Family Physician Lifestyles -- Linking to Burnout: Medscape Survey

The following slides present the major findings of the 2013 physician lifestyle survey, which focused on the links between work burnout and physicians' lives outside of practice.

A national survey published in the Archives of Family Medicine in 2012 reported that US physicians suffer more burnout than other American workers.^[1] Some 45.8% of physicians were experiencing at least 1 symptom of burnout: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. In Medscape's current survey, when family physicians were given the same criteria, the response was as discouraging: 43% responded that they were burned out and 57% said that they were not. The 2 specialties with the highest percentage of burnout were those that dealt with severely ill patients: emergency medicine and critical care. Family physicians were in third place. Tied for fourth place at 42% were internists, ob/gyns, anesthesiologists, and general surgeons. Although generalists led the burnout pace, pediatricians surprisingly were among the least burned-out specialists, along with rheumatologists, ophthalmologists, psychiatrists, and pathologists.

Burnout is serious. According to a 2013 study, job stress, coupled with inadequate treatment for mental illness, may account for the higher-than-average rate of suicide among US physicians.^[2] In the Medscape survey, it was no surprise that physicians in specialties with the highest percentage of burned-out members also reported greater severity in their own burnout. Family physicians, in fact, ranked in third place, matching physicians in general surgery, critical care, and internal medicine with a score of 3.9 (1 = burnout that does not interfere with their lives and 7 = so severe that they are thinking of leaving medicine altogether).

Family physicians were given a list of stressors and were asked to rate how important they were as a cause of burnout on a scale of 1 to 7, where 1 = "not at all important" and 7 = "extremely important," Topping the list with ratings of 5 or greater were factors that suggested an excessive workload and loss of control over the profession, without adequate compensation: "too many bureaucratic tasks and "spending too many hours at work." These were followed by "feeling like a cog in a wheel" and "income not high enough." Patient issues also scored over 4, with "too many difficult patients" as the fifth stressor. The least important stressors were those that involved relationships with colleagues and employers. It is clear that external stressors play the major role in physician burnout. In a Medscape Primary Care roundtable discussion, Roy Poses, MD, of Brown University said, "Most interventions meant to improve burnout have treated it like a psychiatric illness, not a rational response to a badly led, dysfunctional healthcare system."^[3]

A higher percentage of female than male family physicians reported burnout (60% vs 52%), which may be attributed to the fact that women tend to enter generalist professions (family medicine and internal medicine) rather than the lower-stress subspecialties. Women may also have more conflicts between work and home, particularly if they have children.

The rate of burnout is lowest in the youngest and oldest family physicians. It peaks and holds steady throughout most of their professional career, with 31% of burned-out family physicians being within the ages of 46 and 65 compared with about a quarter of less stressed physicians in that age range. Burnout rates drop to 29% in all family physicians between ages 56 and 65, perhaps because of better coping mechanisms or higher income. The rate then decreases significantly to 5% after age 66, which is most likely due to retirement or cutting back on hours.

It comes as no surprise that when asked to score their happiness at work from 1 (very unhappy) to 7 (very happy), burned-out family physicians gave a much lower score (3.5) compared with their more satisfied counterparts (5.4). Family physicians were much happier at home (5) than at work but less so than their non-burned-out peers (5.8). In the Archives of Family Medicine survey,^[1] physicians were asked about work-life balance; those practicing preventive medicine, dermatology, and general pediatrics gave the highest satisfaction ratings, whereas those in general surgery and its subspecialties, as well as obstetrics/gynecology, reported the lowest rates. These ratings generally correlated with the severity ratings in the Medscape survey, with dermatologists and pediatricians rating themselves at the low end of the severity scale and surgeons and family physicians on the high end.

There was no difference at all between burned-out family physicians and their less stressed peers in choosing favorite pastimes. Percentages were closely matched up for all choices, with the most popular pastimes being spending time with family (86% of burned-out family physicians and 89% of those who were less stressed). Exercise was next, chosen by 70% of both groups, followed by travel and reading. Family physicians tend to like indoor activities -- reading (about 62% for both groups), cultural events (48% burnout, 45% no burnout), and food and wine (38% burnout, 40% no burnout) -- more than outdoor ones, such as golf (9% burnout, 13% no burnout) and hunting or fishing (12% both groups).

With an average of 13 paid vacation days per year, Americans are far worse off than those in other developed countries (eg, Italy, 42; France, 37; Germany, 35; United Kingdom, 28; Canada, 26; Japan, 25). US physicians don't fare much better than their American patients. And those who are burned out do worse than their peers. About half of burned-out family physicians take only 2 weeks of vacation, if not less, each year compared with 32% of their peers. And 47% of burned-out family physicians take 2 or more weeks compared with 64% of their happier peers.

According to a 2009 survey from the US Travel Association, activities with the greatest interest among US adults are, in order of popularity, visiting friends and relatives, sightseeing, going to beaches, visiting museums, going to national or state parks, going on cruises, visiting theme parks, traveling to cities, and visiting mountain regions.^[4] Family physicians, burned out or not, like the same vacation types, with the most popular being beach vacations, which were slightly preferred by the burned-out physicians compared with their less stressed colleagues (54% vs 50%). Foreign travel came next in popularity, slightly preferred by the non-burned-out family physicians. There were very few differences between burned-out and non-burned-out family physicians for all types of vacations, although the more stressed group tended to like outdoor sports more than their colleagues -- perhaps to let off steam.

As with pastimes and vacations, in the Medscape survey the proportions of family physicians who were burned out and not burned out matched fairly closely in regard to the types of volunteer work they did. Their 2 top preferred volunteer jobs for both groups were associated with religious organizations and pro-bono clinical work, although a lower percentage of burned-out physicians vs less stressed physicians signed up for these 2 jobs (23%/23% vs 30%/26%, respectively). The third choice, at about 16% in each group, was volunteering in their children's schools. The largest discrepancy between burned-out family physicians and their less stressed peers was seen in those who didn't volunteer at all (28% vs 21%, respectively).

Family physicians were asked to rate their physical health on a scale of 1 to 7, where 1 = in poor health and 7 = extremely healthy. In general, family physicians rated themselves well above average, at 5.5, but, to be expected, those who were burned out were less confident about their health (5.2) than their non-burned-out colleagues (5.7).

The most recent CDC statistics report that 26.2% of Americans exercise less than once a month -- essentially not at all. In the Medscape survey, 5% of non-burned-out family physicians and 6% of the burned-out group confessed to not exercising at all. The CDC also reported that about 21% of US adults participated in enough aerobic and muscle-strengthening exercises to meet guidelines. Guidelines for muscle strengthening require exercising more than twice per week; for aerobic exercises it's at least 150 minutes per week.^[5] More than half of all family physicians who responded exercise at least twice a week, but the percentage is lower among burned-out family physicians (56% vs 66% of their less stressed peers). In addition, 38% of the burned-out group exercised only once a week at most compared with 29% of the less stressed group.

According to a CDC report, 35.8% of US men and women were overweight in 2011 and 27.8% were obese. Only 34.5% were of normal weight and 1.8% were underweight.^[6,7] Family physicians who reported their BMI in the Medscape survey do better than their patients; among the non-burned-out group, 60% claimed to be of normal weight or underweight compared with 44% of their burned-out peers. However, weight is still a problem even among these professionals, and those who are burned out tend to weigh more: 55% reported being overweight or obese compared with 46% of their happier peers.

Although the national quit rate has increased over the past few years, according to recent CDC data, 21% of Americans still smoke.^[8] Smoking is not a problem among the great majority of family physicians, with only 1% of non-burned-out and 3% of burned-out family physicians being current smokers.

As reported in a 2010 Gallup poll, 67% of American adults drink alcohol, a rate that has been "remarkably stable" since this began being tracked in 1939.^[9] In the most recent CDC report, 57.1% of US adults had at least 1 drink within the past month, 18.3% of adults are binge drinkers, and 6.6% confess to being heavy drinkers (adult men having more than 2 drinks per day and adult women having more than 1 drink per day).^[10] Medscape family physician responders have very moderate drinking habits, and no difference was seen between those who are burned out and those who are not. About 34% of family physicians, burned out or not, don't drink at all. Half of all family physicians have fewer than 1 drink per day; about 15% have 1 drink per day.

Income seems to be a significant factor in how burned-out vs non-burned-out family physicians view themselves. In response to this question, 45% of burned-out family physicians consider themselves to have at least adequate savings for their age group and professional stage compared with 63% of their less stressed peers. More significant, there was a 20% difference between those who believe that they have minimal savings to unmanageable debt: 50% of burned-out family physicians compared with 30% of their peers.

According to a 2008 Pew Report, 88% of Americans believe in God or a universal spirit.^[11] In our Medscape poll, instead of asking for specific religious affiliations, we wanted to know whether family physicians have a spiritual belief, regardless of active participation. There was no difference in responses in the burnout and nonburnout groups, but family physicians are generally less religious than the general population. When asked whether they have any religious or spiritual belief, the responses of the 2 groups were very similar: 80% of burned-out and 83% of non-burned-out family physicians professed a spiritual or religious belief. Less than a quarter of all family physicians had no belief system.

When physicians who claimed to have a religious or spiritual belief were asked whether they actively attend services, a slight difference emerged between the burned-out and non-burned-out groups, with 61% of the burned-out believers attending services compared with 69% of their less stressed peers.

Instead of asking Medscape family physicians whether they are Democrat, Republican, or Independent, the survey question focused on whether members considered themselves liberal or conservative in fiscal and social areas. Without clear definitions of these terms, the responses are very subjective; the objective was to get a sense of political biases rather than voting habits. There weren't great differences between the burned-out and non-burned-out groups, although burned-out physicians were slightly more fiscally conservative at 70% compared with 65% of their non-burned-out peers, and 35% declared social conservatism vs 33% of their less stressed colleagues.

According to Paul Griner, MD, author of The Power of Patient Stories: Learning Moments in Medicine, "If you are not spending relaxed time with your loved ones, having some fun outside of work, or enjoying interpersonal relationships, you are at a greater risk for burnout." Like all physicians, burned-out family physicians have a high rate of marriage or life with a domestic partner (81%), but this is slightly lower than the percentage for their less stressed peers (87%).

In the Medscape survey, 32% of burned-out family physicians have 1 child at most, compared with 26% of their non-burned-out peers. Thirty-three percent of burned-out family physicians have 3 or more children, which is lower than the number of children in non-burned-out internist homes (39%).

According to a 2007 report from the Migration Policy Institute, 26.3% of physicians have come to the United States as adults.^[12] In the Medscape survey, 15% of family physicians said that they came to the United States as adults and 78% were born here. Of those born in the United States, 45% said that they were burned out, compared with 38% of those who came here as adults.

This word cloud was created from the write-in responses to a question asking about important stressors. The word "patients" is most prominent, suggesting that this relationship is key in physician burnout. In dealing with this issue, Dr. Griner advises physicians to "participate actively in health reforms that will return a greater level of control to physicians and their patients. These include payment for value and greater patient participation in decision-making about care. Reorganizing primary care practices to allow more time for complex patients and recognition by insurers that excessive hassle is bad for patients and physician are also vital. These changes should lead to more satisfied patients and physicians and less burnout."

In the Archives article,^[1] the authors sum up the very challenging problem of physician burnout: "Collectively, the findings...indicate that (1) the prevalence of burnout among US physicians is at an alarming level, (2) physicians in specialties at the front line of care access (emergency medicine, general Family Medicine, and family medicine) are at greatest risk, (3) physicians work longer hours and have greater struggles with work-life integration than other US workers, and (4) after adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine (MD or DO) increases the risk. These results suggest that the experience of burnout among physicians does not simply mirror larger societal trends."