PHYSICIAN BURNOUT

1. PHYSICIAN BURNOUT Jeffrey B. Cole, MD, MACP CAPT (ret) MC USN Staff General Internist, USAF Hospital, Langley AFB, Virginia

2. DISCLOSURES • I have no conflicts of interest to divulge. • The views expressed in this presentation are those of the presenter and do not reflect the official policy or position of the Department of the Navy, Department of the Air Force, Department of Defense or the U. S. Government. • List of references for this presentation are available upon request.

3. OBJECTIVES • (1) Provide the definition of burnout, and explain how it differs from depression. • (2)Explain the scope of the problem, in terms of “physician distress” and “physician wellness.” • (3)Explain the evolution of physician burnout over time, through history and examples.

4. OBJECTIVES • (4) Describe the major causes of burnout. • (5) Describe the signs and symptoms of burnout. • (6) Describe the consequences of burnout. • (7) Describe the treatment of burnout, specifically through the promotion of wellness.

5. BACKGROUND • Definition of Burnout: Syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment that leads to decreased effectiveness at work (Shanfelt, et al, American Journal of Medicine, 115, 2003). • First described by Dr. Herbert Freudenberger (Psychologist) in 1974. • No DSM-IV code: closest is V62.4 – Acculturation problems. • No ICD-9 code: closest is V69.8 – Other problems related to lifestyle. • ICD-10 code: Z73.0 – Burn-out (state of vital exhaustion).

6. BACKGROUND • Differs from “global impairment of depression” since it primarily affects an individual’s relationship to one’s work. • Occurs most frequently in people whose work requires an intense involvement with people – physicians, nurses, social workers and teachers. • Effects at work can often spill over into one’s personal life. • Leads to friction in personal relationships and isolation from one’s significant other and/or family members.

7. SCOPE OF THE PROBLEM • Review of 115 years of medical literature in 2000 (Myers, American Psychology, 55, 2000) illustrated a clear dichotomy with regards to publications focused on “physician distress” versus “physician wellness.” • Depression: 70,000 articles. • Anxiety: 57,000 articles. • Life satisfaction: 5700 articles. • Happiness: 2958 articles. • Joy: 851 articles.

8. HISTORY AND EXAMPLES • As noted previously – first described and identified by Dr. Herbert Freudenberger in 1974, and featured in his 1980 textbook of the same name. • McCue (NEJM, 306, 1982): One of the first major articles in a major medical journal to address “effects of stress” on physicians. • Intrinsic stressors: suffering, fear, sexuality, death, problem patients, uncertainty. • Effects of stress: training demands, impairment, maladaptation, unhappiness. • Adaptations: emotional withdrawal, social isolation, denial, irony. • Coping: recognition – then coordination, cooperation, communication.

9. HISTORY AND EXAMPLES • Linn, et al (JAMA, 254, 1985): Health status, job satisfaction, job stress and life satisfaction between academic versus clinical faculty (UCLA). • No significant differences: job satisfaction, total stress, anxiety or depression. • Academic faculty: longer work hours, less vacation time, more time in research and teaching, less clinical time. • Academic faculty: more conflict between work and home, more time pressures, less financially secure.

10. HISTORY AND EXAMPLES • Smith, et al (JAMA, 255, 1986): Emotional impairment in Internal Medicine house staff – APDIM survey 1979-1984. • 55.5% of IM programs granted mental health-related leaves of absence. • 0.9% of IM residents were granted mental health-related leaves of absence. • Female rate = 2 x male rate. • Of those granted time off: 79% completed residency, 10% left medicine completely, 5% attempted suicide (40% of these – 2% total – were successful).

11. HISTORY AND EXAMPLES • Spickard, et al (JAMA, 288, 2002): Mid-career burnout in generalist physicians and specialist physicians. • Factors: child development factors (stability versus non-stability), work stressors, personality factors (compulsive triad = doubt, guilt, responsibility), family stressors, gender. • Prevention: personal – balance, self-care, spirituality, support structure, healthy outlook; work – mentor, meaning in work, setting limits, workload control, administrative support.

12. HISTORY AND EXAMPLES • Leigh, et al (Archives of Internal Medicine, 162, 2002): Physician career satisfaction – Family Medicine versus 31 other specialties. • More satisfied than Family Medicine (Top 5, starting with best): Geriatric Medicine, Neonatology, Dermatology, Infectious Diseases, Pediatrics. • Less satisfied than Family Medicine (Bottom 5, starting with worst): Gynecology, Pulmonary Medicine (includes Critical Care Medicine), Obstetrics, Otolaryngology/Head and Neck Surgery, Gastroenterology. • Family Medicine: #14 of 32 specialties. • Emergency Medicine: #16 of 32 specialties. • Psychiatry: #18 of 32 specialties. • Neurology: #20 of 32 specialties. • General Practice: #24 of 32 specialties. • Internal Medicine: #26 of 32 specialties.

13. HISTORY AND EXAMPLES • Shanafelt, et al (Annals of Internal Medicine, 136, 2002): Burnout and self-reported patient care in an Internal Medicine Residency Program (University of Washington). • Used the Maslach Burnout Inventory (Maslach and Jackson, Journal of Occupational Behaviour, 2, 1981) – 22 items, encompassing emotional exhaustion, depersonalization, and personal accomplishment. • 76% met criteria for burnout. • Burned out residents more likely than non-burned out residents to report monthly examples of suboptimal patient care. • High depersonalization scores correlated with reporting of suboptimal patient care practices. • No correlation – gender, depression, at-risk alcohol use.

14. HISTORY AND EXAMPLES • Thomas (JAMA, 292, 2004): Resident burnout. • 21 year review of medical literature (1983-2004): 15 articles identified –California, Massachusetts, Ohio, South Carolina, Washington, Belgium, Israel, Netherlands, New South Wales, Scotland, Switzerland, among other locations – multiple different specialty training programs. • Demographic factors: male > female, higher educational debt, suboptimal support structures. • Personality factors: avoidant, dependent, antisocial and passive-aggressive traits (less so – narcissistic, histrionic, compulsive and schizoid traits).

15. HISTORY AND EXAMPLES • Johns and Ossoff (The Laryngoscope, 115, 2005): Burnout in academic chairs of Otolaryngology/Head and Neck Surgery. • 120 US chairs – 6-part questionnaire: demographics, professional stressors, personal/professional life satisfaction, self-efficacy, spousal/significant other support, and MBI (Maslach Burnout Inventory) – 89% response rate. • Burnout rate: 4% – high, 80% – moderate, 16% – low. • Key correlations: low self-efficacy, low spousal/significant other support, disputes with college dean, budget deficits, working nights and weekends, Medicare audits, loss of key faculty, being a malpractice defendant.

16. HISTORY AND EXAMPLES • Gopal, et al (Archives of Internal Medicine, 165, 2005): Burnout and Internal Medicine resident work-hours restrictions (University of Colorado). • 139 residents: MBI (Maslach Burnout Inventory – emotional exhaustion, depersonalization, personal accomplishment) – 87% response rate. • Key findings – compared to prior year: • 9% decrease in work hours. • 13% decrease in high emotional exhaustion. • 10% decrease in depersonalization. • No change in personal accomplishment. • Additionally: fewer educational conferences, and overall decrease in residency satisfaction. • Not included in this survey – MBI of the residents’ staff attendings.

17. HISTORY AND EXAMPLES • Golub, et al (The Laryngoscope, 118, 2008): Burnout in Academic Faculty of Otolaryngology/Head and Neck Surgery. • 514 Society of University Otolaryngologists – 6-part questionnaire: demographics, professional stressors, personal/professional life satisfaction, self-efficacy, spousal support, and MBI (Maslach Burnout Inventory) – 68% response rate. • Burnout rate: 4% – high, 66% – moderate, 30% – low. • Highest burnout rate: women, associate professors (but not full professors), microvascular surgeons. • Key correlations: balance between professional and personal lives, low self-efficacy, inadequate research time, inadequate administrative time. • NOTE: Reported DOD (HA) plan to remove administrative FTE offsets.

18. HISTORY AND EXAMPLES • Shanafelt, et al (Archives of Internal Medicine, 169, 2009): Career fit and burnout among Internal Medicine academic faculty (Mayo Clinic). • 556 Internal Medicine faculty members – 4-part questionnaire: demographics, work characteristics, work satisfaction, and MBI (Maslach Burnout Inventory) – 84% response rate. • Burnout rate: 34% overall burnout rate. • Most satisfying work: clinical – 68%, research – 19%, education – 9%, administration – 4%. • Highest burnout rate: spending < 20% of one’s time doing the aspect of work that is most enjoyed.

19. HISTORY AND EXAMPLES • Shanafelt, et al (Annals of Surgery, 250, 2009): Burnout and career satisfaction among American Surgeons. • 24,922 American College of Surgeon (ACS) members – 5-part questionnaire: demographics, practice characteristics, career satisfaction, quality of life, and MBI (Maslach Burnout Inventory) – 32% response rate. • Burnout rate: 40% overall burnout rate – highest among Trauma Surgeons, Urologists, Otolaryngologists, Vascular Surgeons, General Surgeons. • Depression rate: 30% with positive symptoms of depression. • Key correlations: younger age, having children (NOTE: double effect for women), area of specialization, number of nights on call per week, hours worked per week, compensation determined on billing only. • Recommendation that a child pursue career in medicine: only 51%.

20. HISTORY AND EXAMPLES • Shanafelt, et al (Annals of Surgery, 251, 2010): Burnout and medical errors among American Surgeons. • 24,922 American College of Surgeon (ACS) members – 4-part questionnaire: self-assessment of medical errors, depression screening, quality of life, and MBI (Maslach Burnout Inventory) – 32% response rate. • 3-month error rate: 8.9% -- 70% attributed to individual, 30% attributed to system. • Level of depersonalization correlated with increase in reporting rate. • Level of emotional exhaustion correlated with increase in reporting rate. • No correlation with error reporting: frequency of overnight call, practice setting, method compensation, number of hours worked.

21. HISTORY AND EXAMPLES • Shanafelt, et al (Archives of Internal Medicine, 172, 2012): Burnout and satisfaction with work-life balance among US Physicians relative to General US population. • 27,276 American Medical Association (AMA) members – 4-part questionnaire: demographics, work-life balance satisfaction, symptoms of depression and suicidal ideation, and MBI (Maslach Burnout Inventory) – 27% response rate. • Burnout symptom rate: 46% of physicians reported at least one symptom of burnout. • Highest burnout rate: “frontline” specialties – Family Medicine, General Internal Medicine, Emergency Medicine. • Key points: physicians with 27% higher burnout rate than general population, higher burnout rate corresponding to higher levels of education.

22. HISTORY AND EXAMPLES • Drybye, et al (Mayo Clinic Proceedings, 88, 2013): Physician satisfaction and burnout at different career stages. • 27,276 American Medical Association (AMA) members – 6-part questionnaire: demographics, work characteristics, career satisfaction, career stage (0-10 years out of residency, 11-20 years, 21 or more years), home conflicts, and MBI (Maslach Burnout Inventory) – 26% response rate. • Early career (0-10 years out of residency) results: lowest satisfaction with career choice, highest frequency of at-home conflicts. • Middle career (11-20 years out of residency) results: worked more hours, took more overnight call, lowest satisfaction with specialty choice, highest rate of burnout.

23. HISTORY AND EXAMPLES • Peckham (Medscape, 28 March 2013): Physician burnout rate by specialty. • Top 5 (starting with highest): Emergency Medicine – 52%, Critical Care Medicine – 50%, Family Medicine – 44%, Obstetrics – 43%, Internal Medicine – 42%. • Bottom 5 (starting with lowest): Pathology – 32%, Psychiatry – 34%, Ophthalmology – 34%, Pediatrics – 34%, Rheumatology – 34%. • Koven (Boston Globe, 26 May 2014): Is burnout a real problem? – Yes, with the following concerns. • Loss of respect and autonomy. • Increased insurance demands and greater and more mandates. • Larger administrative burdens and greater outside influences.

24. HISTORY AND EXAMPLES • Rabin (Washington Post, 31 May 2014): Burnout among primary care physicians, with the following concerns. • Healthcare system inequities. • Affordable Care Act (ACA) administrative demands. • Insurance premium increases. • Overall missed opportunities. • Gunderman (The Atlantic, 17 July 2014): Origin of burnout – medical school. • Emotional exhaustion. • Depersonalization. • Diminished sense of self accomplishment.

25. CAUSES OF BURNOUT • Workload: face-to-face time, documentation time, administrative time. • Specialty choice: see Leigh (2002) and Peckham (2013). • Practice setting: rural/urban, academic/non-academic, inpatient/outpatient. • Patient characteristics: demand, entitlement, adherence, compliance. • Sleep deprivation: self-explanatory. • Personality type: see Thomas (2004).

26. CAUSES OF BURNOUT • Methods of dealing with death and suffering: oncology, critical care, palliative care. • Methods of dealing with medical mistakes: internal defenses, external support. • Malpractice suits: internal defenses, external support, nature of the complaint. • Problems with work-life balance: self-explanatory. • Lack of control over practice environment: admin support medical versus medical supports admin.

27. SIGNS AND SYMPTOMS OF BURNOUT • Depression. • Anxiety. • Substance abuse. • Broken relationships. • Disillusionment. • Denial. • Avoidance. • Lack of attention to detail. • Paralysis by analysis: failure to commit.

28. CONSEQUENCES OF BURNOUT • Absenteeism. • Physical manifestations of emotional dysfunction. • Turnover in personnel. • Cynicism. • Decreased job satisfaction. • Increased incidence of errors and near-misses. • Divorce. • Self-harm.

29. TREATMENT OF BURNOUT: PROMOTION OF WELLNESS • Individual promotion. • Relationships: ensure “protected” time for significant other and family members; collegial connections. • Spiritual practice: personal attentiveness and spiritual aspects of self. • Work attitudes: finding meaning in work; limiting work practice – control over schedule. • Self-care: cultivating personal interests and self-awareness; professional help when needed. • Life philosophy: positive outlook, identifying and acting on values, stressing work/home balance.

30. TREATMENT OF BURNOUT: PROMOTION OF WELLNESS • Organizational promotion. • Physician autonomy: ability to influence work environment and schedule control. • Adequate support services: nursing, secretarial, administrative, social work, ancillary services. • Collegial work environment: healthy relationships and common goals. • Value oriented: medical profession core values as part of the mission. • Minimizing work-home interference: flexibility in child care and scheduling. • Promoting work-life balance: ensuring vacation time and limiting overtime, establishing mentoring, considering periodic sabbaticals.

31. SUMMARY: KEY POINTS • Burnout “component triad.” • Emotional exhaustion. • Depersonalization. • Sense of low personal accomplishment. • The concern: crossover from “work” to “personal life.” • Overachievers underperforming. • Imbalanced response to adversity. • “Death spiral” – if not recognized, one turns more inward to work, avoiding personal life more.

32. SUMMARY: KEY POINTS • Common complaints: • Loss of control of one’s work environment. • Lack of administrative support. • Outside influences – competing demands. • Overall sense of futility. • Physicians in frontline medical specialties are at greatest risk, particularly in Internal Medicine. • All levels of experience are at risk – medical students, interns, residents, fellows, junior staff, senior staff. • Support systems (particularly non-work related) are key to preventing and combating burnout – you are not alone.

33. SUMMARY: KEY POINTS • One of the best defenses is a good offense – do what you like, like what you do. • Fight for balance in all you do, and strive for the following three things. • Meaning. • Purpose. • Worth. • Prevention of burnout is key; if not possible – • Recognition and treatment of burnout is necessary; if not done – • There will be consequences.

34. Questions/Comments