Physician Burnout: Action Items to Confront the Problem

Philip B. Collins, DO | collinsp@rowan.edu

AUTHOR DISCLOSURES:

No relevant financial affiliations.

INTRODUCTION

The well-being of physicians has been a trending topic among professionals in the medical field, medical organizations, and the media in recent years. The increased attention placed on burnout is with good reason, as research indicates that burnout among physicians is increasing at an alarming rate.1 A recent survey shows that 42% of physicians report experiencing burnout, and an even greater, 47% of Family Medicine physicians report experiencing burnout.2 With aspects of physical, mental, emotional, and spiritual health involved, current evidence indicates that our profession, as a whole, is not “well.”

Burnout is defined by three symptoms: loss of enthusiasm for work (emotional exhaustion), cynicism (depersonalization), and low sense of personal accomplishment (lack of efficacy).3 Signs and symptoms can also include excessive absenteeism, reduced job satisfaction, interpersonal conflicts at home and at work, a feeling of detachment from patients and others, disruptive and impulsive behaviors, lack of empathy and patience, and a feeling of dread before going into work.4,5 Among the top causes of burnout are bureaucratic tasks, work hours, lack of respect from administrators/employer, colleagues, or staff, and Electronic Health Record (EHR) systems.2 In a changing medical landscape with increasing EHR utilization, it is likely this will not improve without an intervention.

As physicians, we are particularly susceptible to burnout given the high-stakes nature of our work in regularly caring for sick and sometimes dying patients. The burden of responsibility can be quite stressful; therefore, it is not surprising that physicians are more likely than the general population to experience burnout6. Additionally, stress management or stress reduction techniques are not taught in medical school. There is a mentality in medical education that implies challenges are meant to be responded to by working harder during medical school and residency.7 Given this mentality during training, often times it can be difficult for physicians to find an effective work-life balance and make time for themselves. Physicians work in a field that expects and demands perfection. Having no room for errors is incredibly taxing. Combine this demand for perfection with daily workplace demands, such as crammed schedules, phone calls with insurance companies, and challenging patients, and it becomes easy to see why burnout is very common among physicians. Sometimes the specific job or position carries its own set of stressors. Call rotation, compensation formula, and relationships within the department or group are just a few of the possible issues that may contribute to burnout. Studies have shown that poor leadership can also contribute to burnout8. Home life can be another big factor in the development of burnout, or home life can suffer as a result of burnout. Working long hours can often lead to strained relationships with friends and family, and can be particularly difficult on the spouse or partner of a physician.

Finding time for your spouse/partner/family, while a priority, can be challenging which might increase stress at work due to not having an appropriate outlet for this stress. Additionally, burnout puts physicians at higher risk for substance abuse due to an absence of more effective coping skills.7

Physicians are also just as susceptible as the general population to suffer from depression or other mental illnesses, which can then be exacerbated by the stress associated with being a physician.9 It is thought that the prevalence of depression among physicians may be higher than the numbers indicate due to the underestimation of self-reporting and lack of physicians seeking out appropriate treatment for psychiatric difficulties.10,11,12 Studies show that approximately 6.4% of physicians experience suicidal ideation.6 Unfortunately physicians have higher rates of attempting suicide than the general population and have a far higher suicide completion rate10. While it is difficult to determine an exact number, most findings estimate that 300-400 physicians complete suicide each year.10,13 Depression often goes untreated in physicians for a number of reasons, but the main reason seems to be the stigma associated with the diagnosis.14 Some physicians fear possible peer judgements, sanctions, restrictions, and other negative consequences from state medical boards, hospitals, and/or employers. Physicians’ personal stories of burnout are frequently published and while each case varies, they often share common themes such as high expectations of work output, balancing multiple responsibilities, and unsupported work environments.

Sadly, burnout, depression, and suicide extend their reach into trainees as well. Among medical students, suicide is the second leading cause of death after accidents.10 It is estimated that the prevalence of a history of depression among medical students is 15-30%.15 One study of fourth year students and first year residents revealed 9.4% reported thoughts of suicide in the previous two weeks.16 Long hours, high responsibility, inexperience, learning to handle the death of patients, and being away from family are just a few of the potential factors contributing to this alarming trend.10 Another study found that the harassment and belittling by superiors contributed to mental distress among students and the development of depression in some.17 Several medical schools are now implementing programs to help identify, treat, and manage stress and depression among medical students.18

Unfortunately, the consequences of physician burnout extend beyond the physician. Burnout among physicians has been shown to increase medical errors and lead to lower patient satisfaction.7 Not surprisingly, medical errors and decreased patient satisfaction can lead to higher malpractice risk.7 The overall happiness among physicians at home can be affected negatively as well.19 In addition to the health and well-being of physicians and patients, physician burnout can affect ancillary staff and the patient care they provide. There are higher turnover rates among staff working with physicians suffering from burnout.7,20 As physicians experience burnout, they are more likely to place extreme demands on others, create role ambiguity, and struggle with providing effective feedback to staff.4,5,20,21 This can result in diminished social support in the workplace and lead to staff feeling a reduced sense of accomplishment in the work they do and the effectiveness of their role in patient care.4,20,21 When working in such strained conditions, individuals are likely to develop passive, defensive coping mechanisms, engage in the bare minimum of their role, and refuse to take on responsibility for improving the work place.5 Physicians with burnout will also be less likely to recognize staff efforts and accomplishments, therefore resulting in a lack of appropriate rewards and appreciation, thus fueling staff negativity.4 Stronger staff members may feel more significant effects if physicians begin to designate more work to stronger staff members, resulting in an overload.22 Additionally, if the effects of burnout on staff are not addressed, any new staff that enters the office will quickly experience the effects of burnout as well.20

On a more personal level, physician burnout can result in a loss of interest in personal life matters and personal relationships, thus having an effect on partners and family members.23 Physicians who experience burnout are also less likely to respond to personal life events in effective ways, thus causing increased stress and disappointment for everyone involved in such situations.24 Events such as marriage, the birth or adoption of a new child, and loss of a family member are not given full attention by physicians who experience burnout.24 Additionally, personal relationships of physicians are likely to become more strained when physicians are burned out as a result of physicians requiring ongoing and increasing needs for support from family and friends, which was evident in research from as early as the mid-1990s.25 This can leave family members and friends feeling equally drained and resentful towards the physician as a result of an imbalance in the relationship. Furthermore, negative effects on family life can include feelings of neglect by spouses or children and poor communication, which can vary in severity based on physician career stages and lead to increased risk of divorce or separation and lack of effort in maintaining healthy relationships.26,27,28 a few minutes to mentally scan your body from head to toe and notice any tension or discomfort, making adjustments to posture or the tension as necessary.4 Additional mindfulness and stress reduction resources can be found in Table 1.

Physicians can also reap benefits from adjusting eating habits, maintaining physical activity levels, and improving sleep habits.37 It is important for physicians to eat as consistently as possible and to monitor intake of “emotional” foods such as caffeine, sugar, and alcohol, which can have a strong effects on how individuals react to situations and their tolerance for stress throughout the day.4,37 Physicians are also encouraged to incorporate any kind of physical activity to the daily routine which can include a short walk during a break in the day and/or taking a few minutes to stretch stiff muscles.4,37 It is also important to monitor habits prior to bed and ensure that you are doing all you can to achieve a restful night’s sleep.37 One common mistake at the end of the day is not allowing time for a transition from a highly demanding schedule before going to bed. Additionally, we are also at risk of overusing technology or binge watching television prior to bed which can confuse the brain into thinking it is not yet time to rest. It is important to have a power down routine prior to bed, as well as to set limits to electronic use, which allows you to decompress from the day.

Another way to manage stressors which make you more susceptible to burn out is to participate in activities which stimulate the more creative side of the brain.4,37 Day-to-day operations as a physician include high levels of recalling and implementing information, and such sustained thinking can lead to exhaustion and loss of enthusiasm.4 By engaging in activities of pleasure during non-working hours, you can mitigate some of the effects of a demanding workday. Some activities include engaging in artwork of any kind including mandalas (more popularly known as adult coloring books), participating in group activities or group sports, and challenging yourself to a more complex skill of an existing hobby or seeking out a new hobby.

Furthermore, developing and maintaining appropriate boundaries enhances the seemingly elusive work-life balance37. Boundaries may include refusing to take on new roles or duties that are outside of your scope of ability or would demand more time than you have to offer. Delegating duties to coworkers or sharing the burden with colleagues is an effective way to maintain work-life boundaries. Additionally, it is important to designate some “non-negotiable” events in your life.4,5 For example, making a commitment to attend specific family events, such as a child’s school play or sports game, can enhance your ability to draw the line between work and personal life.4 Likewise, if you find it difficult to leave work at the end of the day, insisting that you will complete just one more thing, you may benefit from scheduling appointments close to the end of the work day which will require you to leave work promptly.5 It is also recommended to utilize earned vacation time periodically to take time away from typical stressors, as well as increase attention to the need for mental health days and to take mental health days when needed.38 Lastly, becoming comfortable with asking for help in both our professional and personal lives goes a long way. Asking for help involves recognizing your own limits and giving yourself permission to say no when necessary.37

While physicians can try to mitigate the symptoms and causes of burnout, health care organizations and policy makers must do their part in addressing the problem as well39,40. Recently, the National Academy of Medicine began a national collaborative effort to identify causes and find solutions to clinician burnout41. The American Medical Association has created online modules to help with preventing burnout and depression. They also have modules available to help deal with other common stressors such as technology and workflow (For additional burnout prevention resources, please see Table 2). Furthermore, the American Osteopathic Association has announced an upcoming curriculum along with online resources aimed at preventing burnout and promoting physician wellness42.

TABLE 1:

Mindfulness and Stress Reduction Resources (31-36)

ONLINE RESOURCES
Online Mindfulness-Based Stress Reduction	www.palousemind- fulness.com	Defining and explaining mindfulness and its usefulness
Relaxation Techniques	www.helpguide. org/articles/stress/ relaxation-tech- niques-for-stress- relief.htm	Various techniques to promote relaxation
Controlling Anger	www.apa.org/help- center/controlling- anger.aspx	Tips for identifying and managing anger
Controlling Stress	www.apa.org/help- center/stress-tips. aspx	Tips for identifying and managing stress
Mental Health America Stress Screener	www.mental- healthamerica.net/ stress-screener	Screening tool for stress
Mayo Clinic	www.mayoclinic. org/healthy-life- style/stress-man- agement/basics/ stress-basics/hlv- 20049495	Stress Management
MOBILE APPLICATIONS
Free	The Mindfulness App	Meditation practice & reminders
Free	Headspace	Daily Meditations
Free	Calm	Meditations and calm sounds
Free	Insight Timer	Guided Meditations
Free	Aura	Daily Personalized Meditations

TABLE 2:

Burnout Prevention Resources (43-46)

TITLE	URL	DESCRIPTION
AMA Steps Forward	https://www. stepsforward.org/ modules/physician- burnout	Modules designed to help prevent burnout
AMA Steps Forward	https://www. stepsforward.org/ modules/physician- wellness	Modules designed to promote physician wellness in training
National Academy of Medicine	https://nam.edu/ initiatives/clinician- resilience-and-well- being/	Action Collaborative on Clinician Well-Being and Resilience
The Happy MD	https://www.the- happymd.com	Resources for Burnout Prevention

CONCLUSION

Physician burnout is more than dissatisfaction with a job or career – it affects all aspects of a physician’s lifestyle and those involved with the physician. Burnout is a serious risk to all physicians and the patients for whom we provide care to. It is imperative that we as a profession make wellness a priority, not just for ourselves, but also to model this self-care for our patients and our families. Those of us that are educators should implement self-care and burnout prevention as a priority for our students as well. Wellness promotion and burnout prevention can and should begin in medical school, and continue throughout training and into our careers. In order to provide appropriate and adequate care for our patients we must first take care of ourselves.

REFERENCES:

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023.

2. Peckham C. Medscape National Physician Burnout & Depression Report 2018. Medscape. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235. Published January 17, 2018. Accessed February 21, 2018.

3. Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.

4. Burnout Response. Workplace Strategies for Mental Health - Burnout Response. https://www.workplacestrategiesformentalhealth.com/ managing-workplace-issues/burnout-response. Accessed September 10, 2017.

5. Paiva T. Kissmetrics Blog. How to Prevent Employee Burnout. https:// blog.kissmetrics.com/prevent-employee-burnout/. Accessed September 5, 2017.

6. 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.

7. Drummond D. Physician Burnout: Its Origin, Symptoms, and Five Main Causes. Fam Pract Manag. 2015 Sep-Oct;22(5):42-47.

8. Shanafelt T, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432–440.

9. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. 2004 Dec. 161(12):2295-302.

10. Andrew LB. Physician Suicide. Medscape website. http://emedicine. medscape.com/article/806779-overview#a1. June 12, 2017. Accessed July 14, 2017.

11. Guille C, Speller H, Laff R, Epperson CN, Sen S. Utilization and Barriers to Mental Health Services Among Depressed Medical Interns: A Prospective Multisite Study. Journal of Graduate Medical Education. 2010;2(2):210-214. doi:10.4300/jgme-d-09-00086.1.

12. Morris NP. Why doctors are leery about seeking mental health care for themselves. The Washington Post. https://www.washingtonpost.com/ national/health-science/why-doctors-are-leery-about-seeking-mental- health-care-for-themselves/2017/01/06/b19bc4ba-ad02-11e6-a31b- 4b6397e625d0_story.html?utm_term=.10059eb458a5. Published January 7, 2017. Accessed December 30, 2017.

13. Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, Laszlo J, Litts DA, Mann J, Mansky PA, Michels R, Miles SH, Proujansky R, Reynolds III CF, Silverman MM. Confronting Depression and Suicide in Physicians: A Consensus Statement. JAMA. 2003;289(23):3161–3166. doi:10.1001/ jama.289.23.3161

14. Hendin H, Reynolds C, Fox D, et al. Licensing and Physician Mental Health: Problems and Possibilities. Journal of Medical Licensure and Discipline. 2007. 93:6-11.

15. Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: a meta-analysis. Med Educ. 2016 Apr. 50 (4):456-68.

16. Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med. 2009 Feb. 84 (2):236-41.

17. Frank E, Carrera JS, Stratton T, Bickel J, Nora LM. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ. 2006 Sep 30. 333(7570):682.

18. Moutier C, Norcross W, Jong P, Norman M, Kirby B, McGuire T, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012 Mar. 87 (3):320-6.

19. Peckham, C. Medscape Lifestyle Report 2013: Physician Lifestyles -- Linking to Burnout: A Medscape Survey. https://www.medscape.com/ features/slideshow/lifestyle/2013/public

20. Burnout: Impact on Nursing and Quality of Care. NetCE. http://www. netce.com/coursecontent.php?courseid=1167. Accessed September 6, 2017.

21. Brown LW, Quick JC. Environmental Influences on Individual Burnout and a Preventive Approach for Organizations. Journal of Applied Biobehavioral Research. 2013;18(2):104-121. doi:10.1111/jabr.12002.
    

22. Garton E. Employee Burnout Is a Problem with the Company, Not the Person. Harvard Business Review. https://hbr.org/2017/04/employee- burnout-is-a-problem-with-the-company-not-the-person. Published July 20, 2017. Accessed September 5, 2017.

23. Gundersen L. Physician Burnout. Ann Intern Med. 2001;135:145–148. doi: 10.7326/0003-4819-135-2-200107170-00023.

24. Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, and Shanafelt TD. Personal life events and medical student burnout: A multicenter study. Academic Medicine. 2006; 81 (4), 374-385.

25. Adams GA, King LA, and King DW. Relationships of job and family involvement, family social support, and work–family conflict with job and life satisfaction. J of Applied Psychology. 1996; 81 (4), 411-420. http:// dx.doi.org/10.1037/0021-9010.81.4.411.

26. Lacy BE and Chan JL. Physician burnout: The hidden health care crisis. Clinical Gastroenterology and Hepatology. 2018; 16 (3), 311-317.

27. Law M, Lam M, Wu D, Veinot P, and Mylopoulos M. Changes in personal relationships during residency and their effects on resident wellness: A qualitative study. Academic Medicine. 2017; 92 (11), 1601-1606.

28. Hill EJ, Jacob JI, Shannon LL, Brennan RT, Blanchard VL, and Martinengo G. Exploring the relationship of workplace flexibility, gender, and life stage to family-to-work conflict, and stress and burnout. Community, Work & Family. 2008; 11 (2), 165-181.

29. Maslach C, Schaufeli WB, Leiter MP. Job Burnout. Annual Review of Psychology. 2001;52(1):397-422. doi:10.1146/annurev.psych.52.1.397.

30. Mindfulness. Psychology Today. https://www.psychologytoday.com/ basics/mindfulness. Accessed December 30, 2017.

31. Online MBSR/Mindfulness (Free). Online MBSR/Mindfulness (Free). https://palousemindfulness.com/. Accessed February 22, 2018.

32. Robinson L, Segal R, Segal J, Smith M. Relaxation Techniques. Help Guide. https://www.helpguide.org/articles/stress/relaxation-techniques-for- stress-relief.htm. Published February 2018. Accessed February 22, 2018.

33. American Psychological Association. http://www.apa.org/helpcenter/ controlling-anger.aspx. Accessed February 22, 2018.

34. American Psychological Association. http://www.apa.org/helpcenter/ stress-tips.aspx. Accessed February 22, 2018.

35. Stress Screener. Mental Health America. http://www. mentalhealthamerica.net/stress-screener. Published February 3, 2014. Accessed February 22, 2018.

36. Stress management Stress basics. Mayo Clinic. https://www.mayoclinic. org/healthy-lifestyle/stress-management/basics/stress-basics/hlv- 20049495. Published March 31, 2017. Accessed February 24, 2018.

37. Jedynak-Bell C. Physician Burnout and Physician Wellness. http://c.ymcdn. com/sites/www.txosteo.org/resource/resmgr/2015_Annual/Sun_10AM_ Physician_Burnout_a.pdf. Published August 9, 2015. Accessed September 13, 2017.

38. Forbes Coaches Council. Avoid Workplace Burnout: How To Get Your Employees To Take A Vacation. Forbes. https://www.forbes.com/sites/ forbescoachescouncil/2017/07/14/avoid-workplace-burnout-how-to- get-your-employees-to-take-a-vacation/#31df5b16615a. Published July 14, 2017. Accessed September 13, 2017.

39. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714-1721

40. Dyrbye LN, Shanafelt TD. Physician burnout: a potential threat to successful health care reform. JAMA. 2011;305(19):2009-2010

41. Action Collaborative on Clinician Well-Being and Resilience. National Academy of Medicine website. https://nam.edu/initiatives/clinician- resilience-and-well-being/. Accessed August 12, 2017.

42. Raymond R. Addressing Doctor Burnout and Depression: Resources for Trainers, Families coming soon. The DO website. https://thedo. osteopathic.org/2017/08/addressing-doctor-burnout-depression-resources-for-trainers-families-coming-soon/. August 15, 2017. Accessed on November 11, 2017.

43. Preventing Physician Burnout. AMA Steps Forward. https://www. stepsforward.org/modules/physician-burnout. Accessed February 22, 2018.

44. Physician Wellness: Preventing Resident and Fellow Burnout. AMA Steps Forward. https://www.stepsforward.org/modules/physician-wellness. Accessed February 22, 2018.

45. Clinician Resilience and Well-being. National Academy of Medicine. https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed February 22, 2018.

46. Drummond D. Stop Physician Burnout Tools, Coaching, Speaking, Training. Stop Physician Burnout Tools, Coaching, Speaking, Training - TheHappyMD.com. https://www.thehappymd.com/. Accessed February 24, 2018.