Physician burnout

Physician burnout has been classified as a psychological syndrome that can be expressed as a prolonged response to due chronic occupational stressors.[1] In the practice of medicine, it has been known to affect a wide variety of individuals from medical students to practicing physicians; although, its impact reaches far beyond that. Because of the toll taken on the healthcare industry, various treatment and prevention strategies have been developed at individual, team, and organizational levels in hopes to seek the best method of addressing this epidemic.

Characteristics

Prevalence

Research suggests that occupational burnout among physicians exceeds 50% in the USA.[2] This refers to not only physicians currently practicing medicine, but also those in training. Signs of burnout have even been traced back to medical students who have experienced disconnect between taught professional behaviors and those witnessed in practice.

"Our data show wide variability in the prevalence of burnout by clinical specialty, and that anxiety, social support and empathy during medical school relate to the risk of burnout during residency," says Liselotte Dyrbye, M.D., a Mayo Clinic researcher and first author of the article "Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians[3]"

Signs

Burnout has been referred to as a compilation of cynicism, depersonalization, and a low sense of accomplishment.[4][5] Other symptoms included feelings of emotional exhaustion, inadequacy, and detachment. This is thought to be due to imbalances whether that be in regards to workload, personal values, incentive, justice, and a sense of community. Factors such as time pressure, chaotic work environments and a lack of alignment between physicians and executives have been known to exacerbate this burden.[2] These elements can cause clinicians to become frustrated and overwhelmed. Moreover, the correlation between lack of control and burnout has been explored and shows that an increased sense of lack of control has been linked to a greater risk of being affected by burnout.

Physician Burnout of medical practitioners isn’t an individual problem. It has consequences for the whole healthcare industry. Healthcare in the US is expensive; but it is even more costly to replace a physician (approximately $250,000 to $1000000).

The practitioner also takes more leaves to reduce their burnout; which affects their overall productivity and reduces earnings significantly. Also, patients might switch to other clinicians and medical practitioners if they are absent for too long.

Furthermore, the impact of burnout has shown to negatively impact overall care delivery, more error rates are found, and patient care is gravely affected. An AMIA study has shown that physician burnout has the following indicators:

  • More physician turnover
  • More instances of substance abuse and higher rates of addiction in physicians
  • More cases of health malpractice in the overall clinic or department.
  • Excessive errors in patient care, treatments; sometimes proven to be fatal.
  • Time and money wasted is useless, repetitive tests and unrequired consultations

One study,[6] claimed that "We found that physicians with burnout had more than twice the odds of self-reported medical error, after adjusting for specialty, work hours, fatigue and work unit safety rating(...)"

Models[1]

Likewise, burnout has been analyzed using differing conceptual models. One strategy examined burnout as a product of three stages. Stage one consists of exhaustion at work that progresses into detachment and negative feelings at work that later starts to affect patients and coworkers in stage two. Lastly, stage three is composed of feelings of inadequacy and failure. However, a more recent approach sought to choose three stages that served as a bridge between said stages and imbalances. The first groups together all job stressors such as imbalances caused by work demands while the second solely addressed individual strain in the form of anxiety and exhaustion. Lastly, the third described changes in mood and behavior as defensive coping that could be closely linked to cynicism.

Impacted populations

Physicians

The progression of physician burnout takes a toll on the individual whether it be a medical student or practicing clinician mainly through adverse psychological affects that have lasting consequences. A concept known as asymmetrical rewards speaks of how physicians are rarely recognized for what they do well, yet there is much attention surrounding medical malpractice suits ready to capitalize on a physician’s errors. In addition, clinicians become desensitized to patients and medicine resulting a perspective shift towards viewing patient care as a chore more than a desire to heal. However, the effects of burnout extend past the physicians themselves to ultimately affect anyone in contact with them.

Resident Physicians

Burnout in physicians appears to be the highest for resident physicians. Due to the large number of hours taken on by resident physicians, they are often more prone to burnout. In addition to the long hours, residents are still in the process of learning clinical knowledge. Stressful events, such as death of a patient, managing a critically ill patient, medical error, and verbal abuse from patients, their families and/or colleagues have been reported in a study done at medical schools in the Philadelphia area.[7] In this study, researchers found that 70% of residents experienced at least one work-related stress event and that nearly 5% showed symptoms of PTSD from a stressful event at work. Similar to the work-life balance struggle physicians face, residents may struggle to manage everything going on in their lives. Negative effects of this burnout include decreased job satisfaction, being absent while at work and possibility for medical errors.[8] Some studies have even shown reduced feelings of personal accomplishment and emotional exhaustion.[9] Residents who considered themselves to be experiencing burnout report more medical errors than residents who do not.[10] In a 24 month-long study performed at Mayo Clinic in 2016, found that burnout and low job satisfaction were associated with reductions in professional work effort.[11] In 2008, the Healthcare Management Review suggested that healthcare settings that put programs in place to reduce physician burnout would see greater patient satisfaction and recovery.[12] Resident interventions aimed to improve communication and role conflict have been shown to improve self-acceptance, acceptance of aggression and inner directedness in residents, interns, and nurses.[13]  Although burnout in resident physicians has become common knowledge in the medical community, few systems are in place to combat this issue. Some possible solutions are support groups, stress-management/coping training and self-care education.[8]

Medical Students

An estimated 43-45% of medical student students report feelings of burnout.[14] It has been proposed that physician burnout originates from physicians years' in medical school.[15] In 2010, a study was done by Emory School of Medicine and Vanderbilt School of Medicine to understand the prevalence and factors of burnout in medical students. Here, burnout was defined as emotional exhaustion, depersonalization and decreased physical exhaustion. The study administered the Maslach Burnout Inventory Human Services Survey to 249 medical students. This survey asked questions about stress levels, workload, relaxation habits, support systems and demographics. The study found that 21% of first-year students, 41% of second-year students, 43% of third-year, and 31% of fourth-year students felt symptoms of burnout. Factors associated with a higher rate of burnout include lower support, higher stress, and feelings of lack of control over one's life. There is no single solution to this issue, but easing student and physician workload and promoting wellness and resilience in the medical field has been shown to help.[16] Specifically in medical students, mindfulness-based meditation sessions have been shown to improve mood disturbance.[17]

Colleagues

Friends and family often feel the burden when interacting with burned-out clinicians since most of these individuals will be disengaged and can exhibit symptoms of major depressive disorder. Coworkers are also likely to be impacted. For example, burnout initiated by a chaotic, unsupportive work environment results in higher rates of miscommunication and unresolved conflicts. It has also been shown that a workforce afflicted by burnout contributes to an overall greater hostile atmosphere.

Health Industry

Other impacted populations include the patients and healthcare industry seeing as burnout results in decreased quality of care.[18] Research has generated evidence supporting an inverse correlation between burnout and productivity. Thus the shift in decreased productivity sometimes ends in decreased physician retention due to low job satisfaction and decreased mental health. Since successful medical interactions are based on trust between providers and patients, this constant staff turnover can go on to reflect poorly upon the institution.

Treatment & prevention

Individual-approach

Treatment strategies first focused on addressing the individual. Physician-oriented approaches ranged from cognitive behavioral techniques (CBT) such as meditation and coping strategies to professional coaching which aimed at reinforcing individual resilience. Professional coaching involves the implementation of mentors that would aid in guiding physicians using their previous experiences with patients. Gazelle, Liebschutz, and Riess discussed the benefits of professional coaching as being able to cater to each provider using his or her own previous experiences therefore personalizing the intervention as opposed to CBT which delivers treatment in a standardized manner. On the other hand, Dr. Kelly speaks of how altering perception of patients from chores and potential litigation sources to opportunities to heal is key to the reversal of burnout.

Organizational-approach

However, some research suggests that a combination of individual, team, and organization approaches is the only way to address all levels of burnout and successfully put an end to this epidemic.[19] Generally, organizational approaches have shown much promise as successful treatment options by reducing workloads and distributing more flexible schedules among employees. A shift to realign goals between physicians and executive administrators could also contribute to reducing the risk of burnout. A systematic review analyzing individual and organizational strategies found that organization-oriented approaches were more effective.[20] Other examples of team approaches are the implementation of honest discussions between caregivers to emphasize compassion as well as organization-wide events to enhance workforce well-being. While Gazelle and Panagioti concluded that organizational approaches were superior to individualized interventions, the final verdict has not yet been reached as Wuest’s combined intervention addressing burnout at the individual, team, and organizational levels might be the key.

References
  1. Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry, 15(2), 103-111. doi:10.1002/wps.20311
  2. Rothenberger, D. A. (2017). Physician Burnout and Well-Being: A Systematic Review and Framework for Action. Diseases of the Colon & Rectum, 60(6), 567-576. doi:10.1097/DCR.0000000000000844
  3. Dyrbye, Liselotte N.; Burke, Sara E.; Hardeman, Rachel R.; Herrin, Jeph; Wittlin, Natalie M.; Yeazel, Mark; Dovidio, John F.; Cunningham, Brooke; White, Richard O. (2018-09-18). "Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians". JAMA. 320 (11): 1114–1130. doi:10.1001/jama.2018.12615. ISSN 0098-7484. PMC 6233627. PMID 30422299.
  4. Gazelle, G., Liebschutz, J. M., & Riess, H. (2014). Physician Burnout: Coaching a Way Out. Journal of General Internal Medicine, 30(4), 508-513. doi:10.1007/s11606-014-3144-y
  5. "How to recognize and respond to burnout in a fellow physician". American Medical Association. 30 August 2018. Retrieved 12 July 2020.
  6. Tawfik, Daniel S.; Profit, Jochen; Morgenthaler, Timothy I.; Satele, Daniel V.; Sinsky, Christine A.; Dyrbye, Liselotte N.; Tutty, Michael A.; West, Colin P.; Shanafelt, Tait D. (November 2018). "Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors". Mayo Clinic Proceedings. 93 (11): 1571–1580. doi:10.1016/j.mayocp.2018.05.014. PMC 6258067. PMID 30001832.
  7. Coverdale, John; Balon, Richard; Beresin, Eugene V.; Brenner, Adam M.; Louie, Alan K.; Guerrero, Anthony P. S.; Roberts, Laura Weiss (2019-04-01). "What Are Some Stressful Adversities in Psychiatry Residency Training, and How Should They Be Managed Professionally?". Academic Psychiatry. 43 (2): 145–150. doi:10.1007/s40596-019-01026-w. ISSN 1545-7230. PMID 30697662.
  8. McCray, Laura W.; Cronholm, Peter F.; Bogner, Hillary R.; Gallo, Joseph J.; Neill, Richard A. (October 2008). "Resident physician burnout: is there hope?". Family Medicine. 40 (9): 626–632. ISSN 0742-3225. PMC 2903755. PMID 18830837.
  9. West, C. P.; Dyrbye, L. N.; Shanafelt, T. D. (March 5, 2018). "Physician burnout: contributors, consequences and solutions". Journal of Internal Medicine. 283 (6): 516–529. doi:10.1111/joim.12752. ISSN 1365-2796. PMID 29505159.
  10. West, Colin P.; Huschka, Mashele M.; Novotny, Paul J.; Sloan, Jeff A.; Kolars, Joseph C.; Habermann, Thomas M.; Shanafelt, Tait D. (2006-09-06). "Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study". JAMA. 296 (9): 1071–1078. doi:10.1001/jama.296.9.1071. ISSN 1538-3598. PMID 16954486.
  11. Shanafelt, Tait D.; Mungo, Michelle; Schmitgen, Jaime; Storz, Kristin A.; Reeves, David; Hayes, Sharonne N.; Sloan, Jeff A.; Swensen, Stephen J.; Buskirk, Steven J. (April 2016). "Longitudinal Study Evaluating the Association Between Physician Burnout and Changes in Professional Work Effort". Mayo Clinic Proceedings. 91 (4): 422–431. doi:10.1016/j.mayocp.2016.02.001. ISSN 1942-5546. PMID 27046522.
  12. Halbesleben, Jonathon R. B.; Rathert, Cheryl (January 2008). "Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients". Health Care Management Review. 33 (1): 29–39. doi:10.1097/01.HMR.0000304493.87898.72. ISSN 0361-6274. PMID 18091442. S2CID 41671522.
  13. Bair, J. P.; Greenspan, B. K. (June 1986). "TEAMS: teamwork training for interns, residents, and nurses". Hospital & Community Psychiatry. 37 (6): 633–635. doi:10.1176/ps.37.6.633. ISSN 0022-1597. PMID 3721426.
  14. Dyrbye, Liselotte N.; Thomas, Matthew R.; Huntington, Jefrey L.; Lawson, Karen L.; Novotny, Paul J.; Sloan, Jeff A.; Shanafelt, Tait D. (April 2006). "Personal life events and medical student burnout: a multicenter study". Academic Medicine. 81 (4): 374–384. doi:10.1097/00001888-200604000-00010. ISSN 1040-2446. PMID 16565189. S2CID 19962588.
  15. Santen, Sally A.; Holt, Danielle B.; Kemp, Jean D.; Hemphill, Robin R. (August 2010). "Burnout in medical students: examining the prevalence and associated factors". Southern Medical Journal. 103 (8): 758–763. doi:10.1097/SMJ.0b013e3181e6d6d4. ISSN 1541-8243. PMID 20622724. S2CID 29804833.
  16. MacKinnon, Matthew; Murray, Suzanne (2018-02-01). "Reframing Physician Burnout as an Organizational Problem: A Novel Pragmatic Approach to Physician Burnout". Academic Psychiatry. 42 (1): 123–128. doi:10.1007/s40596-017-0689-1. ISSN 1545-7230. PMID 28247366. S2CID 42941512.
  17. Rosenzweig, Steven; Reibel, Diane K.; Greeson, Jeffrey M.; Brainard, George C.; Hojat, Mohammadreza (2003). "Mindfulness-based stress reduction lowers psychological distress in medical students". Teaching and Learning in Medicine. 15 (2): 88–92. doi:10.1207/S15328015TLM1502_03. ISSN 1040-1334. PMID 12708065. S2CID 30922233.
  18. Dewa, C. S., Loong, D., Bonato, S., Xuan Thanh, N., & Jacobs, P. (2015). How does burnout affect physician productivity? A systematic literature review. BMC Health Services Research, 325(14). doi:10.1186/1472-6963-14-325
  19. Wuest, T. K., MD, MMM, Goldberg, M. J., MD, & Kelly, J. D., IV, MD. (2017). Cinical Faceoff: Physician Burnout - Fact, Fantasy, or the Fourth Component of Triple Aim? Clinical Orthopaedics and Related Research, 475(5), 1309-1314. doi:10.1007/s11999-016-5193-5
  20. Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., . . . Esmail, A. (2017). Controlled Interventions to Reduce Burnout in Physicians A Systematic Review and Meta-analysis. JAMA Internal Medicine, 177(2), 195-205. doi:10.1001/jamainternmed.2016.7674
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