Up in Smoke: The Challenges of Physician Burnout

The days are long, the nights short – unless you’re on call or night float, in which case that is reversed. Regardless of where you are in your training, whether in medical school or already out of residency, there will be days when it all just feels like too much. Too much work, too much emotional energy expended, too much illness. Too many petty tasks or meaningless phone calls or purposeless turf wars. Hopefully, those times will be few and far between, buoyed by the days where you make a tricky diagnosis, have an appreciative patient, or just get out of the hospital with daylight left and go for a run. However, for a significant number of physicians, these despondent days stack one atop the next, stretching into weeks where they feel to exhausted to invest energy in their patients, let alone themselves. These individuals are likely suffering from burnout.

What is burnout? Although you, like me, probably have the sense about burnout that “I’ll know it when I see it,” technically burnout is considered to consist of three main components. The first is emotional exhaustion, that sense of feeling drained and depleted. Emotional exhaustion can appear as a helpless, trapped feeling, along with a loss of interest in work. The second feature is depersonalization, which refers to how one interacts with others. With depersonalization, we objectify our patients, distancing ourselves from them and from your colleagues as well. The final component is the feeling of a lack of personal success or achievement.
Burnout appears to plague physicians at higher rates than other US workers. In a study comparing physicians to the general population of workers, burnout rates over a one year period were 37.9% for physicians compared to 27.8% for the working population at large. Nearly half of all physicians who filled out the survey endorsed at least one symptom of burnout in the last 12 months. That means if you haven’t been experiencing symptoms of burnout, the person sitting next to you in the work room likely has. Interestingly, at least in this study, the two populations did not vary in terms of depression, which the authors argue in their paper, suggests that “the higher distress among physicians was limited to professional burnout” (Shanafelt et al. 2012).
Rates of burnout vary significantly by specialty, from 30% to 65%, not surprising for any medical student who has experienced the cultural differences between different specialties. However things don’t necessarily fall out where one might expect. One study found that, when they controlled for a number of factors including call schedule and hours worked per week, rates of burnout were highest in emergency medicine, general internal medicine, family medicine, and radiology, while being relatively lower in dermatology. Level of burnout also varies across the lifespan of one’s career, but is pervasive throughout. Burnout is all too common in both medical students (28-45%) and residents (averaging 50% but varying from 27 to 75% by specialty). After completing formal training, things don’t necessarily get better. Those early in their career seem to experience significantly more depersonalization – feeling disconnected from and resentful of their patients – but this seems to decrease over time. They also experienced the lowest levels of career satisfaction. However, emotional exhaustion and overall burnout was greatest at midcareer.
Burnout effects more than the physician who is suffering. When asked, physicians experiencing burnout were more likely to report suboptimal patient care, although other studies have failed to show a correlation between burnout and medical error. Burnout is associated with decreased productivity and burnt out physicians are also more likely to consider switching to a non-clinical career or retiring early. This affects the entire healthcare system when one considers the shortage of doctors particularly in some of the fields with the highest rates of burnout – like general internal medicine and family medicine.
OK, so now what? Clearly physician burnout is a problem and fortunately it is slowly garnishing greater attention in both popular culture and within the healthcare system itself. There is, however, a dearth of actual data on what to do about it, both how to prevent burnout and how to deal with burnout when it strikes. Given its prevalence, there are calls for changes on the institutional level, with some arguing that burnout is the product of the system rather than the failure of the individual, which is how it can feel at the time. You likely went into this field to help people, and now you’re resenting your patients and feel you can’t do anything right – it’s hard not to take that personally. But maybe that’s the first step: recognizing that even the best, most empathic, talented physicians can fall prey to burnout. By removing some of the stigma, we can encourage a conversation around the problem. This in itself helps with burnout as studies have found that venting and laughing with colleagues decreases stress.
A few studies have looked at ways to combat burnout. One studied resident wellness behaviors in relation to burnout and found a number of things you know intuitively. Restful sleep, for example, was associated with lower burnout and greater life satisfaction. The authors remark, “Interestingly, only one fifth of the sample reports at least 5 days of restful sleep” (Lenhensohn et al. 2013).  Interestingly? Were these researchers ever residents themselves? Try more like one in seven – on my day off – and then, I still wake up at 5am thinking I’ve missed my alarm. Also no big surprise given all the research on the benefits of exercise, higher levels of physical activity were associated with lower rates of emotional exhaustion and depersonalization. On the flip side, even fairly minimal alcohol consumption was connected with higher levels of stress, depression, and burnout. Of course, all of this suffers from the chicken or the egg issue, as we recognize correlation does not equal causation. At least a few studies, including a randomized controlled trial, have shown more deliberate relaxation exercises such as meditation and mindfulness help to stave off burnout. Others studies tout the benefits of participating psychotherapy, creating a distinct separation between work and home (you mean forwarding all my pages to my cell phone and answering them even when I’m not on call might not be healthy?!), listening to music, getting regular massage, and spending time outdoors. All of this, though, takes time when we have none of it and some of the interventions – like mindfulness and meditation – require a certain amount of practice before you are likely to reap the benefits.
In her book, Burnout: The Cost of Caring, psychologist Christina Maslach says simply, ‘‘If all of the knowledge and advice about how to beat burnout could be summed up in one word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.’’ For myself, I will do what I can, when I can. Some days, when I have the luxury, I will make myself the priority – get enough sleep, eat well, exercise, laugh with friends. Others days, I will get by, my own needs somewhere in the background as patient care takes center stage. It is an imperfect balance, but one that I choose.
Megan Riddle, MD PhD, is a psychiatry resident at the University of Washington. She is a graduate of the Weill Cornell/Rockefeller/Sloan-Kettering Tri-Institutional MD-PhD Program. When not at work, she can often be found walking her dog on the trails near her home. Feel free to connect with her on linkedin.
Citations
Dewa, C. S., Loong, D., Bonato, S., Thanh, N. X., & Jacobs, P. (2014). How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res, 14, 325.
Dyrbye, L. N., Varkey, P., Boone, S. L., Satele, D. V., Sloan, J. A., & Shanafelt, T. D. (2013). Physician satisfaction and burnout at different career stages. Mayo Clin Proc, 88(12), 1358-1367.
Ishak, W. W., Lederer, S., Mandili, C., Nikravesh, R., Seligman, L., Vasa, M., . . . Bernstein, C. A. (2009). Burnout during residency training: a literature review. J Grad Med Educ, 1(2), 236-242.
Lebensohn, P., Dodds, S., Benn, R., Brooks, A. J., Birch, M., Cook, P., . . . Maizes, V. (2013). Resident wellness behaviors: relationship to stress, depression, and burnout. Fam Med, 45(8), 541-549.
Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., . . . Oreskovich, M. R. (2012). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med, 172(18), 1377-1385.