Burnout May Erode Docs' Sense of Calling, Put Patients at Risk

Nancy A. Melville

February 23, 2017

Erosion of physicians' sense that medicine is a calling may have adverse consequences for doctors and their patients, new research suggests.

Two new studies aimed at better understanding internal and external factors that motivate physicians and prevent burnout show that having a sense of calling or commitment to medicine is a key factor in physicians' well-being, whereas extrinsic incentives, such as salary, are less meaningful.

"If the practice of medicine is not seen as work that is personally rewarding and serving a greater good, physician performance may suffer and, more importantly, so too may the quality of care that patients receive," authors of a study led by Audiey C. Kao, MD, PhD write. The study was published online February 8 in Mayo Clinic Proceedings.

Reports of physician burnout have increased in recent years. The investigators note that the "rapid adoption of electronic health records and the proliferation of pay-for-performance metrics have markedly altered how physicians experience their everyday work lives."

Dr Kao and colleagues cite a recent study that shows that for every hour physicians spend in direct patient contact during their workday, they spend 2 additional hours in front of the computer or doing paperwork.

"These changes in the structural and relational dimensions of providing patient care are engendering growing frustration among physicians about how their time and skills are being utilized as well as contributing to the increasing rate of professional burnout," they write.

The consequences of burnout can be far-reaching. Effects can include poorer patient satisfaction and health outcomes and an increased risk of medical errors.

In an effort to better understand the effect that professional burnout can have on physicians' view of medicine as a calling, Dr Kao and colleagues conducted a national survey to evaluate the link between professional burnout and sense of calling. A total of 2263 physicians completed the survey, which was administered between October 2014 and May 2015.

The survey included six validated true-false statements and defined a sense of calling as "committing one's life to personally meaningful work that serves a prosocial purpose."

Of the respondents, 28.5% reported experiencing some degree of burnout. In comparison with physicians who had no symptoms of burnout, those with the highest degree of burnout had significantly lower responses associated with viewing medicine as a calling. In addition, they were much less likely to see their work as one of the most important aspects of their lives (odds ratio [OR], 0.38; P < .001) or to believe their work makes the world a better place (OR, 0.38; P = .02).

Those with a higher degree of burnout were also less likely to enjoy talking about their work with others (OR, 0.23; P < .001). Among respondents with no burnout symptoms who enjoyed their work, 92.9% reported they would choose medicine again, compared to 31.9% of those who reported burnout (P < .001).

Dr Kao, of the Ethics Standards Group of the American Medical Association, in Chicago, Illinois, noted that because the study was cross-sectional, no definitive conclusions can be drawn with respect to burnout undermining doctors' sense of calling or that preserving or having a sense of calling is protective against burnout.

However, he noted that research in fields other than healthcare shows that performance-based incentives that focus more on a person's sense of autonomy may be beneficial in supporting a sense of calling.

"Physicians' sense of competence may be undermined if they think that the performance measures they are being held accountable for are not meaningful measures of their clinical competency or quality of care delivered," Dr Kao told Medscape Medical News.

"Therefore, streamlining the number of performance-based incentives used and improving the quality of the performance-based measures should be an important consideration for payers and policy makers."

Supporting Physician Well-being

A second study, published online February 6 in the Journal of General Internal Medicine, further underscores the importance of internal factors, including a sense of calling, in comparison with external factors, such as financial compensation, in physician well-being.

This study included 1289 US physicians who responded to a 38-item survey between October and December 2011. The survey was designed to uncover specific motivators associated with career and life satisfaction; it addressed issues such as professional commitment and personal experience.

A total of 88.4% of respondents said they perceived medical practice as a calling, and 82.2% reported they experienced at least 2.5 personally rewarding hours per day. However, 45.5% reported feeling burned out.

A sense of calling was strongly associated with a high degree of meaning in life (OR, 5.14) and a commitment to direct patient care (OR, 2.50).

Factors strongly associated with career satisfaction included personally rewarding hours per day (OR, 5.28), life satisfaction (OR, 4.46), and commitment to clinical practice (OR, 3.46). In addition, long-term relationships with patients were positively associated with a high degree of meaning in life and with career satisfaction.

Burnout was negatively associated with all measures of physician well-being. Importantly, extrinsic motivators, including annual income, were not associated with life meaning or commitment.

"We found that a sense of calling was most strongly associated with high life meaning and commitment to direct patient care, and that personally rewarding hours were most strongly associated with career and life satisfaction and commitment to clinical practice," first author Hyo Jung Tak, PhD, of the Department of Health Services Research and Administration at the University of Nebraska Medical Center, in Omaha, told Medscape Medical News.

Dr Tak noted that it was surprising that factors such as annual income, which have been thought to be important to physician career satisfaction, were not significantly associated with measures of physician well-being, such as life satisfaction and career commitment.

"We [have believed] that there are two ways to motivate physicians: 'Push' them from the outside with extrinsic motivators ― for instance, with financial incentives or bureaucratic regulations ― or 'pull' them from the inside with intrinsic motivators ― for instance, by appealing to their sense of calling, altruism, etc. But our study suggests that physicians with a greater sense of well-being seem to have more intrinsic motivations.

"A focus only on extrinsic motivators fails to consider other important determinants of physician well-being. Besides financial compensation and social prestige, some physicians may be intrinsically motivated by the opportunity to express altruism through their work or to pursue a calling that contributes toward a social mission, teaching, or research," said Dr Tak.

Dr Tak noted that the study also suggests that finding medicine personally rewarding may protect against the corrosive, burnout-causing effects of a heavy workload.

The investigators note that the study findings may have important ramifications for medical education and practice.

"Further studies should examine this dynamic process shaped by the interplay between internal and external motivating factors over the course of physicians' professional development. Understanding the effects of intrinsic motivating factors may help inform efforts to support physician well-being," they write.

Dr Kao's study was supported by the American Medical Association. Dr Tak's study was supported by the Templeton Foundation and a pilot grant from the Bucksbaum Institute for Clinical Excellence at the University of Chicago. The authors have disclosed no relevant financial relationships.

Mayo Clinic Proc. Published online February 8, 2017. Abstract

J Gen Intern Med. Published online February 6, 2017. Abstract

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