Provider Burnout


Provider Burnout

Article Author:
Rahulkumar Singh
Article Author:
Keith Volner
Article Editor:
Dan Marlowe
Updated:
11/15/2020 4:32:03 AM
For CME on this topic:
Provider Burnout CME
PubMed Link:
Provider Burnout

Introduction

Burnout is a job-related stress syndrome resulting in emotional exhaustion, depersonalization, and reduced personal accomplishment. It was first described by Maslach et al. in the Maslach Burnout Inventory Manuel (1996). In February 2003, the European Forum of Medical Associations and the World Health Organization issued statements about serious concerns regarding burnout levels in healthcare providers and advised that all national medical associations pay attention to this issue. In the last decade, it has been more apparent that provider burnout is turning into an epidemic. National studies suggest that over fifty percent of physicians experience symptoms related to burnout, which is significantly higher than the general population.[1][2] A similar trend regarding rates of exhaustion has been seen in both medical students as well as in graduate medical education (i.e., residents/fellows.[3] Healthcare has experienced major challenges over the last thirty years with an aging population, managed care, and the integration of technology.

The reality of these challenges can be seen manifest in long working hours, high and sometimes unsustainable productivity goals, and greater overall difficulty of balancing work and life; all of which are some of the major precursors of provider burnout.[4][5] If not addressed burnout promptly leads to depression, addiction, and suicidal ideation.[6] Also, it has a negative impact on physicians, patients, and organizational outcomes. Studies suggest that burnout is not only an individual provider issue but a sign of corporate malaise, and like this solutions should also target these regulatory issues.[7][8] In this article, we will concentrate on physician burnout in particular.

Etiology

Factors Responsible for provider burnout includes 

  • Increased work hours
  • Bureaucratic/administrative work
  • Electronic Health Record (increased screen time)
  • Failure to achieve work-life integration
  • Increased focus on productivity 
  • Lack of leadership support
  • Lack of meaningful work
  • Lack of collegiality at work
  • Lack of individual and organizational value alignment
  • Lack of flexibility/work control

Epidemiology

National studies have shown that fifty percent of physicians are burned out. While some studies have shown a slight preponderance of female gender toward higher rates of burnout, one large systematic review showed that the difference is not clear [9][10]. The rate of burnout seems to be higher among emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties.[11]  A survey of inpatient vs outpatient physicians found that, "Outpatient physicians reported more emotional exhaustion than inpatient physicians.  No statistically significant differences in depersonalization or personal accomplishment." [12].  The authors conclude that their findings do not support any significant difference between inpatient or outpatient physicians' rates of burnout.  A systematic review of surgical subspecialties burnout rates found that residents had significantly higher burnout rates than attending surgeons among multiple specialties, including otolaryngology, obstetrics and gynecology, and orthopedic surgery.  [13]A study of 886 medical students performed multiple surveys throughout the medical school education and noted an increased burnout rate from 17% at matriculation to 38% after the residency match. [14] All of this data seems to imply that this syndrome begins very early on in medical education and persists throughout the acculturation process of healthcare professionals.

Pathophysiology

While physicians work in highly stressful environments and situations, it is not a usual part of the medical education curriculum how to manage the on-going nature of that stress. This lack of instruction could be a basis for the high rate of burnout as it seems to be an individual's response to this chronic stress that determines whether an individual will suffer burnout syndrome or not. Pathological responses to stress including drug or alcohol addiction, isolation, or repression can lead to further burnout related symptoms and increase the risk for depression and suicide among physicians. It should be noted that suicide is not typically thought to be a result of burnout alone, and it is more commonly seen in those with other mental illnesses such as depression. [15] It should also be noted that there is a higher mortality rate among suicide attempts in physicians compared to the general population.[16] Therefore, the interplay and progression between stress response, burnout syndrome, depression or other mental health disorders, and eventually suicide if left unchecked, unrecognized, and untreated can be seen.

  • Stress---> Burnout ---> Depression ---> Suicide

History and Physical

Symptoms of Burnout 

  • Emotional exhaustion - refers to mental and physical fatigue
  • Depersonalization - refers to cynicism (loss of altruism)
  • -Personal achievement - refers to a lack of competence and self-efficacy

Signs of Burnout 

  • Poor quality of work and increased medical errors
  • Patient safety issues
  • Poor patient satisfaction
  • Lack of physician engagement 
  • Poor retention rate and early retirement [17][18]

 

Evaluation

The Maslach Burnout Inventory (MBI) is the most widely used tool and developed in 1980. Though there are other tools available (e.g., Copenhagen Burnout Inventory), the MBI is still regarded as the gold standard in measuring provider burnout. It has 22 items and consists of three domains. Increased scores on emotional exhaustion and depersonalization correlate with the greater extent of experienced burnout, as does diminished personal accomplishment. MBI can be used for single-item measures of emotional exhaustion and depersonalization and have been validated as accurate proxy measures of burnout in larger surveys.[19]

Treatment / Management

Studies suggest that burnout is not an individual issue alone but also a hazard of organizational dysfunction. Though Initiatives at the individual level are important to tackle this epidemic, studies have shown that changes must be made at the organizational level as well to maximize the effectiveness of either. [7][8]

Personal Initiatives 

  • Improving physician wellness and resilience. Resiliency refers to the stress coping abilities of a person.
  • Mindfulness is one of the proven techniques which has been shown to provide the coping mechanism to deal with stress. 
  • Reducing personal work effort has also been shown to decrease burnout. A longitudinal study was done by Shanafelt et al. at Mayo Clinic found that increased burnout is inversely proportional to professional work effort. Another study by the Association of American Medical Colleges demonstrated an increase in burnout in US physicians between 2011 to 2014. This result translated into approximately a one percent decrease in physician professional effort, which equals a loss equivalent of the entire graduating class of 7 medical colleges.
  • Self-care practices (e.g., exercise, regular health check-up)
  • Self-awareness.[20]

Organizational Intiatives[21][22]

-  Recognizing organizational issues and assessing the extent of burnout of employees regularly

  • Effective leadership
  • Developing Specific and targeted interventions
  • Improving collegiality at work (e.g., Peer support group/Physician discussion initiative). 
  • Recognizing work and incentivizing using a compensation model
  • Value alignment is important to make sure that physicians and organizations are committed to similar goals. Also, organizational culture must support these shared values.
  • Providing physicians with more flexibility 
  • Investment in physician wellbeing 
  • Development of evidence-based strategies

 

 

Differential Diagnosis

  • Stress
  • Fatigue
  • Depression
  • Addiction
  • Suicide

 

Complications

  • Depression - Burnout, and depression overlap but they are a different entity altogether. Depression leads to a lack of energy in one's life but burnout is only work-related (Bakker et al. Anxiety Stress Coping, 2000)
  • Addictions 
  • Suicide 

 

Pearls and Other Issues

By 2025, the US Department of Health and Human Services projects that there will be a population of approximately 45,000 to 90,000 physicians with poor working conditions and high levels of stress.  Stress is a reason for deterring people from entering the profession. One of the steps to be taken to improve this shortfall is vigilance among the instructors and institutions training doctors and nurses. Healthcare leaders have a very critical role to play in addressing this issue. There is clear evidence to support that physicians are spending 20% of their professional time in the area of work they found meaningful tend to experience symptoms of burnout at a significantly lower rate with a ceiling effect at 20%. [23] Thus, finding meaningful work for and maximizing the skill set of each team member should be a top priority for healthcare leaders. Studies have also shown that supportive leadership has a positive impact on provider burnout, which makes a reasonable argument to include burnout as a part of the quality measure of every healthcare organization and something that should be evaluated at regular intervals.[24]  

 

Enhancing Healthcare Team Outcomes

Organizations have a significant role to play in dealing with this epidemic; however, to reduce burnout and promote physician engagement, both physicians and organizations have to share this responsibility.  Physician organizations like the American Medical Association (AMA) and the American College of Physicians (ACP) are taking notice and have started allocating resources to the study and development of interventions targeting burnout. STEPS Forward is a program pioneered by the AMA and is an example of this kind of initiative.  It is a 7 step process laid out by the AMA that organizations can follow. Ultimately, healthcare needs more academic and non-academic institutions to study burnout and publish data to understand and help physicians and organizations manage this syndrome more effectively. When issues become apparent, an interprofessional team of clinicians, social workers, and nurses assisting the individual in working through personal challenges will provide the best outcome. [Level V]

 


References

[1] Shanafelt TD,Boone S,Tan L,Dyrbye LN,Sotile W,Satele D,West CP,Sloan J,Oreskovich MR, Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of internal medicine. 2012 Oct 8;     [PubMed PMID: 22911330]
[2] Shanafelt TD,Hasan O,Dyrbye LN,Sinsky C,Satele D,Sloan J,West CP, Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic proceedings. 2015 Dec;     [PubMed PMID: 26653297]
[3] Dyrbye LN,West CP,Satele D,Boone S,Tan L,Sloan J,Shanafelt TD, Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Academic medicine : journal of the Association of American Medical Colleges. 2014 Mar;     [PubMed PMID: 24448053]
[4] Shanafelt TD,Dyrbye LN,Sinsky C,Hasan O,Satele D,Sloan J,West CP, Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clinic proceedings. 2016 Jul;     [PubMed PMID: 27313121]
[5] Sinsky C,Tutty M,Colligan L, Allocation of Physician Time in Ambulatory Practice. Annals of internal medicine. 2017 May 2;     [PubMed PMID: 28460382]
[6] Fridner A,Belkić K,Minucci D,Pavan L,Marini M,Pingel B,Putoto G,Simonato P,Løvseth LT,Schenck-Gustafsson K, Work environment and recent suicidal thoughts among male university hospital physicians in Sweden and Italy: the health and organization among university hospital physicians in Europe (HOUPE) study. Gender medicine. 2011 Aug;     [PubMed PMID: 21727034]
[7] Williams ES,Konrad TR,Linzer M,McMurray J,Pathman DE,Gerrity M,Schwartz MD,Scheckler WE,Douglas J, Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study. Health services research. 2002 Feb;     [PubMed PMID: 11949917]
[8] Maslach C,Leiter MP, Understanding the burnout experience: recent research and its implications for psychiatry. World psychiatry : official journal of the World Psychiatric Association (WPA). 2016 Jun;     [PubMed PMID: 27265691]
[9] De Hert S, Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies. Local and regional anesthesia. 2020     [PubMed PMID: 33149664]
[10] Rotenstein LS,Torre M,Ramos MA,Rosales RC,Guille C,Sen S,Mata DA, Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018 Sep 18     [PubMed PMID: 30326495]
[11] Harry E,Sinsky C,Dyrbye LN,Makowski MS,Trockel M,Tutty M,Carlasare LE,West CP,Shanafelt TD, Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey. Joint Commission journal on quality and patient safety. 2020 Oct 4     [PubMed PMID: 33168367]
[12]     [PubMed PMID: 24167011]
[13]     [PubMed PMID: 27410167]
[14]     [PubMed PMID: 31081911]
[15] Kuhn CM,Flanagan EM, Self-care as a professional imperative: physician burnout, depression, and suicide. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2017 Feb     [PubMed PMID: 27910035]
[16] Petersen MR,Burnett CA, The suicide mortality of working physicians and dentists. Occupational medicine (Oxford, England). 2008 Jan     [PubMed PMID: 17965446]
[17] West CP,Dyrbye LN,Shanafelt TD, Physician burnout: contributors, consequences and solutions. Journal of internal medicine. 2018 Jun     [PubMed PMID: 29505159]
[18]     [PubMed PMID: 26930395]
[19] West CP,Dyrbye LN,Satele DV,Sloan JA,Shanafelt TD, Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. Journal of general internal medicine. 2012 Nov;     [PubMed PMID: 22362127]
[20] Nedrow A,Steckler NA,Hardman J, Physician resilience and burnout: can you make the switch? Family practice management. 2013 Jan-Feb;     [PubMed PMID: 23418835]
[21] Shanafelt TD,Noseworthy JH, Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clinic proceedings. 2017 Jan;     [PubMed PMID: 27871627]
[22] West CP,Dyrbye LN,Rabatin JT,Call TG,Davidson JH,Multari A,Romanski SA,Hellyer JM,Sloan JA,Shanafelt TD, Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA internal medicine. 2014 Apr;     [PubMed PMID: 24515493]
[23] Shanafelt TD,West CP,Sloan JA,Novotny PJ,Poland GA,Menaker R,Rummans TA,Dyrbye LN, Career fit and burnout among academic faculty. Archives of internal medicine. 2009 May 25;     [PubMed PMID: 19468093]
[24] Shanafelt TD,Gorringe G,Menaker R,Storz KA,Reeves D,Buskirk SJ,Sloan JA,Swensen SJ, Impact of organizational leadership on physician burnout and satisfaction. Mayo Clinic proceedings. 2015 Apr;     [PubMed PMID: 25796117]