One in 15 American doctors contemplated suicide last year.1 Although accurate data are difficult to obtain, a reasonable estimate is that 400 medical students or medical doctors commit suicide annually in the US.2 The lifetime rate of depression among medical doctors is similar to that of the general population, however, the suicide rate (in the US) is disproportionately high: 1.5 to 3.8 times higher among male doctors and 3.7 to 4.5 times higher among female doctors as compared with the general population.3,4 This high suicide rate has been attributed to the high rates of burnout in doctors, a syndrome which most know is characterised by exhaustion, cynicism and reduced effectiveness. Physician burnout has been shown to influence not just physician safety but quality of care, patient safety, physician turnover and patient satisfaction.5
This data was presented at a recent meeting in Seattle, which one of us attended last month. More surprising than that was that this was a surgical, not a psychiatric or general practice meeting. Usually surgical meetings are full of famous institutions telling us about how good they are at treating rare (or not so rare) conditions and about new toys which will allow you to do operations better, such as how a robot (at 3M$US) does an operation better than a laparoscope (20K$US), which is better than a pair of gloved human hands (7.5$US), or even more surprisingly that two robots (6M$US) are better than one. Suddenly all the chatter about new robots disappears as the very human topic of physician health and burnout dominates the podium to very full house. For the main session to be on burnout was a surprise—or was it?
Burnout is important. As most of us know, a doctor with burnout suffers from emotional exhaustion, depersonalisation and a sense of reduced personal accomplishment, and this is a problem for themselves, their family, their colleagues, their institution and most importantly their patients. As burnout evolves, the physician’s work performance deteriorates, errors are more common and patients may be harmed.6,7 Family members, friends and close colleagues may begin to note erratic and unusual behaviours. Coworkers may be subjected to non-professional interactions, including verbal abuse. The burned-out physician’s unpredictable behaviour, mood swings and propensity for errors can insidiously undermine, or even destroy, the ability of the medical team to function effectively. Left unchecked, the harmful consequences of burnout worsen, and damage to patient care and satisfaction are impaired, at times even leading to public disciplinary findings, thus hurting the reputation of the doctor, their colleagues and entire healthcare organisations. Although burnout is a systemic issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician.5
Stress-induced burnout among medical students, physicians in training and practicing physicians is not new, but until recently it was generally assumed to be infrequent and controllable.8 Unfortunately, international studies suggest that at least one-third and up to half of doctors are experiencing or will experience professional burnout.5
The term burnout first appeared in the literature in 1974 when American psychologist Herbert Freudenberger9 coined the term to describe the consequences of severe or prolonged stress and anxiety experienced by people working in the “healing professions”. He suggested their “high ideals” and the need to repeatedly sacrifice themselves to help others put them at risk of job-induced emotional and physical exhaustion. The term burnout, however, was soon being used to describe the results of stress in other occupations, not just in healthcare.
The origins of burnout were assumed to be rooted in the personal characteristics of a few susceptible individuals. As noted by Balch and Shanafelt, “one of the tragic paradoxes of burnout is that those who are most susceptible seem to be the most dedicated, conscientious, responsible and motivated. Individuals with these traits are often idealistic and have perfectionist qualities…”.10 Those are the very traits sought by most medical schools, most training programmes and fellowships, most patients seeking a doctor, and most doctors seeking to hire a new associate. Idealism, perfectionism and a strong work ethic lead some physicians to “submerse themselves in their work and devote themselves to it until they have nothing left to give.”10
In the mid-1990s, Linzer et al11–13 identified four factors associated with burnout in primary care practices: 1) a lack of control over work conditions and decision making; 2) time pressure such that there was a perception by physicians that they were only valued for their productivity; 3) a chaotic and inefficient work environment that inappropriately used physicians to do clerical and other mundane tasks; and 4) a lack of alignment among physicians and executives regarding values, mission, purpose and compensation. A key finding in their study was that physician satisfaction was derived primarily from patient relationships, not compensation.
Shanafelt and Noseworthy14 proposed that the local work environment is a major factor in determining whether physicians are likely to develop burnout or, alternatively, to become fully engaged and dedicated to their work. They grouped drivers of physician burnout versus engagement into seven dimensions within the modern workplace: 1) workload and job demands, 2) efficiency and resources, 3) flexibility/control over work, 4) work–life integration, 5) alignment of individual and organisational culture and values, 6) social support/sense of community at work, and 7) the degree of meaning derived from work.
Rotherberger5 reports that based on a multivariate logistic analysis, seven factors were independently associated with burnout among the 7,905 surgeons who participated in the ACS survey: 1) subspecialty choice (higher risk among trauma, urologic, otolaryngologic, vascular, and general surgeons); 2) youngest child age ≤21 years; 3) compensation based entirely on billing/productivity; 4) spouse working as a healthcare professional; 5) a high number of nights on call per week; 6) a high number of years in practice; and 7) a high number of hours worked per week.15,16
Burnout develops gradually over time. Kraft17 summarised the work of Freudenberger,9 describing 12 stages of burnout: 1) a compulsion to prove oneself, 2) working harder, 3) neglecting one’s own needs, 4) displacement of conflicts, 5) revision of values, 6) denial of emerging problems, 7) withdrawal, 8) obvious behaviour changes, 9) depersonalisation, 10) inner emptiness, 11) depression and 12) burnout syndrome. These stages are not necessarily sequential, and not all are necessarily involved in a specific case. The duration of each stage varies, and sometimes several stages occur simultaneously. The onset of each case is unique, making it difficult to identify burnout early in its course.
Both proven and novel interventions are being promoted and assessed in a variety of healthcare and other settings. Many doctors have developed their own responses to dealing with the stresses of their work. Some have adopted a healthy lifestyle, including nutritious diets, exercise routines and sports activities. Others have turned to religion, meditation, yoga and mindfulness activities. Still others focus on their family, social interactions, volunteer work and hobbies (eg, traveling, reading non-medical books and writing journals).5
Anecdotal evidence suggests that these personal approaches are useful, but for physicians to be engaged and productive caregivers, the healthcare organisations must work to control or eliminate known drivers of burnout and must help enhance physician defenses and support systems.
A recent comprehensive systematic review and meta-analysis of 15 randomised controlled trials and 37 observational studies assessing the effect of interventions on burnout showed that both individual-focused and structural or organisational strategies decreased physician burnout.18 A review in the Lancet reports that the results substantiate that both individual-focused and structural or organisational interventions can reduce physician burnout.19 Although no specific physician burnout interventions have been shown to be better than other interventions, both strategies are probably necessary. However, their combination has not been studied. The most commonly studied interventions have involved mindfulness, stress management and small group discussions, and the results suggest that these strategies can be effective approaches to reduce burnout domain scores. Duty hour limitation policies also appear effective.
The Mayo Clinic is currently applying nine organisational strategies to promote physician well-being.18 As stated by the authors, these are:18
- Acknowledge and assess the problem. Acknowledging the problem of burnout and demonstrating that the organisation cares about the well-being of its physicians is a necessary first step toward making progress.
- Harness the power of leadership. Although the importance of leadership for organisational success is obvious, its direct effect on the professional satisfaction of individual physicians is underappreciated. Recent evidence suggests that the leadership behaviors of the physician supervisor play a critical role in the well-being of the physicians they lead. To be effective, leaders must also recognise the unique talents of the individual physicians on their team and know what motivates them.20 Evidence suggests that physicians who spend at least 20% of their professional effort focused on the dimension of work they find most meaningful are at dramatically lower risk for burnout.
- Develop and implement targeted interventions. Inefficiency in the practice environment (including clerical load) is a universal driver of dissatisfaction and burnout, but how it manifests and the specific factors that create inefficiency vary widely among surgical, primary care, radiology, and pathology work units (and among organisations).
- Cultivate community at work. Physicians deal with unique challenges and have a professional identity and role that is distinct from other disciplines. Peer support has always been critical to helping physicians navigate these professional challenges. This support can be formal or informal and encompasses a wide range of activities, including celebrating achievements (eg, personal and professional milestones), supporting one another through challenging experiences (eg, loss of a patient, medical errors, a malpractice suit), and sharing ideas on how to navigate the ups and downs of a career in medicine.
- Use rewards and incentives wisely. People can be motivated by rewards. To harness this principle, many healthcare organisations have linked physicians’ financial compensation to productivity. In some settings, physicians’ income is entirely based on productivity, and in others it is structured as a base salary with a productivity bonus. Physicians are not salespeople. Although some variation in productivity (eg, patient volumes and relative value unit generation) can be attributed to physicians’ experience, efficiency and skill, such variation is relatively narrow. Physicians in an equally efficient practice environment primarily increase productivity or revenue generation in three ways: (1) shortening the time spent per patient, (2) ordering more tests/procedures or (3) working longer. The first two approaches may erode quality of care and the third approach increases the risk of physician burnout and may, therefore, be self-defeating in the long run. Consistent with this notion, evidence suggests that productivity-based compensation increases the risk of physician burnout.
- Align values and strengthen culture. Most healthcare organisations have an altruistic mission statement that centres on serving patients and providing them the best possible medical care. An organisation’s culture, values and principles in large part determine whether it will achieve its mission. It is critical for organisations to (1) be mindful of factors that influence culture, (2) assess ways to keep values fresh, and (3) periodically take stock of whether actions and values are aligned.
- Promote flexibility and work-life integration. The high work hours expected of a full-time position in medicine make it difficult for physicians to integrate their personal and professional lives. These challenges may be even more problematic for women physicians due to different cultural and societal expectations. Providing physicians with the option to adjust professional work effort (with a commensurate reduction in compensation) allows them to tailor their work hours to meet both personal and professional obligations.
- Provide resources to promote resilience and self-care. Providing individual physicians with tools for self-calibration, resources to promote self care, and training in skills that promote resilience are three tangible ways that organisations can help individuals care for themselves.
- Facilitate and fund organisational science. Instituting operational efforts to reduce burnout and promote physician engagement will be the primary objective for most medical centres.
Other healthcare organisations can and should develop their own strategies by following these three generic action steps:
- Recognise and acknowledge that physician burnout is a major threat to the healthcare system.
- Use what we now know about the drivers of burnout (discussed above) to improve the workplace environment and build physician well-being.
- Build an economic case to justify expenditures to remedy burnout.
Burnout is common and can be very destructive so we need to look after ourselves, we also need institutions to realise that we are not robots. Without appropriate organisational support and structure to deliver our care, not only do doctors suffer, but so does patient care, as well as the institutions within which we work.
As individual doctors we need to look after ourselves. This involves ensuring our work environment is a positive influence, and includes taking our annual leave, not working when we are sick, knowing our individual limits, sharing the load with colleagues and learning to say no. But above all, remembering, as healthcare providers, we are a team of human beings, not robots.