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 providers 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 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 providers, 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 provider burnout in particular.

Etiology

Factors responsible for provider burnout include:

• 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 providers 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 providers found that "outpatient providers reported more emotional exhaustion than inpatient providers." 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 providers' 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 providers.

Pathophysiology

While providers work in highly stressful environments and situations, it is not a usual part of the medical education curriculum how to manage the ongoing 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 providers. 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 providers 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 provider 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 provider 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 providers between 2011 to 2014. This result translated into approximately a one percent decrease in provider 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/provider discussion initiative).
• Recognizing work and incentivizing using a compensation model
• Value alignment is important to make sure that providers and organizations are committed to similar goals. Also, organizational culture must support these shared values.
• Providing providers with more flexibility
• Investment in provider wellbeing
• Development of evidence-based strategies

Differential Diagnosis

Provider burnout symptoms and signs mimic the other mental health disorders. It is crucial to rule out other diagnoses to improve outcomes. Following differentials should be considered in making a diagnosis of provider burnout.

• Fatigue
• Depression
• Addiction
• Generalized anxiety disorder

Prognosis

The prognosis of provider burnout is excellent when early intervention is done. Early diagnosis and appropriate measures to cope with stress along with institutional support with a decrease in workload and flexible work arrangements can bring positive outcomes in terms of patient care as well as providers' health.

Complications

Provider burnout if not recognized early and treated could have serious consequences. Following are the complications of provider burnout.

• Depression - burnout, and depression overlap but they are different entities 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

Deterrence and Patient Education

Provider burnout can be addressed at the individual as well as at an organizational level. On individual level providers should be helped to find ways to cope with stress, and on the organization level by seeking ways to address the factors contributing to provider burnout. There are five ways to reduce provider burnout

1. Invest in leadership development
2. Offer flexible work arrangements
3. Reduce the technological burden
4. Provide tools for individual intervention
5. Reduce the burden of non-clinical activities

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 providers 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 those providers who 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 provider engagement, both providers and organizations have to share this responsibility. Providers 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 seven-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 providers and organizations manage this syndrome more effectively. When issues become apparent, an interprofessional team of providers, social workers, and nurses assisting the individual in working through personal challenges will provide the best outcome.[Level V]