Medical Science Educator https://doi.org/10.1007/s40670-018-00654-5 COMMENTARY Burnout, Cognitive Overload, and Metacognition in Medicine Morkos Iskander1,2 # International Association of Medical Science Educators 2018 Introduction Burnout in the Medical Workforce The number of physicians reportedly suffering from burnout, An increasing body of evidence suggests that the emotional a phenomenon where the individual appears overwhelmed by burden of working in healthcare is directly linked to the higher tasks usually within their competence, has been increasing risk of burnout compared to the general population [20–22]. internationally [1, 2]. Burnout represents a large burden for This is further supported by comparative studies that have the medical profession, from undergraduate training to the connected the level of psychological stress and related emo- postgraduate world [3–7]. The impact of burnout has effects tional load to burnout, demonstrating a linear correlation be- on physician productivity, although the exact effect remain tween them [23, 24]. The link between burnout and depression difficult to quantify [8]. By extension, a physician suffering has been widely debated in literature, with consensus being from burnout is likely to have ramifications to the wider team difficult to attain. Nevertheless, while the symptom cluster of of colleagues [9]. Evidence suggests that, independent to level depression and burnout tend to overlap, sometimes signifi- of experience, the extent of the relationship between burnout cantly, distinction between the two is possible [25–29]. It is and work extends beyond total capacity and directly affects clear from the evidence that the depression and burnout are patient safety [10–12]. The widespread impact on burnout on connected conditions, which may coexist in a single physi- both the providers and recipients of healthcare is therefore a cian. However, establishing the distinction between them may critical aspect of clinical practice. prove invaluable to direct care and support as required. Factors affecting the phenomenon of physician burnout Recently, evidence for burnout as a distinct clinical entity have been considered in literature, with reported risk factors has emerged from neuroscience. It has been demonstrated that being younger age, longer working hours with high workload, individuals suffering from burnout exhibited a diminished low job satisfaction, negative or poor personal relationships neurophysiological responses to stimuli compared to control and interpersonal demands, job insecurity, and female gender, subjects [30]. Further studies examining the evoked responses as well as a weak association with specialty [13–15]. These to stimuli across sensory modalities have indicated intact path- findings place physicians in common with other healthcare ways at the sensory level, although a comparative deficit ex- professions [16–18]. However, healthcare professions as a ists at the point of directing attention [31, 32]. However, the group stand apart as particularly prone to burnout [5, 19]. deficit is situated at the level of performance at tasks, and did The implication of this suggests that risk factors are shared not appear to be focused on a particular cognitive process [33]. within the healthcare professions. This may also imply that It is therefore possible to extrapolate that the core risk reduction and prevention strategies can be applied across symptomology of burnout does not lie in memory subtypes, the spectrum. Prior to considering the prevention, it is invalu- from sensory memory through working memory and long- able to evaluate the stressors associated with healthcare that term memory. Rather, the functional deficit is situated at the serve to predispose these professions to burnout. nexus of metacognition. * Morkos Iskander Cognition and Metacognition in Burnout [email protected] By utilizing the theoretical framework of cognitive load theo- 1 Department of Educational Research, Faculty of Social Sciences, ry, it is possible to gain an insight into the phenomenon of Lancaster University, Lancaster, UK burnout, and how this affects the individual physician. 2 Health Education North West, Liverpool, Merseyside, UK Cognitive load theory [CLT] argues that task completion relies Med.Sci.Educ. on the complex interplay between sensory inputs, long-term demands, as well as the psychological and emotional factors memory acting as a repository of acquired knowledge and faced. It can be deduced that as occupational complexity and skills, with working memory as the intermediate stage, acting demands increase, with coinciding rise in the emotive strains, to attribute meanings to the sensory information, and deposit the total load placed on individuals rises. The relationship new learned information into the long-term memory [34]. between each aspect of life and the total load, rather the cu- However, while both sensory and long-term memories are mulative effect of professional and personal stresses may be capable of dealing with large volumes of information, the exponential. For physicians, where professional demands are capacity of working memory is comparatively very limited consistently high, the tolerance for additional loads is likely to [35, 36]. Cognitive overload is presumed to occur when this be consistently lower than that for non-physicians. This effect capacity is exceeded, requiring the individual to co-ordinate a is further compounded by physicians being emotionally larger than possible number of elements to accomplish tasks invested in the profession and professional identity. In combi- successfully. Dictating the direction of working memory is the nation, once these stresses reach the level of cognitive load individual’s attention or metacognitive capacity, guiding capacity and exceed it, the physician in question is may be working memory to relevant sensory information, as well as expected to exhibit the symptoms of cognitive overload. appropriate knowledge or schemas in the long-term memory, While the symptoms may vary, they can include increased as well as directing the learning process [37]. rate of errors, inability to carry out activities to a similar com- The value of appreciating the role of attention in managing petence as achieved previously, or a more subtle signs such as the function of working memory has been highlighted in sev- a deterioration in intrapersonal and communication skills. eral studies, indicating that the value added by engaging atten- Reaching the point of cognitive overload is therefore likely tion leads to a higher degree of performance [38, 39]. to be the immediate precedent of burnout. This may therefore Following this line of argument, a physician approaching the allow for anticipation of burnout, with adequate supportive point of cognitive overload may begin to exhibit symptoms interventions instigated. similar to depressive symptoms, with the addition of deteriora- An individual’s capacity for cognitive load is fixed, and not tion in quality or quantity of work, relative to their own previ- amenable to change. We must therefore address burnout from ous standard. While the current understanding of depression is different angles. While it is not practicable to manage a phy- a prolonged affective state of hopelessness and diminished sician’s personal life, we can deduce that the professional ca- functionality, without a clear triggering point, the phenomenon pability is liable to extensive training. Additionally, the provi- of burnout may be distinguished as a self-protective neuropsy- sion of supported practice environments, such that the physi- chological response to attempting to function beyond a fixed cian is not tasked unsupported with clinical situation beyond capacity. Both depression and burnout can however result in a their current competence, would also be protective against reduced ability to function effectively at the normal baseline. cognitive overload. Specific training may be beneficial for Metacognition functions as a method for continuously re- improving metacognition, and thus provide physicians with evaluation, bridging and coordinating the different aspects of the skill set to minimize the risk of cognitive overload and memory function, and therefore directing attention [40]. It is subsequent burnout, tailored to individual practice. It is there- defined as the dynamic skill and judgment regarding the indi- fore imperative to begin specific training targeting metacog- vidual’s knowledge as applied to current situations. From this nition and resilience for medical students, and continue the vantage point, it is evident that the executive role of metacog- program throughout the postgraduate training and beyond. nition in learning continues beyond the acute phase of experi- Finally, we as a profession have a duty of care to our col- ence, and into the construction of schema within the long-term leagues as well as our patients to guard against physician memory [41]. It is significant to note recent systematic reviews burnout. As its symptoms are appreciated we will be in a and meta-analyses concluded that attempting to enhance the position to act as support for our colleagues, recognizing when capacity or function of working memory in healthy individuals they are approaching the point of cognitive overload and in- does not result in significant levels of improvement [42, 43], stituting strategies to assist them. This can only serve to safe- compared to metacognition, which is more akin to