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.