Editor's Note: The problem of physician burnout has been illuminated by a number of recent studies, including Medscape's 2015 Physician Lifestyle Report, which surveyed approximately 20,000 physicians and asked about severity of burnout, factors contributing to burnout, and its association with a range of other issues, including happiness outside of work, alcohol and marijuana use, and financial status. Burnout is not a new problem, but an emphasis on burnout prevention and physician wellness is a relatively new response. What are the strategies that are protective against burnout? Medscape spoke with Tait D. Shanafelt, MD, a nationally recognized researcher on this topic and program director of the Physician Well-Being program at Mayo Clinic, about prevention, recognition, and interventions for physicians exhibiting signs of burnout.
Is Burnout Really on the Rise?
Medscape: In our recent survey, we found a 16% increase in the incidence of self-reported burnout in just 2 years. Just under half of the approximately 20,000 physicians who completed our survey indicated that they were experiencing some degree of burnout. That rose to over half of physicians in primary care, emergency medicine, and critical care. How do these results compare with your own research?
Dr Shanafelt: The trend that you are reporting is consistent with what we are seeing in national studies. When assessed using validated, full-length, gold-standard tools, the rates of burnout in primary care, family medicine, and emergency medicine were well above 50% when we reported the national data in 2011. Those rates all increased in the 2014 reassessment that we will soon be reporting.
Extensive evidence published over the past decade illustrates that burnout not only is a problem for the individual physician and his or her family, but also has profound effects on quality of care.[2,3] When you consider the rates of burnout that you observed and that we are seeing nationally, I think it indicates that burnout among physicians and nurses is one of the most prevalent and insidious problems undermining the quality of the US healthcare delivery system.
Medscape: A recent series of articles we posted about physician suicide garnered hundreds of comments from the tens of thousands of physicians who read it, many noting that they had experienced the suicide of a friend or colleague. Many pointed the finger at factors inherent in physician training, including high levels of competitiveness and punishing work schedules, factors that you also identified in a recently published study of matriculating medical students. A minority, less sympathetic, argued that physicians who succumbed to these pressures probably shouldn't have been in medical school to begin with. Are there medical students who are inherently at higher risk for burnout?
Dr Shanafelt: That is a question that I am asked frequently. I think it is misguided to imply that when there is a suicide or a physician leaves the profession, "they were just never cut out for this in the first place."
We know that those who are at greatest risk for burnout are those who are the most dedicated and committed to their work. Those are the professionals that are at greatest risk to be consumed by their job and have difficulty drawing healthy boundaries or recognizing work overload.
Physician suicide is a substantial and underappreciated problem in both physicians in general and the general public. Physicians' risk for death by suicide is markedly higher than for age- and sex-matched professionals in other fields. In one national study of approximately 8000 surgeons, we found that over 6% of US surgeons had thought of killing themselves in the past 12 months. On a practical level, that means that 1 of every 16 of my colleagues that I interact with from day to day has thought of killing themselves in the past year.
In that study of US surgeons, we found that burnout, as well as medical errors, were independent predictors of suicidal ideation after adjusting for depression. The issue of physician suicide is not limited to an "inherently weak" subset of physicians. In fact, most physicians would consider our colleagues who have chosen to pursue surgical disciplines as having signed up for a particularly demanding area of the profession relative to what have been coined "lifestyle specialties" with more contained work hours. No physician is immune to the risk for burnout and its potential repercussions.
Medscape: What is the role of screening tools to identify physicians in distress or be used to identify applicants to medical school at higher risk for burnout? Are these tools for use throughout a physician's professional career?
Dr Shanafelt: I do believe that self-assessment tools for physicians that can provide individualized feedback, as well as comparison to national benchmarks for context, can be helpful. Our research team at Mayo Clinic has spent the last 7 years developing and validating precisely such instruments in national samples of physicians.[6,7] The ability of physicians to perform self-calibration in a confidential or anonymous manner, with links to resources at the time they are needed, would be a useful approach.
The hope is that such tools will allow physicians to monitor themselves at regular intervals throughout the course of their careers.
The concept of applying a screening tool among applicants to medical school to "weed out" those at high risk for burnout is fraught with problems. First, we have found that matriculating medical students have lower degrees of burnout and better mental health–related quality of life than college graduates going into other professions. Once medical school begins, however, their mental health in these dimensions deteriorates and falls below that of their peers in other fields. The available research suggests that medical students with narcissistic personality traits are at lower risk for burnout. Similarly, individuals with those qualities—those who are more callous and less empathetic—may be at lower risk for burnout. Neither of these traits are the qualities we are trying to enrich in the medical profession. When we have an issue that is affecting approximately 50% of US physicians and which may disproportionally affect the most dedicated and committed physicians, it suggests that we need to look at the process of training and the practice environment. The notion of trying to "filter out those at risk" is a fundamentally flawed concept.
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Cite this: Two Sides of the Physician Coin: Burnout and Well-being - Medscape - Feb 09, 2015.