Burnout

A recent Medline search revealed 2,722 published articles on the topic of health professional burnout in the past 3 years alone, including 10 papers in this journal. Burnout is being studied so frequently that it is hard to find a current medical journal without papers addressing it. More recently, the discussion has spilled over into the lay press and on the internet. Physician burnout has even been termed a public health crisis by some authors because higher burnout scores are associated with an increased incidence of medical errors.1 Some of this heightened interest can be traced to a publication in 2014 by Tom Bodenheimer, MD, and Christine Sinsky, MD.2 In that paper, the authors advocated for expanding the triple aim to a quadruple aim by adding provider well-being to the three original goals of American health care defined by Berwick in 2008.3 The Bodenheimer article came at a time when electronic health records were being widely adopted in medical practices and hospitals and less than a decade after work hour restrictions were implemented in graduate medical education. Today, clinicians continue to struggle with substantial changes in their daily workflows, and burnout is thought to be a problem for over half of them.4 A review of the literature on burnout reads like a differential diagnosis. Authors have addressed workload, work hours, administrative burden, physician employment status, scope of practice, the roles of technology and data reporting, resilience, wellness behaviors, lack of mentoring, underrepresented minority status, and practice organizational characteristics. The problem has been studied in practicing physicians, faculty members, medical students, residents, primary care clinical team members, and behavioral health professionals. One can get burned out trying to read everything that is being written about burnout!

In this issue of Family Medicine, we feature a paper by Stephanie Hooker, PhD, MPH, and colleagues that addresses professional burnout among family medicine residency directors.5 Hooker and colleagues take an interesting approach to this problem by seeking a correlation between burnout and meaning salience, a concept defined as having a life purpose as measured by a validated survey tool called the “Thoughts of Meaning Scale.” The study is interesting and adds new information to our existing knowledge, but it has two major weaknesses, both of which are acknowledged by the authors. First, the authors studied the problem in family medicine residency directors, presumably because CERA (Council of Academic Family Medicine Educational Research Alliance) regularly conducts a survey of this population.6 This is unfortunate because family medicine program directors are less likely to be burned out than practicing physicians.7 The study’s results might be applicable to family physicians in general and perhaps even to other health care professionals, so one would hope that someday it will be replicated with these broader populations. The second problem with the study is that it does not examine causation. The authors used cross-sectional methods and therefore could only measure a correlation between meaning salience and burnout. One cannot tell from this study whether having less meaning in your life causes you to be burned out or if being burned out causes you to report less meaning. Both of these notions are plausible, so we should be careful not to overinterpret this study. Nevertheless, meaning salience is inversely correlated with burnout among family medicine residency directors. So what might this mean? On the one hand, it is hard to imagine that physicians could spend 25 years completing their educations only to struggle to find meaning in the work for which they’ve spent half a lifetime preparing. But studies of burnout tend to associate the problem less with the burdens of caring for patients than with the administrative work that fills much of our days. None of us like to think that 25 years of training were required to type progress notes and fill out insurance forms. Residency directors have more administrative staff around them than most practicing physicians, so maybe this explains their lower burnout rate.

The data seem clear that burnout is more prevalent than it used to be. Why might this be the case? Do physicians work more hours per week than they used to? Certainly it is hard to answer this question definitively when many of us are completing medical records from our computers at home, blurring what is and is not “working.” But there are little objective data that physicians work more hours now than in the past, and residents certainly work fewer. Are medical records more burdensome now than they used to be? Again, this is hard to measure because there are many different types of electronic record systems and physicians vary widely in their record keeping efficiency.4 But personal experience suggests that completing medical records is no more time consuming now that it was when we were dictating notes and reviewing them two days later. Does the problem lie in physicians doing different kinds of work than they used to? Clearly physicians are more likely to be employed and less likely to practice in hospitals and nursing homes, and burnout rates have been noted to be higher under these conditions. But here again, there is little research to support a causal relationship with burnout.8

In the absence of clear and convincing proof, we are left to imagine why burnout is such a burning issue. We are left with our own experiences; we are left with what we choose to believe. Older physicians reflect about what has been lost from their daily work. The young among us might perseverate on how different the reality of modern medicine is to what they thought it would be like. Clinicians see lots of patients, but we know each of them less intimately and for shorter durations. Health care has become transactional with the unit of care being the visit, but we still imagine family medicine as relational with the unit of care being the doctor-patient dyad. We imagine being able to use data from our medical records systems to better manage patients and confront a reality in which these data are more often used to manage us. We entered medicine by learning that professionals should place the highest priority on patient needs, and now find ourselves in health systems operated as businesses that prioritize efficiency and profit. And perhaps worst of all, we too often lack a sense that we have control over any of this. In short, we acutely feel a lack of agency to control our own profession and by extension, our own lives. Perhaps agency is an important concept to consider, because the social science literature has identified agency as an important contributor to mental health.9,10 Maybe the high rate of burnout in medicine is really an indictment of what often passes for physician leadership in today’s health care system. We count on physician leaders to stand up for us when conflicting priorities arise and too often find them to be little more than overpaid sycophants. If our leaders do not stand up for us, we are left with self-advocacy and we risk being branded uncollaborative complainers.

All of this probably sounds familiar, but is any of it really true? Physicians have more tools to help patients than ever before. Physicians can easily move from community to community and even, unlike lawyers, from state to state. None of us are trapped doing what we are doing. If our work lacks meaning, why do we stay? Medicine is not immune to the sometimes-overwhelming problems in our world. We are told how hard our lives are. But if we listen carefully to the stories of our patients, it is hard not to see how blessed we are in comparison. If we feel lost as physicians in this health care system, consider for a moment what it is like for them! The organizations in which we work say they want us to be happy, but they clearly don’t know what to do. The unspoken question is why our happiness is their responsibility in the first place. If we are treated like expensive employees, we should not respond by acting that way. In the absence of conclusive evidence about physician burnout, perhaps we need to believe more in our own agency and expect more from those chosen to be our leaders. And while we are at it, we should take better care of one another. Maybe the solution to burnout lies not in thinking more about ourselves, but in feeling closer to one another. It is important that we study burnout. It is also important not to believe everything we read.