Beating Burnout: When Clinicians are Overworked, Overtired, and Overwhelmed

If Katy H. Goldsborough, MD, a hematologist/oncologist with Edward-Elmhurst Healthcare in Naperville, Illinois, started to feel “burned out,” no one would blame her: Dr. Goldsborough has been a full-time practicing physician with her current group since 2009, and she and her husband are parents to four children under age 10.

Add to that reimbursement challenges, the looming switch to more complicated ICD-10 billing codes, the emotional toll of caring for seriously ill patients, the rollout of cumbersome electronic medical record (EMR) systems, and the increasing number of patients now eligible for health care under the Affordable Care Act, and you have a prescription for widespread burnout and dissatisfaction.

Burnout is a clinical condition characterized by physical and emotional exhaustion, depersonalization, and little sense of personal accomplishment. While burnout is not a phenomenon unique to clinicians, they are particularly susceptible to it.

And the problem is only getting worse: In 2002, 22 percent of internal medicine physicians reported experiencing burnout;¹ more recent data show 46 percent of physicians stating they have experienced burnout.²

ASH Clinical News spoke with several clinicians about what constitutes burnout, its prevalence in medicine, and how physicians can best avoid it – or at least manage it.

A Complex and Multifaceted Problem

Tait D. Shanafelt, MD, professor of medical education and medicine and a hematologist at the Mayo Clinic in Rochester, Minnesota, has been studying physician burnout for more than a decade.

“Burnout is a complex and multifaceted phenomena,” Dr. Shanafelt told ASH Clinical News. “The main factors causing this physical and emotional exhaustion are related to workload, work efficiency, autonomy and a sense of control over work, work-life integration, and meaning at work. Individual, organizational, and national factors contribute to each of these dimensions.”

What are the most common complaints among today’s practicing hematologists? In a 2013 “Survey of Practice-Based Hematology” conducted by ASH, 25 percent of respondents named delayed, inadequate, and reduced reimbursement as a major practice-affecting issue. Twenty-three percent listed high staff turnover, poor recruitment and retention, understaffing, and other staffing issues as major concerns, followed by insurance problems (15%), drug and practice costs (13%), and EMR and documentation (12%).³

“Professionally, burnout can contribute to cynicism, unprofessional behavior, medical errors, and staff attrition,” Dr. Shanafelt added. “On a personal level, studies suggest burnout is related to broken relationships, substance abuse, and suicide.”

Much of Dr. Shanafelt’s work utilizes the Maslach Burnout Inventory, a tool developed by Christina Maslach, PhD, from the University of California at Berkeley. The Maslach Inventory measures three general scales to calculate burnout: emotional exhaustion, depersonalization, and general accomplishment.

In one study, Dr. Shanafelt and colleagues found that burnout seems to be a common manifestation of distress among oncologists: 35 percent of medical oncologists, 38 percent of radiation oncologists, and 28 to 36 percent of surgical oncologists reported experiencing burnout.⁴

To better characterize the prevalence of burnout among health-care workers, Dr. Shanafelt and his colleagues also compared the frequency of work-related mental and physical exhaustion among physicians with the general population. In a survey of 7,288 physicians assessed using the Maslach Burnout Inventory, 45.8 percent of physicians reported at least one symptom of burnout.⁵ Compared with a probability-based sample of 3,442 working adults, physicians were more likely to have symptoms of burnout (37.9% vs. 27.8%) and to be dissatisfied with their personal level of work-life balance (40.2% vs. 23.2%).

Who Burns out Fastest?

Where a physician is in his or her career path – early, middle, or late career – also plays a role in susceptibility for burnout.

A cross-sectional study of physicians from all specialties confirmed that burnout is a challenge at all career stages.⁶ After evaluating professional life and career satisfaction among early-career (those who had been working in the health-care field for 10 years or less), middle-career (11-20 years), or late-career (21 years or more) professionals, researchers found that early-career physicians had the lowest satisfaction with overall career choice, the highest frequency of work-home conflicts, and the highest rates of depersonalization.

Middle-career physicians seemed to fare even worse: They worked more hours, took more overnight calls, had the lowest satisfaction with specialty choice and work-life balance, and had the highest rates of emotional exhaustion and burnout.6 It is no wonder, then, that middle-career physicians were most likely to plan to leave the practice of medicine for reasons other than retirement in the next 24 months (4.8%, 12.5%, and 5.2% for early, middle, and late career, respectively).⁶

Expectations Versus Reality

In a survey of oncology fellows, Dr. Shanafelt and colleagues found that the clash between expectations and reality is felt the deepest by fellows and early-career hematologists and oncologists.⁷ The frequency of burnout was highest among first-year fellows, but decreased during the subsequent two years of fellowship (from 43.3% at year 1, to 31.7% at year 2, and 28.1% at year 3).

Fellows expected that after completion of training, they would be working a median of six hours per week less than what practicing oncologists actually reported working. Mounting student loan debt also lowered career satisfaction and made fellows more likely to pursue private practice and to shy away from an academic career.⁷

That doesn’t mean physicians automatically become more fulfilled with their work lives once they have a few years under their belt, though. According to Dr. Shanafelt’s poll, practicing oncologists had lower fatigue and better quality of life than oncology fellows, but were ultimately less satisfied with work-life balance and their choice of specialty.⁷

It seems that the stresses don’t dissipate; instead, the sources of stress change. “In training, the stress was mainly from trying to impress attendings,” Dr. Goldsborough recalled. “As a practicing physician, the stress is from trying to always make the right recommendations for patients.”

Does Stress “Go Viral”?

Burnout doesn’t just affect doctors; it has far-reaching implications for the health-care system as well. “While burned-out physicians attempt to maintain quality of care at their own expense, work conditions that result in burnout are associated with poorer care quality,” wrote Mark Linzer, MD, an internal medicine specialist at Hennepin County Medical Center in Minneapolis, Minnesota, and his colleagues. “Burned-out doctors are more likely to leave their practice, thus reducing access to care. Turnover sacrifices continuity, and replacement costs are at least $250,000 per primary-care physician.”⁸

This is a substantial problem: One in four respondents (24%) of ASH’s practice-based survey indicated that they are considering retiring in the next five years.³

Can Anything Be Done?

There are steps that institutions can take to help their clinicians battle burnout – and help themselves in the process.

“The key is to measure stress, burnout, and their predictors, then meet to discuss plans to make change to address the findings, make the changes, and then measure again,” Dr. Linzer told ASH Clinical News. “Incorporate wellness metrics into the ongoing organizational plan, and acknowledge that one of the best ways to meet organizational goals is to address wellness.”

In 2013, Dr. Linzer and colleagues outlined 10 steps to prevent burnout in a commentary in the Journal of General Internal Medicine (Table). Echoing the results of the ASH Practice-Based Survey, they identified increased use of information technology (IT) as one of the main challenges clinicians face in the modern health-care environment.⁸

“We suggest elbow-to-elbow training in the clinic with IT specialists, with the use of more templates and smart phrases, and also exploring the use of documentation specialists or medical scribes in the clinic,” he said. “The costs of scribes can be supported through additional patients seen when documentation issues are managed by scribing. It is quite miraculous what happens when a scribe does the typing for a provider.”

Dr. Linzer also encourages using practice extenders, such as nurse practitioners, physician assistants, and locum tenens providers, to support other members of the health-care team and “float” providers to cover clinicians with predictable life events. “All are part of the team practice model of the future,” he noted.

Mitigation and Management

According to ASH’s practice-based survey, hematologists today are operating in an era of mergers: More than half of respondents who had practices other than community-based private practices indicated that their practice is affiliated with a larger practice, hospital, academic medical center, or health-care system. Eighteen percent of the respondents in community-based private practices indicated that their practices are planning to merge with or be acquired by a larger organization in the next three years.

Frequent changes in organizational structures and increasing third-party control by managers, government, insurance companies, and medical corporations are contributing to the diminished sense of personal accomplishment and clinical autonomy experienced by burned-out doctors, according to Karen Trollope-Kumar, MD, PhD, associate clinical professor of Family Medicine at McMaster University in Hamilton, Ontario, and colleagues, “as well as demanding work, long hours, poor ergonomics, escape into work, personality, and interpersonal problems.”⁹

The laundry list of stressors that contribute to physician burnout has grown in recent years, but so has the recognition and the management of it.

“I’ve been in practice for 30 years now and, early in my practice years, burnout was just not discussed,” Dr. Trollope-Kumar told ASH Clinical News. “But in the last 10 to 15 years, there has been much more awareness of physician wellness. Now there is more programming, such as continuing medical education [CME] and helplines for students and residents, geared toward physician wellness.”

Physician self-awareness about stress and burnout should be part of an open dialogue from the beginning of medical school, she contended, and physicians should be made aware of the available resources for managing burnout, such as helplines and professional associations and societies.

Personally, Dr. Trollope-Kumar has found peer support to be an invaluable tool for building resilience. “I belong to a CME group where we talk about advancing medical education, but we inevitably talk about our stressful cases or professional issues that we are having difficulty with,” she said. “A support system doesn’t have to be formal; it can be done informally with a small group of physicians who meet on a regular basis.”

Are You and Your Job Compatible?

Finding the right fit is also key to preventing burnout. Before settling on hematology/oncology, Dr. Goldsborough considered lifestyle and potential emotional involvement when choosing her specialty, also taking into account the daily schedule and pace of the various specialties.

“I am fairly comfortable with end-of-life conversations and also with close involvement with patients and their families,” she explained. “I think that I would burn out faster if I were in the surgical or emergency medicine fields, because I function best on a set schedule and with adequate sleep at night.”

While physician burnout is a critical issue that needs to be addressed across the full spectrum of medical specialties, clinicians in certain fields may face a greater degree of stress than some of their colleagues. Hematopoietic transplantation physicians are hit particularly hard, according to Linda J. Burns, MD, former ASH president and medical director of health services research at the National Marrow Donor Program/Be The Match and the Senior Scientific Director of the Center for International Blood and Marrow Transplant Research, both in Minneapolis, Minnesota.

Dr. Burns and colleagues recently conducted a survey among transplanters to better understand the challenges to recruitment and retention of transplant physicians.¹⁰ The majority of the survey respondents were academic practitioners, but “similar issues appear to be concerns for all transplant physicians, regardless of type of practice,” she said. “The issues leading to burnout – including the complexity of patients, high number of working hours and nights on call, and amount of administrative tasks – are common among all types of practice.”
However, she noted, “transplant is somewhat unique in that, although it is curative therapy for many patients, it raises patients’ risk for treatment-related morbidity and mortality at the same time – particularly for those patients undergoing allogeneic transplant.” Risks for relapse or late complications could lead to the need for ongoing chronic care. Indeed, for survey respondents who were dissatisfied with their career, “excessive hours, insufficient salary, and the emotional drain of caring for transplant recipients” were the most commonly cited causes.

“While a long-term physician-patient relationship is one of the joys of being a transplanter, it is also emotionally difficult when a patient struggles with or dies from complications,” Dr. Burns added.

Crafting a Personal Prevention Plan

The first step to preventing burnout: Educating people about what it is and what causes it.

“Understanding the factors that cause burnout is the first step to developing interventions,” Dr. Burns agreed. “Just as important is recognizing that the health-care team as just that – a team. Each team member working at the highest level of his or her competency, while at the same time avoiding redundancy in tasks, can lighten the load.” For example, she offered, if a pharmacist meets with a patient and caregiver at the time of discharge to review the medications, a nurse does not need to duplicate the task.

“It is also very important to support each other in difficult circumstances, whether counseling a family during end-of-life decision making or after the loss of a patient,” Dr. Burns added. “Some centers have incorporated Schwartz Rounds – a forum for staff to come together for reflection on job challenges to help staff feel valued and improve relationships with their patients and colleagues.”

And, as a multifaceted problem, preventing and treating burnout requires a multifaceted approach at both the organizational and individual levels.

“At the organizational level, efforts to improve efficiency, provide flexibility and control over work, and help clinicians cultivate and recognize meaning in their work can be useful,” Dr. Shanafelt said. “The behaviors of organizational leaders have also been found to be a critical factor on the personal satisfaction and burnout of the physicians working within the organization.”

Dr. Shanafelt urges physicians not just to rely on the organizations they work for to manage and mitigate burnout, but to step up and address its causes on a personal level.
All of the clinicians we spoke with had a common strategy to avoiding burnout: Spending meaningful time outside of work with family and friends.

For Dr. Goldsborough, that means striking the right balance between work and life. “While I devote some time to professional reading and paperwork at home after my children go to bed, it’s important that I reserve at least an hour in the evening to unwind and do something I enjoy.”

Dr. Linzer’s personal burnout prevention plan, in addition to putting his 10-step plan into practice, involves running multiple times a week “by the lakes and streams of Minnesota, and playing in our hospital band, the New Prescriptions.”

For Dr. Burns, “my family helps me mitigate burnout, as well as making time for exercise, gardening, reading, and maintaining friendships.”

“At the individual level, identifying both personal and professional values, and integrating for some professional life in accord with these values is a critical first step,” Dr. Shanafelt added. Of course, you also need to love what you do. “Focus on the aspects of work from which you derive the greatest fulfillment to connect with your work,” he recommended.—By Shalmali Pal 

References

1. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-67.
2. “Medscape 2015 Physician Lifestyle Report.” Accessed July 26, 2015 from http://www.medscape.com/viewarticle/838437.
3. American Society of Hematology, “2013 Survey of Practice-Based Hematology.”
4. Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol. 2012;30:1235-41.
5. Shanafelt T, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-85.
6. Dyrbye LN, Varkey P, Boone SL, et al. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88:1358-67.
7. Shanafelt T, Raymond M, Horn L, et al. Oncology fellows’ career plans, expectations, and well-being: do fellows know what they are getting into? J Clin Oncol. 2014;32:2991-7.
8. Linzer M, Levine R, Meltzer D, et al. 10 Bold steps to prevent burnout in general internal medicine. J Gen Intern Med. 2013;29:18-20.
9. Jensen PM, Trollope-Kumar K, Waters H, et al. Building physician resilience. Can Fam Physician. 2008;54:722-29.
10. Burns L, Gajewski J, Majhail N, et al. Challenges and potential solutions for recruitment and retention of hematopoietic cell transplantation physicians: the National Marrow Donor
11. Program’s System Capacity Initiative Physician Workforce Group report. Biol Blood Marrow Transplant. 2014;20:617-21.