We talked to editorial member Brett T. Litz Ph.D. about our recent post on doctor burnout. He wrote us an insightful piece about burnout from a military perspective.

Unfortunately, the term “burnout” is loose and too easily misapplied or trivialized.  Response to chronic stress and strain and acute high magnitude events in the medical community is a serious matter.  I see it as analogous to the continuum of stress reactions that arises from military service and I believe that schemes used to operationalize these reactions will lend clarity to the discourse in the medical community.

In the military (and other high demand, high stress occupations), there are putative zones of responses to cumulative adversity, strains, conflicts, traumas, losses, and moral and ethical challenges.  In the military, there is general consensus that there is a distinction between in the

  • The green zone, which entails performing at a high level and being “good to go,”
  • The yellow zone, which entails reacting to stress in a normal manner (e.g., transient high levels of arousal, hypervigilance, and alertness and so forth),
  • The orange zone, which entails stress injury, and
  • The red zone, which is mental illness, such as posttraumatic stress disorder (fig. 1).

There is nothing wrong or abnormal about yellow or an acute stress response to intense challenges; this is not burnout. However, the orange zone is.  This is a non-normal state that is pre-clinical or sub-syndromal but serious. It is a response that needs to be identified by peers and leaders / supervisors, and the medical personnel who are experiencing it.

  • In the orange zone, a professional is “not themselves,” they may be detached / dissociative (not really present or engaged), substantially over-reactive, quick tempered, and so forth.
  • Stress injury or burnout involves systemic dyscontrol and disinhibition.  In the military, the service member is not mission ready, they are not capable and they might endanger others if this is not recognized and responded to.  There is a similar risk in the medical community.
  • Decision-making and problem-solving would be compromised and patient care will suffer unless something is done.  There is a need for early detection and intervention, in this case, what is called indicated prevention (fig. 2, Institute of Medicine Prevention scheme).

In the not too distant past, work contexts and organizations would use psychological debriefing and crisis counseling to help anyone who is exposed to a very serious work incident, for example, a suicide by a patient or an assault.  This is a form of selective intervention and there is no evidence for its efficacy.  By contrast, there is good evidence for indicated prevention.  In the military, it entails intervening early when service members have been exposed to a trauma, loss, or a serious moral and ethical challenge and they are manifesting pre-clinical or subsyndromal PTSD (orange zone behaviors).   The medical community would do well to adopt this scheme.

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