by Jeremy Lazarus, MD, and Alexander von Hafften, MD

Introduction

Health care professional wellbeing is the foundation of health care quality and outcomes.1 Declining nurse, pharmacist, physician, resident, and medical student well-being were well documented prior to the COVID-19 pandemic.1,2,3 The pandemic is increasing distress in the health care workforce and is bringing national attention to health care professional burnout.

This is the first of three articles on physician burnout. This article defines physician burnout and summarizes why it is important. The second article will summarize system and organizational strategies to reduce physician and medical student burnout. The third article will summarize individual physician interventions to improve physician and medical student wellbeing.

Brief history

Physician distress, burnout, anxiety, depression, substance use disorders, and suicide are not new phenomena. The first JAMA editorial regarding physician suicide was published in 1903.4 For much of the 20th century, physician distress focused on the vulnerabilities of individual physicians.5 By the 1970s, this perspective was changing. In 1976, Maslach published research on health and social service professional burnout.6 In 1981, Maslach and Jackson published the Maslach Burnout Inventory (MBI).7 The MBI is the first and most commonly used tool for measuring burnout.

What is physician burnout?

Physician burnout encompasses a combination of emotional exhaustion, depersonalization, detachment, cynicism, and sense of low personal achievement.7 Physician burnout evolves over time. It is not a response to a challenging job or long work hours. It is not a personal failing or deficit of resilience. Physician burnout is an individual response to systemic issues and needs a comprehensive and individualized response.2,8,9

Physician burnout is a syndrome, not a medical disorder, mood disorder, or anxiety disorder.  However, burnout may precipitate or exacerbate depression, anxiety, substance misuse, and risk for suicide. A depressive disorder, anxiety disorder, and substance use disorder may be precipitated by burnout and contribute to burnout. An individual physician may experience burnout, a mood disorder, an anxiety disorder, and a substance use disorder. Physician distress, burnout, depression, anxiety, and substance misuse are risk factors for physician suicide.

What are contributors to physician burnout?

Physician burnout has multiple causes including the health care system, health care organizations, physician-patient interactions, and patients. An individual physician’s vulnerability and response to these factors may contribute as well. Physicians work in high-strain settings with expanding duties and responsibilities, decreasing autonomy and support, and decreasing direct face-to-face time with patients.

The electronic health record (EHR) is a good example. Even though EHRs may contribute to care coordination and patient safety, they have produced unintended adverse consequences. EHRs disrupt physician-patient interactions, contribute to task shifting from non-physicians to physicians, and facilitate ever-
increasing reporting requirements by third parties regarding patient care metrics and regulatory requirements. Sinsky reported that for every hour of direct face-to-face time with patients, physicians spend nearly two additional hours of EHR and desk work within the workday and an additional one to two hours of EHR work at home.10 For physicians, work-life balance has always been a challenge, and technology has made it worse.

Some other major contributors to physician burnout include:9

  • Perceived lack of peer support, lack of professionalism, and disengaged health care organization leadership.
  • Loss of meaning of patient care and in medicine arising from decreased supports, increased responsibility, and decreased autonomy and flexibility.
  • Work compression, work environment intensity, and fatigue.

How common is physician burnout?

Much of the data regarding physician burnout comes from self-report assessments. Physician distress and burnout are common. The rate of physician burnout is approximately 50 percent among U.S. physicians, residents, and medical students.3,9 Burnout may be 20-60 percent higher among female physicians than male physicians.11 Female physicians may be more likely to describe emotional exhaustion while male physicians more likely to describe depersonalization.11 The rate of burnout among physicians varies by clinical specialty, with specialties on the front lines of access to care being at highest risk.2,9

Does physician distress and burnout impact patient care?

Physician distress and burnout decrease quality of care, patient safety, and patient satisfaction.  Physician burnout decreases physician engagement, productivity, and increases turnover and early retirement. “Patient care quality goes hand in hand with physician wellbeing.”12,13

Key points

  1. Burnout is a syndrome of emotional exhaustion, depersonalization, cynicism, and decreased sense of accomplishment.
  2. Physician burnout is not a deficit of physician resilience.
  3. Physician burnout is common and begins in medical school.
  4. Physician burnout is associated with substance misuse, anxiety, depression, and suicide.
  5. Physician burnout is associated with medical errors, decreased productivity, lower patient satisfaction, and higher physician turnover.

Call to action

The American Medical Association (AMA), National Academy of Medicine (NAM), American Association of Medical Colleges (AAMC), Federation of State Medical Boards (FSMB), and many medical societies have published policies, guidelines, and recommendations to promote physician health and wellbeing. Health care system and organizational interventions will be the focus of the second article in this series. ■

  1. Noseworthy J, Madara J, Cosgrove D, et al: Physician burnout is a public health crisis: A message to our fellow health care CEOs. Health Affairs. March 2017. Available from https://www.healthaffairs.org/do/10.1377/hblog20170328.059397/full/
  2. Shanafelt TD, Noseworthy JH: Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clinic Proceedings 92(1):129–46, 2017.
  3. Dyrbye LN, Shanafelt, CA, Sinsky PF et al: Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC, 2017. Available from https://nam.edu/wp-content/uploads/2017/07/Burnout-Among-Health-Care-Professionals-A-Call-to-Explore-and-Address-This-Underrecognized-Threat.pdf
  4. JAMA: Suicides of physicians and the reasons. JAMA 41(4):263-264, 1903.
  5. Legha RK: A history of physician suicide in America. J Med Humanit 33(4):219-244, 2012.
  6. Maslach C: Burned-out. Human Behavior 5 (9):16-22, 1976.
  7. Maslach C, Jackson SE: The measurement of experienced burnout. Journal of Occupational Behavior 2:99-113, 1981.
  8. Mayer, LE: From burnout to impairment, in combating physician burnout. Edited by LoboPrabhu S, Summers RF, Moffic, Washington DC, American Psychiatric Association Publishing, 2020, pages 85-100.
  9. American Psychiatric Association. APA Wellbeing Ambassador Toolkit. Physician Burnout and Depression: Challenges and Opportunities, Slide 16, January 2018.
  10. Sinsky C, Colligan L, Li L, et al: Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 165(11):753-760, 2016.
  11. Templeton K, Bernstein, CA, Sukhera J: Gender-based differences in burnout: Issues faced by women physicians. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington DC, 2019.
  12. Shanafelt, TD: Enhancing meaning in work: prescriptions for preventing physician burnout and promoting-patient centered care. JAMA 302(12):1338-1340, 2009.
  13. Shanafelt TD, Balch CM, Bechamps G, et al: Burnout and medical errors among American surgeons. Ann Surg 251(6):995-1000, 2010.

This article was originally published in the Alaska State Medical Association (ASMA) bimonthly newsletter, Heartbeat. It has been reprinted with permission.


Categories: Communications, Colorado Medicine, Resources, Initiatives, Physician Wellness