Burnout in clinical research and how to prevent it
As today is World Mental Health Day, I believe it is appropriate to share some thoughts on the topic and raise awareness about it. Something that always frustrates me is that mental health is still considered taboo, even in today's society. In my experience, the majority of people are still ashamed to talk about it, and at the same time, others feel awkward participating in such discussions. It's as if mental health issues are as contagious as the flu.
What is a “Burnout”?
So, let's briefly discuss what burnout is. Here is the definition: "Burnout is a state of physical, emotional, and mental exhaustion often caused by prolonged periods of chronic stress and overwork. It is typically associated with work-related stress but can also result from other sources of stress, such as caregiving or personal life challenges."
Here, I'd also like to add that the term "burnout" is often used to imply the need for a break - a cup of tea, a long weekend in the mountains, or a tropical vacation. While each of these is beneficial on its own, especially when you're tired and in need of self-care, burnout is a different matter. Burnout is typically a condition where a cup of tea or a brisk walk in the mountains won't alleviate the darkness. Once symptoms of burnout begin to appear, it's too late for prevention. In Bulgaria, we say “Late love for a braid” or “Късно либе за китка”.
Burnout is much more serious than simply feeling tired after a long week. Below, I have tried to summarize what burnout may feel like, although this can vary for each individual. I would also like to mention that I have never personally experienced a deep, full-blown burnout sensation. However, there have been several occasions in my career/life where I have come close to it and noticed the symptoms relatively early.
Dear clinical research professionals, If you find yourself experiencing any of the symptoms below, it might be time for an intervention:
Burnout is a gradual process that doesn't happen overnight, but can creep up on you. The signs and symptoms may be subtle at first but become worse over time. Consider these early symptoms as major red flags indicating that something is wrong and needs to be addressed. By paying attention and actively reducing your stress, you can prevent a major breakdown. However, balancing work, progressing in your career (especially in a competitive field like clinical trials), maintaining a good work-life balance, nurturing relationships, staying active, seeing friends and family, and practicing self-care can be challenging. I understand that it's easier said than done.
Why and when burnout happens?
As we all know, the clinical research field is extremely competitive and fast-paced. From breaking into the industry to managing daily responsibilities and staying up-to-date with trends, it can be challenging to excel in this line of work. Burnout is experienced in all areas and industries, but there are specific factors that are unique to our industry due to the nature of the work environment. While it is difficult to pinpoint a single thing that will push you over the edge of burnout, here are some aspects where burnout may originate in the field of clinical research:
Toxic work culture
A toxic company or toxic work culture can be the biggest contributor to employee burnout. I have divided them into several minor factors, which I classify as a toxic work environment in different aspects.
High Workload: Clinical research can be demanding, with tight deadlines and numerous responsibilities. CRAs often need to manage multiple projects simultaneously, resulting in long working hours, frequent on-site visits and reports, meeting study deadlines, enrolment challenges for each project, and overall high stress levels.
In my opinion, the role of a CRA should not be fulfilled to maximum productivity, such as working 8 hours per day or 40 hours per week. Let me explain why - the CRA role is highly specific and dynamic in nature. CRAs are not only required to travel extensively, when this alone can lead to unpredictable situations like flat tire, traffic jams, road closures, or accidents, which cannot be confined to a 9 to 5 schedule. Once it took me twice the usual time to reach the site, all because of heavy snowfall in the mountains and the fact that I didn't have tire chains. It would have been much faster if I had snowboarded to the site; no carrying space for the OSF on my snowboard however.
Of course, I am well aware of the argument that most employers will respond with: they do not wish to pay a full-time salary to someone working at only 60% capacity. I understand. However, this is not a black and white matter. Very often, CRAs are required to work more than 40 hours per week or exceed 100% capacity. While this is even encouraged in some companies, there are no compensations offered for overtime, not even a pat on the shoulder. Therefore, I believe that once the final timesheet breakthrough comes, the employees are still covering their productivity objectives.
Long and Unpredictable Hours: Being a CRA can involve irregular and long working hours, especially during clinical trials or data collection phases. The unpredictability of work schedules can fairly easily disrupt your so well laid work-life balance. However, as a CRA, you are required to immediately (if not sooner) resolve certain urgent tasks that may arise unexpectedly, such as, but not limited to: SAEs & SUSARs or any patient safety concerns; database cleaning & lock; site staff turnover; unscheduled visits; protocol deviations; study audits & inspections and all sort of site emergencies (let’s not forget about the PI and his Medidata forgotten password).
With that being said, I do admit that there are CROs, that are able to manage the workload for their clinical research associates far better than others (a big shout out to PSI CRO AG CRO AG for understanding and managing this need so well). However, I do have close friends and colleagues who are traveling on site visits 18 out of 20 work days per month. Maintaining such a schedule is dooming both the whole project and the CRA responsible to failure, as this is the fastest track to being unable to juggle all your tasks and not meeting the project milestones, due to constantly being in the field.
Toxic project managers: This is a really important one. I have to admit that throughout my modest career, I have almost never faced a challenge with a "toxic" manager. It's quite the opposite-almost all of my managers have been amazing professionals and mentors whom I look up to.
However, the situation with a toxic manager is painfully familiar to many people, and it is usually the original cause of CRA burnout, switching companies, and in some cases, even professional careers. Remember, people never really leave certain positions but rather toxic work environments. For the most part, it is up to the managers to create a positive work environment.
I have been in situations where, at some point, I felt extremely frustrated, overburdened, and mostly unheard by my manager. I'd like to add to this part that communication with other people is often the most challenging part of the job, regardless of the field. This could happen in both online or face-to-face communication (there are things that could be left unintelligible in both types) and could leave the other person with a bitter feeling after the conversation, simply because you did not express yourself properly, or the other party understood something completely different. In many cases, you could just be lost in translation. Or in rare occasions, the manager could simply be an arse 🤷♀️.
I would advise you to adopt a straightforward approach to things. If you dislike something, bring it up, discuss it, come up with an action plan, and try to resolve it. However, this approach may be outside the comfort zone for many people, who may instead engage in what is called "quiet quitting."
**And if you are interested in reading a practical step-by-step guide on dealing with difficult managers, check out my other article here.
Pressure to Publish: In academia and research institutions, there is often a significant emphasis on publishing research findings. The pressure to produce publishable results can be intense, leading to stress and burnout. This is especially valid for clinical trials investigators who are working on publications or at stages in their careers where they are trying to build their name and reputation.
Isolation and working form home
I am personally a big fan of working from home, as long as it is done correctly and you possess the necessary work ethic and self-discipline to actually perform your job, while no one is watching 😉
Working from home is a blissful experience that was adopted mostly due to the not-so-blissful consequences of Covid-19. I truly believe that this is the future, and modern society is moving closer to location-independent work.
However, like everything else, remote work can become tricky, especially for people with more introverted tendencies. Going to the office, as dreadful as it was, came with a lot of experiences associated with that activity, such as making friends at the office, visiting a certain coffee shop or restaurant in the area, and perhaps going to the nearby gym or having your kids attend the nearby school.
Now, with remote work, you no longer have all these reasons to leave your house. This means that you are more prone to isolation if you don't take the initiative to go out and do stuff. It requires a little bit of extra effort, but at the same time, it is so rewarding to find and dedicate time in your day to go outside, socialize (moderately is enough, after all, socialization is overrated 😛), see some sunlight, and get some physical activity.
Sleep depravation and physical health
Studies have shown many times that sleep deprivation and the lack of physical exercise are proven to be the biggest factors not only for burnout, but also for even more severe mental conditions, like depression, anxiety, and panic attacks.
Did you know that one study proved that driving when sleep deprived is even more dangerous than drunk driving? Now imagine what chronic lack of sleep does to your body and mental health. I feel I cannot stress enough how important sleep is, and how underestimated it is at the same time. Sleep affects all aspects of your life and has a direct effect on your productivity and motivation at work.
*An awesome book that explains the importance and mechanism of sleep is "Why We Sleep?" by Matthew Walker.
And this brings me to my next point - EXERCISE!
Now, the level of physical activity in which you might wish to engage is very different for everyone. For some people, a brisk walk in the park twice a week may be enough. However, for others (like myself), anything less than heavy workouts like CrossFit or HIIT 7 times per week, combined with lighter workout activities such as walking, yoga, running with the dog, or hiking, and of course, some extreme sports like kitesurfing, snowboarding, mountain-biking is just insufficient. However, the point here is NOT to become an Olympic champion in any discipline, but to engage in enough moderate activity to maintain your sanity 😉. This can go a long way, especially in preventing burnout.
How can CRO’s prevent their employee burnout?
Preventing employee burnout in CROs is crucial for maintaining a productive and healthy work environment. Here are some strategies, which I believe could help to achieve this:
Thoughtful Management Selection
Selecting the right individuals for management positions is crucial. Just because someone is a good employee, meeting their KPIs or whatever, does not necessarily mean they will be good managers. In my experience, people management is often the most challenging aspect of any job, and it is a skill that can be acquired like any other. Without acquiring the necessary skills and training for management, you are setting your team up for disaster. Managers should possess strong leadership skills, empathy, patience, vision, and the ability to support their teams when sh*t hits the fan. They should also be able to recognize signs of burnout and provide guidance and resources to address it.
Workload Management
Balancing workloads for clinical research professionals is crucial. CROs should ensure that employees are not consistently overwhelmed with excessive work. Adequate staffing and realistic project timelines can help reduce stress and burnout, as well as facilitate meeting milestones and retaining valuable personnel within the company.
Kill the Micromanagement
Trust your employees to effectively perform the tasks they were hired for. If you don't trust them, then don't hire them in the first place. Micromanagement can lead to frustration for both parties and ultimately create a dreadful work environment. Provide professionals with the autonomy to manage their responsibilities, as long as they meet project goals and quality standards.
Values-Driven Work Culture
Focus on creating a work culture that embraces meaningful values and principles. This includes being part of a bigger cause, promoting work-life balance, and investing in the development of our people. When employees believe in the purpose and mission of their work, they are more likely to feel motivated and fulfilled. Remember, the focus of our work culture is on shared values and a common mission, not just on having free pizza in the office.
What can YOU do to prevent burnout?
Exercise
As I have already mentioned, staying active and getting enough exercise is crucial for your mental and physical health. And both aspects are strongly connected. Exercise helps reduce stress, releases "happy" hormones, elevates your mood and keeps you fit (for carrying loads of monitor folders for your next on site visit).
Drink water
It may sound cliché, but staying hydrated is important for all physiological needs of your body, as well as for your mental health. So remember to drink water.
Stop drinking alcohol
I understand that this statement may trigger some people, and those who know me personally know that I often discuss the downsides (as there are no positives) of drinking alcohol. Hear me out - alcohol has become so normalized in today's society, especially in Bulgaria, that as soon as you find yourself in a social setting and refuse a drink, people start asking if you are sick. Take a moment to let that sink in. There is a social stigma on marijuana and other drug substances, but at the same time, drinking alcohol has been glorified and associated with fun, even though alcohol may have even more severe and long-lasting negative effects on your health. And no, not even one glass of red at dinner is beneficial for your heart, this is bullsh*t.
I won't engage in a lecture on why alcohol is bad. However, if you are interested in the topic or would like to learn more, check out Andrew Huberman's podcast on "What Alcohol Does To Your Body, Brain & Health”.
While alcohol may seem like a great way to manage stress, it actually does the exact opposite - it increases it. Alcohol is also responsible for dopamine spikes, followed by dopamine lows, during which you feel even worse than before drinking. It also has a tremendous negative impact on your sleep, as the quality of the sleep you get is actually a lot worse than when you do not drink. Alcohol also reduces cognitive function and makes you numb, which makes it harder to appreciate the simple joys of life.
Even moderate consumption of 1 glass of wine per day (which, by the way, is indeed classified as moderate drinking) will have negative health consequences, such as liver disease, impotence, and a weakened immune system in the long run. Needless to say, all these factors will definitely impact your mental health and increase the risk of burnout.
Minimize refine sugar intake
Maintaining a healthy diet is essential for mental health in general. However, if there is one single food supplement, that has a massive impact on your mental health, it is the strongest narcotic of all - sugar.
Since ancient times, our ancestors' and our own bodies were designed to always seek out the most sweet and fatty foods they could find. This was an essential mechanism for their survival, as in those uncertain times, they never knew when or from where the next meal would come (or if they would become the next meal themselves). That is why our bodies are naturally inclined to crave the comfort of sugary and fatty foods. This innate craving ensures our survival and satisfaction for as long as possible.
Unfortunately, in modern society, where we no longer hunt mammoths or run from beasts, the abundance of sugar and junk food high in fat has the exact opposite effect on our survival. Excessive consumption is not only the sole reason for cardiovascular disease and obesity, but it also significantly impacts our mental health. Some studies suggest that high sugar intake may affect the body's response to stress. Burnout is often characterized by chronic stress, and sugar consumption may exacerbate the physiological stress response. Refined sugar is associated with mood swings and increased feelings of anxiety and depression. These effects can worsen the emotional aspects of burnout.
Get plenty of sleep
I have already discussed this above. However, I want to add that sleep deprivation was used as a torture technique in the past, and maybe even nowadays, if you were unlucky enough to be detained in a non-government compliant prison located in a no-man's land. Why would you voluntarily torture yourself by staying up late watching a lame TV show or partying all night, only to feel like something dragged in by the cat on the next day?
Practice mindfulness
I know that some people, or at least I do, get this reaction like I want to vomit a bit in my mouth when someone says "practice mindfulness." But this was before I realized that I had a very wrong idea of what mindfulness is. Of course, mindfulness may come in the form of sitting cross-legged on the ground with your eyes closed, taking deep breaths for what seems like hours at a time. But it can also be anything really, that brings your focus inward, towards your own mind and thoughts. I find that self-reflection, identifying and acknowledging what you feel, and approaching stressful thoughts with curiosity rather than criticism, may be extremely helpful during hard times. Mindfulness can be practiced in various forms that help channel your thoughts towards resolving an issue. For example, I find it extremely relaxing and calming to listen to a book and reflect on myself while running or walking my dog, doing yoga, or listening to music or podcasts. Some people keep a journal, others write blogs. Writing is also a great tool to structure your thoughts and revise them until you gain a clear perspective on things.
Stay connected and focus on meaningful relationships
Staying connected and seeking friendship and advice when you are most vulnerable can be extremely helpful. It always helps to have someone to talk to. Sometimes we have the tendency to stay in our heads and obsess over an issue, making it feel like the end of the world. Having a trusted someone to share our negative thoughts with, can be extremely healing and provide a fresh perspective on the issues we are dealing with. You might even discover that you are not alone in your struggles. And we all know that shared struggles are half the struggle - that is why people enjoy group workouts.
Get a dog 🐕 (you can thank me later)
When I rescued my dog, I had no idea what I was getting myself into. Not even a clue. Getting a dog at 22 taught me discipline, taking responsibility, and caring for another being besides myself. Don't get me wrong - it comes with plenty of responsibilities. You need to be able to provide time, space, love, discipline, and dedication to your new furry friend.
But let me tell you - what you get in return is worth every destroyed couch, wall, pharmacology book, etc. (Perhaps, don't get a German Shorthaired Pointer unless you're up for an adventure). Your dog becomes your best friend, your partner in crime (literally), and adventure. They provide an endless amount of fun, playtime, and companionship. Ultimately, they give you a reason to get up and go on an adventure every single day. One simply cannot feel lonely or sad for long, if owning a dog (especially a GSP). In many ways, I believe that my dog was the one who rescued me. Despite the challenges, this was one of the best decisions in my life.
I mean, look at this fluffy face - it’s ADORABLE 😍 They call them emotional support dogs for a reason.
Finally, mental health and burnout are serious issues that should not be disregarded. If you find yourself in a situation where nothing else helps, please talk with friends and family, seek professional help, and do not feel ashamed to address the issue. I have had a very positive experience with the platform Better Help, as it is extremely convenient and you get matched with a therapist who suits your needs immediately.
However, if professional help is something that you cannot afford, I strongly recommend reading some psychology and self-help literature. Here are my top personal favorites that came to mind, but I am sure there are many more good examples:
In conclusion, mental health and burnout are topics that I believe are not being discussed enough. While we are bombarded by images of people who seem to have it all on social media, it is easy to feel like you are the only one experiencing a difficult time. Trust me, you are not alone. We are all in this together. And as challenging as it may seem at times, things will get better if you have the courage to take action. As my favourite fish, Dori says “Just keep swimming” 😊