Internist Lifestyles -- Linking to Burnout: A 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 Internal 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 internists were given the same criteria, the response was as discouraging: 42% responded that they were burned out and 58% 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. Internists matched up in fourth place with ob/gyns and anesthesiologists, right behind family physicians, the other major primary care group. Surprisingly, pediatricians 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. Internists, in fact, ranked in third place, matching physicians in general surgery, critical care, and family 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).

Internists 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. The least important stressors (but still scoring > 3) 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 internists reported burnout (50% vs 39%), 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 internists. It peaks and holds steady throughout most of their professional career, with 30% of burned-out internists 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 21% in all internists 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 internists gave a much lower score (3.5) compared with their more satisfied counterparts (5.3). Internists were much happier at home (5) than at work but less so than their non-burned-out peers (5.7). In the Archives of Internal 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 internists on the high end.

There was no difference at all between burned-out internists 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 (88% of burned-out internists and 84% of those who were less stressed). Exercise was next, followed by travel (67% and 64%, respectively, of all internists). Internists tend to like indoor activities -- reading (59%), cultural events (49%), and food and wine (40%) -- more than outdoor ones, such as golf (9%) and hunting or fishing (6%)

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 44% of burned-out internists take only 2 weeks of vacation, if not less, each year compared with 29% of their happier peers. And only 10% of burned-out internists take 4 or more weeks compared with 17% of their 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] Internists, burned out or not, like the same vacation types, with the most popular being foreign travel, slightly favored by those who were not burned out (55% vs 52%). The burned-out physicians slightly preferred beach vacations compared with their less stressed colleagues (50% vs 47%). There were, however, very little differences between burned-out and non-burned-out internists for all types of vacations. The main difference, of course, is that the burned-out group spends less time taking them.

As with pastimes and vacations, in the Medscape survey the proportions of internists who were burned out and not burned out matched up closely in regard to the types of volunteer work they did. About 20% of their work was associated with religious organizations and about 19% of both groups did pro-bono clinical work, with 13% volunteering in their children's schools. There was, however, a larger difference between burned-out internists and their less stressed peers in the percentage of those who didn't volunteer at all (36% vs 29%, respectively).

Internists 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, internists 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 (5.8), a difference of slightly over 10%.

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 internists 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 internists who responded exercise at least twice a week, but the percentage is lower among burned-out internists (51% vs 63% of their less stressed peers). In addition, 41% of the burned-out group exercised only once a week at most compared with 30% 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] Internists 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 53% 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: 46% reported being overweight or obese compared with 39% 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 internists -- both for those who are burned out and those who are not -- with only 2% being 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 internist responders have very moderate drinking habits, and little difference was seen between those who are burned out and those who are not. Thirty-nine percent of burned-out internists don't drink at all compared with 36% of less stressed-out physicians. Forty-eight percent of all internists have fewer than 1 drink per day; 12% of those who report burnout and 16% of those who do not have 1 or more drinks per day.

Income seems to be a significant factor in how burned-out vs non-burned-out internists view themselves. In response to this question, 49% of burned-out internists consider themselves to have at least adequate savings for their age group and professional stage compared with 62% of their less stressed peers. More significant, there was a 15% difference between those who believe that they have minimal or no savings and unmanageable debt: 44% of burned-out internists compared with 29% 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 internists have a spiritual belief, regardless of active participation. There was no difference in responses in the burnout and nonburnout groups, but internists 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 identical: 77% of all internists professed a spiritual or religious belief. Less than a quarter of all internists 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 59% of the burned-out believers attending services compared with 62% of their peers.

Instead of asking Medscape internists 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 internists have a high rate of marriage or life with a domestic partner (80%), but this is slightly lower than the percentage for their less stressed peers (85%).

In the Medscape survey, 41% of burned-out internists have 1 child at most, compared with 30% of their non-burned-out peers. Twenty-three percent of burned-out internists have 3 or more children, which is lower than the number of children in non-burned-out internist homes (31%).

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, 30% said that they came to the United States as adults and 60% were born here. Of those born in the United States or who came here as children, about 45% said that they were burned out, compared with 38% of those who came here as adults. Although the burnout rate in adult foreign-born internists is lower than that in those who grew up in or were born in the United States, it is higher than that in the foreign-born population of subspecialists.

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 internal 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."