Causes and Cures: Systemic Anxiety and Burnout in O&P

Much has been written recently about the degree of anxiety in healthcare professions resulting in a high burnout rate that was exacerbated by waves of COVID-19. In 2022 alone, nearly 1.7 million healthcare workers quit and 47 percent plan to leave their current roles by 2025.^1,2 O&P has not been immune to these effects. Because O&P clinicians work directly with patients, and patients are often ambiguous about acceptance of their devices, O&P clinicians’ relative anxiety and burnout is somewhat higher than occupational and physical therapists’, just outside the zone of being at-risk of burnout.³

Stress can be defined as the psychophysiological reaction to a real or imagined threat. While threats can be physical, there are often more subtle mental threats such as failing a project, not meeting expectations, letting a patient down, or not meeting your own career goals—basically, anything that causes negative emotions, avoidance, or the need to protect oneself. Anxiety is the long-term exposure to the perception of threats or stress; chronic anxiety, or burnout, negatively affects one’s physical and psychological functioning. The reality is that anyone who functions within a social or organizational structure will have exposure to stress. However long-term exposure, especially when coupled with loss of some level of control contributes to a sense of burnout and learned helplessness.⁴

Learned helplessness is a sense of powerlessness that results when people are repeatedly subjected to random negative feedback that they cannot control. This can affect clinicians and patients when they feel powerless in the face of unreasonable organizational behavior, compartmentalization, departmental politics, unrealistic goals, and hierarchism.⁵

Previously productive employees may simply resign themselves to tolerating their conditions rather than transforming them. Some people are more susceptible to the anxiety around them because they are less differentiated and have porous emotional boundaries. Others have more solid boundaries are less affected this external input.

In a recent burnout survey of 438 O&P clinicians, the average score of the profession was “at-risk” for burnout. About 29 percent or one in three are at the level of burnout that it has affected them psychologically and limited their effectiveness at work. Of those, one in ten were at a severe level of burnout that caused adverse psychologic and even physiologic changes and are considering leaving the field. Demographically, certified prosthetist/orthotists who were office managers at corporate and regional offices with 11-15 years of experience had the highest levels of burnout. The reasons given included increased patient volume demands, management pressure, helplessness with reimbursement, and career disenchantment.⁶

While the number of patients has not increased appreciably in 20 years, the documentation requirements have more than doubled, limiting the actual time with patients discussing their needs.⁷ Management was cited as a source of burnout because of the pressure for revenue and that clinical skills were not valued. Additionally, many clinicians felt powerless to control the payers’ behavior, who determine pricing and whose arbitrary denials seem to indicate they do not value patient care.⁶

What was particularly concerning was the level of burnout by experience among younger clinicians. Although the highest levels of anxiety were seen at the age group with 11-15 years of experience, commonly seen in other surveys, the second highest level of burnout was seen at between zero and five years of experience, a time when burnout should normally be at the lowest. Clinicians indicated many reasons that included high debt ratio, variable residency quality, and disenchantment with their clinical role compared to the expectations established at school.⁶

This was compounded by the unintended consequence of combined orthotic-prosthetic residencies that increase the amount of knowledge they are trying to learn. In the past, residencies were focused on prosthetics or orthotics first then on the other discipline later. The effect of the increased learning load may force the learner to focus on just one solution rather than develop multiple solutions. The particular concern is what happens when this younger group approaches the typically challenging career happiness trough of 11-15 years. Many also see colleagues in other professions with master’s degrees achieving greater salary and benefit levels than in O&P.^4,7,8

Individual and Systemic Effects

At first glance, the most concerning aspect of anxiety and burnout may be an attrition rate among residents and younger clinicians, which is difficult to ascertain depending on personal or contextual effects. Some have estimated this to be as high as 15-18 percent. However, there could be deeper negative effects at the personal and organizational level.

Chronic stress or burnout has long been known to contribute to mental and physical disease processes. One of the most dramatic is thinning of the prefrontal cortex that helps us to act appropriately, provides insight, and provides complex decision-making and abstract reasoning rather than concrete or habitual responses. Burnout impacts our ability to pay attention and retain memories, making it harder to learn new things and increasing the risk for mistakes.⁴ Burnout also physically enlarges the amygdala, which controls fight-or-flight response. This creates a doubly negative effect. While the prefrontal cortex is getting thinner and weaker, the lower order brain function that exhibits poor decision-making, anxiety, and fear gets larger and stronger, and the world seems more harmful than it is.⁹ This directly influences how we overestimate the risks associated with any innovation.

Kahneman refers to this as System 1- and System 2-type thinking. System 1 is the reactive and impulsive brain that makes instant decisions that are immediate, but are inherently flawed. System 2 is much more insightful, creative, and thoughtful, but slower in nature. When we are busy reacting to perceived stress, we make more judgement mistakes. When individuals or organizations are constantly under threat because of its members being burned out, they are prone to make more mistakes and make poor gambles or choices associated with innovation.¹⁰

Within the group network, the anxiety is transmitted among the members with varying levels of differentiation. Often one member of the group system receives an inordinate amount of group anxiety and may exhibit higher levels of burnout and physical symptoms. Many times, this person may call in sick more often, bearing the burden of everyone’s anxiety.⁴

This systemic anxiety influences how readily members of the group take risks that are inherently part of innovation that can be any new process, product, or concept. The healthier a group is, the more they pursue these novel ideas. A tightly bound and fearful group keeps its members in a tight orbit and prevents future developments.⁴

O&P clinicians are no different. In a comparative analysis among different levels of experience, the burnout rate was compared to a measure of innovation called the technology readiness index (Figure 1). In terms of technology optimism, which measures how hopeful a person is regarding technology, there was a very high significant relationship with burnout. This may mean that people who are burned out look to technology to save them, maybe even to an unhealthy level. There was a strong inverse relationship with technology innovativeness or tendency to implement a technology first. That meant that people who are burned out tend not to be the first to implement the technology. They want it to a high degree, but don’t want to take on the risk.¹¹

This relationship between anxiety and technology can also be back driven with the cadence of innovation and positive attitudes toward innovation lowering group anxiety and reactivity. This means that managers who introduce more innovation and maintain a positive attitude toward innovation lower the group’s anxiety. It’s not that the group isn’t anxious and doesn’t argue, it’s that they know how to argue well and can self-regulate an increase in the group’s capacity for the chaos and risk that innovation provides.⁴ Anecdotally one can see this with students. When they are busy with projects and learning, there is greater collaboration and little time for interpersonal strife. This also points to the hope a curriculum could help them.¹³

Clinicians Lead a Double Life

Within any O&P organization there are at least two main communication pathways that mimic other technical or clinical organizations. One pathway is the human-relational pathway that includes the skills of communication, relationships, and perception. These people are typically comfortable with the undefined questions and seek to grow interpersonal relationships through personal contact. This pathway engages the activities of human connection and is most often represented by the areas of sales, marketing, and management. This group typically feels a sense of reward with revenue, bonuses, and public accolade for their efforts.¹⁴

The other pathway is the processual-technical pathway that is adept with defining tasks, methods, and innovations. They pride themselves on clear and definitive decision-making to make structural and processual changes and are typically teachers, engineers, and accountants. They are rewarded with greater autonomy, being respected by peers, and seen as effective. They will take bonuses and other transactional rewards but find greater pride in being highly regarded.¹⁴

Clinicians exist somewhere in the middle of both pathways because they are academically trained to consider research, engineering, and medical science, but are often evaluated in terms of the revenue they generate and the people they can manage. They may prefer to hold up their clinical outcomes data, areas of specialization, and use of new innovations to other clinicians, but in terms of management, it may come down to the revenue produced, speed of documents, limiting raw material use, and decreasing work in progress. This creates a gap between how clinicians value themselves versus how their contexts value them. They are simply not rewarded in the way they seek rewards and are incentivized for activities that they do not find satisfaction in. Often this means that clinicians will jump at nodal points in their careers between the business and clinical career ladders.

The Cost of Being the Face of the Organization

When I was a young O&P student, my instructor, Gunther Gehl, CP, advised me: “When you are with a patient you must show confidence. They must trust you personally, so when they take a step forward in space, they need to trust that their prosthesis will be there for them, even when they are unsure. So, even if you don’t feel confident, try to appear confident. As clinicians we must ‘sell’ confidence. Good, now go!”

Clinicians’ roles as patient coaches and advisors place a great deal of personal pressure on us. We accept this readily, but it can be challenging when we feel we are taking a risk. This sense of dissonance in representing our skill on behalf of the organization is termed emotional labor.

This is described as “the management of feelings to create a publicly observable facial and bodily display.”¹⁵ An example is flight attendants who are asked to provide “service with a smile” to personify the values of the organization. Employees in healthcare, retail, and other service industries such as O&P must also suppress their individual feelings and opinions, to create not only a professional environment, but one that is warm and friendly to even the most difficult people. Clinicians will often exhibit a halo bias or an overly optimistic estimation of their abilities, which may be forgivable when hoping for the best possible outcome for a patient but may be disheartening when those goals are unfulfilled.

This gap between the individual’s genuine feelings, and those required by the organization that may or may not support those values, often cause internal dissonance that leads to forms of resistance. Managing the ideological requirements of work with individual autonomy may require greater awareness and emotional intelligence.¹⁶ This is “the capability of individuals to recognize their own emotions and those of others, discern between different feelings and label them appropriately, use emotional information to guide thinking and behavior, and adjust emotions to adapt to environments.”¹⁶

The Quiet Quitting Response

To take back some measure of control, many employees may exhibit a form of quiet quitting, which is a term defined as the private decision to intentionally reduce effort devoted to a job, especially duties that go beyond those specifically identified, without notifying one’s boss or manager.¹⁷ Among O&P clinicians, this was not true of a majority of respondents, with 31 percent indicating they do not practice quiet quitting and 48 percent admitting they rarely or sometimes pull back from activities for work-life balance (Figure 2). However, 15 percent indicate they quietly quit often or regularly, which closely corresponds to the percentage of people severely burned out. Among the same group, 11 percent admit to cutting back at least 30-50 percent in their jobs, while 28 percent admit they only do what is explicitly defined in their job description or less. By experience, the 16-20 years of experience group have the highest rate of quiet quitting, whereas the group of 11-15 years of experience have the highest burnout. This could be that the slightly older group has learned to modulate and adapt their output after their disappointment in their careers. In the comments, most agreed that quiet quitting was a real concept, but there was some disagreement if this was a generational issue, abuse by management, work-life balance, burnout, or residual effects of the pandemic.¹⁸

The highest rated statements, out of five, were: “If I worked harder my reward would probably be more work” at 3.29; “I am trying to limit how much work affects by work-life balance right now” at 3.24; followed by “I feel burned out at work” at 3.01. Although, when asked what would appeal to them most, 33 percent chose the same job but more money, and 25.4 percent said a higher-level job and more money. Thirty-six percent said they are interested in a career change or retirement, which is somewhat concerning. More money and more time off were listed highly when asked about “number one and number two ways that could help motivate you,” at a score of 1.59 and 1.56, but also highly listed was “more professional development,” at 1.58 and “greater chance for promotion,” at 1.53. This would seem to say that development and being recognized are equal to pay and benefits.¹⁸

Since there were so many statistically significant correlations, it appeared that quiet quitting could only be observed as a symptom, but it arises from a variety of reasons. The most predictive factors were based on self-assessments of how hard they work, percentage they have cut back, how much they contribute, and work-life balance, meaning that quiet quitting was intentional and not an unconscious behavior reaction. People know what they are doing.

Creating the Curriculum For Change

How do we help create programs that increase career attractiveness, increase toughness, and optimize a sense of fulfillment? One thing is to understand that clinicians, like people in any other profession, require different things as they matriculate through the timeline of their careers (Figure 3). At Stage 1, clinicians begin the role of followership after they graduate. They need time to learn about their own interests and their value. Stage 2 is as a valued collaborator to cooperate within a team to support others as well as learn to grow to provide the foundation as a specialist. Stage 3 is as an instructor to both learn greater interpersonal people skills, but also solidify clinical knowledge by teaching concepts to others. Next is Stage 4 as the manager to lead teams with greater departmental or office goals as well as providing goals for others. At Stage 5, you begin to act as an influencer of people as well as other departments for a common organizational goal. Finally, the next stage is as a leader of groups where you spend less time personally doing tasks and function more as a coordinator. You define not only tasks, but what the mission and vision are to accomplish them.¹⁹

When I asked a clinical group, “What is the one skill you personally would like to invest in?” they listed business practices, developing referral sources, business development, upper-limb casting, diagnostic understanding, digital tools and alignment, organizational psychology, leadership practices, group culture, and learning styles. If you notice, many of the needs were not necessarily core clinical skills, but those that may not be covered in traditional O&P programs. Just like physicians who then pursue master’s degrees in business administration, many O&P clinicians desire instruction in tasks that provide the greatest anxiety.²⁰

First, the clinical leaders were asked to prioritize what skills new employees should be more proficient in, and then they were asked what skills they felt most competent to provide (Figure 4). The difference or gap between the two would indicate things they felt were important but least likely to provide. The areas of the biggest leadership delta were communicating effectively in the clinic setting, ability to lead a clinical team and projects, ability to build clinical expertise and credibility, and developing business revenue and awareness. The comments also supported this finding.²¹

This emphasis on communication, project management, process, and quality led me to consider the curriculum of engineering management. It uses the problem-solving logic of engineering and applies it to organizational, administrative, legal, and planning activities of management to optimize performance of technically driven organizations. This applied, rather than theoretical, curriculum emphasizes many of the same needs expressed in terms of analyzing, organizing, managing, innovating, resource allocation, planning, adapting, and business strategy that clinicians identified that major hospital systems utilize.²¹

The 12 domains of engineering management are separated into four major areas and among these the priorities were set. A survey was created for a professional clinical group to rate the importance of each domain (Figure 5).²² In terms of leadership and organization, number one was leadership practice (traits, skills, and communication), and number two was innovation management (process, decision, and proliferation). In operations and accounting, number one was financial resource planning (income statement, balance sheet, and cash flow) and number two was project management (prioritization, process tools, and implementation), and in healthcare business and revenue development number one was market development and referrals (analysis, messaging, and marketing) and number two was billing and reimbursement (L-Code system, appeals, and strategies). Finally, the technologic areas were adapted slightly for clinical decision-making and the winning instruction was clinical decision-making and factor analysis (determining prioritization, and decision structure) and instructional design for clinicians (contexts, techniques, and instructional process).

When asked in a comment section, “What two classes do you need today immediately?” the practitioners indicated market development, building referrals, leadership, organizational structure, decision-making, and innovation management. Unexpectedly, outcomes and research were not chosen at a high degree (Figure 6).²¹

In terms of technical skills, practitioners prioritized, in order, socket systems, digital scanning and printing, microprocessor knee prosthetics, and digital tools.²¹

By building these areas of expertise, we can bolster the inherent weaknesses that are present in O&P and provide the foundation for real rather than imagined success. This professional development needs to occur not only at the beginning of one’s professional career, but during the entire timeline. With this innovation cadence, periodic review, and objective improvement, organizations can help retain the brightest and best clinicians that will define future performance.

Gerald Stark, PhD, MSEM, CPO/L, FAAOP(D), is the director of clinical affairs for Ottobock Patient Care in Austin, Texas.

Read more in “Relationships and Innovation” in EDGE Advantage.

References

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3. Stark, G., (2021, June). Clinical Burnout in Prosthetics and Orthotics. DOI: https://opedge.com/oandp_l/clinical-burnout-in-o-p-results-are-in-6-22-2021/
4. Stark, G., (2016). The relationship of the attributional dimension of emotional differentiation on attributional dimension of technology readiness for orthotic and prosthetic clinicians. (Doctorate of Education). University of Tennessee at Chattanooga, Chattanooga ,Tennessee. DOI: https://scholar.utc.edu/cgi/viewcontent.cgi?article=1641&context=theses
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8. Stark, G, (2019, December). Does the prosthetist’s generation affect transfemoral interface choice? O & P Edge, Loveland, Colorado. DOI: https://opedge.com/does-the-prosthetists-generation-affect-transfemoral-interface-choice/
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18. Stark, G., (2023). Survey: Quiet Quitting in Orthotics and Prosthetics. Signal Mountain, Tennessee.
19. Parnes, R., (2021, October). The 6 stages of career development, and courses to help evolve your skill set. LinkIn. DOI: https://www.linkedin.com/business/learning/blog/career-success-tips/6-stages-of-career-development-evolving-your-skillset
20. Stark, G., (2022, May), Clinical Leadership Academy Survey. Signal Mountain, Tennessee.
21. Stark, G., (2022, July), Clinical Leadership Academy Priorities. Signal Mountain, Tennessee.
22. Shah, K., Nowocin, W. (Ed.). (2019). A Guide to the Engineering Management Body of Knowledge (5th ed.). Huntsville, Alabama: American Society for Engineering Management.

Opener Credit: Vaobullan/stock.adobe.com