Measuring and Managing Physician Burnout

Measuring and Managing Physician Burnout

Physician burnout is widely recognized as a challenge not only for physicians, their families, and their colleagues, but also for the US population that depends on access to engaged and effective healthcare providers. The World Health Organization recently defined burnout as 

A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 

1) Feelings of energy depletion or exhaustion.

2) Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job.

3) Reduced professional efficacy. 

Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.”  

Despite near-universal awareness, the problem is poorly quantified.

Measuring Burnout

Quantifying the prevalence and severity of burnout is inherently difficult. First, burnout is an internal experience that can only be described by the person suffering from it. Second, burnout is a continuum rather than a binary state.  

The Maslach Burnout Inventory (MBI) is the most commonly used measure of physician burnout. The MBI delineates burnout according to three components: emotional exhaustion, depersonalization, and reduced personal accomplishment. However, the cutoff criteria of what constitutes burnout and where to delineate low, medium, or high severity is subjective and varies widely in academic literature.

Other measurement tools have emerged to improve upon the MBI, whether by framing some of the questions negatively or by addressing the high cost of the MBI materials. Alternative approaches include the Copenhagen Burnout Inventory, Oldenberg Burnout Inventory, Patient Health Questionnaire-9 (PHQ-9), Stanford Professional Fulfillment Index, and the Well-Being Index.  

The vast array of diagnostic tools and cutoff points can be dizzying, but they all point to the same high-level conclusions:

#1 Burnout affects healthcare providers at higher rates than the overall population

In a 2014 study, approximately 54% of physicians reported at least 1 symptom of burnout, almost twice the rate of the general U.S. working population. Physicians explain that an heavy load of bureaucratic tasks and excessive work hours (especially take-home work) are the primary contributors to emotional exhaustion, depersonalization, and reduced job satisfaction.  After all, they “didn’t go to medical school in order to enter data in the EHR.”  

#2 Burnout affects primary care providers at higher rates than specialists

In an Archives of Internal Medicine article, researchers noted “substantial differences in burnout were observed by specialty, with the highest rates among physicians at the front line of care access (family medicine, general internal medicine, and emergency medicine).” Confirming this result year in and year out, the annual Medscape survey across 29 specialties consistently places Family Medicine and Internal Medicine in the top 5 for burnout and bottom 5 for happiest at work. 

#3 Burnout is reported at higher rates for women than men 

Among US physicians, women report burnout at 25% higher rates than men. Researchers note that women may be more likely to admit to psychological problems and seek help than men. Women also disproportionately assume childcare and family responsibilities, increasing the cost of challenges to work-life balance.

Healthcare executives must seek solutions to the root causes of burnout – excessive clerical tasks borne by the provider and the take-home work that results. Without a change, provider turnover will continue to climb and patient access will continue to erode.

What is Physician Burnout?

What is Physician Burnout?

Physician burnout has become a national epidemic with multiple studies proving that about half of all doctors suffer from at least one of the three common symptoms associated with this condition. Physician burnout negatively impacts quality of care, patient safety, physician and patient turnover rates, and patient satisfaction in addition to increasing the number of medical errors that have become common in the United States. According to a Mayo Clinic Proceedings study by Daniel Tawfik, MD, medical errors are responsible for 100,000 to 200,000 deaths each year. However, research connecting physician burnout to these errors is limited. 

Up until pretty recently, the most prevalent approach to reducing medical errors was to fix the workplace safety by adding in more checklists for physicians to complete and adding in “solutions” like yoga and breathing exercises for the physicians. Tawfik’s study shows that this is insufficient, comparable to placing a Bandaid over a large gash. Fixing these medical errors starts by addressing physician burnout, understanding what it is, how to identify it in yourself and your colleagues, and finding ways to prevent it. 

Defining Physician Burnout

An accurate comparison for physician burnout is that energy is like a bank account that can have a positive or negative balance. Every time a physician engages in the activities of their life and medical practice, he or she withdraws energy and the balance decreases. During times of rest and rebalance, energy is deposited, causing that balance to increase. The problem comes when it dips into a negative balance. The account doesn’t close; instead, energy is still spent (in this case working) despite the fact that the currency (energy) is, in fact, depleted. 

Burnout is a long-term stress reaction characterized by a series of symptoms we will later discuss that is a result of a constantly depleted energy account and with a negative balance over time. Yes, a physician can continue to function and work in this state but as only a shadow of the doctor that he or she is when the account has a positive balance. 

Signs & Symptoms of Physician Burnout

The industry-wide accepted standard for burnout diagnosis is the Maslach Burnout Inventory that was developed in the 1970s by Christina Maslach and her colleagues at the University of San Francisco. She described burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit, and will.” The three distinct symptoms most commonly associated with physician burnout:

Symptom #1: Physical and Emotional Exhaustion

The physician is feeling both physically and emotionally drained, depleted, worn out, and unable to recover during non-working hours. This is by far the most common symptom of burnout and is the one most physicians identify with when taking burnout prevalence surveys. A thought process that the physician suffering from physical and emotional exhaustion may identify with is, “I’m not sure how much longer I can go on like this.”

Symptom #2: Depersonalization

When physicians display this symptom, it often comes in the form of cynicism, a need to vent about their patients or their job, and a negative or callous attitude. Doctors in this stage are feeling so emotionally drained that they are not emotionally available for their patients or anyone for that matter. 

Symptom #3: Reduced Sense of Personal Accomplishment

In this stage of physician burnout, you may begin to doubt the meaning and quality of your work and see yourself as incompetent. A piece of internal dialogue commonly associated with this symptom is thinking, “What does it matter? My work doesn’t really serve a purpose anyway,” or even, “I’m afraid that if I don’t change something, someone is going to get hurt and it’ll be all my fault.”  

Effects on patients, practice, and physicians

Physician burnout affects all parties involved: the physician’s patients, the practice, the physician’s family, and, of course, the physician him/herself. Physician burnout is directly linked to a series of unsavory consequences that you definitely want to keep out of your practice:

  • Lower patient satisfaction due to poorer quality of care
  • Higher physician and staff turnover
  • Higher and more severe medical error rates and malpractice risks
  • Physician alcohol and drug abuse and addiction
  • Higher physician suicide rates

There is a higher risk of death by suicide for both female and male physicians relative to other professionals but goes widely underreported. 

Physician burnout fits with the old adage “death by 1,000 paper cuts.” It can happen slowly over time, each day and each task exacerbating the physician’s condition until it comes crashing down with a trigger like a lawsuit, a tragic circumstance in one’s personal life, a significantly damaging medical error, etc. If left untreated, physician burnout will only erode the mental health of doctors and threaten patient care. 

In Their Words: Always Fresh and Ready to Start the Day

As more and more practices adopt the TCM Model, we’ve begun a series of interviews with providers across the country to understand how their practices and their lives have been transformed.  In this edition we hear from Karl Sash, MD, Board Certified in Internal Medicine and Geriatric Medicine. He did his undergraduate work at the University of Regina, completing medical school in 1993 and an internal medicine residency in 1997 at University of Saskatchewan and a geriatrics fellowship at Duke in 1999. He is affiliated with St. Vincent Hospital Evansville (Indiana) and he adopted the TCM Model in 2017. What follows are his reflections.

Remembering his initial perception of the TCM Model

My first thought was – great concept. But then you wonder how do you take time from your busy practice for the execution? At the very base of it, there’s a cultural change required which includes educating patients as to why their exam room experience will be different. Plus changing protocols and routines related to the EHR. Then there’s staff training related to the new skills required, and in our case, some additional hiring. It’s an evolution that takes some time and energy, particularly with staff that weren’t originally hired for this kind of transformed exam room. But the benefits definitely outweigh the efforts.

Investing in teammates

Moving to the TCM Model focused on maximizing the roles of our medical assistants, specifically increasing their patient-related skills. Some were enthusiastic, others more hesitant, but it wasn’t long before it all started to gel. I would say that our MAs greatly prefer the team approach now and are very comfortable with their responsibilities. I would add that it’s important for the provider to show respect for what the Team Care Assistant is doing in the exam room.

Better patient care

I’m more focused on the patient now. There’s more direct interaction, more eye contact, and more opportunity for me to see the big picture. I am working 1.5 hours less per day, seeing 2 more patients per day (my goal was to cover the expense of the additional MA), seeing 20+ complex visits per day (almost all are legitimate 214s and a few 215s), all this while managing 500 nursing home residents with NPs and hospice. What’s happening is that an innovative approach is actually creating a more traditional feel. And it all translates to better care including increased screening rates. Outside the exam room, my quality of life is noticeably better. I’m getting more sleep and more exercise. I don’t feel beat up at the end of the day. The analogy that comes to mind is that if you’re in a hospital, do you want to be cared for by a provider at the beginning of his or her shift or during the last hour? With the TCM Model, I feel like I’m always at the beginning of a shift.

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