Burnout, Drop Out, Suicide: Physician Loss in Emergency Medicine, Part I

Christine R. Stehman, MD; Zachary Testo, MD; Rachel S. Gershaw, DO, MPH; Adam R. Kellogg, MD

Disclosures

Western J Emerg Med. 2019;20(3):485-494. 

In This Article

Results

Scope of Burnout in Physicians

Freudenberger and Maslach initially identified and studied burnout in non-medical fields; however, as early as 1981, research began to focus on burnout in physicians and medicine.[10] In 2012 a landmark study identifying burnout as high scores in either the MBI's depersonalization or emotional exhaustion dimension found that 37.9% of physicians met criteria for burnout compared to 27.8% of the general United States (U.S.) workforce.[8] Since 2013, Medscape has published the results of an annual survey of physicians. Per this report, the percentage of physicians experiencing burnout has steadily risen.[11] Most recently, 44% of respondent physicians indicated feeling burned out, a percentage that correlates with the most recent survey by Shanafelt et al. (43.9% respondents had at least one symptom of burnout).[11,12]

Burnout has been studied at all levels of medical training and starts early: one study identified 52.8% of students (an equal mix of all four years) from seven medical schools meeting criteria.[13] Burnout continues during residency, though it has been less frequently explored. In 2002 Shanafelt et al. found that 76% (n = 87/115) of one internal medicine program's residents met criteria for burnout.[14] In a 2018 study, researchers surveying 3588 second-year resident physicians across multiple specialties found that 45.2% experienced at least one symptom of burnout at least weekly.[15] A recent systematic review and meta-analysis aggregated 26 studies including 4664 residents of multiple specialties and found a burnout prevalence of 35.7%, consistent with previous work.[16] This early-career burnout seems to predict later-career burnout, as suggested by a small study of internal medicine residents (N = 81) over 10 years.[17] They found high univariate correlations between emotional distress in residency and later emotional exhaustion (correlation coefficient = 0.30, P = 0.007) and depersonalization (correlation coefficient = 0.25, P = 0.029).[17] For an expanded list of different burnout and wellness surveys and scales, please see Table 1 in the Appendix.

Causes of Burnout

Historically, medicine saw burnout as a sign of personal weakness or of being ill-suited to the profession.[18] Without consideration of organizational and societal influences on burnout development, authors suggested that "self-rescue" would occur if one simply recognized his or her condition and engaged in improved communication and management-skills training or routine exercise.[19–21] Even leading researchers espoused these beliefs: Shanafelt et al. stated that physician burnout was related to stressful work, doing too much and putting others' needs before their own.[22] However, the results of Shanafelt's landmark 2012 study on the prevalence of burnout appeared to have changed his views, and he called on others to take a different perspective:

"The fact that almost 1 in 2 U.S. Physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals."[8]

Although individual characteristics do contribute to burnout susceptibility, and physicians cope with burnout using exercise and meditation, the problem has not improved.[11,23]

Individual physicians seem to recognize the importance of outside forces on their experience of burnout, even if society and organizations have not fully embraced this. The responses to the yearly Medscape survey now lists only organizational and environmental causes for burnout, such as bureaucratic tasks, long work hours, electronic health records (EHR), lack of respect, lack of control/autonomy, and profits over patients.[11] The following discussion will focus on three contributing factors: EHRs, financial concerns, and the "second victim" syndrome (SVS).

Electronic Health Records. While charting was once used to communicate relevant clinical information between members of the healthcare team, the EHR has shifted medicine's focus to billing, coding, and protection from litigation. EHRs are independently associated with higher rates of burnout among users.[24] Clinical time spent more on the computer than with patients impairs patient contact (ie, "the best part of being a doctor"). Less one-on-one time with patients leads to a decrease in humanism and conflicts with physicians' inherent altruism. This in turn increases the risk of burnout and substantiates the views of the Medscape respondents: profits over patients.[25,26]

EHRs impact physician workflow as time-consuming distractions that create new problems, such as downtimes and electronic-prescription system failures. Downtimes are typically scheduled at "slow times" for the hospital in the middle of the night, when EPs and emergency departments (ED) are often busiest and staffing scarce. The EHR's billing-centric design slows chart-completion, and online availability can lead to uncompensated charting at home.[26,27] While physicians generally agree that EHRs have improved access to medical records and provide some benefits, they decrease patient interaction, worsen work-life balance, and decrease job satisfaction, resulting in overall net harm to physicians.[27]

Financial Concerns. While Medscape respondents mention "lack of compensation/reimbursement," their concerns may be tied to medical school debt.[11] The cost of medical education continues to rise; physicians who graduated in 2016 carry an average debt over $190,000, which correlates with burnout.[28,29] Additionally, physicians feel under-prepared to navigate their finances while transitioning to attending-level income.[30] This lack of preparation may lead to living above their means, worsening their debt despite high income, resulting in increased stress and burnout.[31]

Second Victim Syndrome. Another likely contributor to and consequence of burnout is the SVS phenomenon.[34–36] SVS embodies the psychological trauma healthcare workers suffer from involvement in an "adverse event." Typically related to committing a medical error resulting in a poor patient outcome, SVS may also involve any adverse patient outcome, expected or unexpected, with the physician becoming the "second victim."[37] One study found that 30% of physicians (all specialties) experienced emotional issues related to a "bad outcome," while another found up to 60% of surgical residents experienced SVS.[38,39]

Society sets a zero-mistake standard for physicians.[32] This high standard may isolate those who make mistakes leaving them without healthy ways to cope, resulting in dysfunctional approaches to recovery.[32,35,36] Poor responses (isolation, anger, sadness, substance abuse, and callousness toward patients and colleagues) place the physician more at risk for burnout.[35,36] When suffering from SVS, the perception of not being supported or even of being victimized by one's own hospital or organization can exacerbate the syndrome.[32,40] This sense of victimization comes despite research suggesting that medical errors leading to poor patient outcomes stem from system failures and not just the individual who committed the error.[41,42] This is a continuous chain of events; if a physician is burned out, he or she is more likely to commit an error during patient care, which puts them at risk for SVS and litigation stress and likely exacerbates their burnout.[32,36,43–45] This cycle and its associated emotional toll lead to negative consequences, which may include depression and departing medicine by either attrition or suicide.[35]

Consequences of Burnout

Additional consequences of burnout include poor clinical care, increased mistakes, patient dissatisfaction, dysfunctional interactions between colleagues, the contagion of burnout, substance abuse/self-medication, depression, and suicide.

Clinical Care. Health systems now recognize the negative impact of burnout on healthcare quality, patient safety, and financial performance.[46] A study of U.S. surgeons found both an increased rate of medical errors and greater medicolegal risk for physicians experiencing burnout.[47] A recent meta-analysis found a statistically significant negative relationship between physician burnout and patient safety (r = -0.23), as well as burnout and quality of care (r = -0.26).[48] As clinical care suffers, so does patient satisfaction, which in turn may further decrease health outcomes.[49,50] Burnout may also affect a physician's colleagues by being contagious: burned-out physicians negatively interact with co-workers and perform more poorly at their jobs, creating a negative work environment and putting others at risk for burnout.[3,51,52]

Leaving Jobs/Medicine. Physicians suffering burnout are significantly more likely to leave healthcare.[53,54] Physicians first reduce work hours or change jobs or specialties, negatively affecting the health system. The estimated cost to replace a physician is $160,000–$1,000,000, depending on specialty and experience. This estimate does not include intangibles such as team disruption.[11,46,55–57] If this job change does not help, physicians may seek administrative positions or leave medicine entirely.[58]

Depression and Self-medication. Burnout occurs on a continuum with depression. The 2012 study by Shanafelt et al. found that 37.8% of respondents screened positive for depression on a standardized and validated two-question screening tool.[8] The most recent Medscape survey indicated that 15% are not only burned out, but also are either "colloquially" or clinically depressed.[11] Multiple barriers separate physicians from depression assistance. Such barriers include feeling that they do not require professional intervention and, perhaps more importantly, fearing the loss of medical licensure and hospital credentialing.[11,59] A 2014 survey found that nearly 40% of physicians would be reluctant to seek care for mental health due to licensure concerns.[60]

While many physicians deal with burnout and depression in isolation, some have developed harmful coping strategies such as alcohol and drug use.[11] In general, older research suggests that approximately 10–12% of physicians will develop at least one substance abuse disorder, similar to the general population rate.[61] More recent data suggest physicians primarily abuse alcohol, with 12.9% of male physicians and 21.9% of female physicians affected, numbers higher than the general population. (Overall 6.2% of the U.S. population 18 years or older has an alcohol use disorder, 8.4% of men and 4.2% of women.)[62,63]

Suicide. Society is shocked when a physician commits suicide. It is estimated that 400 physicians in the U.S. die by suicide each year.[64] Compared to the general population, male and female physicians are at greater relative risk (RR) of suicide (RR = 3.4 and RR = 5.7, respectively).[65,66] Shanafelt, et al. reported that 6.4% of respondents had considered suicide in the previous year.[8] In the most recent Medscape report, 14% of respondents had considered suicide and 1% of respondents had attempted suicide, results similar to a study of female physicians (1.5% attempted suicide).[11,67] Physicians in training are not immune to these risks. Approximately 10% of medical students report suicidal ideation, and suicide is the second leading cause of death among resident trainees in the U.S. (4.1 per 100,000, or approximately five residents per year).[68–70]

While these rates of physician depression and suicidal ideation do not significantly differ from those of the general working population (37.8% and 6.4%, respectively), there are reasons to believe that physician depression is both under-reported and under-treated.[8] Physicians are less likely to seek treatment since depression remains stigmatized in medical culture.[41,71] Depressed physicians may feel like failures, isolated and cut off from their colleagues whom they believe are coping better. Feelings of isolation, loss of belonging, and failure, combined with the perception of being a burden on partners, family, friends and society, drive some to see suicide as an answer.[72]

Given that physicians do not seek help and approximately one in seven has considered suicide, someone reading this may be suffering from depression and contemplating suicide. If that is you, please reach out to a friend, a helpline (call 1–800-273-8255 or text HOME to 741741), a therapist, or to an employee assistance program. Anyone with concerns that a colleague is suffering should reach out, ask, listen, and assist him or her in finding help. For a comprehensive list of suicide prevention and self help resources, please see Table 2 in the Appendix.

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