Burnout: The perfect storm of physician stress

Burnout: The perfect storm of physician stress

To the literal-minded, burning out is the fate of light bulbs and matches.  But whether you read the popular press or medical journals today, you’re likely to find writers who are deeply concerned about physician burnout.

What defines physician burnout, and who exactly is suffering from it?  Is burnout an actual clinical syndrome, a slang term connoting fatigue and boredom, or a hazy combination of the two?  Which medical specialties have the highest rates of burnout, and are men or women physicians more susceptible?  The more you read, the more you realize how much pop psychology and sloppy language are clouding an important issue.

A perfect example of murky logic comes to us courtesy of Dr. Danielle Ofri, who wrote a recent piece for Time called “The Epidemic of Disillusioned Doctors.”  She claims that young women physicians who work in salaried primary care positions are more “resilient” than other doctors, and less likely to become disillusioned about medicine.

Now disillusionment and burnout aren’t identical concepts.  You can be quite disillusioned about the politics of medicine, and pessimistic about the future of private practice, while you take care of your patients every day with dedication and enthusiasm.

But in Dr. Ofri’s view, disillusionment and burnout are twin states of mind, and they are the harbingers of medical errors, substance abuse and depression.  The doctors she considers least likely to suffer such problems are those in her own demographic subset.  “The newer generation of female, salaried, primary-care doctors have the most optimistic outlook on medicine,” she writes.  “This bodes well for patients.”

Wait a moment.  May we see the data to back up this claim?  The source that Dr. Ofri refers to is a 2012 publication from The Physicians Foundation, a nonprofit organization that surveyed more than 13,000 physicians.  The survey addressed professional satisfaction and morale, among other issues, and reached conclusions rather different from Dr. Ofri’s.

“The majority of female physicians, employed physicians, and primary care physicians, though less pessimistic than their male, practice owner and specialist peers, are nevertheless pessimistic about the medical profession and express low levels of morale,” the report concluded, wryly noting that younger physicians “simply may not have practiced long enough to become disaffected.”

Burned out, or just negative?

I have no trouble believing that a majority of physicians feel negatively about the future of American medicine in view of the Affordable Care Act’s threat to physician pay and autonomy.

But it’s important to distinguish negativity or pessimism from burnout.  There is a clinical definition of “burnout” in the ICD-10 codes:  a “state of vital exhaustion”, listed under the category of “problems related to life-management difficulty”.  The Merriam-Webster dictionary defines burnout as “exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration.”

More than thirty years ago, a Stanford social psychologist named Christina Maslach developed a well-respected quantitative tool to study the phenomenon of professional burnout. The Maslach Burnout Inventory addresses three general scales:

Emotional exhaustion:  Measures feelings of being emotionally overextended and exhausted by one’s work;

Depersonalization:  Measures an unfeeling and impersonal response toward recipients of one’s service, care treatment, or instruction;

Personal accomplishment:  Measures feelings of competence and successful achievement in one’s work.

A recent study in the Archives of Internal Medicine used a version of the Maslach scale to investigate burnout and satisfaction among U.S. physicians.  Nearly 38% of physicians surveyed reported high emotional exhaustion, 29% had high depersonalization, and 12% had a low sense of personal accomplishment.

Emergency medicine, general internal medicine, neurology, and family medicine had the highest rates of burnout, the study found.  Pathology, dermatology, general pediatrics, and preventive medicine had the lowest rates.  (Anesthesiologists were slightly above the mean in their rate of burnout, on a par with OB/GYN and orthopedic surgery.) Characteristics associated with a lower risk for burnout included being older (sorry, Dr. Ofri), and being married.

The study also questioned physicians about their satisfaction with work-life balance.  Female physicians were more likely to be dissatisfied with their work-life balance than male physicians (43% vs. 39%).  Interestingly, three of five specialties that reported the lowest satisfaction with work-life balance also had lower than average rates of burnout:  general surgery, general surgery subspecialty, and internal medicine subspecialty.  Apparently, for the physicians in these fields, the work itself was satisfying enough to compensate for the time it required.

The annual Medscape Physician Lifestyle Report similarly uses a version of the Maslach criteria to define burnout:  loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.  The 2013 report found that physicians in emergency medicine, critical care, and family medicine reported the highest burnout rates, around 50%.  OB/GYN physicians reported the most severe degree of burnout, interfering with life and making them consider leaving medicine altogether.

Again, in contrast to Dr. Ofri’s perception, more female physicians than male physicians reported symptoms of burnout (45% vs. 37%), which Medscape attributed to the fact that “women tend to enter generalist professions (family medicine, internal medicine, and obstetrics/gynecology).”  Physicians between the ages of 46 and 55 reported the highest burnout rate (32%), with the lowest rates in the under-35 and over-65 physician age groups (less than 10% each).

Anesthesiologists ranked fourth in burnout rate in the Medscape survey, tied with OB/GYN, general surgery, and internal medicine, but their rank of 14th in the severity scale “suggests that the severity of anesthesiologists’ burnout is not particularly intense”.  A much higher percentage of female anesthesiologists reported burnout in comparison with their male counterparts, 56% vs. 42%.  The three highest-ranked causes of burnout for anesthesiologists were too many bureaucratic tasks, the impact of the Affordable Care Act, and spending too many hours at work.

Are younger physicians at less risk?

Sadly, the process of burnout seems to begin early in physician careers.  Survey data from over 1500 anesthesiology residents, reported recently in Anesthesia and Analgesia, demonstrated high risk of burnout in 41%, and high risk of depression in 22%.  High risk of both burnout and depression occurred in 17% of residents.  Female gender, working more than 70 hours per week, and consuming more than five alcoholic drinks per week were factors associated with increased risk for both burnout and depression.

Alarmingly, a third of the residents who scored high for burnout and depression risk reported multiple medication errors during the last year, compared with less than 1% of the residents at lower risk.  The lower-risk resident group also reported more consistent performance of best practices including checking airway equipment, checking the anesthesia machine, and reading about the next day’s cases.

The study concluded: “Burnout, depression, and suicidal ideation are very prevalent in anesthesiology residents.  In addition to effects on the health of anesthesiology trainees, burnout and depression may also affect patient care and safety.”

The perfect storm of physician stress

All the studies cited here are based on survey data.  It’s certainly possible that the responses were skewed in some ways.  Busier and more successful physicians may be less likely to take time to fill out surveys, or even to open an email that contains information about a survey.

Yet burnout appears to be a significant problem for American physicians today, and the combination of burnout and depression may be deadly.  At least 400 physicians commit suicide in the U.S. each year, and it seems likely that many are underreported because they are labeled as accidental overdoses.  The suicide rate for female physicians is 2.5 to 4 times higher than that of the general population.   In contrast to Dr. Ofri’s opinion, female physicians in primary care fields appear clearly at higher risk for burnout than most of their colleagues.

We are facing a perfect storm of physician stress.

  • Increased pressure to see more patients and do more cases in less time leads to physical and emotional exhaustion.
  • Declining pay means physicians can afford less of the support services at home and at work that would make their lives more manageable.
  • The federal government’s push to make physicians follow protocols and impose penalties for noncompliance eliminates autonomy and reduces personal satisfaction in the practice of medicine.
  • In contrast to previous generations, many physicians today feel torn between the demands of home and work, adding to a sense of failure or diminished accomplishment.
  • Electronic medical records increase the depersonalization of patient contacts by forcing physicians to spend time on endless data entry that would be better spent with patients.

Is all this a recipe for burnout?  Of course it is.  Physician burnout should be taken seriously, not glossed over with pseudoscience or politically correct propaganda for the Affordable Care Act.   It’s not too late for today’s physicians to oppose the destructive forces that threaten American healthcare, and keep the next generation of young physicians from ending up as real burnouts—shift workers on mega-healthcare assembly lines.

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center.  She blogs at A Penned Point.

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  • http://www.thehappymd.com/ Dike Drummond MD

    Great post Dr. Sibert and the external stresses of the practice of medicine and your specific job situation represent only one of the four main causes of burnout.

    The other three are
    1) The stress of the practice of medicine – dealing with sick, scared, injured people and making decisions with life and death responsibility is draining … even if you live the physician’s dream of “just seeing patients”.

    2) The stress of trying to balance work and life once you are out of your training — and the guilt at the difficulty of the task

    3) The programming of our medical education which produces a world class crop of workaholic, superhero, emotion free, lone ranger, perfectionists. This is great for getting through a long rotation … not such a good formula for a happy, balanced life.

    Here is a full post on the four causes.
    http://www.thehappymd.com/blog/bid/290379/Physician-Burnout-The-Four-Horsemen-of-the-Burnout-Apocalypse

    The causes of physician burnout are multifactorial, the prevention tools are as well AND it is the responsibility of the healthcare organizations that employ docs to fill in the gaps in their education.

    I honestly believe the organizations that build physician friendly workplaces, where everyone understands burnout and the culture acknowledges our humanity and normalizes asking for support when the going gets rough … will develop a competitive advantage in the very near future.

    My two cents,

    Dike
    Dike Drummond MD
    117 ways to Prevent Physician Burnout in the MATRIX Report here
    http://www.tinyurl.com/bpmatrix

    • rbthe4th2

      I wish we could find a few places that were friendly to docs. They are few and far between. I know the monopoly around here sure isn’t. There are a few small choices otherwise that are.

  • http://www.zdoggmd.com ZDoggMD

    This is a topic near and dear to my heart, so much so that I gave a rambling TEDMED talk about it:

    http://zdoggmd.com/2013/06/tedmed/

    I think in the end, we need to rebuild our system from the ground up with team-based support structures, intelligent use of technology, and an emphasis that begins in med school on fixing our wacky medical culture.

    Thanks Karen for discussing this crucial topic!

  • Bob

    There are a few infallible rules, including supply and demand, which fits into these surveys, which excluded the traditional ones where results on patients lives are most often death. Oncology, burn centers and others were once deadly to most if not all patient’s.
    So when 4 million are added to Medicare every year and 45 million in the near future to Medicaid, and forces profits down for physicians, while telling patients that their care will improve by using data entered by physicians, how does this increase satisfaction for anyone?
    So physicians support this and participate because this will somehow improve their satisfaction rates?
    What happens if a sizable number of physicians “opt out”?

  • buzzkillerjsmith

    I was with Dr. S. until the last paragraph. “It’s not too late….”

    Yes it is too late. Abandon all hope. Then move on.

  • Cyril Marcus

    Hopelessness has been identified in many studies as the most important factor for completed suicides. A feeling that “there is no way out” has been implicated in the multiple recent bullying related suicides in adolescents.

    There is quite a bit of anecdotal evidence that hopelessness may be a driving factor in physician suicide. This was first noticed after 20 physicians who went through Dr. Douglas Talbott’s ASAM Ridgeview program killed themselves in a 12 year period.

    These boot camp like programs of coercion and abuse are political organizations fronting as addiction medicine specialists and non-profit organizations of benevolence that help physicians and protect the public.

    The ASAM has a certification process for physicians and claim to be “addiction” specialists. This “board certification” is not recognized by the American Board of Medical Specialties and is not a recognized medical specialty. The goal of the ASAM is to be recognized as the experts in addiction medicine with the consensus expert opinion based on the 12-step prohibitionist brain disease model. The ASAM has aligned itself with a number of inpatient drug treatment centers (Hazelden, Talbott, Marworth, Bradford) and are heavily funded by the drug testing industry.
    Most state physicians health programs (PHPs) are now run by ASAM physicians under the FSPHP–Both the ASAM and FSPHP are fronts for AA that claim to have no ties to further the agenda with no real scrutiny.

    They infiltrated “impaired physician” programs by joining, gaining power, and removing dissenters. Groupthink and 12-step indoctrination are the goals. By advertising as advocates for doctors who are “caring,” “confidential resources,” “giving help,” and advocating for “colleagues in need” the outward appearance is one of benevolence.

    The biggest obstacle is that this system allows them to throw the normal rules of conduct under the imperative of a higher goal assumed to trump all other consideration. Those outside of programs either defend or ignore the reports of ethical and criminal violations, complacent in their trust of these “experts” claiming they are just helping sick doctors and protecting the public.
    With no oversight or regulatory body involved this is all done with impunity, immunity, and undercover. They use the accusation of substance abuse as an indication to disregard the claims of the accused. The physician is left without rights, depersonalized, and dehumanized. The imposition of confinement, stigmatization, lack of oversight of the organizations, peer-review protected confidentiality, and lack of procedural protection is a one-way train to hopelessness and despair.
    By establishing a system that of coercion, control, secrecy, and misinformation, they are claiming an “80% success rate” and deeming their programs “the new paradigm in addiction medicine treatment.
    They had a major influence on the DSM-V where drug abuse and dependence are no longer separate entities. They are also working behind the scenes to get legislation to randomly drug test all physicians.
    They are now after the “disruptive physician” and the evidentiary criteria are fairly low and red flags include “deviating from workplace norm in dress or conduct” and being tardy for meetings.
    They have identified “the aging physician” as a potential problem because “as the population of physicians ages,” “cognitive functioning” becomes “a more common threat to the quality of medical care.”

    So any physician referred to one of these programs or coerced into it is subject to groupthink 12-step indoctrination under the threat of having their licenses removed. Since ideology and dogma has trumped evidence based medicine and those running these programs participate in abuse, fraud, civil rights violations, coercion, and control many doctors have committed suicide. And when they do they just attribute it to “their disease.”

    Like all cults they rely on propaganda and misinformation. For example they are claiming the PHP programs as the “new paradigm in addiction treatment” claiming an 80% success rate. They have also created a myth that medical mistakes are the result of a hidden cadre of drug addicted doctors and are behind the recent call to randomly drug test all physicians. Of course who will run such a program? They will. They also want to expand to other organizations such as the DOT.

    There is a lot of anecdotal evidence that the marked suicide rate in physicians is because of this.

    The propaganda and misinformation is based on a study that is misleading and full of methodological flaws but there are no critical analysis or even criticisms to be found from the medical community. In fact the study they base this success rate on leaves a lot of unanswered questions.

    The mean age of the 904 physicians is 44.1 years.

    They report that 24 of 102 physicians that were transferred and lost to follow “left care with no apparent referral.” What happened to them? These are physicians with multiple identifiers (state license, DEA, UPIN, etc) not transient drifters.

    Of the 802 left in the program they report 155 failed to complete the contract. Of these, 48 involuntarily stopped or had their license revoked and 22 died with 6 of those being suicides.

    This study is looking at defined endpoints while being monitored so 6 killed themselves while being actively monitored by the program.

    But what about the 24 that left with no apparent referral? It is unlikely the just left on a whim. There must have been some precipitant event.

    More importantly what happened to those 48 who were reported to the Medical Board for noncompliance and had their licenses revoked–that would be the critical time when this population would be at most risk for completing a suicide. That would be when hope was lost and the coerced physician, knowing that the fight was over, would take that step.

    Coerced and forced indoctrination into a belief system can Kill. It is imperative that the medical community expose the ASAM and FSPHP as the AA front groups they are before it is too late.