Author: Kimberly Iwaki, MD (EM Resident Physician, PGY-3, NUEM) // Edited by: Ricardo Rivera, MD // Expert Commentary: Dave W Lu, MD
Citation: [Peer-Reviewed, Web Publication] Iwaki K, Rivera R (2016, October 18). Physician Burnout [NUEM Blog. Expert Commentary By Lu D]. Retrieved from http://www.nuemblog.com/blog/burnout
Over the past decade, medical practice has become increasingly difficult due to worsening stressors in the workplace, leading to a rising prevalence of physician burnout. In the era of the electronic medical record (EMR), physicians find themselves subjected to closer scrutiny of quality metrics while the commitment to an increasing patient load continues to rise . As a result, there has been an increasing focus on physician burnout with significant concerns that this phenomenon not only impacts physicians’ well-being, but also affects their ability to care for patients.
Burnout is characterized by depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment . Multiple studies have reported that burnout rates are highest among emergency medicine (EM) physicians with a prevalence as high as 57.1% .
In a 2014 study by Mayo, comparing physicians to the general population, they found that overall burnout across medical specialties was 48.8% compared to 28.4% in the general population. When comparing these two groups, physicians were significantly older (53 years old vs. 52 years old), more likely to be men (62.2% vs. 54.4%), more likely to be married (82.9% vs. 67.5%), and worked a median of 10 hours more per week. Even after adjusting for these variables, the burnout rate remained significantly higher for physicians .
Physician burnout often begins in residency and tragic events such as resident physician suicide have begun to shed light on this struggle. Multiple studies have found significantly higher suicide rates among medical professionals in practice, with male and female physicians at 40% and 130% increased risk respectively with gender and age-matched comparisons in the general population . Collier et al report that increased rates of depression, burnout, and suicidal ideation among resident physicians may start as early as medical school .
In 2015, the Accreditation Council for Graduate Medical Education (ACGME) convened to investigate the cause of physician burnout and provide solutions. The ACGME Council of Review Committee Residents (CRCR), consisting of 28 residents and fellows across all specialties, conducted an inquiry exercise to determine actions residency programs can take to improve wellness among their residents. Participants, subdivided into 4 small groups, were asked to answer one of four questions in Figure 2, which were later discussed in a larger group forum where common themes were identified.
Participants identified certain recurrent themes that could potentially improve resident well-being if implemented uniformly :
Theme 1: Creating awareness
- Creating awareness regarding stress and depression, with a goal to improve response to mental health issues, decrease barriers to those seeking help, and make services more readily available.
Theme 2: Mentorship
- Effective mentorship including formal mentorship and periodic “check-ins” with residents regarding mental health and well being.
While ACGME has been focused on identifying and addressing burnout in residency, the steps to prevent it must go beyond training programs. Lu et al reported that among EM physicians, burnout rates are not significantly different between residents and attendings . Zwack and Schweitzer conducted semi-structured physician interviews to identify what qualities were associated with decreased burnout. Using the Maslach Burnout Inventory, a tool developed for assessing burnout, they evaluated physicians’ emotional exhaustion, depersonalization, and sense of personal accomplishment. Through their interview process, key themes emerged among physicians with low burnout scores:
1. Gratification from doctor-patient relationships
- A general practitioner reported “showing interest in the person behind the symptoms.”
- A neurosurgeon noted the “importance of being someone whose opinion counts, someone who is given a part to play when there are vital decisions to make.”
- The patients’ appreciation and gratitude was important to many of those who were interviewed.
2. Gratification from medical efficacy
- Treatment successes: “What I still derive energy from is the experience of success, of healing… Many of the patients we discharge have fully regained their health. They’ve had their appendix, their gallbladder, or a tumor removed – whatever. They are completed cured.”
3. Leisure-time activity to reduce stress
- Sporting activities to reduce tension and engaging in music, literature and art to “extend horizons and put professional concerns into perspective.” Participants prioritized these extracurricular activities, rather than just taking part in them when they “had time to do so.”
4. Quest for and cultivation of contact with colleagues
- Debriefing when “something’s not going well” or “feedback from colleagues” was listed as a way of reducing emotional pressure caused by participants’ own fallibility and inadequacies in dealing with difficult patients and complex medical issues.
5. Cultivating relationships with family and friends
- Having a reliable close relationship with those outside of medicine.
6. Personal reflection
- Reflection to identify where you are and where you want to be, brought meaning to their lives.
7. Cultivation of one’s own professionalism
- Continuing to increase your knowledge as to not lose genuine interest in your field.
- Having an internal list of priorities and sticking to them despite what others may tell you.
9. Limiting working hours
10. Ritualized time-out periods
- Taking regular breaks (not just if you have time) whether it be a nap or a vacation maintained professional stamina.
11. Regular spiritual practices or regular meditation
12. Acceptance and realism
- Accepting that there are several aspects of your job that you do not like and rather than complaining about it, accepting it will protect against disappointment, resentment and self-blame.
13. Active engagement with the downsides of the medical profession
- As above, addressing the issue in a productive manner or accepting it, rather than regarding oneself as a victim.
14. Recognizing when change is necessary
- “Younger physicians indicated that staying too long in a debilitating or unsatisfactory first job hinders the development of professional self-confidence. They noted that... a move at the right time can put a physician back on track .”
Zwack and Schweit have delivered key themes that are promising for reducing burnout rates in the medical profession and may provide a starting point for physicians to develop preventative strategies to avoid burnout. As awareness of burnout increases, both residency programs and employers are also taking positive steps such as providing supportive workplaces and better access to mental health services. Yet despite some headway into understanding physician burnout, identifying human factors that promote healthy clinical practice, and implementing institutional change, improvement is gradual and there continues to be a need for further research and translation.
Thanks Kim for the timely article on burnout. Burnout has become a buzzword within the medical community over the last few years. Literally thousands of articles have detailed the phenomenon of burnout among not only physicians, but also medical students, nurses, counselors, and other healthcare providers. Although greater awareness of burnout among physicians may be contributing to its increasing prevalence in recent studies, it remains undeniable that burnout is a significant problem that needs to be addressed in our current system of healthcare delivery.
Burnout is most obviously detrimental in its effects on the individual provider. It is well established that burnout is associated with low work morale and increased absenteeism. Physicians with high levels of burnout tend to express greater intention to leave their work, which may mean a reduction in clinical hours or early retirement . There is also growing evidence that burnout is associated with deleterious health effects – including depression, substance abuse, suicidal ideation – and potentially even increased risks of type II diabetes and cardiovascular disease [10-12].
The more insidious impact of burnout, however, may lie in its effects on patient care. While the few studies examining burnout in relation to patient care have not yielded any definitive conclusions, there is growing evidence suggesting that patients treated by burned out physicians may receive poorer care (e.g. higher hospitalization and ED visit rates, increased exposure to diagnostic testing, and lower adherence to recommended treatment) [13-15]. In surveys of physicians, burnout is also associated with greater rates of self-reported medical errors and suboptimal care (e.g. failure to adhere to practice standards and poor communication with patients) [3,16-17].
It is not surprising that EM physicians experience the highest levels of burnout among all specialties. In contrast to other specialties such as Ophthalmology or Dermatology, ED patients are not “filtered.” As a “front line” specialty, EM physicians see any and all patients who walk through the door . This sense of lack of control, along with the pressures of practicing in a high-stakes environment, no doubt contribute to EM physicians’ high rates of burnout.
So what are we to do? First, it is important to recognize that burnout is modifiable. The tips listed above are a great start for individual providers looking to prevent or ameliorate the impact of burnout on their professional lives. However, I would add that system-wide changes also need to be made by healthcare organizations in order to fully address provider burnout. A critical examination of an organization’s workplace culture, disciplinary policy, and incentive compensation structure, for example, may lead to meaningful changes in provider burnout. Finally, I would emphasize that if improving your own work-life isn’t motivation enough to address burnout, consider the impact your burnout may have on patient care. We don’t always need a validated instrument to tell that someone is burned out or in distress. If you recognize that you are suffering with burnout, take some time to step back, reassess, and address it, if not for your own sake but your patient’s too.
Dave W. Lu, MD, MBE, MS
Assistant Professor; Tufts University School of Medicine, Maine Medical Center; Department of Emergency Medicine
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