Burning Out in Georgia

By Faria Khan, M.D.

A thirty-eight year old physician friend of mine recently told me, “I’m just going to stick it out another 15 years, but I hate this. I’m trying to find something good to invest in so I can retire early.” She’s not the only one who has told me something along these lines. After all our years of training, are we not enjoying what we do? Is this just stress talking or is it something bigger?

Chances are you have if you have been practicing medicine in the United States within the past ten years, you have heard about physician burnout. Numerous articles have been written about it by various sources such as Medscape, Huffington Post, US News, and many more in response to multiple international studies reporting this phenomenon in medicine. In 2011, the AMA along with researchers at the Mayo clinic, conducted a study that focused on burnout in US physicians compared to physicians in other parts of the world. Over 7,000 doctors were given a 22-item questionnaire (the Maslach Burnout Inventory or MBI) concerning the three defining features of burnout – emotional exhaustion, depersonalization, and doubt. The study showed that burnout is significantly more common in doctors compared to other working professionals. It also found that physicians in primary and emergency care settings are at greatest risk. (1)

Three Symptoms of Burnout:

Feelings of being worn-out or spent emotionally – emotional exhaustion.

Inability to empathize with patients; cynicism towards patients- depersonalization.

Feelings that career is meaningless- doubt.

So, is burnout just stress? Although stress is the number one predictor of burnout, there is a distinction between the two. Dike Drummond, MD, professional business coach and author, says that the difference has to do with the ability to recover from the above symptoms during time away from work. If a physician is able to re-energize during time off, she is stressed at work. If she cannot re-energize away from work, she is burned out. (5,6)Looking specifically at Georgia, a survey of over 500 physicians showed that over half the doctors in the state have experienced symptoms of burnout “always” or “often”. Several of the surveyed doctors were in their mid 50s or older and were considering early retirement because of it. (3,4)(2)

Despite the recent media attention, burning out professionally is not a new idea. In 1974, the word “burnout” was originated and described by psychologist Herbert Freudenberger. In the years following, occupational burnout was found to be particularly associated with professions that deal with human services. In addition to physicians and nurses, other professionals with significant levels of burnout include teachers, police officers, customer service respresentatives, social workers, and lawyers. By the early 1980’s, psychologist Christina Maslach introduced the MBI which is considered the gold-standard in the evaluation of burnout. More recently, studies have suggested that burnout may actually be a form of depression as many features are similar. (7)

The rise of burnout in medicine is thought to be a result of the unique pressures of modern practice. As we doctors know, the practice of medicine can be very challenging and intense. As more physicians become employed rather than owning their own practices, they begin to feel like robots who are: expected to meet carefully measured productivity targets which are tied to compensation, monitored constantly by insurers that set strict rules on the use of medications and procedures, and required to submit an incredible amount of time-consuming documentation for reimbursement. Even when all the painstaking documentation is close to perfect, reimbursement rates continue to decline. In addition to less patient time, many physicians are expected to stay “plugged in” despite being away from their clinic/hospital for out-of-office issues that might arise. (8)

Increasingly, there is evidence suggesting that burnout may increase medical errors, worsen quality of care, cause a loss of professionalism, and foster early retirement (a serious concern as the medical needs of our aging American population continue to rise). Burnout has also been linked to alcohol and drug abuse, destroyed relationships (physicians have a higher rate of divorce than the rest of the American population), and suicide. In fact, doctors are at least twice as likely to kill themselves compared to the general population. Approximately 400 physicians commit suicide yearly. (9,10,11)

Some experts feel that the rates of burnout might be over-reported for many reasons including the idea that the symptoms captured by the MBI might be transient (not persistent) therefore showing stress not burnout. Others point out that there is no convincing evidence that suicide is directly connected to burnout. Nevertheless, most physicians feel that professional wellness is a priority and that some emphasis should be placed on this for more work-life balance. (12,13,14)

Cognitive behavioral therapy which focuses on changing a pattern of thinking in order to change feelings and cognitive restructuring which focuses on identifying and stopping maladaptive thought processes have both been the mainstay of occupational burnout prevention and treatment for the individual. Other traditional tools include stress management, relaxation techniques, and schedule changes. When looking only at prevention, tips such as beginning one’s day with a relaxation technique (such as meditation), exercise, healthful eating, good sleep, boundary setting, technology breaks, and the nourishment of one’s creative side have been shown to be successful. Beyond individual treatment and equally important in the prevention of burnout, according to Maslach and Leiter, is supportive leadership within the employee’s organization that ensures resources that promote work/life balance and energy revitalization.

Using the above ideas as a guide, many proposals have been put forth regarding treatment of physician burnout. As early as 2001, an article published in the Annals discussed treatment and prevention of this syndrome. (15) Tips at the time included joining a support group, considering therapy, attending wellness conferences, and addressing spiritual needs. Other suggestions throughout the years included taking breaks and staying connected to things outside of medicine (hobbies).

In Italy, pediatric oncologists who underwent a program of art therapy demonstrated a significantly decreased level of burnout (16). At the Mayo clinic in Jacksonville, Florida, art classes and meditation time for internal medicine residents were found to decrease burnout. This has led to the established the Fellows’ and Residents’ Health and Wellness Initiative (FERHAWI) humanities program which gives residents protected time within their schedules to focus on guided visual imagery, art (origami and painting), and discussion of art. (17)

Stanford has created the Balance in Life program which emphasizes psychological, physical, social, and professional wellness for its residents. Key factors in their program include resident mentorship, healthy food options for snacks while at work, scheduled meetings for counseling, and scheduled social gatherings. (18) For its emergency department physicians, Stanford has created a time banking program. Meal delivery, babysitting, handyman services, elder care, dry cleaning pickup, housecleaning, and other services are given back to doctors who earn credits for these perks when spending time on mentoring, committee work, and last minute shift coverages – things that are often inherent parts of modern day practice that drain time away from family, friends, and other activities. (19) The “Steps Forward” module was created by the AMA as a curriculum guide for medical training institutions in order to encourage the establishment of successful wellness programs for their doctors-in-training.

There is some evidence that the practice of mindfulness (being totally present and in the moment) is a promising tool for combating burnout. A handful of smaller studies show that training courses on mindfulness help physicians increase empathy and decrease emotional exhaustion. One criticism of this is that training in this takes time which is difficult to find in physicians’ already time-demanding careers. (20)

The good news is many of these ideas seem to be working. Maybe we can get back to enjoying our careers every day instead of just “sticking it out”!

REFERENCES:

1. (Shanafelt, M. T. (2012). Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Retrieved November 17, 2016, from http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1351351).
2. (Drummond, D. (2014).Stop physician burnout: What to do when working harder isn’t working. United States: Heritage Press Publications.)
3. (Miller, A. (2016). Many Georgia doctors are dissatisfied, survey shows. Retrieved November 14, 2016, from http://www.georgiahealthnews.com/2016/10/georgia-doctors-dissatisfied-survey-shows/).
4. (Cryts, A. (n.d.). Many Georgia docs burned out, look to early retirement. Retrieved November 14, 2016, from http://www.fiercehealthcare.com/practices/many-georgia-docs-burned-out-likely-to-pursue-early-retirement).
5. (Drummond, D. (2014).Stop physician burnout: What to do when working harder isn’t working. United States: Heritage Press Publications.)
6. (How to beat burnout: 7 signs physicians should know. (2016). Retrieved November 17, 2016, from https://wire.ama-assn.org/life-career/how-beat-burnout-7-signs-physicians-should-know)
7. (Occupational burnout. (n.d.). Retrieved November 20, 2016, from https://en.wikipedia.org/wiki/Occupational_burnout)
8. (Shanafelt, T., MD, & Dyrbye, L., MD. (n.d.). Journal of Clinical Oncology. Retrieved November 17, 2016, from http://ascopubs.org/doi/abs/10.1200/jco.2011.39.7380)
9. (Sinha, P. (2014). Why Do Doctors Commit Suicide? Retrieved November 17, 2016, from http://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html) (Sifferlin, A., & Sifferlin, A. (n.d.).
10. Is Your Doctor Burned Out? Nearly Half of U.S. Physicians Say They’re Exhausted | TIME.com. Retrieved November 17, 2016, from http://healthland.time.com/2012/08/21/is-your-doctor-burned-out-nearly-half-of-u-s-physicians-say-theyre-exhausted/)
11. (Shanafelt, T., MD, & Dyrbye, L., MD. (n.d.). Journal of Clinical Oncology. Retrieved November 17, 2016, from http://ascopubs.org/doi/abs/10.1200/jco.2011.39.7380)
12. ( Sifferlin, A., & Sifferlin, A. (n.d.).
13. Is Your Doctor Burned Out? Nearly Half of U.S. Physicians Say They’re Exhausted | TIME.com. Retrieved November 17, 2016, from http://healthland.time.com/2012/08/21/is-your-doctor-burned-out-nearly-half-of-u-s-physicians-say-theyre-exhausted/)
14. (Cox, E., MD. (n.d.). Doctor Burnout, Stress and Depression: Not an Easy Fix … Retrieved November 15, 2016, from http://health.usnews.com/health-news/patient-advice/articles/2016-04-12/doctor-burnout-stress-and-depression-not-an-easy-fix).
15. (Gundersen, L. (2001). Physician Burnout. Retrieved November 20, 2016, from http://annals.org/aim/article/714658/physician-burnout)
16. (Italia, S., Favara-Scacco, C., Cataldo, A. D., & Russo, G. (2008). Evaluation and art therapy treatment of the burnout syndrome in oncology units.Psycho-Oncology, 17(7), 676-680. doi:10.1002/pon.1293).
17. (Henry, T. A. (2016). Preventing burnout in residency programs: Mayo Clinic’s unique approach. Retrieved November 23, 2016, from https://wire.ama-assn.org/education/preventing-burnout-residency-programs-mayo-clinics-unique-approach).
18. (Vassar, L. (2016). How one program achieved resident wellness, work-life balance. Retrieved November 23, 2016, from https://wire.ama-assn.org/life-career/how-one-program-achieved-resident-wellness-work-life-balance)
19. (Schulte, B. (n.d.). Time in the bank: A Stanford plan to save doctors from burnout. Retrieved November 23, 2016, from https://www.washingtonpost.com/news/inspired-life/wp/2015/08/20/the-innovative-stanford-program-thats-saving-emergency-room-doctors-from-burnout/).
20. (Shapiro, S. L., & Carlson, L. E. (2009).The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. Washington, DC: American Psychological Association.)