Physician Burnout - Treating Physicians

Physician burnout is a world-wide phenomenon that has increased during recent decades. Various sources report that roughly half of physicians display burnout symptoms. This article looks beyond past burnout stereotypes to its global definition, associated signs, and contributors. Assessment resources and methods are presented and discussed.

Although article content touches on the overall risks burnout presents within healthcare systems, the primary focus is on those physicians at risk for and suffering because of burnout’s toll. Heightening awareness of this occupational phenomenon is required to identify and research solutions, particularly by linking contributors with systems and organizational function.

Burnout BasicsThe history of burnout dates back to the 1970s and 80s when Freudenberger described a set of symptoms as “burn-out.” Maslach has provided further discussion and study of this phenomenon, including its occurrence among medical personnel. Regardless of occupation, Maslach and colleagues describe three definitions, or indicators, of burnout, those being:

• Emotional exhaustion,
• Depersonalization, and
• Low personal accomplishment.

Each of these three definitions is associated with various signs discussed in burnout literature and included in the World Health Organization (WHO) description. It notes that burnout is an occupational phenomenon that is listed in the International Classification of Diseases (ICD). The ICD-11 has added detail to the definition provided in the ICD-10. The updated definition includes signs found throughout burnout literature, such as:

• Energy depletion,
• Mental distancing from work, often with associated cynicism, and
• Reduction in professional efficacy.

WHO makes particular note that burnout is not a medical condition. Rather, it refers specifically to phenomena in the occupational context and is not appropriate for application to other areas of one’s life. This point is especially vital when considering burnout contributors, much as occurs in this article’s primary section.

Various relatively current sources indicate the rate of reported and/or assessed burnout at almost 1 in every 2 physicians. In a 2019 report, 44% of more than 15,000 physicians in at least 30 specialties reported to Medscape that they feel burned out. This reflects a steady increase since 2013.

Levels of burnout across specialties range from 28 to 54%. Women are more likely than men to report burnout with data comparisons of 50 to 39%, although males accounted for 60% of survey respondents. Self-report of burnout, as applied in the Medscape report, has been noted to have an accuracy rate 72% of the time when compared with the Maslach Burnout Inventory. Although this is older data, it is worthy of consideration given the proportion of physicians reporting burnout at an increasing rate.

Burnout: Its Definition and How It’s Assessed    This article’s opening paragraphs provided burnout definitions presented by Maslach and the WHO as part of an overview discussion. Burnout assessment involves expanded discussion of its definition with particular emphasis on how it is described by those living with feelings associated with burnout.  

Definition Overview
Although emotional exhaustion has been noted to be a primary burnout indicator, others report that depersonalization is more likely associated with negative outcomes. These physicians have high cynicism scores, reflective of being detached and uncaring. Those who score high in emotional exhaustion report feeling over-extended as well as physically and emotionally drained. A high inefficacy score is related to physicians having diminished confidence and doubting that their work matters. It is reported that healthcare burnout researchers omit low personal accomplishment, replacing it with job satisfaction measures.

Burnout Assessment
The National Academy of Medicine (NAM) provides information about valid and reliable instruments for measuring burnout and other related factors. The page links to sources that offer additional guidance for organizations. It presents the most commonly used assessment as being The Maslach Burnout Inventory (MBI) that assesses the three areas noted above and measurement of workplaces factors that may be contributing to burnout.

Mind Garden offers the MBI and other assessments. The Maslach Burnout Toolkit for medical personnel includes, as part of its survey, items that measure work environment factors that may contribute to burnout. The entire assessment, including workplace and individual measures, can be completed in about 30 minutes. Discussion presented by the NAM and other researchers indicate successful use of a limited number of MBI queries to improve response rates.

Woven within discussion in the resources presented thus far are burnout contributors. Given that about half of physicians report regular feelings of burnout, there is compelling need to examine contributing factors. Doing so leads to inquiry that ultimately can provide solutions.

Burnout: The Burden of ContributorsThis article examines contributors that are systems and/or organizational in origin. Doing so is well supported in medical burnout literature, including resources cited here. Consider that burnout among physicians is double that of other American workers, even with controls applied.

At times, this discussion seems personal. That is because loss of sleep, financial concerns, and extended work hours are just that—very personal. As are concerns about depression, coping mechanisms, and work/life imbalance.

The 2019 Medscape report asked respondents to report on what contributed most to burnout. Almost 60% indicated this to be too many bureaucratic tasks including charting and paperwork. The next highest ranked at 34% was too much time at work, followed by increases in technology use such as EHRs/EMRs at 32%, and lack of respect from administrators and colleagues at 30%.

Burnout’s root causes noted above are affected by organizational structure and functionality. Consider how healthcare organizations and systems affect these contributors:

1. Lack of power/control: Physicians who have historically served in leadership roles that guide clinical decisions have had to relinquish these to administrators. This power shift toward business models causes concerns that the focus is now on money, rather than on optimum patient care and physician satisfaction.
   • There is a notable increase of burnout for those who spend less than 20% of their work effort on personally meaningful endeavors.
2. QI programs: “Quality Improvement“ (QI) programs that require more paperwork,  another bureaucratic, busy-work burden for physicians. It fulfills a requirement rather than encouraging professional systems in which physicians develop their own QI strategies by listening to patients to continually enrich practice expertise. 
   • From the same report noted in item 1, there is burnout increase due to “clerical burden.”
3. Inefficient workflow: Clinical functions should be stream-lined to benefit the medical professionals providing patient care by having non-medical tasks efficiently handled by staff. This approach frees time to see more patients, increase revenue, and allow you to do the most enjoyable part of medicine – seeing patients.
4. Electronic medical records (EMR’s) were designed to increase productivity and efficiency though that has not come to fruition. Moving through numerous pages or screens to complete an encounter is neither efficient nor satisfying.  
   • These are regularly cited as a burden, including the task of physician order entry with computers.
5. Staff shortcomings: Physicians are caring individuals who believe staff are trustworthy and able to complete tasks efficiently. Regardless of cause, when an employee does not meet job expectations, it is time to document their behavior and have a personal discussion about short-comings. Inability to improve needs to result in termination.
6. The 2019 Medscape study noted lack of respect from patients as a 16% cause of physician burnout. This can cause practitioners to feel abused and powerless, especially considering the added effects of those 30% of physicians who reported burnout due to lack of respect from employers, colleagues, and staff.
7. Lack of leadership training: There has been a recent rise in physicians starting a private practice. Although taking this step can be stressful, it is very rewarding to design a clinic around your needs and those of your patients. Once the clinic is up and running, many physicians run into issues that require a firm handle on leadership, financial, legal, and marketing skills. Think too of how lack of physician leadership training limits workplace functionality without fully accessing the decision-making capacity of bright, caring professionals.

It is particularly relevant to consider all of the above in relation to reports that organizations that offer physicians control over workplace issues result in higher professional satisfaction and less stress.

Other burnout contributors are associated with workload and workplace culture. Added to these are a physician culture that would benefit from shorter shifts, heightened peer support, and reversal of blame. Until workplace factors improve, these contributors to burnout will continue:

1. Skipping lunch: Physicians may habitually skip lunch or eat a snack while charting to complete documentation and catch up due to workload and workplace inefficiencies. If the workplace culture condones this practice, physicians sacrifice their deserved breaks and mealtime.
2. 50+ hour work weeks: The 2019 Medscape survey notes that burnout reporting increases with number of hours worked. Emotional exhaustion sets in, particularly as practitioners sacrifice their personal and family needs. Towards the end of a 60-hour week, physicians wonder how many others lack the mental stamina to maintain their high level of work.
   • Each additional hour of work and night or weekend call increases burnout risk by 3 to 9%. Think of how quickly that adds up.
3. High Debt is common among physicians due to extended education that is expensive and not sufficiently relieved by loan forgiveness incentives. There is then the draw to accept added hours to meet financial obligations, adding to the catch-22 of burnout. 
4. Neglecting sleep at the end of a long day or week is tempting in order for physicians to spend time with family, friends, or participating in a hobby. Balancing these with household responsibilities leaves physicians stretched thin and sleep suffering. Sleep deprivation and exhaustion affect the quality of patient care and an overall drop in mood/patience.
5. Ignoring one’s own advice. It is fascinating to listen to physicians complaining about their patients not following preventive care tips and healthy habits when they themselves aren’t doing so either. If patients take the advice, so should physicians. Caring for self and monitoring one’s own health are hallmarks of wellness.
6. Vitamin D deficiency. The evidence supporting vitamin D deficiencies and depression is mixed, yet everyone should get some quality time outdoors. Enjoying the sunlight and getting outside is quite refreshing. Consider the value of workplaces that encourage all staff to get outside to enjoy and appreciate nature and soak up some vitamin D.
7. Charting on weekends is unpaid work. Apparently there are healthcare settings in which physicians save their charting for the weekends. The idea of procrastinating on documentation and then trying to remember what was done days ago is likely associated with job dissatisfaction and workplace issues. 
8. Under-utilization of other professionals such as attorneys and accountants. Physicians have invested over a decade achieving an education to be excellent physicians. They know patient care, yet have not learned about tax laws, investing, home repair, and the basics of contracts. Unless physicians outsource these tasks to improve work/life balance by enjoying off-time, burnout concerns will continue.

This article’s broad discussion of physician burnout prompts a number of questions about workplace factors, the effects of burnout on patient outcomes, and how to transform healthcare systems. Each contributor to physician burnout holds answers on how to improve systems, from education to documentation, on behalf of physicians, those they care for, and those who care for these noble practitioners. As noted on one of the Mind Garden physician burnout solutions pages, “In order to fully remedy and prevent burnout, solutions must focus on organization change—not personal change.”  
 
Request Dr. Jared Heathman for speaking engagements on physician burnout.  Contact our office at 281-849-4080 with your information for further details.
 
References 
Dyrbye, L. N., Shanafelt, T. D., Sinsky, C. A., Cipriano, P. F., Bhatt, J., Ommaya, A.,…Meyers, D. (2017). Burnout among healthcare professionals: A call to explore and address this unrecognized threat to safe, high-quality care. Retrieved from https://medschool.ucsd.edu/som/hear/resources/Documents/Burnout-Among-Health-Care-Professionals-A-Call-to-Explore-and-Address-This-Underrecognized-Threat.pdf
 
Kane, L. (2019). Medscape national physician burnout, depression & suicide report, 2019.
 
Mind Garden. (2018). Maslach burnout tool for medical personnel. Retrieved from https://www.mindgarden.com/documents/Maslach-Burnout-Toolkit-for-Medical-Personnel-Intro-Sheet.pdf
 
Mind Garden. (2019). Physician burnout solutions. Retrieved from https://www.mindgarden.com/content/34-physician-burnout-solutions#horizontalTab1
 
National Academy of Medicine. (2020). Action collaborative on clinician well-being and resilience. Retrieved from https://nam.edu/initiatives/clinician-resilience-and-well-being/
 
Ostrov, B. F. (2018). Stanford’s chief wellness officer aims to end physician burnout. Retrieved from https://californiahealthline.org/news/stanfords-chief-wellness-officer-aims-to-prevent-physician-burnout/
 
Stehman, C. R., Testo, Z., Gershaw, R. S., & Kellogg, A. R. (2019). Burnout, dropout, suicide: Physician loss in emergency medicine, Part I. Western Journal of Emergency Medicine, 20(3): 485-494. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6526882/
 
West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018). Physician burnout: Contributors, consequences, & solutions. Journal of Internal Medicine, 283(6): 516-529. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12752
 
World Health Organization. (2019). Burn-out an “occupational phenomenon”: International Classification of Diseases. Retrieved from https://www.who.int/mental_health/evidence/burn-out/en/