Pulmonologist 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 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 given the same criteria, pulmonologists indicated that they, too, were burned out, though not as badly as some other specialists: 38% of pulmonologists reported feeling burned out. 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. Pulmonologists were in seventh place on the list, tied with diabetes, cardiology, and oncology physicians. 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. On a scale of 1 to 7 (1 = burnout that does not interfere with my life; 7 = so severe that I am thinking of leaving medicine altogether), pulmonologists had a mean severity score of 3.7, tied with HIV/infectious disease specialists and cardiologists. The mean burnout score for pulmonologists fell toward the middle of the list of specialties surveyed by Medscape. Ob/gyn and women's health specialists, along with pathologists, had the highest mean burnout scores: 4.1 and 4, respectively. Ophthalmologists had the lowest mean burnout score at 3.4.

Pulmonologists 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," "spending too many hours at work," "the present and future impact of the Affordable Care Act," and "income not high enough." The least important stressors were "difficult employer," "compassion fatigue," "difficult colleagues or staff," and "too many difficult patients." 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 pulmonologists reported burnout (63% vs 38% of men), which is consistent with the general physician population. Women may have more conflicts between work and home, particularly if they have children. It should be noted that far fewer female pulmonologists responded to the survey. Of interest, however, among ob/gyns, where women outnumber men, men are more burned out.

The rate of burnout is lowest in the youngest and oldest pulmonologists. In mid-life, the percentage of pulmonologists reporting burnout trends upward, with 31% experiencing burnout between the ages of 46 and 55 and 33% experiencing burnout between the ages of 56 and 65. The burnout rate drops significantly to 6% after age 65, but this could be 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 pulmonologists gave a very low score (3.6) compared with their more satisfied counterparts (5.2). This rate matched that of the general population. They were much happier at home (5.1) than at work but less so than their non-burned-out peers (5.6). 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 pulmonologists on the high end.

There was hardly any difference between burned-out pulmonologists and their less stressed peers in choosing favorite pastimes. Percentages were nearly identical for almost all choices, with the most popular pastime being spending time with family (87% of burned-out pulmonologists and 85% of those who were less stressed). Exercise was next (69% burnout vs 67% no burnout), followed by travel (66% vs 63%). Pulmonologists also like to spend time reading (59% of both groups), cultural events (49% vs 51%), and food and wine (38% vs 45%). Collecting (3% vs 5%), engaging in social media (5% vs 6%), and nonmedical writing (6% vs 4%) were pulmonologists' least favorite pastimes.

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 28% of burned-out pulmonologists take less than 1-2 weeks of vacation each year, compared with 21% of their happier peers. Seventy percent of burned-out pulmonologists take 2-4 weeks of vacation vs 76% of their peers. Very few pulmonologists take more than 4 weeks of vacation per year (2% of those suffering burnout vs 3% of those without burnout).

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] Unlike most of the physician specialists surveyed by Medscape, pulmonologists differed slightly on their top vacation spots. Burned-out pulmonologists (48%) favored the beach, whereas those who were not burned out favored foreign travel (56%). For those who are burned out, vacation homes (26%) and road trips (23%) rank among the favorites. The non-burned-out group also enjoys vacation homes and road trips (18% for both) as well as luxury spas/hotels and camping trips (also 18%). Twenty-percent of all pulmonologists enjoy taking cultural trips.

As with pastimes and vacations, in the Medscape survey the proportions of pulmonologists who were burned out and not burned out matched up closely in regard to the types of volunteer work they did. Twenty-two percent of burned-out pulmonologists vs 20% of their more relaxed counterparts cited pro-bono clinical work as their top volunteer activity, followed by work with religious organizations (19% vs 14%) and their children's schools (12% of both groups). Some 34% of burned-out pulmonologists and 31% of those who are not burned out do not volunteer at all.

Pulmonologists 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, pulmonologists were well above average (5.5), but, to be expected, those who were burned out were less confident about their health (5.3) than their non-burned-out colleagues (5.8), a difference of slightly less than 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, 6% of non-burned-out pulmonologists 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] More than half of all pulmonologists who responded exercise at least twice a week, but the percentage is slightly lower among non-burned-out pulmonologists (58% vs 59% of their stressed-out peers). Among those who work out once a week at most, the lower-stress group beat their burned-out colleagues, 38% to 36%.

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] Pulmonologists 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 52% 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-eight percent reported being overweight or obese compared with 42% 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 pulmonologists; just 2% of those in the burnout group and 1% of the non-burnout group say that they are current smokers. Eighty-six percent of both groups say that they never smoked, while 10% of both groups say that they once smoked but quit more than 5 years ago. The rest have been smoke-free for less than 5 years.

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 pulmonology responders have very moderate drinking habits: 51% of all pulmonologists said that they have fewer than 1 drink per day, and 13% of burned-out physicians and 19% in the less stressed group report having 1-2 drinks per day. One percent of those who report burnout and 2% of those in the non-burnout group have 2 or more drinks per day, while 35% of the burned-out group and 28% of their less stressed colleagues don't drink alcohol at all.

Income seems to be a significant factor in how burned-out vs non-burned-out pulmonologists view themselves. In response to this question, 62% of burned-out pulmonologists consider themselves to have adequate savings for their age group and professional stage compared with 72% of their less stressed peers -- a difference of 10%. There was a 13% difference between those who believe that they have minimal or no savings and unmanageable debt: 34% of burned-out pulmonologists compared with 21% of their peers. Four percent of burned-out pulmonologists preferred not to answer this question compared with 7% 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 pulmonologists have a spiritual belief, regardless of active participation. There was no difference in responses in the burnout and non-burnout groups, but pulmonologists are generally are less religious than the general population. When asked whether they have any religious or spiritual belief, 75% of burned-out pulmonologists and 76% of those not burned out said that they do.

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 56% of the burned-out believers attending services compared with 51% of their peers.

Instead of asking Medscape pulmonologists 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 fiscally conservative at 72% compared with 62% of their non-burned-out peers. There was little difference in their tendency toward social liberalism (60% of the burnout group and 62% of their less stressed 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 pulmonologists have a high rate of marriage or life with a domestic partner (88%), only slightly lower than the percentage for their less stressed peers (89%).

In the Medscape survey, 32% of burned-out pulmonologists have 1 child at most, compared with 23% of their non-burned-out peers. Thirty-five percent of non-burned-out pulmonologists have 3 or more children, compared with 24% of their burned-out colleagues.

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 lowest in pulmonologists who were born in the United States. This differs from the findings in most of the other physician groups surveyed, in which burnout rates were highest in doctors born in this country. Among Medscape pulmonologists, burnout rates were highest in those who came to the United States as children (47%), compared with 39% of those who came here as adults and 35% of those who were born here. This survey does not explain the discrepancy.

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."