• JAMA Research Challenges Perceptions of Physician Burnout

    October 08, 2018, 05:02 pm Michael Devitt – Ask five people what burnout means to them, and you're likely to get five different answers.

    burnout on tablet screen

    For some people, burnout can mean feeling physically and emotionally exhausted after a day at work. For others, it can mean that their job is repetitive or no longer interesting. Some people may feel ignored or that their work has no value, and others may simply think they're not getting paid what they should.

    Those perceptions are no different for physicians. For years, surveys have shown that many physicians feel overworked, stressed out and underappreciated. In particular, some surveys have shown that family physicians have higher burnout rates than many other clinicians.

    Three articles published in the Sept. 18 issue of JAMA shine a spotlight on the ways burnout is perceived in the medical profession. The findings provide a glimpse of how difficult it is to accurately measure this issue and show that, like beauty, burnout is in the eye of the beholder.

    Review Finds Little Consensus in Measuring, Defining Burnout

    The first article discusses a systematic review of 182 studies involving a total of 109,628 physicians in 45 countries.

    The authors initially planned to conduct a meta-analysis to provide a clearer picture of the prevalence of burnout in the medical profession and its effects on the typical physician. But in the course of their research, they uncovered significant differences in the methods used to classify and measure burnout.


    "There was substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods and study quality," the authors explained

    As a result, they chose instead simply to summarize their findings and point out differences in how burnout was measured from study to study.

    Across the studies examined, the prevalence of burnout among physicians ranged from 0 percent to 80.5 percent. The results were similar for burnout subcomponents emotional exhaustion (0 to 86.2 percent), depersonalization (0 to 89.9 percent) and low sense of personal accomplishment (0 to 87.1 percent).

    As for how burnout was measured, most studies used the Maslach Burnout Inventory (MBI), although the MBI version used varied significantly between studies. Several studies modified the MBI in some way, and others did not state which version of the MBI they used.

    Moreover, 14.3 percent of the studies assessed burnout using an instrument other than the MBI. Different studies also used different scoring systems and cutoff scores to determine burnout levels.

    Overall, the authors identified "at least 142 unique definitions for meeting overall burnout or burnout subscale criteria" on the different assessments. They also found "at least 58 unique ways of labeling individuals as experiencing burnout" based on the range of definitions and cutoff scores used. Even after limiting the review to only those studies that measured burnout based on the MBI, they found "at least 47 unique implementations" of MBI versions, cutoff scores or both.

    Given the lack of consensus, the review authors concluded that "a more consistent definition of burnout and improved assessment tools may be necessary" for health care organizations and other agencies to adequately address this issue. They also suggested five ways researchers can better study and measure burnout in the future, including

    • analyzing burnout as a continuous measure, rather than as a snapshot of how a physician feels at a particular point in time;
    • reporting multiple prevalence estimates using a range of cutoff scores instead of only one or two;
    • using tools other than the MBI;
    • using instruments that assess conditions such as depression, anxiety, substance abuse and medical illness in addition to hours worked and physician pay; and
    • strictly adhering to Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

    Resident Study Examines Burnout, Career Choice

    The second article reported on a prospective cohort study of more than 3,500 U.S. resident physicians, including 306 family medicine residents. After agreeing to participate in the study and completing a baseline questionnaire during their first year of medical school, participants completed two follow-up questionnaires: one during the fourth year of medical school and another during their second year of residency.

    The questionnaires asked participants how often they experienced feelings or emotions related to burnout and whether they had become more callous toward people since they started work. Residents also were asked whether they would choose to become a physician again and whether they would choose the same specialty again.

    Slightly more than 45 percent of residents reported at least one symptom of burnout at least weekly: 35.6 percent experienced symptoms of emotional exhaustion, 34.9 percent reported symptoms of depersonalization, and 25.3 percent of residents reported experiencing both symptoms.

    Urology residents reported the highest burnout prevalence at 63.8 percent. Family medicine residents reported the fourth-lowest prevalence (37.2 percent). Dermatology residents (29.6 percent) had the lowest prevalence.

    With regard to career choice, nearly one-third of pathology residents (32.7 percent) expressed regret about becoming a physician. Family medicine residents had the second-lowest prevalence of career choice regret (8.9 percent), behind only plastic surgery (7.4 percent).

    Residents specializing in general surgery had the highest prevalence of specialty choice regret (17.1 percent), and neurosurgery residents had the lowest at 0 percent. Five percent of family medicine residents reported that they regretted their specialty choice.

    The authors acknowledged their findings may not accurately represent the perceptions of all resident physicians because of sample size limitations. They also suggested that factors not measured in the study also could contribute to burnout and regretting one's career choice. Overall, they recommended more research to better understand and address these issues.

    Editorial Criticizes Medical Profession's Approach

    In an accompanying editorial, two family physicians -- Thomas Schwenk, M.D., of the University of Nevada, Reno, School of Medicine and Katherine Gold, M.D., M.S.W., M.S., of the University of Michigan Health System in Ann Arbor -- took issue with the medical profession's overall approach to burnout.

    Likening that approach to the hypothetical case of a patient who presents with intermittent wheezing and is immediately diagnosed with asthma, given lifestyle recommendations and prescribed drugs -- all without further evaluation -- they contended that, "The term burnout has taken on meaning far beyond what is understood about it as an actual diagnosis or even a syndrome.

    "The medical profession has taken a self-reported complaint of unhappiness and dissatisfaction and turned it into a call for action on what is claimed to be a national epidemic that purportedly affects half to two-thirds of practicing physicians."

    Although they acknowledged that, "There is clearly something important and worrisome happening to physician well-being," Schwenk and Gold stated that the medical profession could do a better job of understanding the causes of burnout, the processes behind it, the consequences for physicians and patients, and the best ways to prevent and treat it.

    "Physicians reporting burnout are receiving recommendations for treatments before there is any real understanding of the diagnosis," they wrote. "The profession has violated the very way it has taught, and been taught, to approach the care of patients. The profession can and should do better."

    Schwenk and Gold expanded on these points in separate e-mails to AAFP News.

    Regarding the systematic review's findings, "I actually was quite surprised by the huge number of measures and variations on a single measure and think it does a great disservice in trying to identify the stressors faced by physicians," Gold said.

    Schwenk, on the other hand, said he was not surprised by the variations and inconsistencies in the different studies. "It is one of my major concerns about so much of the research to date," he noted.

    Both authors stressed the need for the medical profession to reach consensus on how burnout is defined and to ensure that definition is recognized and used in future research.

    "I believe that we need to start over and define what we expect the normal experience of a satisfied physician to be in this day and age," said Gold. "Only when that is clear can we start to look at the different aspects of unhappiness, the symptoms, and identify contributors."

    "We need to start with some fundamental measures of physician dissatisfaction, misery or dysfunction that can be correlated with professional or personal function," Schwenk added.

    Both agreed that failing to achieve consensus in defining burnout would hamper efforts to address the issue.

    "It will make progress much more difficult," Schwenk observed, "because it will revert to a more muddled situation of a reservoir of ill-defined misery of unknown cause and a menu of random interventions, with a high likelihood of minimal benefit."

    AAFP Weighs In

    For its part, the AAFP has taken numerous steps to address professional burnout in recent years.

    In 2014, the AAFP published a position paper on family physician burnout, well-being and professional satisfaction. It was significantly revised and reapproved in 2017.

    Also in 2017, the AAFP signed on as an inaugural sponsor of the National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being, a network of more than 60 organizations committed to reversing trends in clinician burnout. Later that year, the AAFP launched its own Physician Health First® initiative to help members assess their personal and professional well-being and address the risk of burnout.

    Since then, the Academy has expanded its physician well-being offerings to include CME videos and a well-being planner, among others.

    The Academy will host several sessions on burnout and related topics during this year's Family Medicine Experience. And in June 2019, the AAFP will hold its second annual Physician Health and Well-being Conference in Phoenix.

    Clif Knight, M.D., the AAFP's senior vice president for education, has led many of the Academy's efforts to address physician burnout. He discusses the JAMA articles and more in this Q&A with AAFP News.

    Q: What are your thoughts on the systematic review?

    A: I think this was very well done and exposes a significant problem that limits the ability to compare from study to study if the measurement tool varies. I believe a blended measurement tool, like the Professional Fulfillment Index would be a great standard for all to adopt.

    Q: What did you think of the findings in the resident study with regard to family physician residents?

    A: It is very encouraging to see that there is a relatively low level of regret. This tells me the resident experience is being well supported in family medicine.

    Q: What were your thoughts on the editorial? Do the authors have a valid point about the medical profession's approach?

    A: I absolutely support the assertions in the editorial. An individual's level of burnout and professional satisfaction is unique to them. The approach for improvement needs to be personalized. The companion topic here is what needs to be done systemically, at the organization level, and within practices to improve the working environment for physicians. We also need to fundamentally change the way the medical profession views occupational stress, burnout and mental health. This needs to be de-stigmatized. A greater emphasis on self-care rather than self-sacrifice needs to be supported as a culture shift.

    Q: The AAFP has done a great deal to address these issues. What else can the AAFP do?

    A: Our involvement in the NAM Action Collaborative (and its Clinician Well-being Knowledge Hub) is critical to making system improvements. We are developing more resources to support practice improvement, including a new resource on team documentation that can make a big difference for many family physicians.

    We will continue to offer educational resources, such as at FMX and the AAFP Family Physician Health and Well-being Conference and in a recent FP Essentials monograph on physician well-being. We are also making decreasing administrative burden a top priority. We are doing much and will continue to focus on addressing the root causes of family physician dissatisfaction.

    Q: Any further thoughts on burnout and how it should be addressed?

    A: I believe that focusing on burnout rather than professional fulfillment is a distraction from making real progress. What good is decreasing the burnout rate if family physicians remain dissatisfied professionally? We need to focus on overall improvement rather than decreasing a negative measure.