Physician wellness: how research is investigating burnout
Dr. Julia Keith, Neuropathologist and Director of Wellness, Laboratory Medicine and Molecular Diagnostics at Sunnybrook Health Sciences Centre and Associate Professor in LMP, discusses wellness for physicians.
What is burnout?
Burnout is classified in the International Classification of Diseases (ICD-11) as an occupational phenomenon resulting from chronic workplace stress.
Burnout is characterized by three dimensions:
- emotional exhaustion
- a low sense of personal accomplishment.
The psychological tool most commonly employed to measure burnout is the Maslach Burnout Inventory (MBI).
Burnout has many negative effects on physicians themselves (including an increased risk of depression, suicide, and substance abuse) and the quality of patient care that they provide (such as an increased risk of committing medical error).
There was a growing awareness of the scope and implications of physician burnout pre-COVID, and some organizations had already adjusted their institutional goals from the ‘triple aim’ of improved patient care, better patient outcomes, and lower costs to include the ‘quadruple aim’ of clinician well-being.
COVID has added a degree of urgency to addressing the physician burnout problem.
The opposite of burnout is a state of engagement; engagement is defined as having both a high level of energy/vigor towards and feeling dedicated to and absorbed in one’s work.
A different psychological tool, The Utrecht Work Engagement scale, is considered the gold standard way of measuring engagement.
There are many positive consequences of work engagement.
Job-related outcomes such as:
- better in-role and extra-role job performance
- commitment to an organization
- reduced intention to leave
Motivational outcomes such as:
- being proactive and taking initiative
- setting lofty goals and striving to meet them
- feeling friendly, helpful and cooperative in one’s workplace.
While physician burnout has been linked to medical error, I suspect that being in a state of work engagement not only fosters patient safety but also cultivates academic success.
How does a burned-out individual experience the creativity, goal-setting, perseverance and collaboration necessary for a thriving research career?
Engaged educators have been shown to have both higher teaching effectiveness scores and students who invest more energy in their own studying.
The emerging field of physician wellness research
The following four papers offer a glimpse into the emerging field of physician wellness scholarship.
1. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017
Much of the work trying to understand the prevalence of burnout among physicians has been done by Shanafelt’s group from Mayo.
They first surveyed all members of the American Medical Association in 2011 using the MBI, then repeated their study in 2014 and 2017.
- 5,000 – 7,000 responded to each survey, a response rate of around 7%
- 44% of American physicians had ‘at least one manifestation of burnout’ and that the prevalence of burnout was higher among physicians than non-physician workers.
- The burnout prevalence reported by Shanafelt et al is similar to other large American studies including the 42% prevalence reported by the Medscape National Physician Burnout and Suicide Report 2020.
2. The American Society for Clinical Pathology’s job satisfaction, well-being, and burnout survey of pathologists
The phenomena of burnout in the specialty of pathology has not been well studied.
40% of Shanafelt’s 150-180 pathologist respondents had at least one manifestation of burnout.
In 2018 the American Society for Clinical Pathology (ASCP) invited their members to complete an electronic burnout survey.
Garcia et al did not use the MBI to assess burnout but rather convened a steering committee who developed their own assessment tool ‘derived from existing instruments’, they employed a ‘snowball sampling’ technique.
- 408 pathologists responded from across the US.
- 71% of pathologists reported having felt burnout at some point, and those who were actively burned out were contemplating changing departments or careers.
- Increasing case volumes/workload was described as the top source of job stress and the top issue contributing to pathologist burnout. Fewer than 20% said they did not feel overwhelmed by their workload.
- Some of their findings regarding job satisfaction are also interesting; most pathologists were either ‘somewhat or very satisfied’ with their current job, over 90% ‘enjoy their work’, but only 56% felt ‘appreciated by their institution’.
3. Medscape US and International Physicians' COVID-19 Experience Report: Risk, Burnout, Loneliness
View a summary of the 2020 report on the Medscape website. You may need to set up a free account to access this report.
This work on physician and pathologist burnout prevalence all took place pre-COVID.
The impacts of COVID on physician health are ongoing and evolving, and the effects of the pandemic thus far on burnout of healthcare providers was recently reviewed (Sharifi et al). A growing body of literature shows the physician burnout situation is worsening.
The Medscape 2020 Physician COVID Experience survey:
- showed that 64% of their 7500 physician respondents felt that their symptoms of burnout had worsened during COVID (70% of females, 61% of males)
- shone a light on the adverse ways our personal relationships have been affected by the pandemic with 44% of physicians reporting their home relationships to be more stressed and 46% of physicians reporting feeling lonelier during COVID.
See the latest Medscape 2021 National Physician Burnout and Suicide Report, which describes how the pandemic has widened the burnout gender gap and worsened the burnout prevalence within some disciplines (including critical care and infectious disease). You may need to set up a free account to access this report.
4. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout
This paper is an excellent starting point for those wishing to prioritize physician wellness.
Workload is generally accepted to be the most significant driving force behind physician burnout, but other drivers have been identified and grouped into the seven different ‘burnout driver dimensions’:
- Workload and job demands
- Efficiency and resources
- Meaning in work
- Culture and values
- Control and flexibility
- Social support and community at work
- Work-life integration.
Shanafelt and Noseworthy argue that physician wellness is a shared responsibility between individual physicians and health care organizations, and that many wellness initiatives fail because they exclusively target the resilience of individual physicians.
Figure 3 of this paper beautifully demonstrates how each of the seven drivers of physician burnout is influenced by factors that operate at the level of:
- an individual
- their work-unit
- their healthcare organization, and
- their region.
This framework is very useful for identifying potential drivers of physician burnout around us and planning corresponding interventions.
Shanafelt and Noseworthy then propose nine organizational strategies that promote physician well-being:
- Acknowledge and assess the problem
- Harness the power of leadership
- Develop and implement targeted interventions
- Cultivate community at work
- Use rewards and incentives wisely
- Align values and strengthen culture
- Promote flexibility and work-life integration
- Provide resources to promote resilience and self-care
- Facilitate and fund organizational science
The Clinician Well-Being Knowledge Hub: Strategies for leaders, organizations, and individuals to promote clinician well-being from the Action Collaborative on Clinician Well-Being and Resilience.
The Physician Wellness Hub from the Canadian Medical Association
Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573–576.
Amanullah S, Shankar RR. The impact of COVID-19 on physician burnout globally; a review. Healthcare (Basel) 2020 22;8(4):421.
Sharifi M, Asadi-Pooya AA, Mousavi-Roknabadi RS. Burnout among Healthcare Providers of COVID-
19; a Systematic Review of Epidemiology and Recommendations. Arch Acad Emerg Med. 2021;9(1):e7.