Physician Burnout: Causes and Prevention
The data is indisputable: Physicians across the globe are emotionally drained and overworked due to increasing demands on the profession. Numerous global studies indicate that one in every three physicians experiences burnout at any given time. Originally used by Herbert Freudenberger in 1974 and subsequently described by Maslach et al. in the Maslach Burnout Inventory Manual (1996), burnout has been called a stress syndrome.
In May 2019, WHO referred to burnout as “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”.
Physician burnout: a global dilemma
Estimates of burnout in physicians often yield high figures and vary between countries, across time, specialties, or sectors, i.e. public/private or rural/urban. The Physicians Foundation’s 2020 Survey of America’s Physicians reported that 58% of physicians had burnout. The 2021 Medscape National Physician Burnout & Suicide Report reported 42% of physicians had burnout. While the figure is stable from the previous year’s report, the COVID-19 pandemic has altered the landscape drastically. It was found that women physicians experience more burnout than men; the burnout rate showed a 3% increase (from 48% to 51%) during the pandemic.
Burnout’s three cardinal components
Burn-out involves three interrelated components:
Exhaustion. It prompts physicians to distance themselves physically, emotionally, and cognitively from work; makes them easily become irritable or downhearted; it may also affect their capacity to be involved with, and responsive to, the needs of patients.
Depersonalization. Also known as “compassion fatigue”. Depersonalization is a stage where physicians become emotionally numb and develop an indifference or cynical attitude toward their patients.
Lack of efficacy. Exhaustion or depersonalization interferes with effectiveness. It makes one doubt his or her efficiency in helping patients with their problems.
How is physician burnout measured?
Grading the severity of burnout is inherently difficult because (1) it is an internal experience that can only be described by the person suffering from it and (2) it is a continuum rather than a binary state.
The Maslach Burnout Inventory (MBI) is the standard tool used to measure physician burnout. The MBI’s Human Services Survey for Medical Personnel (MBI-HSS MP) is a 22-item survey that delineates burnout according to three components:
- Emotional exhaustion: Includes 9 items with a score range of 0–54. A score of <19 indicates low burnout, 19–26 moderate burnout, and >26 high burnout.
- Depersonalization: Includes 5 items with a score range of 0–30. A score of <6 indicates low burnout, 6–9 moderate burnout, and >9 high burnout.
- Personal accomplishment evaluation: Includes 8 items with a score range of 0–48. A score of >39 indicates low burnout, 34–39 moderate burnout, and <34 high burnout.
The survey records responses on a 0-6 scale of “Never”, “A few times a year or less”, “Once a month or less”, “A few times a month”, “Once a week”, “A few times a week”, or “Every day”. However, the cutoff criteria of what represents burnout and where to delineate (low, medium, or high levels of burnout) are subjective.
Despite its acceptability, the use of the full MBI has raised conceptual issues and many researchers reported this ‘structured interview’ tedious and unreliable to use in assessing burnout outside of structured studies. Furthermore, West and colleagues reported that compared to the full MBI, single items measures of emotional exhaustion and depersonalization exhibit strong and consistent associations with key outcomes (e.g., suicidality, perceived major medical error, serious thoughts of dropping out of medical school) in medical students, internal medicine residents, and practicing surgeons.
Alternative measures of burnout
Several different kinds of assessment tools have been proposed to measure physician burnout. McManus applied a three-item assessment to study how personality and learning style determine stress, burnout, and doctors’ attitudes to work but it lacked strong validity evidence. Schmoldt and colleagues introduced an alternative non-proprietary single-item approach in a survey of HMO physicians. Rohland et al., compared this method with the full MBI-HSS in a cohort of 307 Texas medical school graduates. Similarly, Hansen and Girgis also compared the single-item measure in a survey of 740 Australian oncology professionals. Despite the difference in sample size and populations, both studies showed identical psychometric results.
Physician burnout measures independent from the MBI approach such as Copenhagen Burnout Inventory and the Oldenburg Burnout Inventory also exist.
Impact of physician burnout
A high level of burnout can have negative impacts on the following:
Patient care access
There is good evidence that physician burnout can compromise patient care. Burnout results in more doctors cutting down their practice hours, entering early retirement, taking a non-clinical job, or even leaving the medical sector.
Demoralized doctors lack empathy, decision-making skills, and proper patient-peer communication. This translates into poor bedside manners, reduced patient satisfaction, failed interpersonal relationships, and poor patient outcomes. They can also make errors, sometimes fatal.
Some studies reported an increased risk of malpractice among physicians who keep working despite the burnout.
A 2014 study of ICU doctors predicted a higher mortality rate among patients they cared for. According to a systematic review by Carolyn et al., “there is moderate evidence that burnout is associated with safety-related quality of care.”
Healthcare facilities with physicians experiencing burnout are likely to see higher untimely resignations and lower productivity. Furthermore, the institutions may be forced to operate understaffed, putting more stress on the already overworking physicians; end up paying for a doctor’s mistake or mistreatment of the patient(s), or a PR crisis. In certain instances, the cost to replace one physician can go up to $1 million, depending on the specialty, location, and expertise level of the physician. Consequently, it will not only increase the operational expenses of health systems but the overall cost of care.
Physician’s Health and well-being
Provider burnout clearly affects patients and the healthcare system greatly, but sometimes personal lives of the doctors can be overlooked. The depression, anxiety, or lack of self-confidence that a physician may be battling due to burnout at the clinic can easily transcend into more intimate parts of life.
Sleep deprivation and physician burnout go hand-in-hand. Lack of sleep puts stress on personal relationships, impairs cognitive skills, and increases error rates in intensive care units, according to research.
Burnout puts a physician at an increased risk of anxiety, depression, disruptive behavior, or mood disorders, not to mention alcohol/drug misuse and suicidality.
Lastly, burnout impacts dietary habits resulting in diabetes, obesity, heart disease, and some cancers.
Causes Of Physician Burnout
- Chaotic work environment. The practice of health systems in the U.S. today is volume-driven i.e the more patients per day, the shorter the visits will be. This prevents the physicians from providing the ‘right’ type of care. On top of it, there are unrealistic call schedules, local health care politics, personality clashes in the clinic or specific department, and compensation formula.
- Interrupted personal life. Situations that (a) eliminate a physician’s opportunity to recharge his or her energy account and (b) put a strain on personal or social relationships. Frequent schedule changes, emergency cases, and more after-hours time, for example.
- Bureaucratic tasks. While Electronic Medical Records (EMRs) allow better diagnostic and treatment plans, they can also be time-consuming and interfere with the face-to-face time that a patient and physician have together. Arndt et al. reported that a primary care physician spends nearly 6 hours interacting with an EMR during the clinic day. More than 40% of baby boomer physicians reported EHR to be the primary reason for burnout.
- Too little pay. Financial stress is one of the major contributors to provider burnout. In the past, a few physician burnout studies addressed compensation strategy, but not actual compensation or physician finances. When asked the interventions that reduce burnout about 35% of Medscape survey respondents selected “Increased compensation to reduce financial stress”.
- Negative leadership: Shanafelt et al. reported a direct relationship between the leadership quality of the boss and work satisfaction levels. In the healthcare industry, having an ‘absent’ or ‘unskilled’ boss is common. Meaning, physicians, especially juniors, have one more reason to fall prey to burnout.
Interventions That Can Help, Stop or Prevent physician Burnout
Prof. Colin P West from the Department of Medicine and Department of Health Sciences Research at the Mayo Clinic suggested both individual- and organizational-level interventions to reduce physician burnout.
Strategies at the individual level or self-care
Self-care means identifying a few ways to lighten the load and giving it a personal touch. To start, try prioritizing the tasks, delegate if needed, leave work at work, and most importantly, talk to your team and let them know you need some support.
Say ‘no’ and set clear boundaries’ concerning the scheduling, patient volume, and workweek. Accepting too many commitments and not delivering them can cause burnout.
If interrupted personal life contributes to burnout, pay attention to your needs, do what makes you happy, make time for loved ones, practice self-compassion, try mindfulness practices or yoga, and focus on a healthy lifestyle with exercise and adequate sleep. Alone time is important, too.
Strategies at the organizational level
Healthcare systems should invest in leadership development; hiring leaders who will listen to, motivate, and lead doctors will reduce physician stress levels and ensure job satisfaction.
Solutions to mitigate technological burden might involve providing more comprehensive training, streamlining the EMR system, or even hiring medical scribes to take over charting.
Because the physical environment can impact the overall well-being of physicians, hospitals should be designed to include rejuvenation spaces, group function areas, or rest pods.
Many healthcare facilities are infusing Artificial Intelligence (AI) and robots to improve operational flows and maximize patient-physician interaction hours.
Physician burnout has an adverse effect not only on patient care, but also on the well-being of physicians and the future of healthcare systems. Through foresight and thoughtful interventions burnout can be reversed.
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