Physician Burnout

Physician Burnout

Physician burnout is a psychological syndrome that is expressed by a prolonged response to chronic occupational stressors.  This can affect medical professionals at various stages of their medical education and training from medical students to practicing physicians.  Research suggests that over 50% of US physicians are experiencing burnout, including those in training.  Physician burnout peaked in 2021 during the coronavirus pandemic. Physician burnout is a condition that affects all specialties and practice settings including inpatient and outpatient.  However, there are specialties like obstetrics-gynecology, emergency medicine, and surgery have a higher incidence of burnout.  Physician burnout is not due to individual physicians but due to systems that physicians work in.

The signs of burnout include:

• Cynicism
• Depersonalization (lack of empathy)
• Low sense of accomplishment
• Emotional exhaustion
• Inadequacy
• Detachment

Over 40% of US physicians have experienced at least one symptom of burnout, and physician burnout remains one of the main issues facing health care system today.

These signs are due to the imbalance in terms of workload, personal values, incentive, justice, sense of community, and autonomy.  Factors include chaotic work environments and time constraints as well as lack of alignment between physicians and administrators and executives.

The four main factors known to contribute to stress and burnout include:

• Time pressure (especially in patient visits or documentation)
• Lack of control (autonomy)
• Chaotic, fast-paced work environments
• Organizational culture (especially that does not emphasize communication, cohesion, trust, and alignment of values between clinicians and leaders)

This causes frustration and feeling overwhelmed.  Many physicians who are burned out may feel there is a lack of control.  Physician burnout contributes to increased medical errors and reduced productivity.

The causes of physician burnout include the following factors:

• The changing overall health care landscape

The health care landscape continues to evolve.  According to American Association of Medical Colleges (AAMC), there will be a shortage of 124,000 physicians by 2034.  The physician shortage is attributed to less residency and fellowship spots being filled to train physicians as well as physicians leaving or retiring from medicine.  There are limits on Graduate Medical Education (GME) training slots, a result of a 1997 budget cap, have restricted the number of doctors who can complete residency and practice independently.  There is a geographic maldistribution.  A significant number of residents do not complete training in rural area, and fewer than 2% of Medicare-funded residency slots are in rural areas, despite a substantial portion of the elderly living there.  In addition to the physician shortage, there is a change from volume-based care to value-based care.  There is increase in the aging patient population making the demand for health care access more imperative.  The country is projected to need between 17,800 and 48,000 additional primary care physicians by 2037.  The patient population aged 65 and over is expected to grow significantly, doubling by 2039. This demographic shift will increase the demand for healthcare services, especially specialty care. Furthermore, a significant portion of the current physician workforce is nearing retirement age. More than one-quarter of physicians are over 60, and many are likely to retire in the next decade, requiring replacements.   There is a rural disparity in health care where rural areas are projected to have less physicians compared to metro areas, facing nearly a 60% shortage by 2037.   This leads to reduced access to care for patients and increased burnout due to increased workloads.

• Increased pressure from regulators and insurance payors

The changing health care landscape creates a situation where the federal and state regulators and insurance companies are demanding more accountability and increased health care quality at a reduced cost.

• Overall change in technology

There is a drive towards evolving from analog-legacy systems to digital systems fueled partially by the Mores law, which predicts that there will be a constant reduction in the memory capacity of computers due to increased cost for memory.  There are predictions that digital, physical, and biological technology will be combined in the future creating new opportunities and challenges.  It will help with global connectivity and data access, but physicians and health care professionals will have to adapt to changes quickly which is stressful and can increase burnout.

• Lack of an effective electronic health records system

The implementation of the electronic health record (HER) is associated with physician burnout due to lack of usability, demand for standardized documentation, and redundant documentation.  There is excessive need for data entry and lack of operability of these EHRs which cause physician workflows to be inefficient.

• Excessive administrative workload

Physicians are spending less time optimizing use of their medical education and experience in patient care and spending more time on administrative tasks like billing, compliance, and charting.  This increased administrative burden on physicians leads to emotional exhaustion and reduced job satisfaction.

• Longer, demanding work hours

Another major factor contributing to burnout is long, demanding work hours for physicians.  The average physician in the US works 51 works for 51 hours per week, and 25% of physicians work more than 60 hours weekly.   These schedules often include limited opportunities for rest, frequent on-call shifts, and the expectations to work weekends and evenings which encroaches into personal time and vacations.  This makes it difficult for physicians to maintain a healthy work-life balance leading to higher stress levels and emotional and physical exhaustion.

Physician burnout leads to increased incidence of mental health issues in the health care professional community including PTSD, anxiety, and depression.  There are asymmetrical rewards where physicians are rarely recognized for success and advances in health care with more attention centered on medical errors and medical malpractice.  Consequently, clinicians become desensitized to patients and medicine resulting in a perspective towards viewing patient care as a burden rather than a passion.

There are three stages to physician burnout.  The first stage consists of exhaustion at work that progresses to detachment and negative feelings at work that affect patients and coworkers in the second stage.  The third stage consists of feelings of inadequacy and failure; these mood and behavioral changes are defense mechanisms to the stressors.  To prevent progression through the stages of physician burnout, there is focus on reducing stressors and the imbalance of work demands and the strain of anxiety and exhaustion.  This ultimately leads to decreased quality of patient care and productivity as well as increased health care costs.  Physician burnout leads to more turnover, reduced recruitment and retention, and reduced morale.

To overcome and prevent physician burnout, establishing a wellness committee program is crucial.  The treatment and prevention of physician burnout involve an individual and organizational approach.  The individual physician-oriented approach includes cognitive behavioral therapy (CBT) such as mediation and coping strategies to professional coaching aimed at reinforcing individual resilience.  Due to the high incidence of physician burnout, physician coaching has emerged.  Physician coaching involves physicians guiding fellow physicians out of burnout.  The organization approach to treating and preventing burnout includes reducing workloads and more flexible schedules.  These surveys provide valuable information to the administrators to increase awareness and promote communication between physicians and administrators.  This can lead to an emphasis on compassion and well-being and promoting organizational changes quickly to reduce burnout.  This communication can lead to initiatives to reduce documentation or implement more effective EHRs. These conservations lead to a shift towards more alignment of the overall goals in the health care system between physicians and administrators.  There are regulations via Centers for Medicare and Medicaid Services (CMS) that introduced initiatives to reduce the unnecessary documentation on clinicians.

A wellness committee and program can be implemented to monitor and survey physicians about issues within the organization that contribute to burnout.  This wellness committee establishes that burnout and well-being as quality indicators for the organization like productivity, patient satisfaction, and quality metrics.  This committee is led by a chief wellness officer (CWO) who implements strategies to target the needs of physician well-being by improving patient satisfaction, better morale, higher quality of care, reduced medical errors, and improved recruitment and retention.  The wellness committee conducts a burnout survey using a validated assessment tool, and the results of the survey are shared with key stakeholders.  Then the committee meets with those key stakeholders to discuss results and build an intervention plan.  Finally, the committee measures the effects of the interventions and continues to improve.

There are many resources available to reduce physician burnout.  The AMA has a National Burnout Survey that can be used as an assessment tool.  There are other AMA programs that include Steps Forward and Joy in Medicine programs that help with implementing wellness programs and reducing or preventing burnout.  For administrators of a health care organization, there is a tool called Organizational Biopsy which analyzes the organizational issues that impact physician wellness.  This program is part of the larger AMA Health System Program.  The AMA has podcasts on Apple and Spotify as well as toolkits about physician burnout.  The AMA Journal of Ethics has articles about physician burnout, and the AMA education hub has a CME course on physician burnout and wellness.  These resources are available at www. ama-assn.org/practice-management/physician-health/what-physician-burnout.

Physician burnout is a serious issue that is impacting the US health care system.  It is a psychological reaction to exposure to chronic occupational stressors during any stage of medical education and training.   Research suggests that over 50% of US physicians are experiencing burnout, including those in training.  Physician burnout peaked in 2021 during the coronavirus pandemic. Physician burnout is a condition that affects all specialties and practice settings including inpatient and outpatient; however, some specialties like emergency medicine and obstetrics and gynecology have higher incidence of burnout.  The signs of burnout include cynicism, depersonalization (lack of empathy), emotional exhaustion, inadequacy, and detachment.  This can impact other co-workers and patients and lead to mental health issues like depression, anxiety, and PTSD.  Over 40% of US physicians have experienced one of these signs or symptoms of burnout during their career.  The burnout peaked during the coronavirus pandemic.  The factors that contribute to burnout include time, lack of autonomy, and inefficient workflows.  Implementing individual and organizational approaches to identifying and reducing burnout such as coaching and CBT and surveys to analyze wellness protocols.  Reducing physician burnout impacts organizational professional and patient satisfaction, financial well-being, morale, and productivity which improves quality of patient care at a lower cost.  There are numerous resources available to reduce and prevent burnout.