Physician Burnout on the Downswing?

Batya Swift Yasgur, MA, LSW

February 25, 2019

Burnout rates among US physicians showed a modest decline in 2017 from a previous 2014 high, although burnout continues to plague physicians much more than other professionals, new research shows.

The study, the third in a series of national studies measuring burnout in physicians at 3-year intervals, showed that levels were close to 44% in 2017, down from approximately 54% in 2014 and similar to the 45.5% rate in 2011.

There was less fluctuation in the overall prevalence of burnout in nonphysician US workers, which remained roughly 28% at all three time points.

"The good news is that burnout has dropped somewhat from 2017 and is closer to the levels of burnout seen in 2011, which is a cause for optimism," coauthor Christine Sinsky, MD, vice president of professional satisfaction, the American Medical Association (AMA), told Medscape Medical News.

"But the bigger picture is that the degree of burnout present in 2011 and present now is still much too high, which isn't good for physicians and their practices, isn't good for patients, and isn't good for the healthcare system, and is the most concerning piece," she said.

The study was published online February 22 in Mayo Clinic Proceedings.

Ongoing Study

The study is part of a 12-year partnership between the AMA, the Mayo Clinic, and Stanford University to measure burnout at 3-year invervals at four time points, the next of which will take place in 2020, Sinksy said.

Both previous studies showed that symptoms of burnout were markedly more common in physicians than in workers in other professions, after adjusting for work hours, level of education, and other characteristics.

In 2011, 45% of US physicians reported ≥1 manifestations of professional burnout, such as emotional exhaustion or depersonalization, compared to roughly 28% of workers in other professions. The gap widened by 2014, as physician burnout and problems with work-life integration (WLI) increased, the authors report.

The current study surveyed US physicians and a probability-based sample of the US working population between October 12, 2017, and March 15, 2018.

The study employed methods similar to those of previous studies. It assessed "a range of personal and professional characteristics, as well as several dimensions of well-being," the authors write.

The researchers sent surveys to a nationwide sampling of physicians identified by the AMA Masterfile, a nearly complete record of all US physicians.

Among 30,456 physicians who received an invitation to participate, 5197 (17.1%) completed the survey.

To ascertain whether the survey respondents were representative of all physicians, a secondary survey was sent to a random sample of 476 physicians who did not respond to the initial survey. Of those, 248 (52.1%) responded.

No significant differences were found in burnout scores between the two groups of physicians, "suggesting that participants were representative of US physicians," the authors note.

The KnowledgePanel, a probability-based panel designed to be representative of the US population, was used to survey nonphysician workers in other professions.

Physician participants and population control persons provided information on demographic factors (age, sex, and relationship status); hours worked per week; symptoms of burnout; symptoms of depression; suicidal ideation; and satisfaction with WLI.

Physicians were also asked about their practice.

Burnout was characterized using two items from the Maslach Burnout Inventory — emotional exhaustion and depersonalization.

Symptoms of depression were assessed using the two-item Primary Care Evaluation of Mental Disorders.

Satisfaction with WLI was assessed through the statement, "My work schedule leaves me enough time for my personal/family life." Those who "strongly agreed" or "agreed" were considered to be satisfied with their WLI.

"This study is a wonderful opportunity to watch trends in professional satisfaction and burnout over that period of time" said Sinsky.

Nuanced Picture

The 2017 participants were generally similar to those who responded to the 2011 and 2014 surveys, except that they were slightly younger and included more women, "consistent with the increased proportion of women among US physicians in the Masterfile overall," the investigators write.

Of physicians, 43.9% displayed ≥1 symptoms of burnout in 2017, compared with 54.4% in 2014 (P < .001) and 45.5% in 2011 (P <.04).

When the researchers separated the two burnout categories, they found that mean emotional exhaustion scores in 2017 remained higher than in 2014 (23.2% [SD, 13.2] vs 25.5% [13.5]; P = .03), as well as 2011 (22.7% [13.0]; P = .03).

On the other hand, mean depersonalization scores were slightly lower in 2017 than in both 2014 and 2011 (6.8% [6.5] vs 8/1% [6.6] and 7.1 [6.1]; P < .001).

A multivariate analysis in which respondents were pooled from the 2011, 2014, and 2017 surveys and in which adjustment was made for age, sex, specialty, hours worked per week, and practice setting found that physicians who responded in 2017 and 2011 had lower odds of burnout, compared with those who responded in 2014.

A more "nuanced picture" emerged when the researchers compared differences in burnout by specialty during each time point.

Some specialties (eg, obstetrics/gynecology) showed only "minimal" change in burnout at each time point, whereas most other specialties hit a peak of burnout in 2014.

Most specialties (eg, anesthesiology, emergency medicine, orthopedic surgery, general internal medicine, and otolaryngology) exhibited a lower proportion of burnout in 2017 than in 2011, whereas for others (eg, dermatology and urology), the proportion with burnout remained higher in 2017 than in 2011, although lower than in 2014.

Depression Rising

Unlike burnout, depression rose at a "modest but steady" rate from 2011 to 2017 (2011, 38.2%; 2014, 39.8%; 2017, 41.7%; P < .001).

Similar findings were obtained on multivariate analysis that pooled respondents from the 2011, 2014, and 2017 surveys and that adjusted for age, sex, specialty, hours worked per week, and practice setting.

Physicians who responded in 2017 or 2014 had higher odds of screening positive for depression than did physicians who responded in 2011.

Although satisfaction with WLI was greater in 2017 than in 2014, it remained lower than it was in 2011.

A multivariate analysis of the 2017 data found that being a woman and working more hours per week were independently associated with higher rates of burnout and lower degrees of satisfaction with WLI.

"Although the change in burnout is favorable, symptoms of depression among physicians have continued to worsen," the authors comment.

"Distress is a multidimensional construct that includes burnout, depression, stress, WLI, professional satisfaction and fatigue, as well as other domains...[which] have both shared and distinct drivers and do not always move in the same direction," they indicate.

Heavy Workload, Chaotic Environment

The researchers compared 3971 physicians with 5198 employed respondents in the general US working population (both groups were aged 29 to 65 years).

Findings in 2017 were similar to those of 2011 and 2014. Rates of burnout were considerably higher in physicians than in the general US population, which hovered around 28% at all three junctures (2011, 28.6%; 2014, 28.4%; 2017, 28.1%).

Satisfaction with WLI for the general US working population in 2017 was similar to that in 2014 and remained more favorable than in 2011.

Physicians reported working a mean of 12 hours more per week (52.6 vs 40.3 hours), compared to the general population, with 38.9% of physicians and 6.2% of the general population respondents working ≥60 hours (P < .001 for both).

These findings were similar to those in 2011 and 2014.

When investigators compared physicians to the general population, they found that physicians had higher rates of emotional exhaustion (36.4% vs 24.8% [odds ratio (OR), 1.74]; P < .001), depersonalization (18.0% vs 13.5% [1.33]; P < .001), and overall burnout (39.8% vs 28.1% [1.69]; P < .0001)

Physicians remained at increased risk for burnout, compared to the US population, after the researchers adjusted for age, sex, relationship status, and hours worked per week

They also had a lower rate of satisfaction with WLI than the general US working population — a finding that remained after adjusting for other factors.

"We know that burnout is driven by high levels of workload and high levels of chaos in the work environment," said Sinsky.

"Ironically, these pressures have been exacerbated by technology and how it's implemented, since — although well-intended — there are times when technology has added to physician workload and increased chaos in the environment," she continued.

Some physician burnout is "driven by the notion that we are spending our days doing the wrong kind of work for our patients, so as more physician work is directed toward administrative tasks, burnout levels increase and physicians experience decreased meaning in their work," she explained.

Cause for Optimism

Sinsky suggested several potential reasons for the drop in burnout shown in the study.

"Issues of stress and burnout have become normalized as something to talk about," she said.

"Physicians know they're not alone and that at the health system level, there are actors who are working on this problem — for example, the AMA has devoted a tremendous amount of effort to addressing burnout, as have other societies, multiple organizations, and stakeholders, who are taking clinician and physician well-being seriously," she said.

Because of these efforts, burnout is beginning to improve, which is a "cause for optimism."

She reported that the AMA is extensively studying and implementing measures to address causes of burnout.

"We are testing interventions at system levels and working with clinicians across the country to support workflow and teamwork improvements and measuring the impact of these changes on burnout and physician satisfaction," she said.

She noted that the AMA offers extensive Internet-based resources through the STEPS Forward program, a collection of more than 50 online tool kits to help practices and organizations improve workflow, teamwork, and culture and deliver care in more effectively.

Modules, which are available free of charge, may be used to earn CME credits.

In addition, the AMA conducts institutional assessments to provide a baseline metric to facilitate implementing solutions and interventions that may reduce systemic burnout rates.

The AMA website Debunking Regulatory Myths provides information to physicians and practices to clarify commonly misunderstood regulations, because many physicians assume responsibility for administrative tasks that can be performed by other team members without violating any regulations, Sinsky said.

She noted that other stakeholders, such as the Centers for Medicare & Medicaid Services and many insurers, are "starting to recognize the importance of addressing clinician well-being."

In addition, many institutions are starting to include a chief wellness officer in their organization. The chief wellness officer is responsible for the well-being of the workforce, on par with the chief executive officer, the chief operational officer, or the chief financial officer.

The idea was debuted last year and will continue to be developed, with opportunities for training in leadership, at the upcoming American Conference on Physician Health (September 19–21, 2019), sponsored by the AMA, the Mayo Clinic, and Stanford Medicine.

Still Room for Improvement

Commenting on the study for Medscape Medical News, Rikinkumar Patel, MD, MPH, research investigator, Department of Psychiatry, Griffin Memorial Hospital, Norman, Oklahoma, who was not involved in the study, said that despite the improvement, there is still a higher rate of burnout among physicians, compared to the general US population, which "has very severe consequences.

"More strategies are needed to mitigate the burnout in physicians," he said.

Measures he recommended include mindful communication training as well as individual and group counseling based on psychodynamic, cognitive, educational, and motivational interviewing.

Additional measures include half-day workshops for physicians that focus on stress management through improving interpersonal and prioritization skills, as well as brief workshops for managers that emphasize burnout management strategies.

Sinsky added, "As the number of leaders who have taken this on as their area of professional responsibility and focus increases, I think we will see improvements in care environments in which physicians and other clinicians work."

Funding for the study was provided by the Stanford Medicine WellMD Center, the AMA, and the Department of Medicine Program on Physician Well-being of the Mayo Clinic. The authors and Patel have disclosed no relevant financial relationships.

Mayo Clin Proc. Published online February 22, 2019. Full text

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