Submitted by Yury Yakubchyk, MD, Augusta Health Pediatric Hospitalist
Our physicians and clinicians care for patients and families in need in a constantly evolving health care system, and they are driven in this pursuit to put patients first, but often their own well-being suffers. Multiple challenges to physician well-being, including such problems as dissatisfaction, symptoms of burnout, relatively high rates of depression, and increased suicide risk affecting physicians from premedical training through their professional careers. Burnout is a growing problem among the US physicians and has reached alarming proportions: 51% of the US physicians reported feeling burnout—a substantial rise from 40% in 2013 lifestyle survey report1. The medical specialties reporting the highest levels of burnout in 2017: emergency medicine physicians (59%), obstetricians and gynecologists (56%), family physicians (55%), and internists (55%). Even the least burned-out specialties still reported high rates: psychiatry (42%), allergy and immunology (43%), ophthalmology (43%), and endocrinology (46%)2. Female physicians reported higher levels of burnout (55%) than male physicians (45%) due to fact that female physicians often face greater challenges than do male physicians with respect to balancing work and family responsibilities, resulting in increased work–family conflict and stress.
Burnout is a psychological and behavioral syndrome with three components: 1) emotional exhaustion (loss of enthusiasm for your work; downward spiral, even after attempting to rest); 2) denationalization (a distorted perception of oneself that leads to lack of empathy and sometimes viewing people as objects; dysfunctional coping mechanism; keeping your patients at a distance to not drain you more: cynicism, sarcasm, compassion fatigue – nothing left to give); 3) a low sense of personal accomplishment (feeling that you’re ineffective in your work; work has no purpose). Emotional exhaustion is the most widespread of the three components among physicians. Some symptoms of depression may be very similar to those of burnout, but stress and depression are not the same conditions as burnout. Burnout and stress may lead to depression, and stressed-out physicians are more likely to become burned out.
There are multiple causes of burnout and they can vary widely, but every kind of physician, no matter what age or specialty, is at risk. A key cause of burnout for physicians is having to deal with extra administrative issues, such as having to enter increasingly more data into electronic health records (EHRs). According to article in Annals of Internal Medicine, physicians spent 27% of their total time on direct clinical face time with patients and 49% of their time filling out EHR and other administrative work, what may involve medico-legal issues, billing needs, and reporting requirements3. It has to do with filling out forms, entering data, checking boxes, and reading and signing paperwork. Increased performance measurement, more paperwork, and greater use of EHRs were linked to burnout in an open letter written by a group of healthcare leaders4. Each year, US physician practices in four common specialties spend an average of 785 hours per physician and more than $15.4 billion dealing with reporting of quality measures, according to a 2016 study in Health Affairs5. New reporting requirements are popping up everywhere as physicians enter an era of value-based payments, based on an enormous amount of reported data. When physicians have more demands placed on them and consider many of those demands to be meaningless, it’s easy for them to feel cynical about their work and in fact, emotionally exhausted, which is a common sign of burnout.
Another factor in burnout is that physicians are plugged in all the time now. They have to answer mountains of email and calls 24/7 on their smartphones. These extra connections have sopped up the last amount of private time that physicians had, and now physicians have to struggle to reclaim that personal time.
Other causes of burnout include the following:
- The push for greater productivity (independent physicians are trying to make up for stagnant reimbursements, and employed physicians are trying to meet productivity goals that are measured in numbers of patients or work relative value units);
- Having to deal with layers of bureaucracy (in a large organization, when physicians suggest ways to improve quality of care or make their work more efficient, it can be difficult to get a response).
- Working long hours. When physicians frequently work shifts longer than 24 h, the resulting fatigue is associated with negative consequences for physicians, both personally and professionally. Physicians-in-training working traditional > 24-hour on-call shifts are at greatly increased risk of experiencing an occupational sharps injury or a motor vehicle crash on the drive home from work and of making a serious or even fatal medical error. As compared to when working 16-hours shifts, on-call residents have twice as many attentional failures when working overnight and commit 36% more serious medical errors. They also report making 300% more fatigue-related medical errors that lead to a patient’s death6. Plus, long hours at work impinge upon marriages, childcare, and social life. Many physicians think that “overworked” is just how the role is. This attitude also involves putting one’s work life above one’s personal life, which is an obvious cause of burnout. It can be hard to have a social life, have a relationship with a spouse, or take care of a young family.
- Sub-optimum attention to self-wellness by physicians. Current research suggests that physicians are not very good at tending to many of their wellness needs or seeking help from others. Some authors refer to the “ignorance, indifference and carelessness of physicians towards their own health”; physicians neglect to have physical examinations and procrastinate when seeking medical treatment. In a study of physicians’ attitudes towards their own health, Thompson and colleagues7 identified that general practitioners feel pressure from both their patients and colleagues to appear physically well, even when they are sick, because they believe their health is interpreted as an indicator of their medical competence.
All these factors have potential to affect healthcare workers on a personal, physical, emotional and cognitive level which in turn adversely affects care relationships and quality of patient care. We need to be concerned about the effect that this enormous occupational stress has on them as individuals and how it impacts the care provided. The consequences of physician burnout are significant, and threaten our U.S. health care system, including patient safety, quality of care, and health care costs. Costs are impacted by burnout in direct ways (e.g. turnover, early retirement, less than full time work) and indirect ways (e.g. poor quality, including medication and other errors, unnecessary testing and referrals, greater malpractice risk, and possibly higher hospital admissions/readmissions). Prospective longitudinal studies from the Mayo Clinic demonstrate that for every 1-point increase in burnout score, there is a 43 percent increase in likelihood a physician will reduce clinical effort in the following 24 months8. The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training, and lost revenue during this time4. All of this is in addition to the significant toll, sometimes with tragic consequences, that burnout exacts on physicians and their loved ones.
The high level of burnout among physicians should be considered an early warning sign of dysfunction in our health care system. Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner. Dissatisfaction is driven by factors that impede this effort, including administrative and regulatory burdens, limitations of current technology, an inefficient practice environment, excessive clerical work, and conflicting payer requirements. High levels of physician burnout can thus be seen as an indicator of poor performance by the underlying system and environment.
- Peckham C. Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout. January 11, 2017.
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012; 172:1377-1385.
- Sinsky C, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016;165(11):753-760.
- Physician Burnout Is a Public Health Crisis: A Message to Our Fellow Health Care CEOs. March 2017; Health Affairs blog.
- Arnetz BB. Psychosocial challenges facing physicians of today. Soc Sci Med 2001; 52: 203–13.
- Steven W. Lockley et al. Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance. The Joint Commission Journal on Quality and Patient Safety. November 2007 Volume 33 Number 11; 7-18.
- Thompson WT, Cupples ME, Sibbett CH, Skan DI, Bradley T. Challenge of culture, conscience, and contract to general practitioners’ care of their own health: qualitative study. BMJ 2001; 323: 728–31.
- Shanafelt T., Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. January 2017; 92(1):129-146.