Introduction

This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.



The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine.



Thursday, August 30, 2012

Physician burnout: is there anything that we can do?

A recent post by Pauline Chen, MD on the New York Times Wellblog speaks about the nation-wide epidemic of physician burnout. She quotes a recent study published in the Archives of Internal Medicine by Shanafelt, et al (2) that measured the symptoms of burnout using a validated survey instrument (Maslach Burnout Inventory) (3). There were huge differences based on the specialty of the physicians. The highest rates of burnout were found in doctors at the front line of access to medical care: emergency medicine (OR 3.18), general internal medicine (OR 1.64), and family medicine (OR 1.41). These differences remained even after adjusting for age, sex, call schedule, relationship status, primary practice setting, hours worked per week, and years since graduation from medical school.  When compared to a probability-based sample of working adults in the US, physicians had a higher risk for emotional exhaustion (32.1% v. 23.5%), depersonalization (19.4% v. 15.0%), and overall burnout (37.9% v. 27.8%). Overall, 45.8% of physicians had at least one symptom of burnout.

Wow! That is scary! These are practicing physicians who are working themselves to a state of emotional and physical exhaustion. When physicians feel like this they are more likely to make mistakes and medical errors. So, bringing this back to medical education, is there evidence about burnout in learners? Well, a recent article in AcademicMedicine by Dyrbye, et al (4) addressed this question. The authors found that positive mental health had a protective effect on burnout.
In this study, 4,400 medical students from seven medical schools (Mayo College of Medicine; Uniformed Services University of the HealthSciences; University of Alabama School of Medicine; University of California,San Diego; University of Chicago Pritzker School of Medicine; University ofMinnesota Medical School; University of Washington School of Medicine) were surveyed. The students’ mental health was measured using a validated instrument that measures emotional, psychological, and social well-being. The symptoms of burnout were measured using the same Maslach Burnout Inventory that was used in the practicing physician survey.

What the authors found was not surprising: medical students also had high levels of burnout. 42.1% of the students had high scores in emotional exhaustion, 52.5% had a positive depression screen, and 17.4% reported suicidal ideation. When they asked about mental health, interestingly, most students were doing well. 53.1% were flourishing and 42.5% were moderately healthy, while only 4.3% were languishing. Students that were described as languishing reported a low frequency (“never” or “once or twice” in the past month) on more than one of the emotional well-being items and a low frequency on at least six of the signs of positive functioning.
48.2% of students who were languishing reported suicidal thoughts in the past 12 months compared to 25.1% who were moderately mentally healthy (p< 0.001). The scary part was that those who were flourishing still had a 9% rate of suicidal ideation. Students who were languishing were more likely to cheat, more likely to display other dishonest behaviors, less likely to endorse altruistic beliefs, and less likely to care for medically underserved patients.

This is scary stuff! It suggests that a lower, more negative mental attitude in a medical student is correlated with not only their personal feelings about themselves (ie: suicidal ideation) but also how they act within the professional environment (dishonesty and cheating). It may be that if we could identify those students who are languishing, we could intervene to help them improve their mental health. Interventions could impact their professional behavior and quite possibly their performance in the academic realm of medical school. The question is: what are those interventions? More research will be needed to figure out what can be done and what works best.

References
(1) Chen PW. The Widespread Problem of Doctor Burnout.  New YorkTimes.  August 23, 2012
(2) Shanafelt TD, Boone S, Tan L, et al.  Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population.  Arch Intern Med. Published online August 20, 2012.
(3) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, Calif: Consulting Psychologists Press; 1996.
(4) Dyrbye LN, Harper W, Moutier C, et al.  A Multi-institutional Study Exploring the Impact of Positive Mental Health on Medical Students’ Professionalism in an Era of High Burnout. Academic Medicine  2012;87(8):1024-1031.

22 comments:

  1. The literature on burnout over the last 20 years is completely consistent with this study. Burnout starts in medical school.

    Out in private practice ... 1 in 3 doctors on average are suffering from symptomatic burnout on any given office day. These statistics are worldwide, regardless of the doctor's specialty OR the type of healthcare delivery system.

    The biggest cause is the conditioning of our healthcare educational system which effectively installs a survival mechanism in all doctors that has four key components.
    Workaholic
    Superhero
    Emotion Free
    Lone Ranger

    This is a key set of skills we all must use to survive training and NOT a great way to live a life.

    It is this programming that is primarily responsible for the epidemic of burnout we see in medicine. The additional post-graduation stresses of "the business of medicine", our complete lack of functional leadership skills and the uncertainties of political "reform" and the changing practice landscape - 75% of doctors are projected to be employees by 2013 - not to mention raising a family with this #800 gorilla of a career. It is a recipe for this dysfunction.

    Where do we go from here? It is a multifactorial answer. The doctors need the skills to lower stress and prevent burnout as individuals. That is why I created my website. We know what works to create a more resilient doctor and prevent burnout and it is rarely taught in the standard medical school and residency curriculum. And organizations bear a large responsibility because it is so darn easy to focus on the patient .... and not see that - in healthcare especially - the health and wellbeing of the provider has a direct impact on the quality and healing at the level of the patient.

    We have a moral, ethical and business imperative to support the wellness of the providers and not treat doctors like piece workers on a production line.

    These are immensely important topics that deserve more than a blog comment to do them justice. If you REALLY want to explore this issue in a way that has a chance to create meaningful change. Please contact me through my website.

    The doctors are the canary in the coal mine of modern healthcare ... unfortunately that same canary is the one coordinating the care of everyone in your system... and we cannot afford to let them drop.

    My two cents,

    Dike
    Dike Drummond MD
    TheHappyMD (dot) com

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