Understanding Physician Burnout: A Longstanding, Nationwide Epidemic

Emily Lin for Health Empowerment Coalition

Day and night, from emergency rooms to outpatient clinics, clinicians caring for patients with COVID-19, often at the risk of their own safety. With many hospitals nearing or reaching full capacity and reeling from staff shortages, many physicians are experiencing high stress, contributing to burnout. This widespread phenomenon of physician burnout is not a novel occurrence. Rather, it has been a pressing issue long before the beginning of the pandemic. In fact, of the nearly 20,000 physicians surveyed in Medscape’s 2015 Physician Lifestyle Survey, nearly half (46%) reported feeling burned out.¹ Numerous other global studies spanning from the late 20th century to modern-day and involving nearly every medical and surgical specialty have also found a high rate of burnout among physicians, ranging from 30 to 60%.² Importantly, these high rates of burnout are harmful to the quality of patient care, place heavy financial burdens on the US healthcare system, and detrimentally impact physician health. With these severe and wide-ranging negative impacts, it is critical to understand the indicators and origin of physician burnout in the United States as well as develop interventions to reduce its prevalence.

What is burnout?

Burnout is a long-term stress reaction characterized by three key features: emotional exhaustion, depersonalization, and reduced personal accomplishment.³ Emotional exhaustion occurs when a physician has depleted his or her emotional energy and is unable to provide emotional support to his or her patients. Depersonalization involves viewing patients more as objects rather than people and treating them in a detached manner. Lastly, reduced personal accomplishment entails doubting the purpose, meaning, and quality of one’s work, such as the ability to competently solve a patient’s problems.³

Another way to conceptualize burnout is by having a negative balance in one’s “energy account”.⁴ Deposits to the energy account involve restorative, re-energizing activities, such as spending time with family or participating in hobbies. Conversely, withdrawals from the account involve work-related activities and personal responsibilities, such as housework or caretaking. A negative balance occurs when an individual expends more energy through work and personal responsibilities than they partake in restorative, rebalancing activities. This can occur for physicians who work excessive hours, work in a high-intensity specialty with frequent life-or-death decisions and poor patient outcomes, or experience difficulties in their personal life outside of work.

Why is it important to address physician burnout?

Addressing physician burnout is essential; untreated burnout negatively impacts patient care, the financial well-being and productivity of the US healthcare system, and the health of physicians themselves.

Numerous studies draw an association between physician burnout and lower quality patient care. Physician burnout is linked to a doubled risk of medical error and a 17% increased chance of being implicated in a medical malpractice suit.³ The overwork, stress, and fatigue accompanying burnout affect physician judgment, leading to more medication errors, patient misidentifications, or mistakes in diagnoses.⁵ Increased emotional exhaustion is also harmful to patients; greater emotional exhaustion among intensive care unit physicians is associated with higher standardized patient mortality rates.³ These relationships are likely explained by the impaired attention, memory, executive function, and emotional availability experienced by physicians who are burned out.⁶

Physician burnout also causes substantial financial and productivity losses to the US healthcare system. One study conducted from 2011 to 2013 found that increases in emotional exhaustion and reduction in job satisfaction were associated with a greater likelihood of less professional effort and work hours among physicians.³ As a result, physician burnout reduces physician productivity. At the extreme, burnout can lead to more physicians leaving their practices and corresponding national physician shortages. In fact, the Association of American Medical Colleges predicts a shortage of between 37,800 and 124,000 physicians by 2034.⁷ These losses in physician productivity and turnover, in addition to other effects of physician burnout, cost the US healthcare system billions.³ The high cost of replacing each physician as well as greater resource utilization, medical errors, absenteeism, and malpractice claims resulting from burnout was estimated by one study to be about $4.6 billion per year.¹²

Physician burnout also negatively impacts the health of physicians themselves. Physicians who are burned out are more likely to struggle with substance abuse, depression or suicidal ideation, poor self-care, and motor vehicle crashes.³'⁴

What are the causes of physician burnout?

Understanding the drivers of physician burnout is essential for developing effective interventions. The causes can be broadly grouped into two categories: originating from healthcare organizations and systems and originating from individual, physician-level factors.³

Excessive workloads piled on physicians from healthcare organizations can lead to long work hours, frequent overnight calls, and high work intensity (e.g., time pressure, chaotic environment), eventually driving physicians to burn out. Healthcare systems may also employ inefficient electronic health records (EHRs) that generate more frequent interruptions and increase physicians’ clerical burdens through unnecessary data entry.⁸ Such processes reduce the amount of face-to-face time with patients, enhance information overload, and ultimately cause burnout. In fact, computerized physician order entry is associated with 20% greater rates of physician burnout.³ Lastly, an authoritative administration that elicits little input from and offers little control to physicians over their work activities is another burnout driver. Physicians may feel as though they have no ability to alter undesirable work conditions, exacerbating feelings of emotional exhaustion and depersonalization.³

In addition, individual, physician-level attributes may also lead to burnout. Female physicians are more likely to experience burnout, a phenomenon that may be explained by gaps in career advancement, unequal pay, and greater expectations of commitment to family and child care compared to men.³'⁹ Female doctors also report less control over work activities than men and having more female and psychosocially complex patients, adding time pressure to their visits and contributing to burnout.⁹ Physicians’ family members also make a difference, with physicians having children younger than 21 years old or spouses that are also physicians boosting burnout risk.³'¹⁰ More substantial child care responsibilities as well as difficulty balancing home and work responsibilities, respectively, may account for these findings.

What interventions can address physician burnout?

The most effective interventions for addressing physician burnout are multipronged–tackling both organizational and individual-level drivers of burnout.

At the organizational level, to reduce physician workloads, hospitals and clinics can restrict resident hours, particularly on high-intensity rotations involving a fast pace, high patient acuity, and poor patient outcomes. To promote work-life balance as well as accommodate physicians with families, administrators can allow physicians to have more flexible schedules, such as shifts during varying times or the option for part-time employment.³'⁶ Healthcare systems can also take strides to make EHRs more user-friendly and a tool to increase efficiency by providing competent, responsive IT support, comprehensive EHR training to all its clinicians, and employing templates and automated documentation processes.¹¹ Departments may also consider delegating data entry and documentation duties to medical assistants or scribes to give physicians more time with patients.³'⁶ Lastly, healthcare systems may explore the Patient-Centered Medical Home approach to care, in which physicians have a reduced patient panel and increased care team staffing to ensure longer, higher-quality patient visits and care coordination.⁶

Interventions should also address individual, physician-level contributors to burnout. Physicians can participate in mindfulness and stress management training, whether offered through their workplace or sought out independently through community-level programs or apps such as Headspace. Enrollment in exercise programs as well as small group programs centered on facilitating community, connectedness, and meaning in clinical practice should also be promoted by physicians’ own clinics and hospitals or regional and national medical associations.³

These interventions will require significant time, effort, and resources as well as the buy-in of multiple healthcare stakeholders to implement. Interdisciplinary collaboration between hospital administrators, EHR companies, medical schools, and clinicians themselves, among others, is essential if we hope to make progress in solving the urgent issue of physician burnout in the US.

References:

1. Peckham, C. (2015, January 26). Medscape physician lifestyle report 2015. Medscape. https://www.medscape.com/slideshow/lifestyle-2015-overview-6006535

2. Shanafelt, T. D., Sloan, J. A., & Habermann, T. M. (2003). The well-being of physicians. The American Journal of Medicine, 114(6), 513–519. https://doi.org/10.1016/s0002-9343(03)00117-7

3. West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018). Physician burnout: Contributors, consequences and solutions. Journal of Internal Medicine, 283(6), 516–529. https://doi.org/10.1111/joim.12752

4. Drummond, D. (2015, October 1). Physician burnout: Its origin, symptoms, and five main causes. Family Practice Management. https://www.aafp.org/fpm/2015/0900/p42.html

5. Shanafelt, T. D., Balch, C. M., Bechamps, G., Russell, T., Dyrbye, L., Satele, D., Collicott, P., Novotny, P. J., Sloan, J., & Freischlag, J. (2010). Burnout and medical errors among American surgeons. Annals of Surgery, 251(6), 995–1000. https://doi.org/10.1097/sla.0b013e3181bfdab3

6. Agency for Healthcare Research and Quality. (2017, July). Physician burnout. AHRQ. https://www.ahrq.gov/prevention/clinician/ahrq-works/burnout/index.html

7. Heiser, S. (2021, June 11). AAMC report reinforces mounting physician shortage. AAMC. https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-physician-shortage

8. Shanafelt, T. D., Dyrbye, L. N., Sinsky, C., Hasan, O., Satele, D., Sloan, J., & West, C. P. (2016). Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clinic Proceedings, 91(7), 836–848. https://doi.org/10.1016/j.mayocp.2016.05.007

9. McMurray, J. E., Linzer, M., Konrad, T. R., Douglas, J., Shugerman, R., & Nelson, K. (2000). The work lives of women physicians. Journal of General Internal Medicine, 15(6), 372–380. https://doi.org/10.1111/j.1525-1497.2000.im9908009.x

10. Dyrbye, L. N., Shanafelt, T. D., Balch, C. M., Satele, D., & Freischlag, J. (2010). Physicians married or partnered to physicians: A comparative study in the American College of Surgeons. Journal of the American College of Surgeons, 211(5), 663–671. https://doi.org/10.1016/j.jamcollsurg.2010.03.032

11. Drummond, D. (2015, December 1). Eight ways to lower practice stress and get home sooner. Family Practice Management. https://www.aafp.org/fpm/2015/1100/p13.html

12. Hartzband, P., & Groopman, J. (2020). Physician burnout, interrupted. New England Journal of Medicine, 382(26), 2485–2487. https://doi.org/10.1056/nejmp2003149

Author: Emily Lin

Edited by: Joy Jarnagin, Darshana Banka, and Michelle Pan

The Health Empowerment Coalition is a student-led organization that aims to empower individuals across the United States to improve their health literacy and take charge of their health. The views expressed in this article are the authors’ own and do not reflect the official opinions of the institutions at which they work and study. Additionally, the content in this article is not intended to provide medical advice.