The Physician Burnout Epidemic: What It Means for Patients and Reform
In a large analysis published this week in Archives of Internal Medicine, researchers at the Mayo Clinic surveyed 7,288 physicians on their quality of life and job satisfaction. The results are striking -- 46 percent of respondents reported at least one burnout symptom. The report indicates that doctors, as a group and relative to other highly educated individuals working similar hours, suffer high levels of emotional exhaustion and struggle to find a satisfying work-life balance.
"This matters not just for physicians, but for patients," says Dr. Tait Shanafelt, a professor at the Mayo Clinic in Rochester, MN and senior author of the paper. Burnout can diminish professionalism and lessen the quality of care. At the same time, it leads doctors to reduce their hours and retire early. "We're at the cusp of reform," he said. "Precisely when we need more family and internal medicine doctors, students are more likely to enter other fields. This issue has implications for the adequacy of the physician workforce."
"It's a really big problem," confirms Dr. Vineet Arora, a faculty member and associate residency program director at the University of Chicago. She has studied physician fatigue and professionalism. "The issues for doctors in training aren't necessarily the same as for those who are in practice," she says. After residency or fellowship, doctors are older and have less supervision. "There's a recipe for burnout because of the long hours and high workload," she says. "Most health care systems don't provide joy and sustainability in the workplace," she said. "In that case, it doesn't matter happens during education and training. The delivery system has to change."
The investigators used a standard evaluation tool called the Maslach Burnout Inventory to assess physicians' wellbeing. As the authors acknowledge, one limitation to the study is the low response rate. Initially the investigators tried contacting nearly 90,000 physicians nationwide. Among those, 27,000 indicated they'd received an email. Among those doctors, only 7,288 - less than 10 percent of the original sample, or 27 percent of those who received the survey - completed the questionnaire. Although most of the doctors contacted did not complete the questionnaire, Shanafelt stands by the conclusions. "The surveyed sample was representative of the larger group initially contacted," he said. The groups were similar in terms of the doctors' age and gender, and how long they'd been out of medical school. "We didn't just get extreme responses," he adds. "We got the full spectrum - folks who are very satisfied, and very unsatisfied. There was a continuum."
Burnout generally refers to a constellation of symptoms relating to behavior at the workplace. Symptoms include emotional fatigue, depersonalization, lost enthusiasm and a failed sense of personal accomplishment. Depersonalization -- a tendency to treat people as objects, almost as a factory worker might perceive a task to be completed - happens most commonly in individuals whose work centers on interacting with others. "We know that those professionals at highest risk include teachers, social workers, police officers, nurses and physicians," he said. Many experience feelings of burnout occasionally and to a varying degree, he said. "But when it happens a lot, there's reason for concern."Burnout differs from depression, Shanafelt explained. "Depression is a more general form of mood impairment that affects all aspects of a person's life at home and in personal relationships." Burnout, by contrast, applies mainly to the work environment. In this study, the investigators did probe physicians and controls for symptoms of depression and suicidal thoughts. As much as 40 percent of the physicians had signs of depression, and nearly 7 percent said they'd contemplated suicide in the 12 months before completing the survey. However, by contrast to the burnout rates, these problematic feelings among physicians did not differ statistically in frequency relative to other working adults.
"Medicine attracts people who are drawn to self-sacrifice" says Dr. Mary Brandt, a pediatric surgeon and professor at Baylor College of Medicine in Houston. "Good doctors are inclined to keep giving, to always do what's necessary to take of patients," she said. Over time, this leads to compassion fatigue and burnout. "We're losing surgeons prematurely to suicide and depression," she says. "They're quitting the field."
When she gives lectures to medical students, Brandt often adds pointers on healthy eating and lifestyle. This sort of advice - about wellbeing, over the long haul of a medical career - wasn't provided when she was a student or surgical resident. "One of my best friends is an astronaut," she considers. Her friend's experience contrasts with those of most doctors. "Nutrition, exercise, self-care and being well is part of her job," she said. "Among that group, it's unthinkable that you wouldn't take care of yourself because that would put your team at risk."
Shanafelt was surprised by one finding in particular in the new study: the degree to which burnout affects primary care specialists. When the investigators studied the results by field, they found the most symptoms in emergency room doctors, general internists, neurologists and family practitioners. "To see the family doctors and general internists with such a high level of burnout was a bit unexpected," he said." It's concerning, because for many folks they're the front door to the medical system."
"The prevalence of burnout is so high, there's likely a systemic cause," he suggests. "If it were just a few doctors, we might think it's just a problem with particular individuals who don't respond well to pressure or stress," he said. "But with a syndrome that's affecting nearly one out of two doctors, we need to examine the environment in which we deliver care."
Brandt sees progress in her work. "The current generation gets it completely," she said. Wellness is common vernacular for trainees now. They have a very different outlook. "In the past, you'd be considered weak if you discussed your fatigue or needs," she said. "Now, it's understood that the best way to take care of your patients is to take care of yourself.""I'm encouraged," she concludes. "This week's article is one of many. There's an ongoing conversation that wasn't there before."