By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SUMMARY POINTS
- Among practicing U.S. physicians, burnout increased from 45% in 2011 to 54.4% in 2014.
- Recent articles from cardiology, gastroenterology, family medicine, and internal medicine have approached this problematic rise in physician burnout.
- The negative effect of physician burnout on individuals, families of physicians, patients, and healthcare organizations is significant; prevention is a priority.
- A meta-analysis of controlled studies revealed the greatest effect is from a combination of organizational interventions, such as structural changes, shifting work to a team-based focus, and enabling increased provider control of schedule and responsibilities.
- Individual interventions also may be helpful in reducing burnout when combined with organizational efforts.
SYNOPSIS: Although different specialties address the problem of physician burnout, studies suggest the most effect is gained from organizational interventions.
SOURCES: Holoshitz N, Wann S. Burnout — There’s an app for that. Helping physicians deal with job-related stress. JAMA Cardiol 2017; Jun. 14. doi: 10.1001/jamacardio.2017.1758. [Epub ahead of print].
Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205.
Lacy B, Chan J. Physician burnout: The hidden health care crisis. Clin Gastroenterol Hepatol 2017; Jun. 30. http://dx.doi.org/10.1016/j.cgh.2017.06.043.
Z73.0 Burnout: a state of physical or mental exhaustion
In 2015, the International Classification of Diseases, 10th revision (ICD-10) “elevated” burnout to a billable diagnosis.1 Burnout — a syndrome developed in response to workplace stressors and often characterized by emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment — is not unique to the medical profession.2 Yet, well before ICD-10, the medical world recognized a growing need for studies of physician burnout; the effect of this insidious condition on the individual provider, family members, patients, the healthcare team, and the healthcare system has too many implications to ignore.
A Brief Historical Perspective
Drug addicts in treatment who stared at a cigarette until it “burned out” prompted psychologist Herbert Freudenberger, working with this population in the mid-1970s, to coin the term “burnout.” In his research and writings, he applied the term to a phenomenon he observed among his colleagues and staff members who exhibited a slow but steady decline in energy, motivation, and commitment to the job, as well as emotional depletion over time.3
Maslach and Johnson extended the work of Freudenberger and, in the 1980s, developed a scale to measure degree and effect of burnout. Notably, the Maslach Burnout Inventory (MBI) remains in use today as one of the few validated tools to measure this state. The team was the first to describe burnout as an all-encompassing phenomenon involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment stemming from the weight of professional stressors and responsibilities.4
Although the scientific literature did not identify burnout until the 1970s, there is evidence that the syndrome existed well before that time. For example, when viewed through the lens of 2017, a 1953 published case study of a psychiatric nurse diagnosed with “exhaustion reaction” would qualify for a burnout diagnosis.5 Popular literature also hints that burnout existed as far back as the turn of the 19th century, with progressive mental exhaustion, disillusionment, and loss of drive plaguing a protagonist in Thomas Mann's 1901 Buddenbrooks (revived as a 2008 movie).3
The bulk of empirical studies in this field began in the 1980s with the development of research-validated tools. By the turn of the 20th century, articles describing “doctor discontent” and low morale pointed to a growth of burnout in the medical profession, with measurements of physician satisfaction declining from 1986 to 1997.6 In response to this problem, in 2001, the Joint Commission mandated that all hospitals have a policy to address the well-being of physicians (distinct from disciplinary processes).7
In 2015, Shanafelt et al published data regarding burnout collected in 2014 from 6,880 U.S. physicians and compared the results to a similar survey from 2011. There was a significant increase in reports of burnout among U.S. physicians — 45.4% in 2011 to 54.4 % in 2014 (P < 0.001); this trend was consistent across 24 specialties.8
In a 2017 survey looking at a national sample of family physicians, Rassolian et al noted workplace factors frequently associated with physicians self-identifying as “burnt out” included the time burden of electronic medical record documentation (especially time spent at home), a hectic pace, and a chaotic work environment.9
Where Are We Now?
This calendar year has seen an uptick in articles and studies regarding burnout in physicians. In the past seven months multiple articles have been published on the topic in both academic and clinical journals. The three selected for review here represent different perspectives across the broad field of medicine.
In “Burnout — There’s an App for That,” an opinion piece in JAMA Cardiology, Holoshitz et al emphasized the consequences of burnout, such as higher rates of drug and alcohol abuse in physicians with burnout and the association with depression and suicide. These authors urged readers to consider mindful meditation or, acknowledging the difficulty of finding time during a busy day, to download a mindfulness app for both instruction and practice of this technique. They cited a Cochrane database study associating mindfulness with improvement in burnout scores among hospital practitioners as well as primary care providers.
Holoshitz et al noted, “Empathy, membership in a caring community of peers, and a balanced lifestyle are central to countering burnout.” Furthermore, they recommended a change in the relationship between healthcare providers and healthcare institutions. They believe such a change should move in a direction to encourage institutions to support individuals in efforts to adjust work schedules, work intensity, and achieve a true work-life equilibrium.
In “Physician Burnout: The Hidden Health Care Crisis,” gastroenterologists Lacy et al presented a case study of a young gastroenterologist with burnout and reviewed the relevant literature discussing risk factors, causes, and treatment. They applied the characteristics of burnout — emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment — to physicians specifically. They noted that a physician with emotional exhaustion may be depleted of compassion, that depersonalization may lead to detachment, and that a decreased sense of personal accomplishment leaves many feeling less able to complete tasks and less satisfied with patient care.
This team also emphasized prevention, noting that being self-aware of the potential for burnout is the first step in prevention. They encouraged physicians to practice self-care, sleep, exercise, and learn to “say no.” When discussing prevention and treatment, they emphasized literature support for organizational interventions, including leadership efforts to create a positive work environment that allows physicians some autonomy and encourages balance, rather than simply filling schedules with more tasks and/or patient time.
In an article in JAMA Internal Medicine, Panagioti et al presented a meta-analysis of studies regarding interventions to address burnout in physicians. They included 19 studies incorporating 1,550 physicians. They identified three main objectives in their study: 1) Assess the effectiveness of interventions to reduce the development of physician burnout; 2) Assess which type of intervention — organizational or individual — is more effective; and 3) Assess if the experience of the physician or type of healthcare setting affects the effectiveness of the intervention.
Table 1 describes several characteristics of the studies. Notably, the number of eligible studies increased from one in 2005 to six in 2015. Although most studies were performed in the United States, many countries, including Canada, Israel, Australia, and several western European countries, were represented.
Table 1: Selected Characteristics of the Studies Included in the Meta-analysis |
||||
|
Year |
Country and Healthcare Setting |
Physician Intervention |
Organizational Intervention |
Physician Experience Years of Practice |
|
2005 |
Israel; primary care |
Educational workshop weekly for three months |
Mean years = 9 |
|
|
2008 |
Australia; oncologists inpatient unit and clinic |
Intensive 1.5-day workshop with role play followed by monthly video conferences |
Mean years = 16 |
|
|
2009 |
USA; pediatric physicians |
Stress reduction seminars |
Mean years =11 |
|
|
2010 |
Belgium; internal medicine residents |
30 hour communication skills training; 10 hour stress management skills |
Mean years = 3 |
|
|
2011 |
USA; ICU physicians |
Revised staffing schedules for 14 months |
Mean years = 8 |
|
|
2011 |
Argentina; pediatric residents in tertiary care hospital |
2.5 hour x two self-care workshops |
Mean years > 5 |
|
|
2012 |
Canada; ICU |
Revised shift work staffing with particular attention to overnight shift relief |
Mean years >10 |
|
|
2012 |
USA; general medicine inpatient |
Revised scheduling (from four-week to two-week rotations) |
Mean years = 4 |
|
|
2013 |
USA; outpatient specialty clinics — residents and fellows |
12-week individual and team-based exercise programs with incentives |
Mean years < 3 |
|
|
2014 |
USA; general medicine clinic |
19 biweekly discussion groups with mindfulness, education, shared experiences. Compensated as paid time by organization. |
Mean years = 8 |
|
|
2014 |
USA; internal medicine interns in oncology inpatient rotation |
5 hours of protected sleep time (12:30 to 5:30 a.m.) for four weeks |
Range of years: 1-2 |
|
|
2014 |
Spain; primary care |
eight sessions of meditation instruction/practice over two months (plus an eight-hour session) |
Mean years =10 |
|
|
2015 |
Spain; mixed specialty clinics |
two-month mindfulness-based stress reduction program |
Mean years = 9 |
|
|
2015 |
Australia; oncologists in major cancer centers |
seven-hour interactive workshop with stress-reduction techniques; follow-up telephone call |
Mean years > 6 |
|
|
2015 |
Australia; first-year interns inpatient |
Three hour-long debriefing sessions and ongoing focus group |
Mean years = 1 |
|
|
2015 |
USA; primary care |
Changes in workflow and focus on communication |
||
|
2015 |
Canada; residents in ICU with overnight duties (anesthesia, surgery, ED) |
Switch from 16- and 24-hour blocks to 12-hour blocks (6 months) |
Range of years: 1-3 |
|
|
2015 |
USA; first-year internal medicine residents inpatient |
18 bimonthly groups with discussions regarding stress, balance, job satisfaction |
Range of years: 1-2 |
|
|
2016 |
Netherlands; primary care |
eight weekly sessions (2.5 hours each) and a full day retreat focused on mindfulness |
Mean years = 24 |
|
Selected Results
Results were interpreted using standardized mean difference (SMD) — a useful measure when comparing multiple studies with a variety of interventions. Sometimes used interchangeably with “treatment effect,” a negative SMD in this case indicates the degree to which treatment is more effective than control. The following guidelines help to interpret the magnitude of effect: SMD = 0.2 small; SMD = 0.5 medium; SMD = 0.8 large.9 (See Table 2.)
Table 2: Selected Results of Meta-analysis of 19 Studies Regarding Physician Burnout |
|||||||
|
Pooled Results of Interventions |
Physician-directed Intervention |
Organizational Interventions |
Experienced Physicians |
Early Career Physicians |
Primary Care |
Secondary Care |
|
|
SMD |
-0.29 |
-0.18 |
-0.45 |
-0.37 |
-0.27 |
-0.39 |
-0.24 |
|
Confidence Interval |
95% |
95% |
95% |
95% |
95% |
95% |
95% |
|
Magnitude |
Small |
Small |
Medium |
Small |
Small |
Small |
Small |
|
Significance of difference between physician-directed interventions and organizational interventions; P = 0.4 |
|||||||
Based on these results and their analysis, Panagioti et al concluded that interventions for burnout in physicians showed evidence of efficacy (“small significant” reduction in burnout.) More specifically, this group noted that organizational-directed interventions have higher treatment effects than physician-directed interventions, and that the most impact has been shown when experienced physicians are involved and when interventions are performed in primary care settings.
These articles demonstrate different approaches to physician burnout: an opinion article promoting self-care; a literature review promoting prevention; and a meta-analysis suggesting that organizational interventions are most effective in combating burnout, but that individual physician effort at self-regulation and mind-body techniques can be effective. Although these articles limited subjects to physicians, the evidence is mounting that advanced practice practitioners are at risk for burnout as well.10
There is little doubt that rigorous, large-scale studies are necessary to further illuminate the path of burnout prevention and recovery. In the interim, perhaps the most significant takeaway message for all practitioners includes the following:
- Be aware of the potential hazards of burnout; think about preventive efforts early in your career.
- Consider “practicing what you preach” in terms of self-care — make time for exercise, eat well, socialize, and practice mindfulness or self-awareness.
- Actively intervene to remind health organizations that initiatives to encourage a healthy work-life balance among all providers will provide benefit to many — not only the individual provider, but also patients and the healthcare system as a whole. Remind administrators of the financial implications associated with burnt-out providers (resulting from potential increases in poor patient satisfaction ratings, high provider turnover, and early retirement, for example.) Work together with practitioners in your own organization to “speak with one voice” to emphasize the importance of preventing and fighting burnout.
- Speak for implementing practical and concrete interventions, such as decreased work loads, reduction of repetitive non-technical tasks, and adjusting work hours to allow time for personal growth and development.
Few of us imagined our lives as physicians would involve struggling with issues of burnout; most entering the profession expect a fulfilling professional career in concert with a satisfying family and social life. Yet the staggering reality of burnout growth in physicians tells us another story. Learning to guard against burnout can help all providers accept the importance of shaping a professional lifestyle that involves elements of moderation, self-reflection, and self-awareness. Just as the simple act of hand washing has critical importance in the complex issue of infection control, developing a basic habit of self-care, including an expectation that provider self-care will be supported actively by healthcare organizations, can become key in stemming the growth of burnout in our profession.
REFERENCES
- 1 ICD10Data.com. Available at: http://www.icd10data.com/ICD10CM/Codes/Z00-Z99/Z69-Z76/Z73-/Z73.0. Accessed Aug. 21, 2017
- PubMed Health. Depression: What is burnout? Available at: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072470/. Accessed Aug. 10, 2017.
- 3Maslach C, Schaufeli WB. Historical and conceptual development of burnout. Available at: http://www.wilmarschaufeli.nl/publications/Schaufeli/043.pdf. Accessed Aug. 10, 2107.
- Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry 2016;15:103-111.
- Muheim F. Burnout: History of a Phenomenon. Burnout for Experts. New York: Springer Science+Business Media; 2013:37-46.
- Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA 2002;288:1447-1450.
- Spickard A. What do we know about physician well-being? West J Med 2001;174:23-24.
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377-1385.
- Rassolian M, Peterson LE, Fang B, et al. Workplace factors associated with burnout of family physicians. JAMA Intern Med 2017;177:1036-1038.
- Waddimba AC, Nieves MA, Scribani M, et al. Predictors of burnout among physicians and advanced-practice clinicians in central New York. J Hosp Admin 2015;4:6.
- Faraone SV. Interpreting estimates of treatment effects: Implications for managed care. P T 2008;33:700-711.
Although different specialties address the problem of physician burnout, studies suggest the most effect is gained from organizational interventions.
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