Identifying and Assessing Physician Burnout: Insights for Clinical Educators
3-4 Minute Read
Author: Becky Jayakumar, PharmD, BCIDP, BCPA
Purpose
To help clinical educators understand the impact of physician burnout on personal and professional outcomes and identify personal and organizational factors contributing to burnout.
Note: We will cover strategies to mitigate burnout for clinicians and students in a future edition of Preceptor.
Learning Objective
1. Define burnout and its relationship with mental health;
2. Identify risk factors and describe tools for assessing burnout; and
3. Summarize the current state of physician burnout.
Burnout, as a syndrome, is defined as the maladaptive response to chronic workplace stress. The term was originally coined by the psychologist Herbert Freudenberger in the 1970s to describe those who self-sacrificed while working in a helping profession. While the concept of burnout has been extrapolated to areas outside of the workplace, the definition remains focused on the workplace and job-related stresses. To that end, the ICD-11 included burnout in the chapter ‘factors influencing health status or contact with health services” and there are three components that encompass burnout:
Emotional Exhaustion: Feelings of energy depletion or exhaustion.
Depersonalization: Increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job.
Reduced professional efficacy.(1)
Risk Factors for Burnout
Burnout is considered a complex interaction of personal attributes and work-related stress that impact the overall well-being of an individual. The table below includes risk factors that have been reported in the literature.(2)
Assessing Burnout
There are several validated burnout and well-being inventories that can be utilized. A few of the burnout inventories include the Maslach Burnout Inventory, Oldenburg Burnout Inventory, Single Item Burnout Measure, and the Copenhagen Burnout Inventory. Each of these has varying number of questions and areas covered; however, the Maslach Burnout Inventory covers the three areas that are representative of the ICD-11 definition. (3) Lower physician wellbeing scores have been correlated with increased risk of medical errors. The instruments used in these studies included the Stanford Professional Fulfillment Index, Well-Being Index, and the Patient Health Questionnaire-9.(3)
There are several criticisms of the burnout inventories. First, the utilization of these inventories was intended only as a research measure that evaluates the environment. Hence, the inventories are not diagnostic of burnout, nor do they rule out burnout. Furthermore, there are multiple arbitrary cut-off points for low, medium, and high burnout, which have not been validated.(4) Additionally, there are strong correlations between burnout and mental health conditions.
The most evaluated of these is the correlation of emotional exhaustion and depression.(5) Due to the extensive overlap in symptoms, it has been proposed that burnout represents a phase in the development of a depressive disorder in reaction to unresolvable stress.(6) Similarly, burnout is a significant predictor of post-traumatic stress disorder (PTSD) and/or PTSD symptoms. Burnout and PTSD co-occur in 51.5% of individuals.(7-9) Furthermore, the Maslach burnout inventory is often interpreted incorrectly as it was intended to consider burnout only when there were negative scores in all three areas of emotional exhaustion, depersonalization, and professional efficacy. Years later, Maslach developed the five profiles of Maslach Burnout to address the confusion with utilization, which are depicted in table 2.
Maslach Burnout - Five Profiles
Physician Burnout
Burnout affects professionals across fields, but physicians experience significantly higher rates as compared to the general population.(10) Physician burnout often starts as early as medical school with a prevalence of approximately 50% (11,12) and a correlation with alcohol use disorder and dependence.(13)
For those who were not burned out during medical school, 75% develop burnout during their first year of internal medicine residency and burnout has a direct relationship with responsibility.(14,15) For early career clinicians burnout is often correlated with the burdens of student debt, (Mirza) and as expected, most medical residents stated the pandemic increased their level of burnout.(16) Most concerning, those who experience burnout during residency have a 3x increased risk of regretting their decision to become a physician.(17) Burnout does not diminish after training; in 2023, 53% of physicians reported burnout with the highest rates in emergency medicine and internal medicine.(18)
Clinical educators face unique challenges, balancing their duties as physicians with the added responsibility of teaching. The combination of heavy workloads, lack of adequate compensation for the added work of teaching, and the responsibility to teach students critical lessons in patient care makes burnout particularly prevalent among clinical educators. Nearly a third of medical school faculty report some degree of burnout with women faculty reporting higher rates.(19)
As a clinical educator, it is imperative to attend to both your own level of burnout and to that of your learners. Professional identity formation includes the development of self-awareness, coping skills, and help-seeking behaviors. (See From Trickle Up Professionalism Education to Professional Identity Formation).
Consequences of Burnout
Physician burnout has been associated with a number of professional and personal consequences including medical errors, impaired professionalism, reduced patient satisfaction, racial bias, blunted growth in medical knowledge, depression, suicidal ideation, motor vehicle crashes and near misses, and reduced hours or physician turnover associated with more than 4.6 billion dollars per year.(11)
The American Medical Association has developed a tool to help organizations quantify the financial impact of physician burnout. By inputting data such as the number of physicians and rates of turnover and burnout, organizations can calculate the economic cost of burnout particularized to their situation. This tool also helps determine the return on investment for implementing burnout reduction programs, making a clear case for the financial importance of addressing burnout.
In a future edition of Preceptor, we will share tools for dealing with the ubiquity of burnout in the clinical learning environment and how to help students navigate it.■
References
(1) World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. May 28, 2019. Accessed at September 25, 2024.
(2) Grover S, Adarsh H, Naskar C, & Varadharajan N. Physician Burnout: A Review. Journal of Mental Health and Human Behavior. 2008; 23(2):78-85.
(3) National Academy of Medicine. Valid and Reliable Survey Instruments to Measure Burnout, Well-Being, and Other Work-Related Dimensions.
(4) Morgan. BBC; 2021. https://www.bbc.com/worklife/article/20210426-why-we-may-be-measuring-burnout-all-wrong
(5) Bianchi R, Schonfeld IS, Verkuilen. A five-sample confirmatory analytic study of burnout-depression overlap. Journal of Clinical Psychology. 2020;76(4):801-821.
(6) Schonfeld IS, Bianchi R, & Palazzi S. What is the difference between depression and burnout? An ongoing debate. Rivista Dipsichiatria. 2018;53(4):218-219.
(7) Halperin O, Idilbi N, Robes D, Biderman SN, Malka-Zeevi H, & Green G. Predicting post-traumatic stress disorder: The complex relationship between burnout, intentions to leave, and emotional support among healthcare professionals. Nursing Outlook. 2024; 72(2):102134
(8) Klamen DL, Kopacz D, & Grossman LS. Posttraumatic Stress Disorder Symptoms in Resident Physician Related to their Internship. Acad Psychiatry. 1995; 19:142-149.
(9) Einav S, Shalev AY, Ofek H, Freedman S, Matot I, & Weiniger CF. Differences in psychological effects in hospital doctors with and without post-traumatic stress disorder. British Journal of Psychiatry. 2008;193(2):165-6.
(10) Shanefelt TD, West CP, Sinsky C, Trockel M, Tutty M, Satele DV, Carlasare LE, & Dyrbye LN. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. Mayo Clinic Proceedings. 2019; 94(9):1681-1694.
(11) Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Annuals of Internal Medicine. 2008;149(5):334-341.
(12) AAMC. 2023 Graduate Questionnaire. Accessed September 14, 2024. https://www.aamc.org/data-reports/students-residents/report/graduation-questionnaire-gq
(13) Jackson ER, Shanafelt TD, Hasan O, Satele DV, & Dyrbye LN. Burnout and alcohol abuse/dependence among U.S. Medical Students. Academic Medicine. 2016;91(9):1251-1256.
(14) Murphy B. PGY-2s see 27% higher rate of burnout than interns. Here’s why. American Medical Association. Accessed September 13, 2024.
(15) St-Pierre F, Petrosyan R, Gupta A, et al. Impact of the COVID-19 pandemic on internal medicine training in the United States: results from a national survey. BMC Health Services Research. 2023;23(1):1285.
(16) Dyrbye LN, Burke SE, Hardeman RR et al. Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians. JAMA. 2018;320(11):1114-1130.
(17) Kane L. ‘I Cry and No One Cares’: Medscape Physician Burnout & Depression 2023. Accessed September 13, 2024. https://www.medscape.com/slideshow/2023-lifestyle-burnout-6016058
(18) AAMC StandPoint™ Surveys: 2023 State of Medical School Faculty Engagement. Accessed September 13, 2024. https://cloud.email.aamc.org/2023SSReport.