Dell Medical School’s Carrie Barron, MD, and David Ring, MD, PhD, collaborated with Associate Professor Matt McGlone, PhD, of UT Austin’s Moody College of Communication to author the following commentary.
On March 30, we celebrated National Doctor’s Day, the annual holiday recognizing the valuable services and support that physicians provide to individuals, families and communities. Just two days earlier, the American Medical Association (AMA) made a public plea for doctors to get some support of their own.
In the journal Health Affairs, Mayo Clinic CEO John Noseworthy, Cleveland Clinic President Delos Cosgrove and other participants in an AMA summit declared the high rate of physician burnout a “public health crisis” that demands urgent action from medical administrators. Burnout is a syndrome with symptoms that include emotional exhaustion, cynicism, diminished feelings of accomplishment and a tendency to view individuals as objects rather than people.
Although it can happen in any field, studies suggest doctors are more likely to experience burnout than professionals in other lines of work. A survey of 7,000 physicians recently published in the Archives of Internal Medicine found that more than half reported at least one symptom of burnout and about a quarter reported two or more. Across specialties, burnout is most prevalent in physicians on the front lines of care, with those in emergency, family and general internal medicine at greatest risk.
Why It Matters
The consequences threaten our entire health care system. Research correlates burnout with increased medical error, lower patient satisfaction and increased malpractice risk. Additionally, it adversely affects quality of care and patient outcomes. When physicians are running low on empathy, their patients take longer to recover from illness and are less likely to follow treatment recommendations.
Health care costs are affected by burnout directly — via physician turnover, early retirement and malpractice suits — and indirectly — disruptive behavior, unnecessary testing or referrals and higher patient readmission rates. All of this is in addition to the significant and sometimes tragic toll it exacts from the physicians themselves: burnout is not only the leading cause of job dissatisfaction among doctors, but also puts them at significantly increased risk for failed relationships, substance abuse and suicide.
Why It Happens
There are many causes of burnout, but some are easier to pinpoint than others. Obviously, dealing with distress, disease and death on a regular basis is a major contributor. Physicians are expected to cure patients and support their loved ones in the process. When a cure isn’t possible, they may be called upon to guide patients and families through a tumultuous transition of body, mind and spirit. Doing so requires compassion, courage, delicacy, empathy, patience and stamina. Doing so as a matter of routine is deeply draining.
Another factor is the unique challenge medical practice poses to work-life balance. Like many professionals, doctors are expected to put in long hours on the job. When they do impose time limits on their work activities, they risk not only compensation and career advancement, but also the possibility of putting off patients in need. As a result, doctors are more reluctant to restrict their working hours than professionals in other fields. But failing to set limits will eventually result in poor sleep patterns, interference with family activities and events and poor self-care. Ultimately, these deprivations will lead to burnout.
A third is the culture of medicine. Critics of this culture claim burnout is an inevitable outcome of a training and practice regime demanding perpetual self-sacrifice and precise performance from practitioners in the face of equally constant pressure. These demands encourage doctors to embrace a myth of invulnerability and project a steady, stoic demeanor. Consequently, many are unwilling to acknowledge a problem until their sense of depletion is profound, requiring a longer recovery time.
A fourth culprit might be the term “burnout” itself. It began in the 1960s as slang for chronic drug abuse, based on observations of drug addicts staring blankly at lit cigarettes they were holding until they literally burned out. Noting this original usage, psychologist Herbert Freudenberger was the first to apply the term to occupational exhaustion. Instead of a seared cigarette, he likened the syndrome to a charred building. He described burnout as the “high cost of high achievement,” making the overworked feel “their inner resources are consumed as if by fire, leaving a great emptiness inside.”
How to Fix It
This is a vivid and compelling metaphor for the experience of work fatigue. It’s also a misleading one. Burned-out buildings must be torn down and replaced, but exhausted professionals can be restored. In particular, interventions that teach skills for coping with stress such as cognitive restructuring and relaxation techniques have proven effective in burnout recovery for workers in a variety of fields, including medicine.
Just as important as reducing one’s stress is focusing on work aspects that produce personal fulfillment. Doctors who find patient care and good relationships to be the most fulfilling aspects of their work (as opposed to salary and prestige) also happen to be the most resilient in the face of job stress and burnout. According to the 2016 Medscape Physician Compensation Report, doctors who are on the lower end of the salary continuum — such as primary care physicians — report high personal fulfillment from patient care and are the most likely to report that they would choose medicine again if they could have a career “do-over.” Interestingly, specialists in plastic surgery, radiology and orthopedics — all in the top 10 in terms of earnings — were the least likely to report this.
Doctors recover from burnout, but are often reluctant to self-report symptoms in its early phases. This might be due in part to the harsh, fatalistic imagery the term “burnout” brings to mind. Who wants to admit to burnout if they think there is some spark left?
There are more optimistic alternatives. One was suggested by psychologist Christina Maslach, who developed the most widely used survey instrument for measuring burnout, the Maslach Burnout Inventory. This instrument measures workers’ sense of energy, motivation and efficacy at work on a continuum, with “burnout” on the low end and “engagement” on the other. By this reasoning, “burnout” is synonymous with “disengagement,” a term with more hopeful semantics. Another, introduced by traumatology expert Charles Figley, is “compassion fatigue,” which was actually coined with doctors and other caregivers in mind.
While burnout suggests emotional exhaustion from excess workload, compassion fatigue results from immersion in and over-identification with the traumatic stories of others. In 2009, Major Nidal Malik Hasan, an Army psychiatrist, treated soldiers returning from active duty. It seems that he feared his upcoming deployment after hearing their graphic descriptions. He tried to leave the military. Even with the help of a lawyer, it was to no avail. One early November day, he gunned down 13 and wounded 30 at his Fort Hood base. In 2013, a jury recommended he be sentenced to death.
Compassion fatigue was an uncommon term at the time, but many experts explored it as a contributing factor in the shootings. Burnout, compassion fatigue and disengagement are not the same as psychosis, lack of conscience and poor impulse control — conditions that can lead to violence. But stress can exacerbate or trigger underlying conditions. Ideally, vulnerable clinicians can be identified, treated or even encouraged to avoid high-stress, high-stakes positions. A story like this, as troubling as it is, has a certain logic — a fragile person was taxed and went over the edge. What is less logical is that so many physicians who are likely not hardwired for psychological illness are nevertheless suffering from symptoms that are similar to depression. The good news is that when the source is situational, with awareness and grassroots efforts, situations can be changed. Joy can return when the root of the problem is addressed, whether it is cultural or individual. Perhaps a good start is to change the way we talk about it and the language that we use.
Unlike burnout, both disengagement and compassion fatigue clarify the “inner resources” Freudenberger thought were in need of restoration. Restoring one’s engagement with and concern for patients and colleagues are therapeutic goals that can be achieved through rest, recreation and reframing one’s professional outlook. With guidance, most depleted doctors are resilient enough to meet these goals. The term “burnout” just doesn’t reflect their ability to bounce back.