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Physician Burnout: Recognizing The Warning Signs and Keys To Prevention

Statistically, physician burnout is likely impacting someone you know, quite possibly even yourself. The ramifications of this phenomenon can be devastating, life-altering and further reaching than one may initially think. With this in mind, the author discusses the causes, symptoms and consequences of physician burnout, and shares potential insights and solutions from the literature.

The term ‘burnout’ first appeared in a PubMed literature search with respect to physicians in 1981.1 A similar search on the topic of physician burnout in October 2019 yielded over related 400 articles in the past year alone. Multiple sources suggest that anywhere between 50 and 78 percent of doctors are currently experiencing symptoms of burnout.2-6 These statistics vary somewhat due to sample sizes, response rates and likely underreporting along with the method of assessment.6 It is clear when one evaluates the available data that there is a lack of standardization in the understanding of and approaches toward physician burnout.  

Nonetheless, physicians are becoming more and more disillusioned with the practice of medicine. What once was considered a sacred calling to some is now what over one-third of us would not recommend to a young family member.5 The consequences of physician burnout can be devastating to doctors, patients, family and the entire health care community. What is being done about this growing phenomenon? Only a quarter of physicians feel their associated facilities are effectively addressing the issue.5 What can we do to prevent burnout or recognize and intervene when it happens to us or to others?

Defining And Identifying Symptoms Of Physician Burnout 

Maslach’s triad is one of the most commonly employed definitions of burnout applied to the medical community.6,7 It is characterized by three cardinal symptoms: exhaustion, depersonalization and lack of efficacy.3,4,6-8 Wible defines burnout as a “job-related dysphoria without major psychopathy.”8

Symptoms related to physician burnout can vary wildly but may include anxiety, depression, headaches, sleep disturbances, hypertension, cardiac events, alcoholism or substance abuse.5 Those affected often suffer from a loss of meaning or joy in his or her work, cynicism, despair or a sense of reduced personal accomplishment.3,4,6,8

These symptoms can manifest in multiple ways, including poor self-care, recklessness, hopelessness, self-loathing, decreased empathy and self-defeating behaviors.8 It can be as innocuous as not taking time to eat properly, hydrate or rest when needed. Conversely, one can experience severe mental and physical health symptoms necessitating treatment. Many doctors will go into “survival mode,” just powering through day after day, but this is not sustainable long-term.7

Understanding The Causes And Contributing Factors To Physician Burnout

The exact causes of physician burnout are hotly debated in the literature. However, multiple factors are cited again and again. Most consider it to be a systematic issue within the health care system at-large.4 This can include economic forces, increased technological demands and increased clerical burden, including electronic medical records (EMR) and the ever-changing associated documentation requirements.4,6,8 Many doctors consider themselves to be data-entry clerks, insurance middle-people, health care literacy advocates, coders/billers and customer service associates in addition to being clinical providers.2 As a result, the current American health care system has been described as dysfunctional and toxic with respect to the practice of medicine.8

Burnout can be more prevalent depending on specialty, work hours, patient load and stage of one’s career.5,6 Physicians also cite decreased administrative and personal support, financial stressors and lack of autonomy or control in their practice.6

Less tangible causes of burnout are found within the culture of medicine itself. For generations, doctors in general have been taught to sacrifice of themselves for the betterment of their patients. While a noble quest for most, at the same time, physicians are systemwide not taught or encouraged to set boundaries in their professional lives.2 We take it all upon ourselves because we feel we must. It is culturally expected. If a physician does choose to delineate a boundary, such as limiting on-call hours or after-hours obligations, the affected institution or practice must have support measures in place to compensate. Often, this is not available or allowable.

Patient expectations may also play a role. In my experience and in those of physicians I have spoken with, some patients vehemently expect a specific positive outcome, many times in an unreasonably short time frame with minimal effort on their part. Despite logical thinking, the doctor is held responsible for that outcome, even if every decision and recommendation is within or above the standard of care. The doctor-patient relationship has deteriorated over the years, sometimes to the point of the doctor being mistreated, harassed or bullied. This can certainly contribute to disillusionment and burnout at the very least. 

Causes of burnout do not occur in a stepwise or algorithmic fashion, nor does burnout look or feel the same to every person. It can manifest slowly over time or a major traumatic trigger such as a personal tragedy or professional stressor can more acutely initiate the cascade.7

In a very complex landscape of causes, Drummond precisely summarizes five main causes of burnout.7 Although not all-encompassing, it does acknowledge the scope of issues contributing to this concern.

1. The practice of clinical medicine

2. One’s specific job

3. Having a life

4. Conditioning of medical education

5. Leadership skills of immediate supervisors 

Who Is The Physician Experiencing Burnout?

The answer to this question is simple but frightening. It is often the best among us. When researching the profile of a physician prone to burnout, authors have used such descriptors as hyper-responsible, highly dedicated, conscientious and motivated.2,4 These doctors often exhibit high levels of commitment to their profession, show attention to detail and recognize the impact of their professional obligations.4 These are usually terms one uses to describe an ideal physician and surgeon. 

Interestingly, various groups of physicians experience burnout in different ways. This is true of various age groups, races, ethnicities, genders and sexual orientations. There is very little information on the impact of or statistics on burnout in the medical LGBTQ+ community, for whom potential discrimination, harassment and/or isolation may play a role. There is also a need to further investigate the circumstances and approaches to burnout in other communities and groups of people.6

There is however some available data in regard to gender and burnout. Sources show that women physicians experience burnout 20 to 60 percent more than their male colleagues.6 Females are more likely to exhibit symptoms and report dissatisfaction with work-life integration. They are more likely to feel there isn’t enough time to see each patient and have less control over their workload or schedule.6 More than 70 percent of women report experiencing gender discrimination in the workplace, either from other health professionals or from patients.6 Women are more likely to face challenges related to being part of a dual-career couple, have finite years in which to consider childbearing and may face gendered expectations of behavior in their work.6 Males show a much lower likelihood of doubting the meaning or quality of their work, no matter the level of burnout.7 

“Impostor syndrome” can occur in either gender but is more prevalent in women.6 Janet Simon, DPM, a member of the APMA Public Health and Preventive Podiatric Medicine Committee, comments that “impostor syndrome” occurs when there is a perception of lower competence despite excellent evaluations. 

“This leads women to work harder, (which is) then rewarded by emotional and physical exhaustion, cynicism and depersonalization,” explains Dr. Simon, who is in private practice in Albuquerque, N.M.

Recognizing The Consequences Of Burnout

The ramifications of physician burnout are wide-reaching. Burnout has been associated with not only physical and psychological consequences for the physician and decreased satisfaction with one’s work, but there is documented lower patient satisfaction and potentially decreased quality of medical care provided.4,7 

Additionally, there is higher physician and staff turnover with many doctors relocating, exiting clinical practice, moving into administration or leaving medicine completely.2,7 In fact, a recent study found that almost 40 percent of women physicians go part-time or leave medicine completely within six years of completing residency.9 Additionally, a Physicians Foundation survey of 8,700 doctors revealed that almost 15 percent of physicians of any gender under the age of 45 planned either to find a non-clinical job or retire in the near future.10 

What The Research Reveals About Addiction, Mental Illness And Physician Suicide

Underreported, under-discussed and taboo in the medical world are the issues of drug and alcohol addiction, mental illness and suicide among physicians. Specifically related to burnout, these can be some of the most devastating consequences of this epidemic. Alarmingly, doctors have the highest rate of death by suicide of any profession, more than twice that of the general population.2,7,8 Despite a growing industry related to physician wellness, studies indicate the problem is getting worse and, indeed, burnout can be a “fatal disorder.”2,7

Physician suicides average about 400 per year in the United States but the number may even be higher due to underreporting.7,11 In other words, more than one physician dies by suicide every day. This has been attributed, at least in part, to the reluctance to seek help due to stigma, licensing or credentialing concerns, and a tendency to self-treat.6 Loneliness and isolation can be common in medicine, and depression and anxiety can be “normalized” (i.e. “Everyone in my class/residency/profession is depressed or anxious. It goes with the territory”).

Over 20 percent of interns reportedly have suicidal ideations.12 This is not limited to those in residency. In an effort to analyze factors associated with resident well-being, Patrick DeHeer, DPM, FACFAS has initiated an online study and is still at the data gathering stage. Residents can participate at https://www.surveymonkey.com/r/podiatricresidentwellbeing. 

“We need to look at our profession more closely,” relates Dr. DeHeer. “We want to publish the results and involve key stakeholders to provide resources for those in need. I think even more can be done. It is critical.” 

Dr. DeHeer shares the impact of his personal experience with this difficult issue. He knew two people who died by suicide, both doctors. 

“It is shocking when someone you know commits suicide and you are left with the eternal question: Could I have prevented this?” he says.

Stating that there can be warning signs not readily seen, Dr. Simon encourages practitioners to find and be a mentor to others.

“Don’t have blinders on and not recognize when others may be experiencing stress or problems. Take that step to verbalize your concerns via direct communications either in person or with a phone call or letter. Express concern and compassion in this intervention,” encourages Dr. Simon.

Burnout Or ‘Moral Injury’?

Now that we have examined the definitions, causes, symptoms and possible consequences of physician burnout, it is prudent to understand the debates surrounding this complex issue. Some object simply to the use of the word “burnout,” feeling it is a victim-blaming term, suggesting failure on the part of the doctor. Instead, many key opinion leaders in the field use the term “moral injury” to describe the circumstances surrounding the physician experience.2,8

Moral injury is a term (not a diagnosis) applied to combat veterans beginning in the late 1990s. It describes a normal human response to a single or series of abnormal traumatic event(s). The scenario(s) in question cause a forced betrayal of one’s deepest values, identity and morality.2 In other words, the innumerable roles a doctor must play on a daily basis often come in conflict with his or her primary moral goal: taking care of the patient.2

What Can The Health Care Community Do To Combat Burnout?

There needs to be a sweeping paradigm shift in the circumstances under which physicians work, from residency all the way through retirement. There is no clear, single way in which to defeat burnout but hopefully this sparks discussion on meaningful, measurable and validated options to try.

From a work-product standpoint, sources suggest that improvements in workflow, efficiency, teamwork and leadership are necessary.9 Reducing patient volume, introducing mandatory vacation time, looking at modifiable schedules and streamlining administrative processes would certainly help.2,6 However, this is challenging in the context of ever decreasing reimbursement. Physicians are expected to work harder at higher paces and volumes without associated increases in staffing to compensate. Our hands are being tied as far as how best to treat patients. Actions are necessary to foster a mutual respect not only for what revenue physicians generate but the knowledge, effort, care and time that they contribute to each case. 

Technologically, focus should be shifted to support systems and processes that improve efficiency. In so many ways, technology has made our everyday lives easier. This is not so in medicine but there is no reason why it shouldn’t or couldn’t be the case. Involve physicians in the development process and value their feedback.

Support and destigmatize mental health issues among physicians. If associations, hospitals and employers facilitated non-punitive access to psychiatric care, counseling, support groups and advocated for meaningful self-care, doctors may begin to realize there is no shame in seeking or accepting help.8 Physicians are faced with life-altering cases on a regular basis. Podiatry is no exception. Think of the limb salvage work we do. Think of the trauma cases, the patients with infectious diseases and the other complex cases we proudly take part in every day. We must not minimize the value of the work we do. In turn, we must not minimize the resultant stress, pressure and even trauma we may experience. 

Also, giving physicians authentic and actionable pathways to report mistreatment or dysfunction within the system is crucial. Allow physicians to negotiate with leaders and hold hospitals and health care entities to the same expectations of performance and support that the physicians strive to meet.8

The American Podiatric Medical Association does have resources for podiatrists regarding burnout. On their website (www.apma.org/wellbeing), there is a Mayo Clinic survey or “well-being index,” which allows users to assess current status in regard to their well-being and monitor it over time. There are also articles and resources on physician wellness, mostly geared toward individuals.13 

The APMA’s Physicians Recovery Network (PRN) is also a toll-free help line, offering peer consultation for physicians struggling with alcohol, mental health issues or physical impairments. It is free but does not provide or substitute for counseling, therapy or treatment. Although not privileged for legal purposes, importance is placed on confidentiality and anonymity. There are also resources connecting DPMs to recovery programs in each state.14

What Can Physicians Do To Combat Burnout?

We as physicians do have an important role in preventing, treating and dealing with burnout. We can participate in system-wide improvements for our own sake and that of our colleagues and successors. We can be open to technological changes and changes in the world of health care. Most of all, we can be open to accepting and offering help when necessary for ourselves or others. We must be an active part of the change in the culture of medicine. 

One way to cultivate this personally is the concept of physician resilience. Improving resiliency is a potential way for an individual physician to better deal with the stressors inherent to medical practice. Systemic support for such endeavors is still important but small, actionable adaptations may significantly help physicians to work smarter and recapture some of the joy in their practice.

In their book, The Thriving Physician, Simonds and Sotile provide comprehensive details on physician resilience.15 When asked about the most critical things physicians can do to build resilience, they cited the following actions:

• “Grant yourself permission for self-compassion and self-care. Health care providers self-sacrifice to the point of exhaustion and guilt.

Establish a group of trusted colleagues and regularly discuss/debrief various stressors. Focus on the responses to the stressors. Were they useful or damaging? Are there better ways? Remind each other what brought you into medicine. Risk being vulnerable enough to ask for support.

Harvest the uplifts. Doctors are problem-oriented but this can erode coping energies. Look for the good things: a grateful patient, a surprising outcome, an amusing anecdote and write it down. Reflect on it during the day or before going to sleep at night.”

Simonds and Sotile believe that health care institutions need to invest heavily in creating healthier work environments, but maintain that individuals should also take ownership of their own wellness. 

“A resilient physician will be able to see the big picture better and will definitely be better enabled to help others, and help (the) system move in the right direction,” note Simonds and Sotile.  

Final Thoughts 

I am that type-A doctor who chose to leave clinical practice after 12 years. For me, the intricacies of burnout are all too familiar. I do mourn the loss of the patient connection, the feeling of focus in the OR and think often about the positive experiences I had. I sincerely hope I made a difference along the way. I think what saddens me the most is that my experience is not rare. I know many docs who would choose the same path if they felt it was possible financially or logistically. This simply should not be. Something has to change.

Physician burnout is a multifaceted, complex issue with no clear-cut simple solution. My hope is to have shed some light on the topic and inspire our profession to talk openly and debate ways to support our fellow colleagues and ourselves. If we do not, we are destined to continue to lose good doctors to a broken system. 

Dr. Spector is a Fellow of the American College of Foot and Ankle Surgeons, and the current President of the American Association for Women Podiatrists. She is the Associate Editor for Podiatry Today and previously practiced in Pennsylvania and New Jersey.

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By Jennifer J. Spector, DPM, FACFAS, Associate Editor
References

1. Golin M. Physician burnout: when the healer is wounded. Am Med News. 1981;24(29):suppl 1-2. 

2. Talbot SG, Dean W. Beyond burnout: the real problem facing doctors is moral injury. Medical Economics. Available at: https://www.medicaleconomics.com/med-ec-blog/beyond-burnout-real-problem-facing-doctors-moral-injury . Published March 15, 2019. Accessed October 3, 2019.

3. Physician burnout: a global crisis. Lancet. 2019;394(10193):93. 

4. Malay DS. Feel the burn … out. J Foot Ankle Surg. 2019:58(5):821.

5. Walter K. New survey highlights growing physician burnout problem. MD Magazine. Available at: https://www.mdmag.com/medical-news/survey-physician-burnout-problem . Published August 6, 2019. Accessed October 3, 2019. 

6. Templeton K, Bernstein C, Sukhera J, et al. Gender-based differences in burnout: issues faced by women physicians. National Academy of Medicine. Available at: https://nam.edu/gender-based-differences-in-burnout-issues-faced-by-women-physicians/. Accessed October 9, 2019.

7. Drummond D. Physician burnout: its origin, symptoms and five main causes. Fam Pract Manag. 2015;22(5):42-47.

8. Wible P. Not “burnout,” not moral injury – human rights violations. Available at: https://www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rights-violations/ . Published March 18, 2019. Accessed October 3, 2019. 

9. Paturel A. Why women leave medicine. Available at: https://www.aamc.org/news-insights/why-women-leave-medicine . Published October 1, 2019. Accessed October 10, 2019.

10. 2018 survey of America’s physicians practice patterns and perspectives. Physicians Foundation. Available at: https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf. Published September 2018. Accessed October 10, 2019.

11. Wible P. 1103 doctor suicides and 13 reasons why. Available at: https://www.idealmedicalcare.org/1103-doctor-suicides-13-reasons-why/ . Accessed October 9, 2019.

12. ACGME and American Foundation for Suicide Prevention. 10 facts about physician suicide and mental health. Available at: https://www.acgme.org/Portals/0/PDFs/ten%20facts%20about%20physician%20suicide.pdf . Accessed October 16, 2019.

13. Self care leads to better patient care. American Podiatric Medical Association. Available at: www.apma.org/wellbeing. Accessed October 9, 2019. 

14. Physicians’ recovery network. American Podiatric Medical Association. Available at: https://www.apma.org/PracticingDPMs/content.cfm?ItemNumber=1071&navItemNumber=23960. Accessed October 9, 2019.

15. Simonds GR, Sotile WM. The Thriving Physician. Pensacola, Fla.: Studer Group; 2018.

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