Physician burnout

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Physician burnout has been classified as a psychological syndrome that can be expressed as a prolonged response to due chronic occupational stressors. [1] In the practice of medicine, it has been known to affect a wide variety of individuals from medical students to practicing physicians; although, its impact reaches far beyond that. Because of the toll taken on the healthcare industry, various treatment and prevention strategies have been developed at individual, team, and organizational levels in hopes to seek the best method of addressing this epidemic.

Contents

Characteristics

Prevalence

Research suggests that occupational burnout among physicians exceeds 50% in the USA. [2] This refers to not only physicians currently practicing medicine, but also those in training. Signs of burnout have even been traced back to medical students who have experienced disconnect between taught professional behaviors and those witnessed in practice.

"Our data show wide variability in the prevalence of burnout by clinical specialty, and that anxiety, social support and empathy during medical school relate to the risk of burnout during residency," says Liselotte Dyrbye, M.D., a Mayo Clinic researcher and first author of the article "Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians [3] "

In an argument explained in Economic and Political Weekly, Edmond Fernandes, lead author stated that being motivated by the best intentions is not enough; they need to be given adequate rest. The time to regulate work hours is long overdue. With growing population in a country like India, the number of doctors remains grossly insufficient to strike this balance which leads to physician and resident fatigue ending up in medical errors and complications. [4]

Signs

Burnout has been referred to as a compilation of cynicism, depersonalization, and a low sense of accomplishment. [5] [6] Other symptoms included feelings of emotional exhaustion, inadequacy, and detachment. This is thought to be due to imbalances whether that be in regards to workload, personal values, incentive, justice, and a sense of community. Factors such as time pressure, chaotic work environments and a lack of alignment between physicians and executives have been known to exacerbate this burden. [2] These elements can cause clinicians to become frustrated and overwhelmed. Moreover, the correlation between lack of control and burnout has been explored and shows that an increased sense of lack of control has been linked to a greater risk of being affected by burnout.

One study, [7] claimed that "We found that physicians with burnout had more than twice the odds of self-reported medical error, after adjusting for specialty, work hours, fatigue and work unit safety rating(...)"

Causes

The healthcare landscape continues to evolve, and factors like an aging population, [9] physician shortage, change from volume-based care to value-based care, [10] Patients as customer [11] are some drivers of the change. These changes are happening rapidly and concurrently with a consequent adverse impact on physician burnout.

The changing overall healthcare landscape creates a situation whereby the regulators and payers demand more accountability, increased healthcare quality, and reduced cost. These demands also increase physician burnout. [12] [13]

The technological environment is experiencing a rapid evolution from analog-legacy systems to digital systems. This is fueled in part by the Mores law, which postulates that there will be a constant reduction in the price of the memory capacity of computer systems. In 1981, the cost of a gigabyte was $300,000 and by the year 2000, it had dropped to $10. In 2010, the price of storing a gigabyte of data dropped to just 10¢. [15] The 4th industrial revolution is a consequence of the digital process. The 4th Industrial Revolution is a philosophical and ideological construct by the world economic forum that postulates how digital, physical, and biological technology have uniquely combined together in our contemporary world, creating new opportunities and challenges. [16] [14] Although the 4th Industrial Revolution is considered by many as a direct extension of the 3rd, the 4th differs due to the unprecedented volume and velocity of data and enhanced global interconnectivity. [17] This has impacted healthcare and all other sectors. This drive from legacy systems to digital systems demands that physicians adapt to changes quickly, which can be stressful and increase burnout

The implementation of the electronic health record (EHR) is associated with physician burnout. [18] [19] The reasons include lack of EHR usability, demand for standardized documentation as against free flowing narrative texts, and redundant documentation. Excessive data entry requirements, lack of interoperability, and notes geared toward billing tend to be the highest factors contributing to EHR-induced physician burnout. [20] [21] [19] Research indicates that the use of EHRs has increased the amount of time spent on documentation for patients by their respective doctors by 11%-22%. [22] [23]

Models

Likewise, burnout has been analyzed using differing conceptual models. [1] One strategy examined burnout as a product of three stages. Stage one consists of exhaustion at work that progresses into detachment and negative feelings at work that later starts to affect patients and coworkers in stage two. Lastly, stage three is composed of feelings of inadequacy and failure. However, a more recent approach sought to choose three stages that served as a bridge between said stages and imbalances. The first groups together all job stressors such as imbalances caused by work demands while the second solely addressed individual strain in the form of anxiety and exhaustion. Lastly, the third described changes in mood and behavior as defensive coping that could be closely linked to cynicism. [24]

Impacted populations

Physicians

The progression of physician burnout takes a toll on the individual whether it be a medical student or practicing clinician mainly through adverse psychological affects that have lasting consequences. A concept known as asymmetrical rewards speaks of how physicians are rarely recognized for what they do well, yet there is much attention surrounding medical malpractice suits ready to capitalize on a physician's errors. In addition, clinicians become desensitized to patients and medicine resulting a perspective shift towards viewing patient care as a chore more than a desire to heal. However, the effects of burnout extend past the physicians themselves to ultimately affect anyone in contact with them.

Residents

Burnout in physicians appears to be the highest for resident physicians. Due to the large number of hours taken on by resident physicians, they are often more prone to burnout. In addition to the long hours, residents are still in the process of learning clinical knowledge. Stressful events, such as death of a patient, managing a critically ill patient, medical error, and verbal abuse from patients, their families and/or colleagues have been reported in a study done at medical schools in the Philadelphia area. [25] In this study, researchers found that 70% of residents experienced at least one work-related stress event and that nearly 5% showed symptoms of PTSD from a stressful event at work. Similar to the work-life balance struggle physicians face, residents may struggle to manage everything going on in their lives. Negative effects of this burnout include decreased job satisfaction, being absent while at work and possibility for medical errors. [26] Some studies have even shown reduced feelings of personal accomplishment and emotional exhaustion. [12] Residents who considered themselves to be experiencing burnout report more medical errors than residents who do not. [27] In a 24 month-long study performed at Mayo Clinic in 2016, found that burnout and low job satisfaction were associated with reductions in professional work effort. [28] In 2008, the Healthcare Management Review suggested that healthcare settings that put programs in place to reduce physician burnout would see greater patient satisfaction and recovery. [29] Resident interventions aimed to improve communication and role conflict have been shown to improve self-acceptance, acceptance of aggression and inner directedness in residents, interns, and nurses. [30]  Although burnout in resident physicians has become common knowledge in the medical community, few systems are in place to combat this issue. Some possible solutions are support groups, stress-management/coping training and self-care education. [26]

Medical students

An estimated 43-45% of medical student students report feelings of burnout. [31] It has been proposed that physician burnout originates from physicians years' in medical school. [32] In 2010, a study was done by Emory School of Medicine and Vanderbilt School of Medicine to understand the prevalence and factors of burnout in medical students. Here, burnout was defined as emotional exhaustion, depersonalization and decreased physical exhaustion. The study administered the Maslach Burnout Inventory Human Services Survey to 249 medical students. This survey asked questions about stress levels, workload, relaxation habits, support systems and demographics. The study found that 21% of first-year students, 41% of second-year students, 43% of third-year, and 31% of fourth-year students felt symptoms of burnout. Factors associated with a higher rate of burnout include lower support, higher stress, and feelings of lack of control over one's life. There is no single solution to this issue, but easing student and physician workload and promoting wellness and resilience in the medical field has been shown to help. [33] Specifically in medical students, mindfulness-based meditation sessions have been shown to improve mood disturbance. [34]

Colleagues

Friends and family often feel the burden when interacting with burned-out clinicians since most of these individuals will be disengaged and can exhibit symptoms of major depressive disorder. Coworkers are also likely to be impacted. For example, burnout initiated by a chaotic, unsupportive work environment results in higher rates of miscommunication and unresolved conflicts. It has also been shown that a workforce afflicted by burnout contributes to an overall greater hostile atmosphere.

Health industry

Other impacted populations include the patients and healthcare industry seeing as burnout results in decreased quality of care. [35] Research has generated evidence supporting an inverse correlation between burnout and productivity. Thus the shift in decreased productivity sometimes ends in decreased physician retention due to low job satisfaction and decreased mental health. Since successful medical interactions are based on trust between providers and patients, this constant staff turnover can go on to reflect poorly upon the institution.

Treatment & prevention

Individual-approach

Treatment strategies first focused on addressing the individual. Physician-oriented approaches ranged from cognitive behavioral techniques (CBT) such as meditation and coping strategies to professional coaching which aimed at reinforcing individual resilience. Because of the high incidence of physician burnout, the field of physician coaching [36] has emerged. Physician coaching involves the implementation of mentors, usually former physicians, that would guide physicians out of burnout. Gazelle, Liebschutz, and Riess discussed the benefits of physician coaching as being able to cater to each provider using his or her own previous experiences therefore personalizing the intervention as opposed to CBT which delivers treatment in a standardized manner. On the other hand, Dr. Kelly speaks of how altering perception of patients from chores and potential litigation sources to opportunities to heal is key to the reversal of burnout.

Organizational-approach

However, some research suggests that a combination of individual, team, and organization approaches is the only way to address all levels of burnout and successfully put an end to this epidemic. [37] The entire health care system requires transformational change [38] [39] [40] and organizational approaches have shown much promise as successful treatment options by reducing workloads and distributing more flexible schedules among employees. A shift to realign goals between physicians and executive administrators could also contribute to reducing the risk of burnout. A systematic review analyzing individual and organizational strategies found that organization-oriented approaches were more effective. [41] Other examples of team approaches are the implementation of honest discussions between caregivers to emphasize compassion as well as organization-wide events to enhance workforce well-being. While Gazelle and Panagioti concluded that organizational approaches were superior to individualized interventions, the final verdict has not yet been reached as Wuest's combined intervention addressing burnout at the individual, team, and organizational levels might be the key. Institutions across the nation are coming up with various innovative ways of reducing the EHR and technology induced physician burnout. [19] One of the approaches carried out was by the Mount Sinai hospital New York in a project called beyond getting rid of stupid stuff in the EHR(Beyond-GROSS). [19] Beyond-GROSS project seeks to get direct feedback from physicians about aspects of EHR that need improvement. This project was modelled after the Hawaii Pacific hospital's getting rid of stupid stuff in the EHR(GROSS) [42] Some organizations are outsourcing services, like medical scribing, to relieve the documentation burden on physicians and free up time. [43]

Regulatory-approach

Due to the fact that physician burnout can impact overall quality of care, many regulatory bodies are also trying to reduce the adverse effect of burnout by putting forward regulations to counter its identified etiologies like unnecessary physician documentations. Centers for Medicare and Medicaid Services (CMS) initiated the "patient over paperwork" initiative to reduce the burden of unnecessary documentations on clinicians. [44]

Related Research Articles

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

A clinical decision support system (CDSS) is a health information technology that provides clinicians, staff, patients, and other individuals with knowledge and person-specific information to help health and health care. CDSS encompasses a variety of tools to enhance decision-making in the clinical workflow. These tools include computerized alerts and reminders to care providers and patients, clinical guidelines, condition-specific order sets, focused patient data reports and summaries, documentation templates, diagnostic support, and contextually relevant reference information, among other tools. CDSSs constitute a major topic in artificial intelligence in medicine.

A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include those branches of medicine that deal exclusively with children (paediatrics), cancer (oncology), laboratory medicine (pathology), or primary care. After completing medical school or other basic training, physicians or surgeons and other clinicians usually further their medical education in a specific specialty of medicine by completing a multiple-year residency to become a specialist.

Compassion fatigue is an evolving concept in the field of traumatology. The term has been used interchangeably with secondary traumatic stress (STS), which is sometimes simply described as the negative cost of caring. Secondary traumatic stress is the term commonly employed in academic literature, although recent assessments have identified certain distinctions between compassion fatigue and secondary traumatic stress (STS).

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

A health professional, healthcare professional, or healthcare worker is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician, physician assistant, registered dietitian, veterinarian, veterinary technician, optometrist, pharmacist, pharmacy technician, medical assistant, physical therapist, occupational therapist, dentist, midwife, psychologist, audiologist, or healthcare scientist, or who perform services in allied health professions. Experts in public health and community health are also health professionals.

An e-patient is a health consumer who participates fully in their own medical care, primarily by gathering information about medical conditions that impact them and their families, using the Internet and other digital tools. The term encompasses those who seek guidance for their own ailments, and the friends and family members who research on their behalf. E-patients report two effects of their health research: "better health information and services, and different, but not always better, relationships with their doctors."

A depression rating scale is a psychometric instrument (tool), usually a questionnaire whose wording has been validated with experimental evidence, having descriptive words and phrases that indicate the severity of depression for a time period. When used, an observer may make judgements and rate a person at a specified scale level with respect to identified characteristics. Rather than being used to diagnose depression, a depression rating scale may be used to assign a score to a person's behaviour where that score may be used to determine whether that person should be evaluated more thoroughly for a depressive disorder diagnosis. Several rating scales are used for this purpose.

<span class="mw-page-title-main">Occupational burnout</span> Type of occupational stress

The ICD-11 of the World Health Organization (WHO) describes occupational burnout as an occupational phenomenon resulting from chronic workplace stress that hasn't been successfully managed, with symptoms characterized by "feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy." It is classified as a mismatch between the challenges of work and a person's mental and physical resources, but is not recognized by the WHO as a medical condition.

Bullying in the medical profession is common, particularly of student or trainee physicians. It is thought that this is at least in part an outcome of conservative traditional hierarchical structures and teaching methods in the medical profession which may result in a bullying cycle.

Unnecessary health care is health care provided with a higher volume or cost than is appropriate. In the United States, where health care costs are the highest as a percentage of GDP, overuse was the predominant factor in its expense, accounting for about a third of its health care spending in 2012.

Clinical point of care (POC) is the point in time when clinicians deliver healthcare products and services to patients at the time of care.

A medical scribe is an allied health paraprofessional who specializes in charting physician-patient encounters in real time, such as during medical examinations. They also locate information and patients for physicians and complete forms needed for patient care. Depending on which area of practice the scribe works in, the position may also be called clinical scribe, ER scribe or ED scribe, or just scribe. A scribe is trained in health information management and the use of health information technology to support it. A scribe can work on-site or remotely from a HIPAA-secure facility. Medical scribes who work at an off-site location are known as virtual medical scribes.

<span class="mw-page-title-main">Choosing Wisely</span> U.S.-based educational campaign

Choosing Wisely is a United States-based health educational campaign, led by the ABIM Foundation, about unnecessary health care.

Digital health is a discipline that includes digital care programs, technologies with health, healthcare, living, and society to enhance the efficiency of healthcare delivery and to make medicine more personalized and precise. It uses information and communication technologies to facilitate understanding of health problems and challenges faced by people receiving medical treatment and social prescribing in more personalised and precise ways. The definitions of digital health and its remits overlap in many ways with those of health and medical informatics.

Stress in medical students is stress caused by strenuous medical programs, which may have physical and psychological effects on the well-being of medical students. Excessive stress in medical training predisposes students for difficulties in solving interpersonal conflicts as a result of previous stress. A significant percentage of medical students suffer from anxiety disorders because of the long term effects of stress on emotional and behavioral symptomatology. Dental students also suffer from excessive stress especially during the clinical years. This condition has become a focus of concern nationally and globally, therefore the first line of detection and defense from stress are the students themselves. Students need to be given the tools to recognize and cope with stress, as well as being assured that they will not suffer judgment from others for recognizing their need for help in dealing with stress. The instructors, advisers and other faculty members who notice the signs of stress in a student need to approach the student in a non-threatening, non-judgmental way, in an effort to help medical students recognize and handle their stress.

<span class="mw-page-title-main">OpenNotes</span> American healthcare research initiative

OpenNotes is a research initiative and international movement located at Beth Israel Deaconess Medical Center.

<span class="mw-page-title-main">Well-Being Index</span>

The Well-Being Index is an online self-assessment tool invented by researchers at Mayo Clinic that measures mental distress and well-being in seven-nine items. The Well-Being Index is an anonymous tool that allows participants to reassess on a monthly basis, track their well-being scores over time, compare their results to peers' and national averages, and access customized resources based on their assessment results. There are six clinically-validated versions of the Well-Being Index: Advanced Practice Provider, Employee, Medical Student, Nurse, Physician, and Resident/Fellow.

<span class="mw-page-title-main">Impact of the COVID-19 pandemic on healthcare workers</span>

The COVID-19 pandemic has impacted healthcare workers physically and psychologically. Healthcare workers are more vulnerable to COVID-19 infection than the general population due to frequent contact with infected individuals. Healthcare workers have been required to work under stressful conditions without proper protective equipment, and make difficult decisions involving ethical implications. Health and social systems across the globe are struggling to cope. The situation is especially challenging in humanitarian, fragile and low-income country contexts, where health and social systems are already weak. Services to provide sexual and reproductive health care risk being sidelined, which will lead to higher maternal mortality and morbidity.

Douglas Alexander Mata is an American pathologist and epidemiologist currently at Foundation Medicine, Inc. in Cambridge, Massachusetts, known for his contributions to molecular pathological epidemiology and neuropsychiatric epidemiology. His textbook Statistics for Pathologists is a reference text in pathology medical education and his meta-analytical studies on physician mental health have circulated widely in the popular press.

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