Well-Being, Burnout, and the Clinical Laboratory

Steven H. Kroft, MD

Disclosures

Am J Clin Pathol. 2020;153(4):422-424. 

Burnout of health care professionals describes a combination of emotional exhaustion, depersonalization, and loss of sense of personal accomplishment.[1] It is not a new concept, originally developed decades ago to describe the stress incurred by staff in free clinics treating vulnerable populations.[2] Burnout may take a terrible toll on afflicted professionals, having been shown to dramatically increase the risks of major depression, alcohol and other substance abuse, and suicidal ideation.[3] Yet, the issue flew under the radar for many years, a result of a public that regarded it as "the whining of a privileged class"[4] and a culture of "burnout is for the weak" in medicine itself. But the problem has assumed increased urgency in recent years, with a crescendo of research and public awareness, making it one of the highest priority issues in modern health care. This is due to two main factors: (1) the prevalence appears to have increased dramatically in the last decade, reaching epidemic status among health care providers,[3,5] and (2) there is abundant evidence that burned-out health care professionals provide poorer care, including increased errors and decreased patient satisfaction.[3] Furthermore, burned-out providers are less productive and much more likely to leave the medical field, increasing costs for health care systems and potentially exacerbating a looming shortage of health care professionals in the United States.[6]

Burnout is driven by a variety of personal and organizational factors that likely interact in complex ways.[1,3] Some organizational issues highlighted by various studies include a poor management culture, loss of autonomy and control over one's practice environment, growing administrative burdens resulting from health care reform, poorly designed electronic health record systems, increasing workload, and a heightened focus on efficiency. Personal factors include poor work-life balance, resilience and coping mechanisms, competing personal responsibilities, and social support structures.

Despite an explosion of research publications on the topic of physician burnout, little is known regarding the issue in the field of pathology specifically. Furthermore, while burnout in nursing has been studied, little information is available for other allied health professionals, and essentially nothing is known about burnout in the laboratory professional arena. In this issue of the Journal, Garcia et al,[7] Kelly et al,[8] and Garcia et al[9] present comprehensive American Society for Clinical Pathology (ASCP) survey data on job satisfaction, well-being, and burnout of pathologists, pathology trainees, and laboratory professionals, respectively. The results provide an important foundation of data to begin understanding the magnitude and characteristics of burnout in our industry.

The pathologist survey[7] reveals that 71% of pathologists have felt burnout at some point, with a full one-third indicating that it was something they were currently experiencing. While it is difficult to compare prevalence data across studies because of variable survey instruments and differing criteria for what constitutes burnout, the numbers seem to be consistent with US physicians as a group, where aggregate data indicate burnout prevalence rates of one-third to one-half.[1,5,10] Interestingly in this regard, according to a 2016 Medscape burnout survey across specialties, the rates of burnout ranged from a high of 55% in critical care, urology, and emergency medicine to a low of 40% in psychiatry.[11] Pathology, at 45%, ranked 19th out of 25 specialties in the prevalence of burnout. Nearly half of pathologists in the ASCP survey reported experiencing a lot of job-related stress, and 43% reported being moderately or very overwhelmed by their workload. Not surprisingly, pathologists who were experiencing more work-related stress and/or feeling overwhelmed by workload are the most likely to be burned out, and respondents clearly identified workload as the most important factor contributing to their burnout. Interestingly, cultural issues such as being respected and supported by hospital administration or being undervalued by departmental or clinical colleagues were relatively infrequently cited as drivers of burnout. Notably, pathologists practicing in institutions that specifically provided resources to support well-being had lower rates of burnout. Whether this is a causal relationship is unclear; it may well be the case that institutions with a cultural commitment to promoting well-being (and that therefore invest in support programs) are intrinsically less likely to incur burned-out providers. Burnout analyzed by demographic groups (age, time in practice, sex, subspecialty) did not show any clear associations, although women reported feeling more stressed than men. Finally, despite the ominous burnout prevalence numbers, 71% of pathologists indicate that they have somewhat high or high levels of job satisfaction, and only 19% rated their work-life balance as poor. These apparently paradoxical findings underscore the challenges in studying this issue.

The results for pathology residents and fellows[8] were generally similar to those for practicing pathologists: about a third of pathology residents and fellows were currently experiencing burnout at the time of the survey, about 40% indicated that they felt a lot of stress, and more than a third felt moderately or very overwhelmed. Again, workload was a major driver of burnout and job-related stress. The resident and fellow survey also queried levels of anxiety, which showed that almost half of trainees were moderately or severely anxious. Of interest, the top two causes of anxiety were worries about making diagnostic mistakes and wanting to appease more senior members of the team. While, on one hand, this is probably not surprising and could perhaps be considered a natural consequence of being in the early stages of a challenging career, it also suggests room for cultural improvements related to mentoring and support systems. Similarly, concerns about personal competence and the volume of information one was expected to learn were major contributors to job stress. Once again, this would seem to be a self-limited phenomenon for learners of a new and complex trade, but perhaps appropriate management of expectations by program faculty could help mitigate these. Approximately two-thirds of residents indicated that they had poor or fair work-life balance, with about half indicating that their work encroached on their personal time. The latter is difficult to parse in the context of what is traditionally a challenging period of a young physician's life, but it does suggest lack of alignment of expectations between trainees and training programs. The existence of support systems such as mentoring was associated with better well-being, but a drilldown suggests that this was again not a direct effect but that the existence of such programs was perhaps an indicator of a more nurturing culture overall. Gratifyingly, more than two-thirds of pathology trainees felt connected to their colleagues, but conversely, the more than a quarter who felt isolated represents an area of opportunity. Finally, as with practicing pathologists, job satisfaction was fairly high, with about two-thirds of respondents indicating they felt moderate or high levels of job satisfaction and indicating that they enjoyed their work, and most felt valued and respected.

Burnout among lab professionals[9] appears to be more prevalent than for pathologists and pathology trainees. About 85% had experienced burnout at some point, with half reporting it as a current issue. Over half reported experiencing a lot of stress, nearly half indicated they were moderately or very overwhelmed, and almost 40% were moderately or very anxious, and again these were correlated with the presence of burnout. Once again, workload loomed large in the area of job stress, and once again lower rates of burnout were seen when institutions offered well-being resources. Burnout was more prevalent for those in midcareer than for either of the tails, and it was interestingly least prevalent in the oldest age group (65–74 years). Of enormous concern, given the chronic shortage of laboratory professionals, is that half of those experiencing burnout were considering completely changing careers. While the large majority (87.5%) felt a sense of accomplishment in their roles, fewer than half felt valued by professionals outside their team or felt respected in the field of pathology. Again, though, as with pathologists and pathology trainees, job satisfaction was fairly high, with two-thirds of respondents indicating they were somewhat or very satisfied, and work-life balance was reported as poor by only about 20%. Importantly, job satisfaction was associated with feelings of being appreciated and empowered in the workplace.

In aggregate, these data indicate a high prevalence of burnout and job stress in the clinical laboratory professions, and they provide a wealth of correlative data to enrich our understanding of the issue. However, a few caveats are appropriate. First, like any cross-sectional study, we can draw conclusions only about correlation, not causation. Second, although the laboratory professional survey was well powered, the sample sizes in the pathologist and pathology trainee cohorts were rather small. Third, and perhaps most important, inherent in the study designs is a high risk of selection bias. Nevertheless, it is fair to say that we know much more about well-being and burnout in the laboratory field than we did before. It is important also to stress that these surveys represent a starting point and a baseline to inform future surveys, which can begin drilling down on some of the nuances and questions that emerge from the current data sets. And hopefully, these data will stimulate the performance of targeted research studies that can address questions that a cross-sectional survey cannot. Longitudinal studies to get a better handle on causation and outcomes would be of enormous value. For example, how often do burned-out workers who are considering career changes actually change careers? We also do not know the extent to which burnout affects the quality of care we provide in our largely non–patient-facing field. And, very importantly, we can hopefully begin to study the impact of various forms of intervention to reduce burnout and improve satisfaction and well-being. We know from the literature that interventions for physicians and trainees, focusing either on organizational structures or on individuals, can be impactful.[5] What we do not know is what interventions are likely to be successful in our very unique field. Fortunately, the surveys in this month's AJCP provide some clues. In addition to providing a roadmap for what workplace landmines to try to avoid, I think we should also pay close attention to the things that respondents valued the most and gave them the biggest sense of accomplishment. Evidence indicates that the risk of burnout plummets when physicians are allowed to spend at least 20% of their effort doing the things they find most meaningful,[6] and it is probably reasonable to assume that something similar holds for laboratory professionals. So, to that point, pathologists most often highlight "making a positive difference and improving the quality of diagnostic testing for patients,"[7] and laboratory professionals call out "knowing they play a crucial part in patient health care (ie, contributing to the diagnosis and treatment of a patient)."[9] It is gratifying that these values are so well aligned with the theoretical ideals of our profession, and it behooves us to make sure we are maximally enabling our workforce to self-actualize around these principles.

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