#41032: Burnout in Physicians

Burnout is more likely when an individual's experience (actual or perceived) does not match one or more situational factors in a work environment [9]. Among the mismatches that most commonly lead to burnout in any work environment are [9]:

Demographic variables have been studied in relation to burnout, and several have been found to influence the risk of burnout, alone or in combination, including [6]:

Burnout is less prevalent among older individuals because they tend to be more stable and have a more balanced perspective on life [6]. In addition, the increased rate of burnout among younger individuals is a function of a "survival of the fittest" concept. Burnout usually occurs early in one's career (in the first one to five years), and many young, burned-out individuals leave the profession; as a result, the remaining individuals in an occupation are the "survivors" [6].

Across most work settings, levels of burnout have been somewhat consistent among men and women. One meta-analysis demonstrated similar overall rates of burnout among men and women, but there were differences between the sexes with regard to burnout components, with slightly higher levels of emotional exhaustion among women and somewhat higher levels of depersonalization among men [10]. Differences in burnout among male and female physicians will be discussed later in this course.

Family status also seems to play an important role in burnout; rates of burnout are higher among single workers and workers with no children than among married workers and those with children [6]. The emotional resources provided by a family are thought to be the reason for this difference.

In general, educational status seems to have an effect, with higher levels of burnout among workers with higher levels of education [6]. This difference could be the result of the expectations associated with advanced education and job choices [6]. In a study in which burnout was compared among physicians and the general population, an MD or DO degree was associated with a higher risk of burnout, whereas a Bachelor's degree, Master's degree, or doctoral degree (other than MD or DO) was associated with a lower risk [11].

Studies have also been done to explore the relationships between personality traits and the risk of burnout. Maslach noted that characteristics such as low self-esteem or lack of confidence, failure to recognize personal limits, need for approval, drive to overachieve, need for autonomy, impatience, intolerance, and empathy increased susceptibility to burnout [6]. Others have postulated that extreme conscientiousness, perfectionism, and self-giving (selflessness) also increase susceptibility, as does a type D personality (a joint tendency for negative emotions and social inhibition) [12,13,14]. Many of these personality traits are common among physicians; in fact, several are essential for success in this profession, which may explain, in part, the high levels of burnout among physicians.

Age is a factor in burnout among physicians, with the lowest rate (35%) among physicians 34 years of age and younger [47]. The highest rates of burnout are found for physicians who are middle-age: 50% for physicians 45 to 54 years of age and 44% for physicians 35 to 44 years of age [47].

Specialty has an effect on the prevalence according to age. For example, in the Medscape survey, the overall burnout rate was 35% for physicians 34 years or younger, but rates were much higher among physicians in small specialties such as urology (54%), neurology (53%), and physical medicine and rehabilitation (52%) [31].

In a survey of family physicians and general internists, female physicians were nearly twice as likely as male physicians to report burnout (36% vs. 19%) [29]. Other studies have found differences in burnout according to sex, but not at the same magnitude. For example, Dyrbye et al. found burnout rates of 43% for female surgeons and 39% for male surgeons, and in the Medscape survey, the rates were 51% and 43% for female and male physicians, respectively [31,48]. The 2021 Physicians Foundation survey found that 69% of female physicians reported "often experience feeling of burnout," compared with 57% of male physicians [123]. As with physicians overall, the burnout rates among women have varied substantially according to specialty, with the highest rates for female physicians found in urology (67%), orthopedics (61%), critical care (61%), cardiology (60%), general surgery (59%), and emergency medicine (58%) [31]. Among residents, women are more likely than men to have burnout according to scores on the emotional exhaustion and personal achievement subscales [29].

In keeping with Maslach's theory that burnout usually occurs within the first five years of an individual's career, burnout rates are higher among medical students and residents than among physicians. In one study, the odds of burnout were higher for residents and fellows than for medical students and early-career physicians, and all three of these groups were significantly more likely to be burned out than college graduates of similar ages in other careers [49]. Similarly, a systematic review showed that residents in surgical specialties were more likely to be burned out than attending surgeons [50]. At the other end of the spectrum, the burnout rate is low among internal medicine residency program directors, with a rate of overall burnout of approximately 29% in one study [38]. In a comparison of burnout among physicians in early, middle, or late career (10 years or less, 11 to 20 years, and 21 years or more, respectively), the rate for depersonalization was highest among middle-career physicians [51]. The high rates of burnout among physicians in training are of concern because when burnout develops early during training, it tends to persist throughout residency [35].

Over the years, the rate of burnout among physicians has varied across specialties, with the highest rates reported among so-called high-stress specialties, such as critical care, emergency medicine, and oncology, as well as among physicians on the frontline of care, such as family practice and internal medicine [11]. The rates found in the 2019 Medscape report are somewhat consistent with this trend, with critical care, neurology, family medicine, obstetrics/gynecology, and internal medicine being the specialties with the highest rates of burnout (Table 4) [47]. In the 2014 study of 7,000 physicians, emergency medicine, family medicine, and internal medicine were among the 10 specialties with the highest rates of burnout [30]. The 2021 AMA/Mayo Clinic survey noted that burnout greatly increased among physicians practicing in emergency medicine, critical care medicine, hospital medicine, and infectious disease during the COVID-19 pandemic [124]. While the pandemic skewed burnout rates significantly, experts hypothesize that it represents a temporary anomaly.

The 2015 Medscape report also includes information on the degree of burnout, noting the percentage of respondents who reported severe burnout (scores of 6 and 7 on a scale of 1 to 7, with 7 defined as "so severe that I'm thinking of leaving medicine"). The rates of severe burnout ranged from 5% to 12% across specialties. The results showed that the specialties with the highest rates of burnout are not necessarily those with the most severe burnout. Among the five specialties with the highest rates of burnout, only two are among the five specialties with the highest rates of severe burnout: family medicine (11%) and internal medicine (10%) [31]. The other three specialties with the highest rate of severe burnout, urology (12%), plastic surgery (12%), and allergy and clinical immunology (10%), ranked 10th, 16th, and 21st, respectively, of the 26 specialties in terms of the burnout rate.

Nearly half of physicians report that their job is "extremely stressful," and 80% say they feel "overextended," "overworked," or "at full capacity" [37,53]. Physicians also note that they have "too many patient appointments," leading to increased time pressure during visits, which has been strongly associated with lower rates of satisfaction and higher rates of burnout [29,54]. Long hours, many of which are spent on nonclinical tasks, and unsatisfactory work-life balance are the key factors in feeling stressed or overextended. Physicians work an average of 51 to 63 hours per week, or 11 to 23 more hours per week than the mean for the general population [30,34,44,48,53,55].

Approximately 60% of physicians have also noted time pressure associated with electronic documentation [56]. Physicians have reported that they spend an average of 9 to 11 hours per week on administrative (nonclinical) duties, with approximately 38% saying they work 11 hours or more each week on such duties [53,57]. Thus, tasks such as billing, obtaining insurance approvals, financial and personnel management, and negotiating contracts take up 14% to 23% of their work time [53,57]. An excess of "bureaucratic" tasks was the highest ranked cause of burnout in the Medscape Lifestyle Reports, and long hours at work was the second leading cause [31,47]. The time spent on administrative tasks takes away from time forming relationships with patients, the most satisfying factor about medical practice according to approximately 79% of physicians [53].

Long hours at work create conflicts between responsibilities at work and at home, and rates of work-life conflicts among physicians have been reported to range from 41% to 62%, and only 33% to 48% of physicians are satisfied with their work-life balance [11,34,40,47,48,58]. Both long hours and work-life conflicts have been found to be significantly associated with burnout [34,46,48,50,51]. Physicians' satisfaction with work-life balance has decreased since 2011 and is significantly lower than the rate among the general population (61% vs. 36%) [30]. Pooled multivariate analysis with adjustments for age, sex, relationship status, and hours worked per week showed that, compared with the general population, physicians had an increased risk of burnout and a decreased likelihood of being satisfied with work-life balance [30].

The era of information technology in medical practice, most notably electronic health records (EHRs) and computerized physician order entry (CPOE), began in the 1990s, and the technologies have been slow in becoming embraced by the medical community because they are challenging and time-consuming to learn [37]. Approximately 85% of physicians currently use these technologies, and about 60% think that EHRs have improved the quality of care [37]. However, the technology has been slow to improve efficiency of care. Surveys have shown that approximately 43% to 75% of physicians think that EHRs decrease efficiency and 47% to 66% of physicians think that using EHRs detracts from patient interaction [37,53,59]. One study showed that physicians who used EHRs spent slightly more time on administrative tasks than physicians who used paper records (17% of work time vs. 15% of work time) [57]. In another study, emergency department physicians spent a mean of 43% of their time on data entry, a significant difference from the time they spent on direct patient care (28%) [60]. In general, physicians are dissatisfied with the amount of time they spend using electronic documentation systems, and stress levels increase and satisfaction levels decrease with increasing use of EHRs [56,61,62]. Physicians who use EHRs and CPOE are also at higher risk for burnout, and "increased computerization of practice" was the fourth most common cause of burnout in the Medscape Lifestyle Reports [31,61,47]. As more physicians become comfortable with using electronic systems, their satisfaction may improve.

Physicians' autonomy is defined as the ability to determine how they work and decide how much time to spend with patients, what kinds of tests to perform, and what treatments to plan [63]. Autonomy has been reported to be the most important determinant of career satisfaction, yet it appears to be slowly eroding [64,65]. Approximately 50% to 69% of physicians say their clinical autonomy is sometimes or often limited and their decisions are sometimes or often compromised [53,56]. Physicians report being frustrated with decision-making by third parties (insurance companies and government agencies) and restrictions imposed by formularies or guidelines [66]. This loss of physician autonomy has been found to be significantly associated with burnout; lack of clinical and administrative autonomy were both significantly correlated with burnout in emergency physicians, and low control over work was strongly associated with dissatisfaction and burnout among primary care physicians [29,54,66,67,68]. Subjective factors, such as a perception of lack of autonomy, have had a stronger correlation with burnout than objective factors [39].

Many other factors have been noted to be risk factors for physician burnout. According to Maslach, insufficient reward for one's contributions is a risk factor for burnout, and this factor has been shown in studies of physicians. Insufficient income was fifth most commonly selected cause of burnout in the 2019 Medscape Lifestyle Report, and feeling unappreciated was a substantial contributor to burnout in a study of residents [47]. Poor working relationships with colleagues, analogous to Maslach's absence of community, has been reported to be a risk factor for burnout among critical care physicians and nurses [19]. In contrast, good working relationships with other physicians and staff have been associated with a greater likelihood of job satisfaction [54,69].

A factor unique to physicians was found in a 2010 study of U.S. surgeons, in which being sued for malpractice in the last 24 months was strongly associated with burnout [70]. Also unique to physicians is health policy; the impact of the Affordable Care Act was the fifth most common cause of burnout in the 2015 Medscape Lifestyle Report [31]. As many as half of physicians say their work environment is chaotic, and this factor has also been significantly associated with burnout [29,37,54].

The most important first step in preventing stress and burnout is to enhance well-being. Self-care, improving work-life balance, and mindfulness training and other structured interventions are key elements for maintaining physical and emotional well-being (Table 8) [19,65,90,91,92,93,94]. Enhancing physicians' well-being is vital not only to address the consequences of stress and burnout but also to improve patient outcomes. The relationship between physician well-being and patient outcomes is understudied, but a systematic review (18 studies) showed that well-being was associated positively with patient satisfaction, patient adherence to treatment, and interpersonal aspects of patient care [95]. The authors of the review noted that most of the studies were observational and of average quality.

Make Self-Care a Priority

Self-care involves several universal lifestyle measures, such as healthy eating habits, exercise, sleep, and regular health care. The results of studies and surveys have shown that physicians who maintain a healthy diet and follow the Centers for Disease Control and Prevention guidelines for exercise are less likely to be burned out [31,92,96]. Physicians who have successfully avoided burnout recommend self-care as a strategy, with physical well-being ranked as the most common strategy (60%) in a small study of hospice and palliative care physicians [93,94].

Attention to self-care should begin in medical training, and one program was developed to help second-year medical students focus better on personal behaviors, such as exercise, eating habits, sleep, and emotional health. The students were asked to target a specific area for change, set a goal, track their progress toward the goal, and assess their success [97]. Although approximately 50% of the students had not reached their goal by the end of the program, 80% said they were healthier because of the program and 82% said they would use the program again. Such programs during medical training can help foster self-care as a priority.

Improve Work-Life Balance

As noted, work-life balance and work-life conflicts are significantly associated with job satisfaction and burnout. One challenge in achieving an appropriate work-life balance is that physicians often search for a single solution to solve the problem. Drummond, who coaches physicians on how to avoid burnout, notes that burnout is more of a dilemma and so requires ongoing strategies to ensure finding and maintaining an appropriate balance [98].

Physicians who participate regularly in hobbies, personal interests, and meaningful volunteerism are at lower risk of burnout and are more likely to have higher quality of life [92,96]. Experts recommend scheduling time each week to pursue hobbies and participate in activities of interest [92,99,100]. Participating in hobbies was reported by 40% of physicians as a way they avoid burnout [94].

Other strategies include setting strict boundaries between work and home, making time for friends and family, taking regular vacations, and remaining clear about priorities [65,93,94,99]. Personal relationships and personal boundaries were reported by 37% (each) of physicians as a way to avoid burnout. As practical advice, Drummond suggests that physicians work with their families to develop a master "life calendar" that includes not only social events such as having coffee with a friend, reading, and exercise, but also all family members' schedules and special events [100]. Physicians should keep an electronic calendar or take a picture of the calendar with their cell phone, check the calendar when a potential work commitment arises, and learn to say no to colleagues' requests when necessary.

Engage in Mindfulness Training

Mindfulness is defined as purposeful and nonjudgmental attention to one's own experience, thoughts, and feelings [101]. Interventions to enhance mindfulness in primary care physicians have led to short-term and sustained improvements in well-being, reductions in indicators of stress and depression, and lower scores on the emotional exhaustion and depersonalization scales of the MBI [102,103]. A nine-month intervention that involved facilitated physician discussion groups that integrated elements of mindfulness with reflection, shared experience, and small-group learning significantly decreased scores on the depersonalization subscale that was sustained 12 months after the end of the program [104]. Scores on the emotional exhaustion subscale and overall burnout scores also decreased substantially. The intervention improved physicians' sense of meaning in their work but did not lead to significant differences in stress, symptoms of depression, or job satisfaction [104]. Mindfulness has also been associated with more patient-centered communication and an increase in the number of satisfied patients [101].

Explore Other Interventions

Cognitive-behavioral training, physical relaxation (e.g., massage), and mental relaxation (e.g., mediation) may have limited benefit, according to a meta-analysis of interventions to reduce work-related stress in healthcare workers. The study demonstrated low-quality evidence that cognitive-behavioral training, with or without relaxation, reduced stress compared with no intervention, but only after the more than one month of follow-up [105]. Similarly, physical relaxation was most effective one to six months after the intervention. Little evidence supported mental relaxation as a way to reduce work-related stress after up to six months [105].

As discussed, use of EHRs is a leading source of physicians' stress and dissatisfaction, and approximately 61% of physicians have reported that other staff could perform functions in EHRs [37]. Thus, making documentation a team effort can help alleviate physicians' electronic burden. In addition, experts recommend that physicians ask colleagues for help in using EHRs more efficiently and that they create templates as a way to semiautomate documentation [98,106].

Given that a chaotic work environment is associated with high rates of stress, job dissatisfaction, and burnout, eliminating chaos can help prevent stress and burnout [65]. Redesigning work flow can also help; this strategy was associated with significant reductions in the burnout rate in a study of primary care clinicians working at 34 clinics [107].

Physicians can work more efficiently by standardizing workflows and processes whenever possible, minimizing interruptions by batching nonurgent tasks, and creating patient resources or delegating patient education [98]. Taking mini-breaks during the day gives physicians time to recharge and refocus [108].

Physicians can take steps in their practice to promote a healthy work environment, and physicians in hospitals or managed care settings should work with leaders to ensure that all physicians and staff have a healthy work environment [19]. Flexible scheduling is an important element of a healthy work environment, as it gives physicians better control over their time and helps them achieve greater satisfaction with work-life balance [52,108].

Participate in Support Groups

Support from colleagues can help to increase job satisfaction and reduce the likelihood of burnout [44,80,109]. In one study, professional relationships were the second most common strategy for preventing burnout, reported by 57% of physicians [94]. Physicians are often hesitant to seek help, but such support groups are not designed to be solely for physicians with mental health or substance abuse issues. Instead, support groups offer an opportunity for healthy but stressed physicians to discuss professional and personal problems [90]. Two randomized trials have demonstrated that programs offering physicians an opportunity to meet with colleagues in a structured format substantially reduced the rate of burnout and enhanced physician engagement [104,110].

Support groups can also focus on a theme. For example, residents rotating through a medical intensive care unit developed "grief rounds" as a way to discuss their feelings and other issues related to the deaths of patients they cared for [111]. When asked to assess the program, 77% of respondents agreed or strongly agreed that the rounds enhanced their intensive care unit experience. Further study is planned to determine if the grief rounds are associated with a decrease in burnout.

Pursue Professional Passions

Administrative burden and heavy patient loads often reduce the amount of time physicians have to pursue their professional passions, but time to participate in specific clinical or research interests is essential to having meaningful work, which in turn is paramount to physicians' satisfaction [20,92,112]. In the Medscape survey, lack of professional fulfillment was a leading cause of burnout [31]. Surgeons who focus on finding greater meaning in work have been less likely to become burned out, and other physicians have noted that maintaining passion for one's work is helpful in avoiding burnout [94,96].

Encourage Organizational Change

Physicians should work with leaders to effect organizational change that addresses issues associated with job dissatisfaction and burnout, such as excessive hours or workload, inefficiency, electronic burden, lack of physician autonomy, and inadequate resources for high-quality care and patient safety [20,112,113,114]. Physicians can become advocates for making these changes as well as other strategies, such as promoting part-time careers for physicians, providing protected time for physicians to pursue meaningful professional activities, offering programs that enhance physicians' resiliency (such as mindfulness programs) and provide opportunities for physicians to interact with their colleagues, making physician satisfaction and well-being quality indicators, and emphasizing the importance of self-care [20,114,115]. It is vital that physicians are true partners with leaders in collaborating for such changes [112].

Physicians can become champions of a healthy work environment by developing or participating in a wellness committee. This committee should be composed of physicians, other healthcare professionals, and staff and should collaborate with the organization's leaders [108]. Some potential initiatives are opportunities for physicians to openly and honestly discuss medical errors, how to achieve well-being, and how to avoid stress [65]. A wellness committee can also work to ensure that tools are available to assess physician well-being and burnout and that the results generate resources to address physicians' needs.