose. I succumbed to the control fallacy, thinking my feelings of being externally controlled meant I was a victim of fate — I am not a victim of fate and I still have choice in what I do. I experienced the fallacy of fairness by becoming resentful, thinking I knew what was right. I blamed senior leaders for my emotional pain and used a “should” statement, telling myself I should have done things differently early on. For instance, I could have continued to see more patients if I would have known patient numbers was going to be the driver for deciding how much my pay would be reduced.


Wage reduction was a hit to my ego. It brought about irrational, unbalanced thinking and my “ancient brain” reacted similarly to the fight/flight/freeze survival response. Please know, I am not dismissing my anger as wrong. In fact, I remain angry at the uncontrollable aspects of this pandemic and I will sit in my mud puddle of rage for a while longer. But, I will not deny my emotions, as I learned to do so well beginning in medical school. Instead, I am committed to responding more maturely, and improving my self-awareness and self-compassion. Otherwise, I will only be contributing to the hot mess we are in.


Burnout and Beyond

When our core emotions are triggered distorted thinking can occur. None of us are immune to these gut reactions. How we recognize them and manage them is the real key to success. Failure to acknowledge and resolve these distortions creates additional stress in the moment, fuels burnout, and promotes the development of imposter syndrome.


As a reminder, burnout is a long‑term stress reaction characterized by depersonalization, cynical or negative attitudes toward patients and colleagues, emotional exhaustion, and feeling of decreased personal achievement. Imposter syndrome (IS) is the feeling of fraudulence experienced by successful individuals who believe that their achievements are undeserved, despite objective evidence to the contrary. IS is also associated with higher rates of burnout, and it is especially problematic because of its association with increased rates of suicide. IS has been reported to occur in 30% of medical students and between 22-60% of practicing physicians.


How does our current situation lead to IS? Physicians are high achievers and most of us, to some degree, have difficulty internalizing our success. Currently, our ability to feel successful is limited. The care we can provide is restricted by the pandemic for a variety of reasons:

  • Patients who need evaluation for non-COVID illnesses have been put on hold.

  • We have limited resources to treat those affected, protect ourselves and to defeat this enemy.

  • We can treat symptoms, but not cure the disease.

  • We are defeated by knowing this is a long-term affliction with herd immunity no where in sight.

For these reasons and many more, we may believe we are delivering suboptimal care Additionally, most of us do not receive enough validation of the work we are doing. Thus, the framework for IS is set as we lead ourselves down the path of feeling inadequate.

Studies have shown social support, validation of success, positive affirmation, and both personal and shared reflections are protective against IS. This is where we need to focus our reserve energy, validating one another despite the limitations we face.


Refusal to Be Reduced

My current rant comes as a warning to my fellow physicians to beware of feelings of inadequacy, of not being good enough, and of the cognitive distortions that can accompany those feelings. In the midst of this health care dilemma we face:

  • Know you are not an imposter, but a highly qualified individual who does good work.

  • Watch for symptoms of worsening burnout in yourself and others.

  • Reach out if you feel overwhelmed or if you see colleagues struggling.

  • Hold one another accountable to thinking rationally by calling out cognitive distortions.


Lastly, remember this quote from Maya Angelou: ”I can be changed by what happens to me. But I refuse to be reduced by it." ­­


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