By Peter Schnall, MD, MPH**
I first became aware of the issue of burnout as an epidemic among physicians a few years ago when I went to see my internist for my annual medical checkup. Knowing that I was a physician who worked as an occupational health researcher investigating work stress and health, my internist asked me about the latest news about burnout. We had a discussion about burnout before he inquired about my health or examining me. I learned quickly that my doctor knew more about physician burnout than I did, and he said it was being widely discussed among his colleagues.
In late 2017, I made an appointment with my orthopedist for evaluation for knee surgery. During my appointment, a woman entered the room with my doctor and sat down at the computer in the corner of the room. The doctor explained that this woman was a scribe, and it was her job to take detailed notes on the computer during his interactions with his patients. He told me that the medical center refused to pay for this service, but since completing an Electronic Health Record (EHR) was very time consuming — increasing his workload and interfering with his patient care, he decided to hire the assistant at his own expense.
Shortly after seeing my orthopedist, I completed my pre-surgery evaluation with a visit to my cardiologist. He volunteered that he was having difficulties with the administrators at his workplace and a new review board for patient complaints — over which he had little say. He described his general dissatisfaction with his practice at this workplace (and his experience of chronic fatigue), and shared with me that he was considering going into private practice.
These stories above are anecdotal and reflect my unusual relationship with my practitioners, as a physician and also as a professional researcher with expertise in the area of work-related health outcomes including mental health problems. My doctors were interested in my view that work was related to the issue of burnout, and they were curious as to what might be done either to prevent it or treat it.
I too had a personal experience with burnout many years ago when I was completing my last year as Chief Medical Resident at Lincoln Hospital in the South Bronx. I dragged myself through the last three months of my service, going home at the end of the day exhausted, dreading returning to work the next day, sleeping poorly and feeling with each passing day an increasing desire to get away from the workplace (and my patients and colleagues), and feeling that I was doing a poor job as Chief.
My own experience with burnout was more than a feeling. It touched on all three components of burnout syndrome (which Christina Maslach and Michael P. Leiter have done so much to identify and clarify): 1) emotional exhaustion, 2) depersonalization and cynicism toward one’s job and those one serves, and 3) feelings of reduced professional accomplishment.*
Is physician burnout now an epidemic?
The accounts about burnout from my practitioners are consistent with results from physician health surveys over the last decade, which report a steady increase in the prevalence of physicians reporting burnout as high as 50%. Women physicians actually report suffering from higher rates of burnout versus their male counterparts, perhaps due to the fact that they are more likely to be in family practice or in specialties which require seeing patients that demand more of them emotionally.
Typical surveys of professionals and other working people that ask about work-related symptoms usually ask about and only report if the respondent (i.e. the person answering the survey) is frequently “experiencing exhaustion at the end of the workday.” This self-report of exhaustion, which is very common in the American workforce, is not what researchers mean by “burnout.” Research needs to measure depersonalization/cynicism and professional efficacy among physicians, along with exhaustion, to get a more complete picture.
However, it is not only physicians experiencing exhaustion at work, but other professional “human service” occupations such as nurses, teachers, and social workers as well. On top of that, female professionals (in general) continue to shoulder more of the demanding burden of unpaid domestic work and child care compared to male professionals.
Work-related factors appear to be playing an important role in causing burnout symptoms. A recent survey of physicians reports a number of reasons why they believe work is contributing to burnout including:
Did you know? The equivalent of one doctor per day commits suicide in the United States — twice that of the general population and the highest suicide rate of any profession. While burnout doesn’t often lead to suicide, it’s a risk factor we should all be taking more seriously.
Physicians report that tighter work schedules contribute to a decline in the quality of the time spent with patients. The declining amount of time available for patients is partly due to the scheduling practices in large hospital/medical systems or HMOs, where physicians are increasingly employed, which prioritizes larger patient loads and applying lean production practices in hiring as few staff as possible.
New tasks, in particular the need to complete electronic health records, also take minutes from the time a doctor has for each patient. While EHRs are intended to improve the quality of medical care by providing consistent and easily transferable medical records to other practitioners, they unfortunately have turned out to be very time-consuming to keep. Both doctors and patients also complain that the typing at a computer needed to complete the EHR prevents eye contact and interferes with doctor-patient communication.
Can burnout be prevented?
So what can be done to prevent burnout among physicians? The classic diagnostic approach to finding solutions is to first identify the causes of a problem. In the case of physician burnout, we note that the surge in burnout parallels, and perhaps follows, significant changes in the nature of professional health care work. These changes over the past decades — greater patient loads, more demands on time and energy, less control over work processes, and many others — contribute to exhaustion, which when chronic leads to physicians beginning to doubt in their ability to do their jobs well. Increases in work-related demands are a key component of this process. Many of these new and increased demands are intended to increase productivity (and increase profitability), often under the guise of improving the quality of medical care.
If changes in the nature of work are an important contributing cause to the development of burnout, then the solution/treatment is to provide professionals with more resources to do their job and with more say about how they conduct their work.
With the rising prevalence of burnout among physicians, more voices are being raised within and by the AMA on ways to prevent or alleviate burnout. The proposed solutions include improved communications among doctors and co-workers, smoothing of workflow, shifting EHR responsibility to non-physicians. Articles in JAMA journals are beginning to discuss the role of work stressors such as excess demands coupled with lack of control (i.e. job strain) as well as other workplace stressors as contributing to burnout. There is also discussion of the need for reorganization of the workplace as a critical next step — in addition to focusing on ways doctors can better cope with stress on an individual basis. This is all a positive development.
If you’re looking for additional solutions to physician burnout, check out these ten recommendations, including four specific suggestions for changes to working conditions, made by Mark Linzer and colleagues in their article “10 Bold Steps to Prevent Burnout in General Internal Medicine.”
*Learn more: If you want to learn more about burnout and its costs to individuals and employers, check out our previous article, “The Cost of Burnout: Why We Need Healthy Work.”
**This article was commissioned as part of the Healthy Work Campaign. To learn more & obtain free resources, visit https://healthywork.org.
Dr. Peter Schnall is Co-Director of the Healthy Work Campaign, as well as the Founder and Director of the Center for Social Epidemiology, the nonprofit which established the campaign. An epidemiologist, Peter has studied the impact of working conditions on the development of hypertension among workers for over 30 years, as well promoting increasing awareness among students, colleagues and the public of the important role psychosocial work stressors play in the development of chronic mental and physical illnesses. He is also a Clinical Professor of Medicine at University of California, Irvine’s Center for Occupational and Environmental Medicine (COEH). (LinkedIn, Twitter)
We would like to acknowledge the contributions made to this article by our colleagues: