GOING BENEATH THE SURFACE OF PHYSICIAN BURNOUT
Vol 4 #3
Ana Hategan, MD,* Associate Clinical Professor, Department of Psychiatry and Behavioural Neurosciences, Division of Geriatric Psychiatry, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
Caroline Giroux, MD, Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, at Davis, Sacramento, California, USA
Alan Eppel, MB, Professor, Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
* Corresponding author:
Ana Hategan, MD.
Keywords: physician burnout, physician burnout symptoms, physician burnout treatment, physician burnout prevention, physician engagement
The lives of physicians are multifaceted. The responsibilities carried by physicians have been changing over time depending on social and public health needs. Under chronic stress, the duty to care for a patient can transform into a burden that is added to pre-existing obligations of a physician. In the modern medical practice, having a sense of fulfillment and satisfaction appears like such a struggle for physicians. It seems that there is a setup for the modern physician to burn out and, despite openly debating this issue over the last two decades, the risk for physician burnout has remained remarkably high.
The adverse health outcomes of burnout among physicians are linked to a range of contributing factors, including intrinsic factors (e.g., personal characteristics) and extrinsic factors (e.g., increasing workload demands, duty hours, lack of autonomy, diminishing resources, financial pressures, the practice and training environment, poor work-life integration) [1, 2].
This article reviews the current trend of burnout in North America and some challenges faced by physicians, as well as how the mitigation of burnout should be possible not only through individual but mainly institutional measures. A systems diagnostic tool needs to be designed to help medical institutions discover the deeper supporting structures, such as the iceberg model, along with patterns of behaviour, and psychological models that truly underlie physician well-being. What is typically emphasized is only the tip of the iceberg or what is seen above the water in terms of the more visible forces that cause burnout. Knowledge about the bulk of the iceberg and the more invisible forces that trigger physician burnout is starting to be identified and may pertain to an unhealthy culture in a medical model appropriated by various influences (societal, political, and/or financial).
Building on the foundation from current research on physician burnout, we need to further explore those emerging, less visible forces that create the downward invisible pressure on the iceberg, so that a deeper analysis of the relationships between behavioural and occupational predictors of the psychological consequences (i.e., emotional/social/psychological well-being, burnout, depression, suicidal ideation) in physicians can be endeavoured.
- Let’s start with examining the physician health status in the modern North American medical profession
A 2018 survey by the Canadian Medical Association (CMA) (N = 34,517 subjects; 8.5% response rate, and considered a typical response rate for online surveys but sufficient to achieve statistical power) has shown that physician health is a growing concern within the medical profession .
The 2018 CMA National Physician Health Survey is the first in a series of reports on the current physician health status in Canada. Concerning was the finding that burnout among Canadian physicians was higher than the general population, with deleterious consequences on psychological health including depression and lifetime suicidal ideation . In this Canadian survey, despite the fact that 30% reported high levels of physician burnout and 34% screened positive for depression, 82% of physicians surprisingly reported high levels of resilience .
Possibly because there is a different medical and payer system that exacerbates the inner tensions of physicians seeking to provide ethical care, in the United States the situation is even more concerning. The 2018 Survey of America’s Physicians (N = 8,774 responders) has shown that most U.S. physicians (78%) experience feelings of burnout .
The presence of physician burnout has deleterious consequences, including the quality of medical care they provide (increased medical errors and malpractice rates, and lower patient satisfaction with medical care), decreased physician’s professionalism, and increased rates of physician substance abuse, suicide and physician turnover . Therefore, physician burnout is a serious matter.
- What about gender differences that may be associated with burnout?
Although burnout is a rising concern for both sexes, female physicians appear to be predominantly affected . In the 2018 CMA survey, significantly more female physicians reported burnout, depression, and lifetime suicidal ideation than their male counterparts. Despite the fact that most female physicians (88%) reported higher emotional well-being, they were more likely to report more burnout (1.23 higher odds, or 23% increase in odds), screen positive for depression (1.32 higher odds, or 32% increase in odds), and engage in suicidal ideation at some point during their life (1.31 higher odds, or 31% increase in odds) than their male counterparts .
The 2018 Survey of America’s Physicians has shown, yet again, that U.S. female physicians are more likely to express feelings of burnout than males (85% vs. 74%) . More interestingly, Canadian physicians in practice for 31 years or more reported the highest emotional, social and psychological well-being . Why would the younger cohorts of physicians be more at risk of decreased well-being? Up until recently, medicine has been a male-dominated field. Since some graduating classes are now predominantly female, and since more female physicians report burnout, one could wonder if the unchanged societal roles and expectations towards women (to be perfect at home and throughout a career) contribute, at least in part, to this discrepancy.
It would be interesting to explore whether more women are likely to have a physician spouse than their male counterparts. Female physicians whose spouse is also a physician might feel that they are the ones to try to do it all (also perhaps a remnant of patriarchal values). If so, this might at least partially explain the higher burnout rates in female physicians who may feel overwhelmed by the “double-shift”.
Other studies showed similar findings. In the Physician Work Life Study (N = 2,326 respondents; 32% females, adjusted response rate 52%), burnout was reported 1.6 times more often by female physicians compared with their male peers . This study reported that burnout among female physicians was typically caused by the inability to meet the demands of both work and home life, as well as a lack of workplace control. The added stress of being a mother with young children significantly increased burnout among female physicians . Since burnout is often a precursor to more serious psychological health problems including depression and suicide, a meta-analysis has shown that the suicide rate ratio among female physicians was more than double (2.2, 95% CI 1.9-2.7) than that of the general female population, and greater than their male peers (1.4, 95% CI 1.2-1.6) . Further studies addressing an association among physician suicide, burnout, and depression, particularly among women, are greatly needed.
Additionally, the 2018 Survey of America’s Physicians has revealed certain gender differences regarding work patterns that may contribute to burnout, such as female physicians spend 12% more time on paperwork per week than male physicians, female physicians are more likely to see Medicaid patients than male physicians (71% vs. 67%), but male physicians see 12% more patients per day than female physicians .
- Toward an understanding of the interaction between occupational and individual predictors of burnout
Physicians know what it feels like to be exhausted and depleted after long office hours, a night call in the hospital, or a difficult on-call weekend in the hospital. If physicians are able to recover their energy before they return to work, their resilience is still optimal. Recall the findings that 82% of Canadian physicians reported high resilience levels, suggesting that the issue may be broader than individual factors and extends to more systemic factors . If the perception by the majority of physicians is that they are highly resilient, what external forces get in the way of their true potential to create an imbalance leading to burnout?
Physician burnout begins when we are unable to recharge our batteries between call nights or work days in the office or hospital. Then, we begin a downward spiral that has three distinct symptom manifestations: (a) a sense of physical and emotional exhaustion (drained and depleted by work and unable to recover in non-working hours; which is the most common symptom of burnout); (b) depersonalization (a negative, cynical attitude toward patients and work-related concerns); and (c) a reduced sense of personal accomplishment (feelings of ineffective work achievement and perception of incompetence) .
Workplace characteristics that have been found to cause burnout include an overloaded work schedule, lack of control over work schedule, insufficient reward, and conflicting values . In a cross-sectional study among U.S. emergency physicians, the top ranked predictive factors for burnout were self-recognition of burnout, lack of job involvement, negative self-assessment of productivity, and career dissatisfaction . For example, many universal health care systems struggle with chronic shortages of specialists and long patient waiting lists that generally derive from underfunding and undersupply of staff and equipment, which overwhelm the practicing physician. By the same token, the U.S. healthcare system is fragmented, complex and the bureaucratic burden and administrative demands add pressure on physicians. Electronic health records (EHR) exacerbate the problem when the system is cumbersome and less user-friendly. In a large U.S. national study, physicians’ satisfaction with their EHR and computerized physician order entry (CPOE) was generally low . Physicians who used EHR and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout .
In the 2018 Survey of America’s Physicians, the two factors physicians disliked the most about medical practice were EHR and loss of clinical autonomy. In this survey, 80% had no time to see new patients or take on more duties . Remarkably, physicians spent almost one-quarter (23%) of their time on non-clinical paperwork .
Moreover, workplace sexual harassment adds to the discrimination experiences and burnout of physicians. In a 2014 survey of U.S. clinician-researchers (N = 1,066 respondents, 62% response rate), 30% of women reported having experienced sexual harassment compared with 4% of men . Among women reporting harassment, 47% (95% CI 39%-56%) stated that these experiences negatively affected their career advancement, and 59% (95% CI 50%-67%) perceived a negative effect on their confidence as professionals . Even in the current #MeToo era, reporting sexual harassment is taxing; women who report sexual harassment may experience retaliation, stigmatization, and marginalization , which can lead to chronic stress and burnout. Adding harassment by patients to that by peers and superiors, the problem in medicine, particularly for women, is especially concerning and the profession must work together to combat it .
There are multiple daily stresses that are hidden beneath the surface, which add up to the chronic stress among physicians. A partial list of these invisible stresses which make up the bulk of the iceberg’s submerged portion are illustrated in Figure 1.
- Who is there to help the physician prevent burnout?
Physician burnout can be viewed of as one extreme of a continuum with physician engagement on its other end (Figure 1). Therefore, in order to prevent burnout, physicians must be engaged. On a conscious or pre-conscious level, the forces between physician engagement and burnout are in relentless conflict with each other. While we focus on our daily reality of clinical practice, the medical environment is imbued with insidious and taxing stresses that incessantly pull us toward the physician burnout end of the continuum and thwart our experience of active engagement.
Let’s take a look at what makes an engaged physician. Some traits of an engaged physician are: high levels of resilience, high job involvement, enthusiasm in their work, sense of significance, full concentration, engrossment in their job, and ability to provide extra effort when necessary . Unfortunately, as physicians, we are not always engaged. Despite high levels of perceived resilience, we are still burning out. How is the average hardworking physician supposed to thrive in the modern healthcare system where physician burnout building blocks appear to be plenty and inescapable? If physician resilience is not the issue, then what else should healthcare organizations do to help physicians become even more engaged? Or, what barriers between physicians and their enthusiasm should be removed? In order for that to occur, organizations frankly must start listening to their physicians about what they believe the “system needs” are.
Figure 1 illustrates some of the organizational factors leading to burnout. Although most of these factors are familiar to physicians, they can operate invisibly and on a pre-conscious level. The physicians’ personal motivation to fight burnout is real, if the fight is fair. As one is quoted to have said, “It’s hard to fight when the fight isn’t fair .” If there is enough vigour in our medical leaders to counter those invisible forces, it remains to be seen. Particularly, are organizational changes required immediately? We believe the answer is, yes, because the statistics about burnout and its consequences are alarming and the physician casualties lost to suicide every year (an estimated rate of 300 to 400 physicians, or more than double that of general population) are disturbing . There is no better time to act than now to halt this public health crisis affecting not only the physicians’ preventable deaths but those patients and families who lost their physician.
In conclusion, the continuum between physician engagement and burnout is multidimensional and includes factors related not only to each physician as a personal characteristic but mostly the working environment. Recent evidence suggests that the modern physicians may be quite successful in maintaining high levels of well-being and resilience . And yet, a growing gap between societal expectations and professional reality creates the climate in which a significant proportion of physicians in North America experience symptoms of burnout [3, 4, 18].
Although physicians must actively engage in self-care, it is imperative for healthcare organizations to evaluate the balance between demands they place on physicians and the resources provided to sustain an engaged, productive, and satisfied physician workforce. Organizational leaders have a duty and responsibility to ensure that clinical teams are efficiently organized and have the resources necessary to provide optimal patient-centered care .
National efforts must be rallied to support physicians seeking help for physical and psychological health problems. Stress prophylaxis and intervention should be as commonplace as quality improvement initiatives and pursued in the same global manner.
Prevention of burnout is possible and requires specific measures such as flexibility in scheduling, recruiting more professionals to decrease workload, and involving physicians in the development of new, more user-friendly systems of EHR, to name a few. Education to increase awareness and reduce stigma associated with burnout-related symptoms, and improving access to services without affecting the physician’s licence status should be prioritized, and efforts to maintain proper self-care should always be supported by the institutions.
Workplace efforts to promote non-gendered settings and eliminate inappropriate behaviours and mitigate the effect of unconscious biases are needed. Further research on burnout in physicians, particularly among women, as a phenomenon and their associated preventive and intervention strategies are worth investigating simultaneously.
Conflict of Interest and Source of Funding:
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