What is the price of physician stress and burnout?

Becoming a physician is a not just a career choice, it is “a calling” and a lifelong commitment.  Making life and death decisions, keeping patients and families satisfied and maintaining the highest professional standards can absolutely take its toll. Simply earning ones medical degree speaks of years of self-sacrifice and delayed gratification-life, put on-hold for academic and professional achievement. No one with insight into the discipline required of these professionals would begrudge them any of the status and respect they’ve earned.

Further reading: How to avoid the corrosive effects of physician burnout

Unfortunately, for many physicians, the professional rewards of status, security, and meaningful work are threatened by an avalanche of responsibility and stress characterizing today’s practice environment and further contributing to an escalating epidemic of physician stress and burnout.

Burnout Rates

Currently, rates of burnout among physicians are alarmingly high and are markedly higher than in the general population.  A report published in the Archives of Internal Medicine, which surveyed more than 7,000 physicians found that nearly half reported at least one symptom of burnout. ¹ Across physician specialties, burnout is most prevalent in physicians on “the front-line of care,” with those in the fields of emergency medicine, family medicine and general internal medicine being at greatest risk. ¹

Related: It's time to get doctors out of EHR data entry

Burnout is a clinical syndrome characterized by  loss of enthusiasm for work (emotional exhaustion),  feelings of cynicism (depersonalization), as well as   a low sense of personal accomplishment.  Additional symptoms include physical exhaustion, poor judgment, guilt, feelings of ineffectiveness, and a sense of detachment in relationships with coworkers and patients. ²

The Impacts of Severe Stress

If left unaddressed, burnout can result in dire consequences for the physician both personally and professionally. For the individual, burnout is not only a leading cause of job dissatisfaction but can contribute to failed relationships, substance abuse, and suicidal ideation. ²

Further reading: Young doctors are jumping ship to non-clinical roles

While the effects on the individual alone are concerning, the organizational and patient safety impact of burnout can be equally severe.  Research solidly correlates physician burnout with disruptive behavior, increased medical errors, lower patient satisfaction scores, and increased malpractice risk.² Additionally, burnout adversely impacts quality of care and patient outcomes. Lastly, research suggests when physicians are down and running low on empathy, their patients take longer to recover from illnesses and are less likely to adhere to treatment recommendations.^{3, 4}

The Sources of Burnout

Critics of the culture of medicine regard burnout as the inevitable byproduct of an educational system and profession that has long rewarded self-denial, perseverance and expert performance in the face of enormous pressure. Medicine is charged with perpetuating an unhealthy “myth of invulnerability”⁵ and a doctrine of survival of the fittest among its recruits. Anthony Montgomery, Organizational Psychologist and expert in physician burnout, further argues the educational system is largely responsible for perpetuating burnout by neglecting to cultivate an essential set of skills in its learners.  Montgomery explains that medical education is almost exclusively aimed at perfecting students clinical and technical abilities -- with little to no attention given to the development of the social, leadership and teamwork skills desperately needed to successfully interact with patients and colleagues. ⁶

Next: Obstacles to help and treatment

In addition to the longstanding cultural influences contributing to burnout, current changes in medicine resulting from health care reform have introduced workplace pressures that threaten to further destroy the health and morale of America’s doctors.  In the 2015 Medscape Physician Lifestyle Report physicians were asked to rank the causes of burnout in order of significance. Respondents cited:

1)    Too many bureaucratic tasks

2)     Too many hours at work

3)    Insufficient income

4)    Increasing computerization of practice

5)    The impact of the ACA as the most significant causes of burnout.⁷

Ann Whitehead, Vice President of Risk Management and Patient Safety for CAPAssurance, isn’t surprised. “Health care reform has dramatically changed the way medicine is delivered and we’re all in the process of transformation. Physicians are now asked and required to do much more to keep their practices going,” says Whitehead, “Whereas in the past, physicians would call us with basic risk management questions. It is now not uncommon to field calls with questions on a wide range of compliance and regulatory issues--MU2, ICD-10, HIPAA, EHR, reimbursement issues, tele-health, CDS, and many more. It is inevitable that this increase in responsibilities would detract from time spent with patients and career fulfillment.”

Related: Physician wellness is a quality indicator worth measuring

Obstacles to Help and Treatment

It is both sad and ironic that those most directly responsible for health and healing may most be in need of assistance. Unfortunately, seeking help doesn’t come easily for a group of professionals defined by self-sacrifice and perfectionism. The stigma associated with seeking help for mental illness-- as well as concerns about the potential professional and licensing repercussions from having a mental health history have made this group notably reluctant to reach out. ⁵ But asking for help is exactly what physicians must do. Statistics on physician suicide tragically illustrate the consequences of delayed treatment for depression and other mental health issues. Suicide among physicians is disproportionately higher than in the general population-with at least 400 physicians committing suicide each year (described as the equivalent of two to three graduating medical school classes each year).⁸ In a 2015 Time magazine expose “Life Support:  Inside the Movement to Save the Mental Health of America’s Doctors” Dr. Srijan Sen, considered the leading expert on physician depression, states that only 22% of interns who are depressed get help.⁸ Sen adds that those who are most predisposed to depression often possess the traits of sensitivity and empathy that we need in our physicians.

Next: Steps to correcting the issue

Steps to Correct this Issue

Although the root causes of physician burnout are multifold and improvement will likely require intensive and long-term systemic and cultural change, physicians need help. Organizations should consider anonymously surveying medical staff to evaluate physician burnout and soliciting ideas for workplace improvements leading to better work-life balance. Hospitals and medical groups can also promote wellness by offering resource information and staff education via their Physician Health & Wellbeing Committees-whose charter it is to assist physicians with matters related to prevention of impairment and maintenance of health with special attention given to behavioral issues, substance abuse, addiction, mental illness.⁹

Stanford University, known for their progressive approach to burnout prevention, has developed an elaborate and neatly organized on-line resource library for their physicians–WELLMD, which offers health and lifestyle assessments, classes and other information to support wellness and address a myriad mental health needs among physician staff including information on crisis support, coping with grief and loss, concerns about a colleague and information on physician peer support programs. Spreading awareness, educating staff and providing resources is an ideal place to begin.

Author Catherine Miller, RN, JD, is a Senior Risk Management & Patient Safety Specialist at the Cooperative of American Physicians, Inc. (CAP)in its CAPAssurance, A Risk Purchasing Group, program that offers hospitals, large medical groups, and other health care facilities access to top-rated liability protection and risk management services.

References

1.     Shanafelt, T. Boone, S., Litjen, T., Dyrbye, L., Sotile, W., Satele, D., West, C., Sloan, J., Oreskovich, M.      (2012). Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population.  Archives of Internal Medicine. 172(18):1377-1385.

2.     Balch, C., Freischlag, J., Shanafelt, T. (2009).  Stress and Burnout Among Surgeons- Understanding and Managing the Syndrome and Avoiding the Adverse Consequences. Archives of Surgery. 144(4):371-376. 

3.     Rakel, D., Barrett, B., Zhang, Z., Hoeft, T., Chewning, B., Marchand, L., Schneder, J., (2011).  Perception of Empathy in the Therapeutic Encounter:  Effects on the Common Cold.  Patient Education and Counseling Dec; 85(3):390-7.

4.     Eel Canale, S., DZ, L., Maio, V., Wang, X., Rossi, G., Hojat, M., Gonnella, JS. (2012) The Relationship Between Physician Empathy and Disease Complications:  An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy.  Acad Med. 2012 Sep; 87(9): 1243-9.

5.     Andrew, L., Brenner, Barry  (2015). Physician Suicide.  Medscape.  July 9, 2015.

6.     Montgomery , A. The Inevitability of Physician Burnout:  Implications for Interventions. (2014). Burnout Research. 1(2014)50-56.

7.     Peckham, C.  Physician Burnout:  It Just Keeps Getting Worse. Medscape. Jan. 26, 2015.

8.     Oaklander, M., (2015). Life Support:  Inside the Movement to Save the Mental Health of America’s Doctors. (2015) Time Magazine. Sept. 14. 44-50.

9.     CMA On-Call.  Guidelines for Physician Well-Being Committees Policies and Procedures. (2013) Document #5177