Ob/Gyn 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 ob/gyns 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. But ob/gyns were still in the top 10, along with other generalists: family physicians, 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. Ob/gyns, in fact, had the dubious distinction of ranking first, with a mean severity score of 4.1, with 1 = burnout that does not interfere with their lives and 7 = so severe that they are thinking of leaving medicine altogether.

Ob/gyns 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," Topping the list were stressors that suggested an excessive workload and loss of control over the profession, without adequate compensation, with "too many bureaucratic tasks" scoring over 5, followed closely by "spending too many hours at work," "income not high enough," "the present and future impact of Affordable Care Act," and "feeling like just a cog in the wheel," all of which scored over 4. The least important stressors (but still scoring > 3) involved relationships with colleagues and patients. Last on the list was "compassion fatigue." Although not listed, certainly the adverse impact of the liability system on obstetrical care providers is a persistent concern in their professional discourse.^[3] 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."^[4]

A higher percentage of female ob/gyns vs male ob/gyns reported burnout (52% vs 38%). Women now comprise the majority of ob/gyns, and although there is clear evidence to support women patients' preference for a female gynecologist over a male,^[5-7] not all studies reflect this bias and some indicate no strong gender preference.^[8-10] Nonetheless, according to one report, job openings frequently express preferences for female applicants, female ob/gyns are sometimes offered higher starting salaries, and numerous physicians report that male medical students are discouraged from becoming ob/gyns.^[11] And, in fact, a New York Times article reported on a lawsuit by a male gynecologist over sex discrimination in hiring practices.^[12]

The rate of burnout is lowest in the youngest and oldest ob/gyns. It peaks in midlife and holds steady throughout most of their professional career, with about a third of ob/gyns between the ages of 46 and 65 reporting burnout. It drops significantly to 10% 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 ob/gyns gave a very low score (3.5) compared with their more satisfied counterparts (5.4). This rate matched that of the general population. They were much happier at home (5) than at work but less so than their non-burned-out peers (5.8). 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 ob/gyns and their less stressed peers in choosing favorite pastimes. Percentages were nearly identical for all choices, with the most popular pastimes being spending time with family (90% of burned-out ob/gyns and 88% of those who were less stressed). Exercise (67%) and travel were next (70%), with both groups responding identically to each other. Ob/gyns tend to like reading (65%), cultural events (50%), and food and wine (45%) more than outdoor sports such as golf (14%) and hunting or fishing (10%).

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 37% of burned-out ob/gyns take only 2 weeks of vacation, if not less, each year compared with 25% of their peers. And only 14% of burned-out ob/gyns take 4 or more weeks compared with 29% 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] Ob/gyns like the same types of vacations. Burned-out ob/gyns slightly preferred beach vacations compared with their less stressed colleagues (59% vs 55%) and had slightly less interest in foreign travel (49% vs 53%). There was, however, very little difference between the 2 ob/gyn groups in regard to 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 ob/gyns who were burned out and not burned out matched up closely in regard to the types of volunteer work they did. About a quarter of both groups did pro-bono clinical work; 24% of their work was associated with religious organizations and 15% volunteered in their children's schools. There was also no great difference in the number who didn't volunteer at all (26% of burned-out ob/gyns and 24% of less stressed ob/gyns).

Ob/gyns 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, ob/gyns were well above average at 5.5 but, to be expected, those who were burned out were less confident about their health (5.1) than their non-burned-out colleagues (5.7), 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 ob/gyns 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.^[13] Although more than half of all ob/gyns who responded exercise at least twice a week, the percentage is lower among burned-out ob/gyns (53% vs 67% of their less stressed peers). In addition, 41% of the burned-out group exercised once a week at most compared with 28% of the less stressed group.^[14]

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.^[15] Ob/gyns 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 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: Fifty-nine percent reported being overweight or obese compared with 49% 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.^[16] Smoking is not a problem among the great majority of ob/gyns -- both those who are burned out and those who are not -- with only 3% 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.^[17] 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).^[18] Medscape ob/gyn responders have very moderate drinking habits, and little difference was seen between those who are burned out and those who are not. A quarter of burned-out ob/gyns don't drink at all compared with 29% of less stressed-out physicians, and about 55% of all ob/gyns have fewer than 1 drink per day; only 17% of both groups have 1 or more drinks per day.

In response to this question, 56% of burned-out ob/gyns consider themselves to have minimal savings for their age group and professional stage compared with 69% of their less stressed peers -- a difference of 13%. A smaller difference was seen in those who believe that they have no savings and unmanageable debt: 9% of burned-out ob/gyns compared with 4% of their peers. Only 15% of burned-out ob/gyns believe that they have more than adequate savings compared with 21% of their less stressed peers.

According to a 2008 Pew Report, 88% of Americans believe in God or a universal spirit.^[19] In our Medscape poll, instead of asking for specific religious affiliations, we wanted to know whether ob/gyns have a spiritual belief, regardless of active participation. There was no difference in responses in the burnout and nonburnout groups, but ob/gyns are, on the whole, less religious than the general population. When asked whether they have any religious or spiritual belief, 79% of burned-out ob/gyns and 76% of those not burned out said that they do. Slightly less than a quarter of all ob/gyns 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 56% of the burned-out believers attending services compared with 61% of their peers, a difference of 5%.

Instead of asking Medscape ob/gyns 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. Burned-out physicians were more fiscally conservative at 74% compared with 66% of their non-burned-out peers, and about 35% of both declared social conservatism.

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 ob/gyns, burned-out ob/gyns have a high rate of marriage or life with a domestic partner (84%), but this is slightly lower than the percentage for their less stressed peers (88%).

In the Medscape survey, 30% of burned-out ob/gyns have 1 child at most, compared with 20% of their non-burned-out peers. More than 40% of ob/gyns have 3 or more children, with a slightly higher association in non-burned-out ob/gyns (44%) than in their burned-out peers (37%).

According to a 2007 report from the Migration Policy Institute, 26.3% of physicians have come to the United States as adults.^[20] In the Medscape survey, burnout rates are lower in ob/gyns who came to the United States as adults -- 29% compared with 44% of those who were born here and 35% 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."