Physician burnout: Running on an empty tank

It is a freezing day, and glistening ice covers the bare trees, reflecting the early morning light. You should be enjoying this view as you drive into work. Instead, you are sitting in the car and staring at the icy pond where the local crew team practices.

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Over and over in your head, you may be thinking:
“I can’t do this anymore.”
“My patients just ramble on and on.”
“There is just not enough time, and my colleagues are so lazy.”
“What’s the point, I’m not a good doctor.”

If this sounds like you, don’t ignore the signs — you may be experiencing physician burnout. Similar to any problem, recovery usually starts with recognition.

Physician burnout is not a psychiatric disorder — the World Health Organisation (WHO) recognizes this as a syndrome. It is a measure of chronic distress associated with your job.

The three key components are:

• emotional exhaustion, leading to easily becoming irritable or downhearted
• replacement of usual empathy with cynicism, negativity, and feeling emotionally numb, which is called depersonalization
• a low sense of professional effectiveness

Medical school and clinical training are rigorous in ways that may be difficult for other professionals to comprehend. Looking after your health can easily slip to the bottom of the priorities list in the face of the daily challenges of patient care and admin.

Medicine is known for a culture of self-reliance and independence, and unfortunately, it is common for physicians to feel that they cannot show any signs of weakness.

In an interview study of 50 junior doctors about their work experiences, nearly half mentioned the unspoken rules they learned about expressing emotions and seeking help. One interviewee who treated doctors for stress said:

“There was a lot of stigma about people coming to seek help […] for a doctor in general to admit weakness, or if anybody, god forbid, even saw you there, people would talk.”

Burnout is bad for physicians, as proven by increased alcohol and drug misuse rates, not to mention suicide. Burnout is also bad for your patients because it is associated with lower quality of care, lower patient satisfaction, higher physician turnover rates, and increased chances of medical errors.

If you feel utterly exhausted and disconnected from your patients, perhaps even wondering if you still want to be a doctor, rest assured — you are not alone. Chances are your colleagues feel the same.

Find out how to spot the early signs of burnout and the symptoms you shouldn’t ignore. We also offer you strategies to counter the destructive stress that leads to burnout.

Is physician burnout an epidemic?

Physicians at all stages of education and training are at risk for burnout. A 2013 review found nine studies that show levels of burnout between 45–71% in medical students.

Burnout can also lead to depression. A comprehensive 2016 review looking at medical students from 47 countries found that 11.1% experienced depression during their studies. The prevalence of depression ranged between 7.4–24.2%, depending on how the research was conducted and how depression was measured. The study notes these figures were two to five times greater than the United States population of a similar age to medical students.

Sadly, a study has found that up to 15% of medical students reported suicidal ideation at some point during their medical education.

On average, 28.8% of residents report depression or symptoms of depression, with burnout symptoms affecting over 50%, reflecting the high demands of residency and fellowship training.

According to an article published in JAMA Internal Medicine, 25% of family physicians self-reported signs of burnout, based on a single question asking about emotional exhaustion. The data showed a strong correlation between work-related factors — such as stress, chaotic working environment, or time spent on documentation — and burnout.

A 2019 online survey of over 15,000 respondents used a different measure of burnout, which asked about the three elements: emotional exhaustion, depersonalization, and low personal accomplishment. Of these family physicians, 46% reported at least one burnout symptom.

Across all 29 medical specialties, the survey concludes that the overall rate of burnout in 2019 stood at 42%, which fell from 46% five years earlier. The annual survey’s strength is that it uses the same definition of burnout year on year to allow comparisons.

The five specialties with the greatest percentages of burnout were: urology, neurology, nephrology, diabetes and endocrinology, and family medicine.

What causes physician burnout?

Three factors contribute directly to physician burnout. Below, we detail the leading causes and advise on how to counter them.

1. Time

The practice of medicine in the U.S. today is mostly volume-driven. More patients per day and shorter visits have eroded the relationship between physician and patient. They can prevent physicians from providing the type of care they went to medical school to do.

Furthermore, unrealistic call schedules can impact a physician’s quality of life by allowing the workday to continue at home.

With the advent of electronic medical records (EMRs) and smartphones, physicians are accessible 24 hours per day, meaning the workday potentially never ends.

2. Administration

While EMRs allow effective communication between the medical team and a patient’s medical history at multiple locations, they can also be time-consuming and interfere with the precious few minutes that a patient and physician have together.

With the use of EMRs comes the added concern of patients having direct access to the physician through messaging via the EMR.

Rather than answering questions during office visits, patients also expect physicians to provide information outside of scheduled visits through these messaging systems.

3. Patients

Patient satisfaction scores are increasingly common in the U.S. medical system.

Physicians can easily be given a poor score for not giving a patient antibiotics — even if not indicated, not providing a controlled substance at the patient’s request, or for not ordering unnecessary laboratory tests.

Medical organizations also expect physicians to navigate situations where patients are drug-seeking, noncompliant, or even threatening.

Dr. Lotte N. Dyrbye, associate chair of staff satisfaction, faculty development, and diversity in the Department of Medicine at the Mayo Clinic, told Medical News Today, “between 2011 and 2014, the prevalence of burnout increased in U.S. physicians, even though work hours did not.”

She went on to say, however, “During this period, the prevalence of burnout among other U.S. workers did not increase. The drivers of burnout for physicians are factors within the practice environment.”

The early signs and symptoms of burnout

The Maslach Burnout Inventory takes into account three factors for physician burnout:

• Emotional exhaustion: A feeling of emotional and physical depletion.
• Depersonalization: Having a distant feeling toward patients that may lead to cynicism or sarcasm, also described as “compassion fatigue.”
• A low sense of personal accomplishment: A lack of efficacy, or doubting the quality or meaning of your work as a physician.

In addition to the organizational and cultural factors that increase the risk of burnout, there are individual character traits and behaviors associated with it:

• perfectionism and obsessing over negative outcomes
• being the “superhero” and having a misplaced level of responsibility for factors that are outside of your control
• micromanaging situations and feeling that you need to do everything yourself
• judging and self-labeling
• responding to problems by working harder

Some of these factors reflect traits that enable young people to take up medicine in the first place, such as a high degree of personal responsibility and hard work ethic. A recent review shows that organizational factors, such as work demands, the work environment, and work-life balance, are paramount in understanding and solving the problem.

Recognizing the signs and symptoms early on makes it easier to look for effective ways of preventing full-blown burnout.

Burnout intervention strategies

A systematic review and meta-analysis in The Lancet by Prof. Colin P West from the Division of General Internal Medicine and Division of Biomedical Statistics and Informatics at the Mayo Clinic and colleagues analyzed the outcomes of burnout intervention strategies.

The authors show that both individual-focused and organizational or structural interventions were associated with a significant burnout reduction.

1. Strategies at the individual level or self-care

Self-care means having a personalized strategy to look after yourself. It also means reflecting on the fact that life requires attention in multiple facets, including family, career, community, spirituality, and the inner self.

There are many strategies that promote self-care, including having hobbies, making time for family and friends, focusing on a healthy lifestyle with exercise and adequate sleep, and practicing mindfulness.

In an article in The New England Journal of Medicine, Dr. Adam B. Hill shared his take on self-care and recovery.

A palliative care physician and associate program director for pediatric residency training at the Indiana University School of Medicine in Indianapolis, Dr. Hill is no stranger to this topic.

As a former recovering alcoholic who has suffered suicidal tendencies, he uses “counseling, meditation and mindfulness exercises, exercise, deep breathing, support groups, and hot showers” in his self-care. He has also rearranged his own hierarchy of needs. “I learned that I must take care of myself before I can care for anyone else,” he wrote.

2. Burnout at the work level

Dr. Murphy, a physician who has recovered from burnout, highlights in his book that “you can’t be all things to all people.” Recognizing this starts with learning to say no and creating appropriate boundaries concerning your scheduling, patient volume, work week, and size of your patient panel.

Furthermore, it is important to clearly define your work-time and your off-time to your colleagues, employers, patients, and most importantly, yourself.

Likewise, there are several researched methods for improving the work environment for physicians.

Adding a “float pool” to cover for life events, allowing physicians some control over their schedule, decreasing patient panel sizes, adjusting staff ratios, and lengthening visits, can all reduce stress levels.

Flexible and part-time physicians tend to be more satisfied with their careers and are less likely to leave their positions.

3. Administrative or institutional level strategies

Including physician well-being and satisfaction as a quality metric can help shed light on burnout levels in an organization and show which intervention strategies are most impactful.

Research also shows positive effects if administrators allocate time for practicing clinicians to incorporate teamwork, mindfulness, sharing of workload through Patient-Centered Medical Home models, and coaching for challenging experiences.

Finally, adding charting slots throughout the day or increasing the length of visits to allow for charting time could decrease the burden associated with EMRs.

If organizations cannot address physician burnout at all three levels, it is clear that the U.S. healthcare system is steering headlong into a crisis.

Interventions are needed to address factors within the practice environment that contribute to burnout, rather than focusing primarily on individual strategies. That being said, all physicians have a responsibility for self-care.” – Dr. Lotte N. Dyrbye

She concludes, “Regularly assessing one’s level of well-being and taking intentional steps to maintain and improve one’s well-being is essential.”

Looking after your health and well-being, as well as finding a working environment that allows you to enjoy your work as a physician, are key to helping you avoid burnout.

For more practical tips, check out local American College of Physicians chapters, such as the New Mexico chapter and Stanford Medicine. Both offer resources to help with burnout, stress, and physician wellness.

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