Physician 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 members were given the same criteria, the response was nearly as discouraging: 39.8% responded that they were burned out and 60.2% 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. Among the top 10 were most of the generalists: family physicians, ob/gyns, internists, and general surgeons. 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. The exception was pathologists, who had the lowest percentage of burned-out members but ranked second in severity (after ob/gyns).

Topping the list in the Medscape survey were factors that suggested an excessive workload and loss of control over the profession: too many bureaucratic tasks, too many hours at work, feeling like a cog in the wheel, and impact of the Affordable Care Act. On a scale of 1 to 7, where 1 = "not at all important" and 7 = "extremely important," these stressors garnered an average rating of > 4, as did insufficient income. The least important stressors (but still scoring > 3) involved relationships with colleagues and patients. It is clear that external stressors play a 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]

More female physicians reported burnout (45%) than male physicians (37%), which may be attributed to the fact that women tend to enter generalist professions (family medicine, internal medicine, and obstetrics/gynecology) rather than the lower-stress subspecialties.

The rate of burnout is lowest in the youngest and oldest physicians. It peaks in midlife (46-55 years) at 32% and then declines thereafter. This could suggest that older physicians have developed better ways to cope with professional life, that the older generation had a better environment to work in than the current one, or that they are 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 physicians gave a very low score (3.53) compared with their more satisfied counterparts (5.38). They were much happier at home (5.45) than at work but still slightly less so than their non-burned-out peers (5.74). 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 ob/gyns on the high end.

There was no difference at all between burned-out physicians and their less stressed peers in choosing favorite pastimes. Percentages were nearly identical for all choices, with about 86% of physicians in both groups preferring to spend time with family. Exercise was next, followed by travel, with the less burned-out group favoring travel (68%) a bit more than their more stressed colleagues (64%). Physicians tend to like reading (62%), cultural events (50%), and food and wine (44%) more than outdoor sports such as golf (12%) and hunting or fishing (9%).

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. Nearly 40% of burned-out physicians take only 2 weeks of vacation, if not less, each year compared with 25% of their happier peers. And only 17% of burned-out physicians take 4 or more weeks compared with 26% 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] Physicians like the same vacations, with the most popular being foreign travel (53%) and beach vacations (51%). Although burned-out and non-burned-out physicians matched up evenly for all types of vacations, the burned-out physicians slightly preferred beach vacations compared with their less stressed colleagues (53% vs 49%) and had slightly less interest in foreign travel (50% vs 55%). There was also a small preference among burned-out physicians for adventure vacations, winter sports, and camping and hiking compared with their less burned-out peers, perhaps reflecting a greater need for physical activity to alleviate stress.

As with pastimes and vacations, in the Medscape survey the proportions of physicians who were burned out and not burned out matched up closely in regard to the types of volunteer work they did. About 21% of both groups did pro-bono clinical work; 22% of their work was associated with religious organizations and 14% volunteered in their children's schools. The largest difference between the groups was seen in whether they volunteered at all, with 31% of the burned-out group and 27% of the non-burned-out group responding that they didn't volunteer.

Physicians were asked to rate their physical health on a scale of 1 to 7, where 1 = in poor health and 7 = extremely healthy. All physicians were well above average at 5.5 but, to be expected, those who were burned out were less confident about their health (5.25) than their non-burned-out colleagues (5.77), a difference of about 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 physicians and 7% 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 at least twice per week; for aerobic exercises it's at least 150 minutes per week.^[5] More than half of all physicians who responded exercise at least twice a week, but the percentage is lower among burned-out physicians (55% vs 65% of their less stressed peers). In addition, 46% of the burned-out group exercised once a week at most compared with 34% of the less stressed group.^[6]

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.^[7] Physicians who reported their BMI in the Medscape survey do better than their patients; among the non-burned-out group, 57% claimed normal weight compared with half 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: 38% reported being overweight or obese compared with 35% of their happier peers, and 9% of the burned-out physicians reported being obese compared with 5% of the less stressed group.

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 physicians -- both those who are burned out and those who are not -- with only 2% of them 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 responders have very moderate drinking habits, and no difference was seen between those who are burned out and those who are not. Thirty percent of all physician responders said that they didn't drink at all, and about 52% have fewer than 1 drink per day.

In response to this question, 31% of burned-out physicians consider themselves to have minimal savings for their age group and professional stage compared with 21% of their less stressed peers -- a difference of 10%. A smaller difference was seen in those who believe that they have no savings and unmanageable debt: 8% of burned-out physicians compared with 5% of their peers. Only 13% of burned-out physicians believe that they have more than adequate savings compared with 20% of their less stressed 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 physicians have a spiritual belief, regardless of active participation. There was no difference in responses in the burnout and nonburnout groups, but physicians generally are less religious than the general population. When asked whether they have any religious or spiritual belief, 74% of burned-out physicians and 76% of those not burned out said that they do. The remaining quarter 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 57% of the burned-out believers attending services compared with 62% of their peers, a difference of 5%.

Instead of asking Medscape physicians if 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 conservative, with 73% of them indicating conservatism compared with 69% of their non-burned-out peers.

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 physicians have a high rate of marriage or life with a domestic partner (82%), but this is slightly lower than the percentage for their less stressed peers (87%).

In the Medscape survey, 35% of burned-out physicians have 1 child at most, compared with 27% of their non-burned-out peers. There was a slight association between having more children and a lower risk for burnout: A third of all physicians have 3 or more children (30% of burned-out physicians vs 35% of their non-burned-out peers).

According to a 2007 report from the Migration Policy Institute, 26.3% of physicians have come to the United States as adults.^[12] A lower percentage of foreign-born physicians responded to the Medscape survey: 18% said that they came to the United States as adults and 74% were born here. Burnout rates are lower in physicians who came to the United States as adults -- 32% vs 42% of those who were born here and 40% of those who came here as children. This survey does not explain the discrepancy, but one could surmise that 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."