Rheumatologist 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 rheumatologists were given the same criteria, the response was more encouraging: just 35% reported burnout, placing rheumatologists, along with psychiatrists, pathologists, pediatricians, and ophthalmologists, among the least burned-out specialists. 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.

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, with the exception of pathologists, physicians in specialties with the lowest percentage of burned-out members also reported lesser severity in their own burnout. Rheumatologists were among those physicians reporting the least severe burnout, with a mean score of 3.6 (1 = does not interfere with my life; 7 = so severe that I am thinking of leaving medicine altogether).

Rheumatologists 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" and "spending too many hours at work." The least important stressors concerned difficult colleagues, staff, or 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 rheumatologists reported burnout (59% vs 33% of men), which is consistent with the general physician population. 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 rheumatologists. It increases through midlife with 28% of burned-out rheumatologists 46-55 years of age and 37% between 56 and 65. The burnout rate drops significantly to 5% after age 66, 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 rheumatologists gave a low score of 3.9 compared with their more satisfied counterparts, who scored 5.2. This compares with scores of 3.5 and 5.4 in the overall physician population. They were much happier at home (5.1) than at work but less so than their non-burned-out peers (5.7).

The most popular pastimes among both rheumatologists and the overall physician sample were spending time with family, exercise, travel, and reading. However, burned-out rheumatologists were less likely to pursue some activities than were their happier peers, including physical activity (67% vs 79%) and food and wine (32% vs 38%). Of note, burned-out rheumatologists report being more likely to travel (65%) than their non-burned-out colleagues (57%).

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 41% of burned-out rheumatologists take only 2 weeks of vacation, if not less, each year compared with 33% of their happier peers. And 57% of burned-out rheumatologists take 2 or more weeks compared with 64% 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] Rheumatologists, burned out or not, like the same vacation types. Compared with the overall physician population, however, they are significantly more likely to take a foreign vacation rather than a trip to the beach. They are also more likely to participate in cultural activities such as going to museums and taking in a show at the theater. Overall, burned-out rheumatologists were more likely to travel when considering vacations of all types.

As with pastimes and vacations, in the Medscape survey, burned-out and non-burned-out rheumatologists were similar in regard to volunteering. About 26% of both groups did pro-bono clinical work, 23% volunteered with religious organizations, and 8% volunteered in their children's schools. However, 6% of non-burned-out respondents reported working with the homeless, compared with less than 1% of those with burnout, and overall, burned-out rheumatologists are more likely to not volunteer at all (28% vs 25%).

Rheumatologists were asked to rate their physical health on a scale of 1 to 7, where 1 = in poor health and 7 = extremely healthy. Rheumatologists' self-rating (5.6) was the same as that for the whole physician sample, but, as might be expected, those who were burned out were less confident about their health (5.5) 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, 2% of non-burned-out rheumatologists and 11% 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 rheumatologists who responded exercise at least twice a week, the percentage is lower among burned-out rheumatologists (60% vs 68% of their less stressed peers). Around 30% of both groups report exercising once a week at most.

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] Rheumatologists who reported their BMI in the Medscape survey do better than their patients; 60% of both the burned-out and non-burned-out group claim to be of normal weight or underweight. However, weight is still a problem even among these professionals, with nearly 40% of both groups reportedly being overweight or obese.

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 rheumatologists; less than 1% of both those who are burned out and those who are not report being smokers. Nearly 82% of both groups report never having smoked.

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 rheumatologist responders have very moderate drinking habits, and little difference was seen between those who are burned out and those who are not. However, fewer burned-out respondents reported not drinking at all (36% vs 41%). Only about 5% in each group have 2 or more drinks per day.

Income seems to be significant in how burned-out vs non-burned-out rheumatologists view themselves. In response to this question, only 54% of burned-out rheumatologist respondents consider themselves to have adequate savings for their age group and professional stage compared with 70% of their less stressed peers. There was also a significant difference between those who believe that they have minimal savings or unmanageable debt: 37% of burned-out rheumatologists compared with 22% 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 rheumatologists have a spiritual belief, regardless of active participation. There was little difference in responses in the burnout and non-burnout groups, but rheumatologists are slightly less religious than the general population (81% vs 88%).

When physicians who claimed to have a religious or spiritual belief were asked whether they actively attend services, 63% of both burned-out and non-burned-out rheumatologists answered yes.

Instead of asking Medscape rheumatologists 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. Unlike other physician groups, burned-out rheumatologists were less fiscally conservative at 60% compared with 66% of their non-burned-out peers. Forty-five percent of the burned-out group expressed social liberalism compared with 56% of the non-burned-out group.

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 rheumatologists have a high rate of marriage (75%), but this is slightly lower than the percentage for their less stressed peers (78%). Rheumatologists on the whole are less likely to be divorced than the overall physician sample (2% vs 5%) and also less likely to be living with a domestic partner (1% vs 4%).

In the Medscape survey, 30% of burned-out and 22% of non-burned-out rheumatologists have 1 child at most. Non-burned-out rheumatologists are significantly more likely to have 3 or more children (32% vs 24%).

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 rheumatologists who came to the United States as adults -- 30% compared with 37% 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."