What Is Burnout, and Why Is It so Prevalent?

Gabriel A. Sara, MD

Disclosures

January 01, 2017

Burnout: A Growing Problem Among Physicians

Burnout has reached alarming proportions among US physicians. Medscape's Lifestyle Report 2017[1] showed that overall, 51% of US physicians reported feeling burnout—a substantial rise from 40% in Medscape's 2013 lifestyle survey report.

The medical specialties reporting the highest levels of burnout in 2017 were emergency physicians (59%), obstetricians and gynecologists (56%), family physicians (55%), and internists (55%). Even the least burned-out specialties still reported high rates: psychiatry (42%), allergy and immunology (43%), ophthalmology (43%), and diabetes and endocrinology (46%).

Female physicians reported higher levels of burnout (55%) than male physicians (45%). Burnout appears to be even higher among medical residents. A 2015 survey of residents at the University of North Carolina revealed a 70% burnout rate, with the highest rates among those in general surgery (89%), radiology (85%), surgical subspecialties (82%), anesthesiology (81%), and internal medicine (79%).[2]

What Is Burnout?

Burnout is a psychological and behavioral syndrome. Emotional exhaustion is one hallmark of burnout. It has been defined as long-term, unresolvable job stress—a sense of being overwhelmed and depersonalized, and lacking a sense of personal accomplishment.

Stress and depression are not the same conditions as burnout. However, burnout and stress may lead to depression, and stressed-out physicians are more likely to become burned out.

The Maslach Burnout Inventory, a 22-item questionnaire, breaks the syndrome down into three components: emotional exhaustion (loss of enthusiasm for your work); depersonalization (a distorted perception of oneself that leads to lack of empathy and sometimes viewing people as objects); and a low sense of personal accomplishment (feeling that you're ineffective in your work).

Among physicians, emotional exhaustion is the most widespread of the three components. When you look into the eyes of burned-out doctors, the shine is gone. You no longer see the light they had when these physicians started their training or took their first jobs.

Some symptoms of depression may be very similar to those of burnout. However, in depression, you may feel like you're having more bad than good days. You may lack energy, feel irritable and restless, and experience guilt and feelings of worthlessness. If your depression becomes severe, you may feel trapped or hopeless, or think there's no reason to continue living.

When you look into the eyes of burned-out doctors, the shine is gone.

What Are the Causes of Burnout?

There isn't one single cause of burnout. Causes can vary widely, and every kind of physician, no matter what age or specialty, is at risk.

A key cause of burnout for front-line physicians is having to deal with extra administrative issues, such as having to enter increasingly more data into electronic health records (EHRs). Some physicians question whether this work, which takes them away from patient care, actually improves their patients' outcomes. The work may involve medicolegal issues, billing needs, and reporting requirements. It has to do with filling out forms, entering data, checking boxes, and reading and signing paperwork.

The role of these extra tasks in burnout has been cited in physician surveys.[1] Some of the leading causes of burnout cited by physicians in that report were too many bureaucratic tasks, dealing with insurance issues, feeling like a cog in a wheel, and dealing with EHRs. When physicians have more demands placed on them and consider many of those demands to be meaningless, it's easy for them to feel cynical about their work and in fact, emotionally exhausted, which is a common sign of burnout.

Increased performance measurement, more paperwork, and greater use of EHRs were linked to burnout in an open letter written by a group of healthcare leaders, titled "Physician Burnout Is a Public Health Crisis: A Message to Our Fellow Health Care CEOs," published in March 2017 on the Health Affairs blog.[3]

Each year, US physician practices in four common specialties spend an average of 785 hours per physician and more than $15.4 billion dealing with reporting of quality measures, according to a 2016 study in Health Affairs.[4] Physicians who are enrolled in the Merit-based Incentive Payment System track of the Medicare Access and CHIP Reauthorization Act have the burden of satisfying Medicare reporting requirements to show that they are meeting goals devised by the Centers for Medicare & Medicaid Services (CMS).

New reporting requirements are popping up everywhere as physicians enter an era of value-based payments, based on an enormous amount of reported data. For example, clinicians in federally qualified health centers providing data for CMS' Advanced Primary Care Practice Demonstration program reported that professional satisfaction had declined by 10% and feeling burned out increased by 8%, according to a 2017 study.[5]

The data must be reported and tracked through EHRs, which can be a big drain on physicians' time. A 2016 study found that doctors spend almost twice as much time on EHRs and deskwork than on patients.[6] Physicians who mapped out their daily work hours reported 1-2 hours of work each night, mostly involving EHR tasks.

Another factor in burnout is that physicians are plugged in all the time now. They have to answer mountains of email and calls 24/7 on their smartphones. These extra connections have sopped up the last amount of private time that physicians had, and now physicians have to struggle to reclaim that personal time.

Other Causes of Burnout

Causes of burnout may also include the following:

The push for greater productivity. Independent physicians are trying to make up for stagnant reimbursements, and employed physicians are trying to meet productivity goals that are measured in numbers of patients or work relative value units.

Having to deal with layers of bureaucracy. In a large organization, when physicians suggest ways to improve quality of care or make their work more efficient, it can be difficult to get a response. You can feel powerless, like a cog in the wheel.

Working long hours. This has also been linked to burnout, but some say the connection has to be taken with a grain of salt. Many physicians work long hours without any signs of burnout. In many cases, it is not the number of hours worked that matters; it is the content of those hours that produces burnout. Paperwork and other nonclinical duties are added stressors. However, overly excessive hours can disturb physicians' work-life balance.

The Culture of Burnout

Burnout can differ by career stage, according to research done at the Mayo Clinic.[7] Early-career physicians have higher rates of work/home conflicts and depersonalization, whereas midcareer physicians are most likely to plan to stop practicing in the next 2 years for reasons other than retirement, the researchers noted.

New physicians may be inculcated into a culture of burnout, passed down by older physicians in residencies and fellowships. For example, new physicians are often encouraged to be self-reliant as they grapple with clinical issues. The result is that they often try to deal with their emotional problems on their own and don't ask for help.

Long hours at work impinge upon marriages, childcare, and social life.

Many physicians think that "overworked" is just how the role is. This attitude also involves putting one's work life above one's personal life, which is an obvious cause of burnout. It can be hard to have a social life, have a relationship with a spouse, or take care of a young family.

In Medscape's 2016 Residents Lifestyle & Happiness Report,  33% of trainees in years 1-4 and 40% in years 5-8 cited work-life balance as their biggest challenge. Long hours at work impinge upon marriages, childcare, and social life.

In a survey of pediatricians who had graduated a decade earlier, only 43% reported appropriate work-life balance and 30% reported burnout.[8] A 2015 study found that only 36% of physicians were satisfied with their work-life balance, compared with 61% of the general working population.[9]

The burned-out physician can feel like an automaton. "I put patients above everything else and gave everything else, and there wasn't anything left of me but a shell," one physician stated.[10] "I had no identity outside of being a physician. It was after taking time off that I realized I needed to spend time on myself as well."

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