The term "burnout" originated in the 1940s as a word to describe the point at which a jet or rocket engine stops operating [3]. The word was first applied to humans in the 1970s by the psychiatrist Herbert Freudenberger, who used the term to describe the status of overworked volunteers in free mental health clinics [4]. He compared the loss of idealism in these volunteers to a building—once a vital structure—that had burned out, and he defined burnout as the "progressive loss of idealism, energy, and purpose experienced by people in the helping professions as a result of the condition of their work" [5].

Maslach emphasizes that burnout is not a problem related to an individual [9]. Instead, her research indicates that burnout is a problem of the social environment in which people work and is a function of how people within that environment interact with one another and perform their jobs [9]. She notes that burnout is more likely when there is a "major mismatch between the nature of the job and the nature of the person who does the job" [9]. These mismatches are at the core of the development of burnout. The term burnout is now usually limited to mean burnout as described by Maslach: a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment [6].

In general, when an individual first enters a chosen career, he or she is motivated. If the work environment is not supportive of the individual's efforts and concerns, the reality of the job and the individual's expectations begin to diverge and frustration and disappointment arise [6]. These feelings can lead to job dissatisfaction, resulting in decreased productivity, loss of confidence and enthusiasm, and behavior changes. If the situation is not addressed, stress accumulates and causes typical stress-related symptoms. These physical symptoms, when coupled with emotional emptiness, signify the first stage of burnout: mental and physical exhaustion [8]. Left untreated, burnout will continue through four more stages: indifference, feelings of failure as a professional, feelings of failure as a person, and emotional numbness (being "dead inside") (Figure 1) [8].

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.

The use of tools to assess well-being or psychological status in conjunction with the full MBI can help professionals gain a better understanding of the sources of stress for individuals. The Mayo Clinic Physician Well-Being Index is often used in studies of burnout among physicians [24]. In addition, the General Health Questionnaire, developed by Goldberg, is designed to measure common mental health problems (domains of depression, anxiety, somatic symptoms, and social withdrawal) and was developed as a measure to identify individuals who are likely to have or be at risk for the development of psychiatric disorders [25].

Since the early 2000s, many studies and surveys have been done to assess burnout in physicians, and the rates have ranged from 27% to 63%, with rates of 50% to 78% among medical students and residents [28,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,123,124]. These rates are somewhat consistent with the findings of more recent surveys of physicians in all specialties. One of these surveys, a 2014 study of nearly 7,000 physicians, showed an overall rate of burnout of 54% [30]. Another survey, reported on in the 2015 Medscape Lifestyle Report, represents the findings from nearly 20,000 physicians; the overall burnout rate was 46% [31]. Because burnout can be assessed and reported differently in each survey, it can be useful to look at the change over time in each. The rates in both surveys are higher than those previously reported by both authors: from 46% in 2011 to 54% in the 2014 study, and from 40% in 2013 to 46% in the 2015 report [30,31]. These rates reflect a much higher rate of burnout among physicians compared with the general U.S. population, which was reported to be 28% in 2014 [30]. The 2021 Physicians Foundation and AMA/Mayo Clinic surveys reported burnout rates of 61% and 62.8%, respectively [123,124].

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].

The job-related factors contributing to burnout among physicians are similar to those in non-healthcare settings. The most commonly reported causes of stress, job dissatisfaction, and burnout—across career stages and specialties—are work overload, inadequate work-life balance, and lack of control over one's work, causes that are in line with the work environment factors described by Maslach [6,11,29,38,40,45,52]. In addition, physicians are challenged by many stressors unique to the practice of medicine, such as practice demands, evolving health policy, difficult or complex patients, and an inability to keep up with research (Table 5) [26,31,53]. Information technology has changed physicians' work environments, and this, too, is a factor contributing to burnout. Again, the importance of these causative factors varies across specialties.

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].

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].

Burnout and dissatisfaction with work-life balance have been reported to be the strongest predictors of intent to reduce clinical work hours or leave the current position [58]. In a 2019 study, it was found that burnout in the form of physician turnover and fewer available clinic hours resulted in costs of approximately $4.6 billion [122]. A systematic review provided evidence that burnout is associated with decreased productivity, defined as inability to work, increased number of sick days, and intent to leave practice or to change jobs [78]. Similarly, a review of physicians' administrative/payroll records showed that burnout scores correlated with reductions in professional effort (measured in full-time equivalent units) over the subsequent two years [79]. Specifically, the authors found that for each 1-point increase on the emotional exhaustion scale of the MBI, the likelihood of reducing work effort increased [79]. In one study, burned out physicians were significantly more likely than nonburned-out physicians to say that they intended to leave their practice within two years [29].

Studies have also addressed the effect of physician burnout on medical errors, quality of care, and patient satisfaction [118]. One of the first of these studies involved internal medicine residents who were surveyed with the MBI and asked to respond to five statements regarding suboptimal care (e.g., "I did not fully discuss treatment options or answer a patient's questions" or "I made…errors that were not due to a lack of knowledge or inexperience") [32]. Approximately 53% of burned out residents self-reported suboptimal care compared with 21% of nonburned-out residents. In multivariate analyses, burnout was strongly associated with self-report of suboptimal care at least monthly. The authors also evaluated each domain of burnout and found that only a high score on the depersonalization domain was associated with suboptimal care. An association between high burnout scores and self-reports of suboptimal care and of medical errors was also found in later studies involving residents [41,82]. In one of these studies, self-reported medical errors and scores for best practices (following principles identified as best practices in anesthesiology) were significantly associated with high risk of burnout among anesthesiology residents [41]. The median best practice score was significantly lower for residents at high risk of burnout than for residents at low risk. In addition, significantly more residents at high risk for both burnout and depression reported multiple medical errors within the previous year compared with residents at low risk (33% vs. 0.7%) [41].

Burnout was also associated with self-reports of suboptimal care in a study of emergency medicine physicians and residents. The authors completed a burnout evaluation and asked six questions to assess suboptimal care; physicians who had high burnout scores were more likely to report all six acts of suboptimal care [28]. In another study, reporting a major medical error during the last three months was significantly associated with burnout among surgeons [83]. The depersonalization domain had the most effect; for each 1-point increase in the score in this domain, there was an 11% increase in the likelihood of reporting an error, and for each 1-point increase in the score on the emotional exhaustion scale, there was a 5% increase in likelihood. In multivariate analysis that controlled for other personal and professional factors, burnout was an independent predictor of reporting a major medical error. In contrast to these findings, studies of family physicians and general internists have shown no consistent relationships between burnout, medical errors, and quality of care [29,54].

Although recognition of stress is important, physicians have been shown to inaccurately define their own well-being. Shanafelt et al. evaluated surgeons with the Mayo Clinic Physician Well-Being Index and then asked the surgeons to subjectively assess their well-being relative to other physicians [86]. Approximately 89% of the surgeons said that their well-being was at or above average, but 71% of the surgeons who scored in the bottom 30% on the Index relative to national physician norms had said their well-being was at or above average.

Many physicians do not seek help for stress or burnout because of the belief that these conditions are normal for the profession, an attitude that begins in medical school, with students being advised to push through stress [20,86]. This attitude leads physicians to believe that if they just work longer hours, the situation will resolve, but working longer hours only exacerbates stress and accelerates the burnout process. In addition, not dealing with stress appropriately may lead to factors associated with stress, such as alcohol abuse, depression, and suicide ideation. Despite the high rates of these conditions, studies have shown that 33% to 60% of medical students and physicians are reluctant to seek help [27,43,77]. The reasons for the reluctance are concerns about their medical license, discrimination in hospital privileges and professional advancement, perceived stigma, and an inability to take time off from work [27,43,45,87]. To help overcome these barriers, the Joint Commission issued guidelines mandating that medical staff "implement a process to identify and manage matters of individual health for licensed independent practitioners that is separate from actions taken for disciplinary purposes" [88].

The concept of self-care is emphasized in every book or article on preventing job stress and burnout across occupations. Self-care warrants particular emphasis for physicians, as they have been trained to put the care of others ahead of themselves and are not typically good at caring for themselves [89]. Self-care is essential for energizing, restoring, and maintaining the physical and emotional stamina to manage stress and helps increase job satisfaction [6,44,90].

The following strategies to prevent stress and burnout are recommended on the basis of studies of interventions as well as guidance from burnout experts and physicians who have successfully prevented stress and burnout. The strategies address changes in personal and professional lifestyle habits.

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].

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].

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].

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.