emDocs Wellness: Physician Burnout

Author: Jennifer Robertson, MD, MSEd (Assistant Professor, Department of Emergency Medicine, Emory University) // Edited by: Alex Koyfman, MD (@EMHighAK)

What is burnout?

The most stressful jobs have been defined as those having significant responsibility with little control over outcomes (1). For emergency physicians, this may definitely ring true. However, it has also been shown that physicians of other specialties also have highly stressful jobs due to many factors including time pressures (having to see more patients in less time), competence concerns, financial worries, lack of adequate support and/or resources, and work interferences on home life (2, 3). Importantly, most physicians interact with patients regularly and these interpersonal interactions may involve significant emotional demands. Indeed, it is thought that these emotional demands and other job-related stressors contribute to burnout (4).

By definition, burnout is a psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that occurs in workers who engage with other people regularly (5).   Emotional exhaustion is essentially the individual stress component of burnout. As a worker becomes more stressed at his or her job, he or she may become depleted of emotional and physical resources. Thus, exhaustion occurs (5, 6). Depersonalization is also known as cynicism. It refers to a worker’s negative, uncaring, and/or detached response to one or more part(s) of his or her job. This component can lead to a worker to ignore his or her qualities that make him or herself unique and engaging. It, consequently, leads to him or her to distance himself or herself more and more from work (5, 6). Lastly, the third component of burnout represents self-assessment. It refers to feelings of incompetence, ineffectiveness and lack of accomplishment at work (6).  This component is thought to be due to a combination of exhaustion and depersonalization because both of these can decrease a worker’s sense of personal accomplishment and effectiveness (6).

How is burnout measured?

Most research studies use the Maslach Burnout Inventory (MBI) to assess the three components of burnout (5). Of note, the original MBI was designed to assess those workers involved directly in human services, such as health care. Thus, the original MBI is applicable to physicians. However, there are other assessments such as the MBI general survey (MBI-GS) that evaluates for burnout in workers in other occupations (5).

A full description of the MBI can be seen in the references below (5). In short, however, the MBI is a self-administered survey that takes only about 10-15 minutes to complete. The MBI addresses each of the three components of burnout in a 22 element survey. Each element is written in the form of a statement such as “I feel burned out from my work”. Each statement is then answered in terms of the frequency of which the respondent experiences these feelings on a point scale ranging from 0 (“Never”) to 6 “every day”. There are nine statements about exhaustion, five statements about depersonalization, and eight statements regarding lack of personal accomplishment. Each category is scored separately. Higher scores on the emotional exhaustion and depersonalization scales suggest burnout. On the other hand, a lower score on the personal accomplishment scale suggests that the respondent is experiencing burnout. Of note, the MBI is actually labeled as the MBI Human Services Survey. This is so respondents are unaware of its association with burnout and can answer the questions truthfully (5).

What is the potential impact of (physician) burnout?

While burnout can occur in any field, physicians tend to have very high burnout rates (7). This is likely because physicians do indeed deal with many patients with physical, psychological and social situations on a regular basis. A 2012 survey of over 7000 physicians of all specialties demonstrated that 45.8% had at least one symptom of burnout based on MBI data (8). Additionally, when compared to 3442 non-physician working adults, these physicians had more symptoms of burnout and dissatisfaction with work-life balance (8). Higher burnout rates were seen in physicians on the front lines of care access including internal medicine and emergency medicine physicians (8).

Because burnout is prevalent in physicians, it is important to discuss the impact it may have on physician health and well-being. Burnout is problematic as it has been found to be associated with professionalism issues and medical errors. It has also been linked with mental illness, poor physical health, disruptive behavior and decreased quality of care. Burnout has also been associated with substance abuse and personal relationship difficulties (5, 9, 10-18). Future emDocs articles will expand on the topics of mental and physical health in physicians and how burnout may contribute. For now, however, it is important to understand that burnout can contribute to poor mental and physical health in physicians.

Physicians obviously care for the health of other people. Thus, it may come as no surprise that if a physician is burned out and unwell physically and/or mentally, patient care may also suffer (17). In a study of 115 internal medicine residents who completed a MBI, burnout was prevalent in 76%. When compared to the 24% who were not burned out, the burned-out residents were much more likely to self-report at least one suboptimal patient care practice such as not answering patient questions or not providing all treatment options (11). Interestingly, when each of the three MBI categories were evaluated separately, inadequate patient care practices were more strongly associated with those residents who had higher levels of depersonalization (11). In a 2008 survey of nearly 8000 American surgeons, 700 reported concerns that they had made major medical error (s) in the prior three months. Of these 700 surgeons, more than 70% attributed the error to symptoms of burnout and depression (12).  Both depersonalization and emotional exhaustion were correlated with increased likelihoods of reporting errors, while personal accomplishment was inversely associated with reporting errors. Other studies have found similar results regarding physician (and other healthcare workers) burnout and patient care quality (19, 20). Thus, burnout may be an important measure of quality in healthcare and must be addressed and improved for the overall well-being of physicians and patients (17).

What are some potential solutions to (physician) burnout?

Burnout is a topic that is frequently discussed, but finding and implementing ways to treat and prevent to burnout is difficult. While solutions to this growing problem have been proposed, they may be more difficult to implement in real world settings. That being said, proposed solutions include addressing both individuals and workplace systems (6, 21). These may also not only improve burnout, but potentially improve mental and physical health as well.

Another way to look at reducing burnout is actually improving worker engagement. Engagement has suggested to be the opposite of burnout (4). While there is no universal definition of engagement, one author defined it as a “positive attitude held by the employee toward the organization and its value” (22). Engaged employees tend to feel more valued, more empowered and have higher commitment to superior job performance (23). Both individual and systems solutions could be valuable in improving engagement and preventing burnout (6). Upcoming articles will discuss this topic further, but it important to know that enhancing job engagement can lead to improved job satisfaction and lower rates of burnout.

Individual and systems solutions will also be discussed in more depth in future articles. However, certain individual solutions to burnout include mindfulness, peer support and mentoring, individual cognitive behavioral therapy, and exercise and nutrition interventions (24, 25, 26, 27, 28). Mindfulness can be defined as “seeing with discernment” (29). Essentially, it practicing awareness of the present moment and letting go of ruminations about the past and fears regarding the future (30). Mindfulness is essentially the practice of becoming more aware of thoughts, emotions and maladaptive ways of responding to stress. Being mindful of these maladaptive coping mechanisms can help one to learn to cope with stress in more healthy and effective ways (30, 31).

Peer support groups and older mentors have also been found to be helpful for younger physicians. Interestingly, older physicians tend to have better coping strategies and lower levels of burnout than their younger colleagues (24). Proper nutrition and exercise have also been proven helpful for physician’s stamina and overall health (25, 26, 27). Burnout has been shown to lead to increased inflammation in the body, which has been shown to increase the risk of cardiovascular disease (13, 14). Along with stress reduction and other methods of reducing burnout, better nutrition and exercise can lead to less burnout and improved overall health (18). Finally, spirituality, leisure time and hobbies also can help physicians mitigate their risk of burnout (28).

In addition to individual factors to help improve health and well-being, there are also systems-based or organizational factors may help improve physician engagement and mitigate burnout.  Some of these organizational components include allowing more physician autonomy, improving physician leadership, decreasing work hours, having more systems-based wellness programs, initiating physician-led support groups, and delegating tasks to other non-physician adjunct employees (32-34). As previously mentioned, highly engaged workers tend to have better job performance and lower rates of burnout (6, 35). Some of these systems-based interventions can help improve engagement, such as allowing workers to be more involved in decision making (22). Other systems based interventions have also shown to improve physician wellness and prevent burnout such as task delegation and initiating organizational wellness programs (22, 36). Simply having an organization that recognizes workers’ value and is concerned for workers’ well-being is invaluable toward improving engagement and reducing burnout (22).

Future articles will address both individual and systems-based solutions in more detail. It is hoped that discussing these issues can not only treat and prevent physician burnout, but that it also can start to improve the overall mental and physical health of physicians and other healthcare providers.

References/Further Reading

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3. 3. Simpson LA, Grant L. Sources and magnitude of job stress among physicians. Journal of Behavioral Medicine. 1991;14(1):27-42.
4. 4. Maslach C, Leiter MP. Early predictors of job burnout and engagement. Journal of applied psychology. 2008;93(3):498-512.
5. 5. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: MBI. Consulting Psychologists Press; 1981.
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