Physician Burnout Can Be Reduced by Targeted Interventions

Diana Phillips

October 11, 2016

Interventions that promote awareness among physicians of the signs of burnout and target the individual and organizational drivers of it go a long way toward reducing the problem, a new analysis suggests.

In a comprehensive systematic review and meta-analysis of studies evaluating the effect of physician burnout interventions, investigators identify multiple individual and organizational-based programs that produced significant improvements in the prevalence and severity of overall burnout, emotional exhaustion, and depersonalization.

If applied to 2014 national data for US physicians, the effects of the pooled improvement data in this analysis "would return burnout in each domain to levels near or even below those previously reported from 2011 national data," Colin P. West, MD, PhD, from the Division of General Internal Medicine and Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, and colleagues report in an article published online September 28 in the Lancet.

These findings are especially notable in light of the sharp rise in the rate of physician burnout in recent years. For example, the 2016 Medscape Lifestyle Report shows an increase in overall burnout percentages and severity ratings across all specialties compared with the 2015 report. Burnout percentages across the 25 specialties (15,800 physicians) represented in the survey range from 40% to 55%.

For their analysis, Dr West and colleagues identified 15 randomized controlled trials and 37 observational studies that met the review criteria and addressed outcomes and approaches to physician burnout, including pre/post comparison studies. For inclusion, the studies were required to provide physician-specific burnout data based on commonly accepted sources of evidence.

Of the 15 randomized controlled trials, three involved structural interventions (shortened attending rotation length, clinical work process modifications, shortened resident shifts), and 12 were based on individual-focused interventions (facilitated small group curricula, stress management and self-care training, communication skills training, a "belonging" intervention).

Of the 37 cohort studies, 17 involved structural interventions (US duty hour requirements and practice delivery changes), and 20 involved individual-focused interventions (facilitated and nonfacilitated small group curricula, stress management, self-care training, communication skills training, and mindfulness-based approaches).

The majority of the studies used the Maslach Burnout Inventory to assess burnout levels.

Five of the randomized controlled trials and nine cohort studies reported differences in overall burnout. The pooled mean difference estimate was a significant absolute reduction from 54% to 44% (difference, 10%; 95% confidence interval [CI], 5% - 14%; P < .0001; I 2 = 15%). The authors note that structural or organizational interventions were more effective than individual-focused ones (P = .03; I 2 = 79%).

If applied to 2014 national data for US physicians, this 10% absolute reduction in burnout would represent an 18% relative risk reduction, the authors write.

Additional findings include:

  • A significant 2.65-point reduction (95% CI, 1.67 - 3.64; P < .0001; I 2 = 82%) in the estimated pooled mean difference for emotional exhaustion domain score (12 randomized controlled trials, 28 cohort studies).

  • A significant 0.64-point reduction (95% CI, 0.15 - 1.4; P = .01; I 2 = 58%) in the pooled mean difference in depersonalization domain score (11 randomized controlled trials, 25 cohort studies).

  • A significant absolute reduction in the pooled mean differences in high emotional exhaustion from 38% to 24% (difference, 14%; 95% CI, 11% - 18%; P < .0001; I 2 = 0%) in the eight randomized controlled trials and 13 cohort studies reporting this outcome.

  • A significant absolute reduction in the pooled mean differences in high depersonalization from 38% to 34% (difference, 4%; 95% CI, 0% - 8%; P = .04; I 2 = 0%) in the six randomized controlled trials and 10 cohort studies reporting this outcome.

The observed effects were consistent between randomized controlled trials and observational studies, and they were similar for individual-focused and structural or organizational interventions for all outcomes except overall burnout. They were also similar for practicing physicians and residents for all outcomes except high emotional exhaustion, the authors report.

If applied to 2014 national data, the observed absolute reduction in high degree of emotional exhaustion of 14% would represent a 30% relative risk reduction, and the absolute reduction in high degree of depersonalization of 4% would represent a 12% relative risk reduction, the authors write.

"Although the magnitude of the reductions in burnout domain scores appears modest, evidence has linked 1 point changes in burnout scores with meaningful differences in important adverse outcomes," the authors write.

The authors conclude that both individual-focused and structural, organization-level interventions can reduce physician burnout, noting that "both strategies are probably necessary," although their combination has not been studied. "The most commonly studied interventions have involved mindfulness, stress management, and small group discussions, and the results suggest that these strategies can be effective approaches to reduce burnout domain scores," they write. "Duty hour limitation policies also appear effective, although, at present, these results are derived only from observational studies in the USA."

Although the interventions included in the analysis are diverse, all of them "share the initial step of enhancement of awareness," Ronald M. Epstein, MD, and Michael R. Privitera, MD, from the University of Rochester in New York, write in an accompanying comment. "For example, mindfulness training can help individuals be aware of burnout in its early phases—noting changes in the body (eg, headaches or muscle tension), emotions (eg, irritability or sarcasm), or thoughts (blaming self or others)—before it becomes unmanageable, name it, and accept that it is present."

Physicians' awareness of their ability to mitigate burnout is also important, as is monitoring of burnout domains at the organizational level, the commenters write. "[H]ealth-care organisations can monitor these levels as quality indicators and disseminate findings to raise collective awareness and resolve."

In addition to increased awareness, effectively reducing the risk for burnout requires understanding both its individual and system drivers. "Addressing burnout on an individual level will not be enough in the current health-care environment," the commenters write. "Leaders at health-care institutions should take a careful look at what promotes joy, effectiveness, and engagement with clinical practice among their staff and muster the resolve to take positive action."

The study authors call for additional well-designed, generalizable studies looking into benefits by program type and targets "to build on this early foundation of evidence to expand understanding of interventions to address the pervasive problem of physician burnout."

The commenters agree, but stress that "we should not wait for perfect understanding before acting; too much is stake," they write. "Institutions should take the lead and address clinician burnout now that West and colleagues have described effective models that have been implemented successfully."

This study was funded by the 2016 Arnold P. Gold Foundation Research Institute. The authors and commenters have disclosed no relevant financial relationships.

Lancet. Published online September 28, 2016. Article abstract, Comment extract

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