Physician burnout: Quo vadimus?

INTRODUCTION

The term “burnout” was coined by psychologist Herbert Freudenberger in the 1970s and gained prominence in the research literature after American psychologist Christina Maslach developed the Maslach Burnout Inventory (MBI) in 1981.^[1] Burnout is a syndrome of emotional exhaustion, loss of meaning at work, feelings of ineffectiveness, and a tendency to view people as objects rather than as human beings.^[2] The three domains of emotional health assessed in the MBI include emotional exhaustion (“I feel emotionally drained from my work”), depersonalization (“I have become more callous toward people since I took this job”), and reduced sense of personal accomplishment (“lack of feeling that I am positively influencing people’s lives through my work”).^[3] Physician burnout is associated with adverse effects at the personal (relationship difficulties, substance abuse, depression, and suicide) and professional levels (decreased productivity, work and career dissatisfaction, suboptimal patient care, and physician turnover).^[4] Due to these negative spinoffs, physician burnout is considered a public health crisis and also a threat to future medical practice worldwide.^[5]

BURDEN OF PHYSICIAN BURNOUT

The prevalence of burnout amount attending physicians in the United States (US) is about 55% when all specialties were considered.^[2] Burnout is also prevalent among medical trainees (medical students, residents, and fellows) and has been associated with self-reported medical errors and suboptimal patient care.^[3] On an international level, burnout was also reported in many countries, including India [Table 1].

At present, the most widely used and validated instruments to measure burnout include the MBI, Mini-Z survey, and the Copenhagen Burnout Inventory (CBI). The MBI is the reference standard in medical research to measure burnout in various work settings. The full-length MBI is a 22-item questionnaire covering domains of emotional exhaustion, depersonalization, and personal accomplishment. Licenses need to be purchased for the use of the MBI for work-related or research use. An abbreviated two-item version developed by the Mayo Clinic has been validated and used in numerous physician surveys.^[3]

The Mini-Z survey is used by the American College of Physicians, which is shorter than the MBI and free to use.^[6] In addition, the Mini-Z survey is more applicable to physician settings as it includes questions on time constraints for documentation and time spent on electronic medical records at home. The CBI^[7] is a psychometrically robust 19-item questionnaire that assesses burnout in three domains; personal (six items), work-related (seven items), and client-related burnout (six items). Thus, it focuses more on personal exhaustion. The CBI is free to use.

The literature on correlates of burnout from India is comparatively sparse, and the available data are inconsistent. A total of six studies have evaluated this issue [Table 1].^[8-13] Of these, five have been published in the past 3 years, perhaps indicative of the growing trend, and greater interest in studying burnout. The comparison of findings across studies is limited by heterogeneity in terms of participant characteristics (internists vs. residents vs. practicing physicians) and instruments employed to assess burnout. Nevertheless, the findings are striking.

In one of the earliest studies of its kind from India, Bhugra et al.^[9] reported a very low level of burnout among private practitioners in Yamuna Nagar. The authors attributed their findings to the greater degree of flexibility, control overwork, and better work-life balance than private practice provides. More recent studies, however, have contested these findings. In a nation-wide survey of medical practitioners,^[11] the investigators noted high (45%–87%) prevalence of burnout across domains of emotional exhaustion and personal accomplishment. Nearly 90% of the respondents (both medical residents and faculty) in an online survey from a state-funded university hospital in Chandigarh reported concerning levels of burnout (with nearly 75% of them being at moderate or severe risk of burnout).^[13]

Two studies from teaching hospitals in Vishakapatnam and Thiruvananthapuram^[8,12] surveyed attending doctors and residents, respectively. Both found that nearly one-third of the respondents endorsed high burnout. Furthermore, high personal burnout was reported by more than half of the participants (51.8%).^[12] Interestingly, research surveys among dental practitioners^[10] have indicated lower rates of burnout (5.15%).

DETERMINANTS AND MEDIATORS OF PHYSICIAN BURNOUT

The drivers of burnout include a host of personal and work-related factors. As physicians going through rigorous medical training, compulsivity and attention to detail are a personality trait developed in us. Among physicians, culture, and values include a sense of “patient comes first” and a culture of endurance in difficult situations. This may lead to professional isolation, especially when there is no safe space to retreat or lack of social support at work. Increasing workload, varying job demands, as well as changing physician-patient dynamics and interactions have lately been contributing to emotional distress at work. Lack of control over the work schedule, inflexibility at work, and loss of autonomy based on the employer-employee relations are potential drivers of burnout.^[14,15] Pressures of increased documentation time, especially using electronic medical records, and the resulting decreased face-to-face time with limited efficiency and resources add to burnout.^[16] It is to be noted that burnout is not the same as depression, though interestingly, the diagnosis of physician burnout was recently added to the ICD-10 codebook.^[17] Depression has a well-established process of diagnosis and treatment. A high correlation exists between burnout and depression, and it is speculated that drivers of severe burnout may lead to depression.^[18]

The majority of the available Indian studies support a high prevalence of physician burnout.^[8,11-13] Two studies showed a positive association between burnout and female gender,^[8,11] while a couple of others did not support this association.^[12,13] Positive correlates of burnout include working in clinical departments, especially surgical departments, number of years spent in residency,^[8,12] and personality traits such as sociability as well as the self-control and emotionality subconstructs of emotional intelligence (EI),^[19] decreased participation in recreational activities, negative encounters with patient or attendants, and lack of perceived support and empathy from senior doctors.^[13]

Three major changes related to the health-care scenario in India appear to contribute to the increasing trend of physician burnout. First, the mushrooming of multispecialty corporate hospitals, which have been likened to “shopping malls,”^[20] due to their offer of the entire bouquet of health services ranging from simple consultations to complex procedures such as organ transplants, all under one roof. These hospitals have a wide recruitment net, and, as a result, it has become commonplace to find doctors working outside their home state.

The earlier system of provision of care by the local family physician, who would enjoy a better rapport and understanding of the local culture and needs, has been gradually replaced by the corporate hospital culture which places a premium on patient volumes and is manned by physicians who do not share the same language and culture. This, in turn, has led to a diminution in clinician autonomy as well as reduced connectedness with patients, both of which are key drivers of burnout.^[21,22]

The second issue is the supply and demand mismatch of health-care resources. This is especially true of public sector hospitals which, in India, attract high patient volumes due to the provision of subsidized health care. The available infrastructure, both in terms of workforce as well as physical infrastructure, is woefully inadequate to cater to the extant patient load. Over time, this leads to burnout due to poor working conditions.^[14]

The third issue is the inequitable distribution of available health-care resources. Multispecialty hospitals and even public sector teaching hospitals are mostly located in urban areas. As the rural-urban divide in the concentration of doctors’ increases, more and more doctors practicing in urban centers are forced to compete against each other for clientele. Consequently, they often end up doing freelancing in multiple hospitals to earn better. Even private practitioners and family physicians are not spared from this phenomenon. The result is long working hours, decreased family and social time, loneliness, and eventual burnout.^[23]

Given the close links between burnout and risk of cardiovascular disease,^[24,25] we propose an integrated model [Figure 1] which assists in conceptualizing the above determinants of burnout from a basic cardiovascular physiology perspective. Many of these factors may operate in combination and at multiple levels to abet burnout.

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Figure 1:

Understanding burnout syndrome from a basic cardiovascular physiology standpoint.

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STRATEGIES TO MANAGE BURNOUT

While numerous strategies have been proposed in the research literature, a strategy that may work at a certain center may not work at another institution. Thus, it is best to work collaboratively with physician leaders and a wellness committee to identify local resources to address physician well-being. Below, we give a few suggestions to improve physician well-being, from an individual and systemic perspective:

CONCLUSION

“Quo vadimus” refers to the process where we ask ourselves the question, “where do we go from here?.” Burnout is a growing problem in the practice of medicine and is best considered a long-term reaction to stress. Various predictors have been identified, such as diminished clinician autonomy, poor medical infrastructure, impaired work–life balance, reduced sense of personal accomplishment, and lack of support and empathy from senior colleagues. However, physician burnout is not inevitable. Understanding the predictors of burnout, implementing locally relevant strategies based on locally available resources, and reassessing physician well-being can go a long way in addressing physician burnout and emotional well-being. We owe this effort to our physician brethren and our patients.