Nephrologist 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 nephrologists were given the same criteria, 40% responded that they were burned out and 60% 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. Others at the top of the list are generalists: family physicians, internists, and general surgeons. Nephrologists ranked 12th on the list, which is about the average for all of the specialists surveyed. Surprisingly, pediatricians were among the least burned-out specialists, along with rheumatologists, 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. Ranking 11th with a mean burnout severity score of 3.8 (1 = does not interfere with my life; 7 = so severe that I am thinking of leaving medicine altogether), nephrologists' burnout severity is relatively low.

Nephrologists were given a list of stressors and 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. The top-rated stressors were "too many bureaucratic tasks" at 5.7, "spending too many hours at work" at 5.3, and "feeling like a cog in the wheel" at 4.6. The least important stressors were problems with patients 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 far higher percentage of female nephrologists reported burnout (59% vs 39% of men). Women may have more conflicts between work and home, particularly if they have children.

The rate of burnout is lowest in the youngest and oldest nephrologists. It peaks at 31% in the 36-45 age range and then drops to about 24% over the rest of their career. This trend is different from that in most other specialties, where peak burnout occurs after age 46. The rate drops significantly to 7% after age 66, which is to be expected, 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 nephrologists gave a very low score (3.7) compared with their more satisfied counterparts (5.4). They were much happier at home (5.1) than at work but less so than their non-burned-out peers (5.9). 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.

There was no difference at all between burned-out nephrologists and their less stressed peers in choosing favorite pastimes. Percentages were nearly identical for many choices, with the most popular pastime being spending time with family (about 87% of all nephrologists). The second preference was exercise, but there was a fairly wide variation between the 2 groups (chosen by 76% of burned-out nephrologists vs 59% of less stressed peers). Nephrologists in both groups chose travel next (65% of burned-out nephrologists and 60% of their less stressed peers). Also, in both groups, the more passive pastimes -- reading, cultural events, and food and wine -- beat out the more active pursuits, golf and hunting.

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. Thirty-two percent of burned-out nephrologists take 2 weeks of vacation or less each year compared with 19% of their peers. And 68% of burned-out nephrologists take 2 or more weeks compared with 81% 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] Nephrologists, burned out or not, generally like the same types of vacations. Foreign travel topped the list, although 5% more of the non-burned-out group chose this vacation (60% vs 55%). About 40% of both groups liked the beach, the second most popular vacation type. Overall, there was very little difference between the 2 nephrologist groups in regard to preferred types of vacations, although the non-burnout group had a much higher preference for camping, while the opposite held true for adventure trips and winter sports. The main difference, of course, is that the burned-out group spends less time participating in them.

As with pastimes and vacations, in the Medscape survey the proportions of burned-out and non-burned-out nephrologists were similar in regard to the types of volunteer work they did. About 22% of both groups did pro-bono clinical work, and about 19% worked with religious organizations. There was a large difference, however, in the percentage of those who didn't volunteer at all: 36% of the burned-out group vs 26% of their more satisfied peers.

Nephrologists 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, nephrologists' scores were well above average, but, to be expected, those who were burned out were slightly less confident about their health (5.3) than their non-burned-out colleagues (5.9).

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, 8% of non-burned-out nephrologists and 4% 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] Although more than half of all nephrologists who responded exercise at least twice a week, the percentage is lower among burned-out nephrologists (55%) vs their less stressed peers (62%). In addition, 40% of the burned-out group exercise 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] Nephrologists who reported their BMI in the Medscape survey do better than their patients; among the non-burned-out group, 59% 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: Forty-seven percent 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] Only 13% of the burned-out nephrologists and 17% of the non-burned-out group ever smoked, according to their responses. Only 1% of the non-burned-out group and none of the burned-out nephrologists claim to be smokers now.

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 nephrologist responders have very moderate drinking habits, and little difference was seen between those who are burned out and those who are not. Forty-one percent of burned-out nephrologists and 36% of the non-burned-out group don't drink at all. Slightly over half of all nephrologists have fewer than 1 drink per day, and 11% of the non-burnout group and 8% of the burnout group have 1 or more drinks per day.

Income seems to be a factor in how burned-out vs non-burned-out nephrologists view themselves. In response to this question, 60% of burned-out nephrologists consider themselves to have adequate savings for their age group and professional stage compared with 66% of their less stressed peers. There was a 12% difference between those who believe that they have minimal savings to unmanageable debt: 36% of burned-out nephrologists compared with 24% of their happier 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 nephrologists have a spiritual belief, regardless of active participation. On the whole, nephrologists are less religious than the general population. When asked whether they have any religious or spiritual belief, 72% of burned-out nephrologists and 74% of those not burned out said that they do. Slightly over a quarter of all nephrologists have no belief system.

When physicians who claimed to have a religious or spiritual belief were asked whether they actively attend services, there was no difference at all between burned-out and non-burned-out groups, with 64% of believers attending services.

Instead of asking Medscape nephrologists 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 a third 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, nephrologists have a high rate of marriage or life with a domestic partner, and there was hardly any difference between those who were burned out (84%) and their less stressed peers (83%). Divorce rates are also low at 4%-5%.

In the Medscape survey, about a third of burned-out (35%) and non-burned-out (32%) nephrologists have 1 child at most. About a quarter of nephrologists have 3 or more children, with only a slightly higher association in non-burned-out nephrologists (28%) vs their burned-out peers (22%).

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, burnout rates are lower in nephrologists who came to the United States as adults (32%) compared with 44% of those who were born here and 56% of those who came here as children. This survey does not explain the discrepancy, but one could surmise that adult foreign-born physicians might have fewer expectations.

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."