Mid-Career Burnout in Generalist and Specialist Physicians

A study of US physicians showed that physicians in 1997 were less satisfied in every aspect of their professional life than those asked similar questions in 1986. They were dissatisfied with the time they have with individual patients and their lack of incentives for high-quality care.¹ Similarly, a 1998 study revealed that two thirds of Canadian physicians have a workload they consider too heavy, and more than half stated their family and personal lives have suffered because they chose medicine as a profession.² Dissatisfaction has been documented in several diverse physician groups, including primary care,³ surgery,⁴ infectious disease specialists,⁵ and anesthesiologists.⁶ The leaders of medical school departments are exposed to similar pressures.⁷ These recent articles highlight the growing discontent of physicians with the increasing complexities of the practice of medicine. Burnout, a term that has moved from colloquial speech into the social and psychological vernacular, describes this phenomenon.

There is a growing awareness within medicine that physicians and other health care professionals are at risk for burnout, which threatens the sustainability of the health care enterprise. Preventing burnout by promoting the well-being of physicians has been the focus of several recent initiatives. The Western Journal of Medicine devoted its entire January 2001 issue to offer guidance in living positive and healthy lives.⁸ In addition, the Joint Commission on Accreditation of Healthcare Organizations has mandated that as of January 1, 2001, all hospitals have a process to address physician well-being, separate from disciplinary processes.⁹

We review the definition of burnout and its sources; examine the interaction of physician personality factors and the unique stressors they encounter in the workplace and at home; and highlight current resources for preventing burnout and promoting well-being in physicians and within their organizations.

Burnout as a syndrome is present in many individuals under constant pressure.¹⁰ Physicians in particular are frequently overloaded with the demands of caring for sick patients within constraints of fewer organizational resources.¹¹ The symptoms and signs of burnout include emotional exhaustion, cynicism, and perceived clinical ineffectiveness, and a sense of depersonalization in relationships with coworkers, patients, or both. Burnout has been associated with impaired job performance and poor health, including headaches, sleep disturbances, irritability, marital difficulties, fatigue, hypertension, anxiety, depression, myocardial infarction, and may contribute to alcoholism and drug addiction.^{12 - 14}

Maslach and Leither¹⁰ describe burnout as the index of the dislocation between what people are doing vs what they are expected to do. Burnout represents a deterioration of values, dignity, spirit, and will. They describe this constellation as "an erosion of the soul." Burnout spreads gradually and continuously over time, sending people into a downward spiral from which it is hard to recover.¹⁰ Deterioration of physician well-being from excessive stress has been described as the silent anguish of the healers.¹⁵ The seeds of burnout may be sown in medical school and residency training, where fatigue and emotional exhaustion are often the norm.^{16 - 18} By mid-career, the momentum of burnout is maintained by the subtle reinforcement of the esteem and recognition of one's peers for being a hard worker and placing service to others before self-care.

Research on burnout in the workplace reveals several common themes. The risk of burnout increases in individuals who consistently experience work overload and a perceived lack of control over the extent to which the load exceeds their capacity. Workers who are burned out find their work unrewarding, experience a breakdown in community, believe they are treated unfairly, and are confronted with conflicting values.¹⁰ These conflicts apply to many medical practice situations and may contribute to the general unrest in physicians worldwide.^{1 ,19 - 21}

Symptoms of burnout can lead to physician error, and these errors can in turn contribute to burnout.²² Given the potential human costs of medical mistakes, the emotional impact of actual or perceived errors can be devastating for physicians.²³ Dissatisfaction and distress have significant costs not only for physicians and their families but for patients and health care organizations as well.²¹ One study estimated that the cost of replacing a primary care physician ranged from $236 383 for a family practitioner to $264 345 for a general pediatrician.²⁴

A longitudinal study of male physicians documented the important role of family backgrounds in the subsequent risk of maladjustment to professional life.¹² Those physicians with the least stable childhood and adolescence were at higher risk for unstable marriages, alcohol and drug use, and the need for psychotherapy. A stable childhood, as defined in this study, included good childhood health; father-child relation seemed warm, encouraging, and conducive both to autonomy and to self-esteem; a home atmosphere that was warm and cohesive; the child was close to at least one sibling; and did well in school both academically and athletically.¹²

There is ample evidence that physicians are caught in a web of pressures including financial deficits, Medicare/Medicaid audits, concern over fraud and abuse, and malpractice suits in which they perceive little control.^{1 ,7 ,21 ,25}

A study of factors that predict professional satisfaction, organizational commitment, and burnout among physicians working for the Kaiser system found that the single most important predictor for these outcomes was a sense of control over the practice environment.²⁶ Three additional factors—perceived work demands, social support from colleagues, and satisfication with resources—predicted these outcomes, which were also related to age and specialty.²⁶ Pediatricians were more satisfied and committed to the health maintenance organization and were less likely to manifest burnout. Older physicians had higher levels of satisfaction and commitment and lower reported levels of burnout.²⁶ Chairs of departments of obstetrics and gynecology were surveyed and reported that burnout decreased with age and the length of service as a chair.⁷ This same age trend was noted in a study of burnout among surgeons, as was the pivotal importance of perceived control and autonomy in one's practice.⁴ The influence of health care organizations on physician well-being has been reviewed, and external factors, such as payment reduction, regulation, and business practices of insurers, were found to contribute to physician stress.²⁷ Factors internal to the organization, such as styles of leadership and management, administrative policies and procedures, and organizational culture, also have powerful effects on physician well-being.²⁷ These observations emphasize that burnout may be as related to physicians' work environments as to their personality traits.

Certain personality traits may enhance the risk of burnout by influencing the individual's response to stressors in the workplace. Compulsiveness is a character trait found in many physicians and, although it may be adaptive behavior for the demands of medical education, it can also have an enormous detrimental impact on their professional, personal, and family lives. The compulsive triad of doubt, guilt feelings, and an exaggerated sense of responsibility has been well described.²⁸ Physicians with compulsiveness have chronic feelings of not doing enough, difficulty setting limits, hypertrophied guilt feelings that interfere with the healthy pursuit of pleasure, and the confusion of selfishness with healthy self-interest. A dissociation (diminishing awareness of one's physical and emotional needs) leads to a self-destructive pattern of overwork. A psychology of postponement takes root in which physicians habitually delay attending to their significant relationships and other sources of renewal until all the work is done or the next professional hurdle is achieved.²⁹ Osler noted this self-denying habit of physicians over a century ago when in an address to medical students, he warned:

Engrossed late and soon in professional cares . . . you may so lay waste that you may find, too late, with hearts given way, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.³⁰

In a continuing education course for physicians who had overprescribed narcotics for their patients, the same personality traits described above were noted. Most physicians who attended this course were burned out, had poor prescribing habits, treated 40 to 50 patients each day, were isolated in rural solo practices, and had very little support for themselves or their families.³¹

Marital problems and stresses in the family are causes of serious emotional and behavioral issues in physicians. Myers³² has summarized the relationship problems that can occur in physicians' marriages and urges physicians not to let the practice of medicine disrupt the marriage. A questionnaire to chairs of departments of obstetrics and gynecology revealed that a supportive spouse or partner was important to prevent burnout⁷ ; other studies have come to the same conclusion.³³

Female physicians face unique stressors. The number of women entering medicine continues to grow and in 1998 comprised 23% of all US practicing physicians. By 2010, it is expected that 30% of all physicians and 50% or more of all medical students will be women.³⁴ The Physician Worklife Study, a nationally representative random stratified sample of nearly 6000 physicians in primary and specialty nonsurgical care, assessed US physician burnout.³⁵ Female physicians were 60% more likely than male physicians to report signs or symptoms of burnout. The odds of burnout in women increased 12% to 15% for each additional 5 hours worked per week of more than 40 hours. Female physicians are also more likely to experience sexual harassment from colleagues, patients, or both. At home, female physicians tend to have responsibility for managment of domestic responsibilities and, if they have children, balance the role of mother with career demands.³⁶

The best prevention for physician burnout is to promote personal and professional well-being on all levels: physical, emotional, psychological, and spiritual. This must occur throughout the professional life cycle of physicians, from medical school through retirement. It is a challenge not only for individual physicians in their own lives but also for the profession of medicine and the organizations in which physicians work.

Yamey and Wilkes³⁷ have suggested that the majority of organized medicine's experience with physician health and function has been from work with impaired physicians. As a result, we know much about physicians' disease and despair, their substance misuse, burnout, and dysfunctional relationships but very little about what keeps them feeling well.³⁷

Two key themes that run throughout the Western Journal of Medicine's issue⁸ on physician well-being are the ability of physicians to influence their own happiness through personal values and choices, and the need for some control over their workplace. Physician groups, national associations, and management groups should address these important themes of physician well-being. The Canadian Medical Association adopted a policy, which outlines strategies and recommendations that address a range of health and well-being issues and is generally applicable to all physicians.^{38 - 39}

Health care organizations have an economic stake in physician well-being. Workers who are satisfied tend to be more productive.⁴⁰ There is evidence that the well-being of physicians is related to patient satisfaction, a key outcome variable tracked by most organizations.⁴¹ The satisfaction of physicians in an organization will enhance recruitment and retention of staff, saving the enormous cost of staff and physician turnover.^{21 ,24 ,42 - 43} Physician well-being prevents burnout and the less frequent but significant problem of physician impairment.^{44 - 45} Furthermore, attention to well-being promotes patient safety and reduces the probability of errors,^{18 ,46} thereby diminishing the threat of malpractice litigation.²² It is also expected that satisfied physicians will optimize their utilization patterns. Health system administrators and managers are beginning to study the extent of physician burnout in their settings as a precursor to recommending meaningful organizational changes.^{28 ,47 - 48}

Specific suggestions for health care organizations to promote physician well-being include measurement of intrinsic values, such as the extent to which physicians experience a sense of meaning in their work, in addition to extrinsic values such as productivity; establishment of a physician health committee that has equal status with quality assurance and other committees, whose function is to review corporate decisions and contracts for their impact on physician wellness and measure physician well-being as an outcome; establishment of a mentor program, in which senior physicians guide and support junior members in their career development and in balancing their personal and professional lives; provision of confidential support groups that meet monthly on a voluntary basis with group-generated topics and facilitation by an outside professional; provision of an annual well-being retreat on company time; provision of membership in a fitness center; contractual requirements that all physicians have their own primary care physician; a sabbatical program linked to productivity incentives; provision of periodic continuing medical education programs on various topics related to well-being; flexible scheduling to allow time off for critical family events such as births, deaths, graduations, caring for aging parents, and leaves of absence to pursue travel and avocational interests; paperwork reduction; involvement of physicians in the design and management of their practice environments; and inclusion of questions about physician health and well-being in board certification and recertification examinations.

Weiner et al⁴⁹ studied the methods used by 130 primary care physicians to promote their own well-being. The 6 main practices found were spending time with family and friends, religious or spiritual activity, self-care, finding meaning in work, setting limits at work, and adopting a healthy philosophical outlook, such as being positive or focusing on success.⁴⁹ These data are consistent with the predictors of happiness identified through positive psychology, the discipline that seeks to measure and understand, and then build human strengths and civic virtues.⁵⁰ Ryff and Singer⁵¹ provide an excellent summary of the factors that promote positive psychological functioning: self-acceptance, positive relations with others, autonomy (self-determination and internal locus of self-evaluation), environmental mastery (choosing or creating environments suitable to one's physical conditions), purpose in life, and personal growth (continuing to develop one's potential). Strategies to prevent physician burnout are listed in the .

Personal
Influence happiness through personal values and choices
Spending time with family and friends
Religious or spiritual activity
Self-care (nutrition, exercise)
Adopting a healthy philosophical outlook
A supportive spouse or partner

Work
Control over environment: workload
Finding meaning in work and setting limits
Having a mentor
Having adequate administrative support systems

Personal growth and renewal involve not only the time outside of work (evenings, weekends, or vacations). Comprehensive, sustainable renewal is possible in all spheres of physicians' lives—patient encounters, paperwork, surgery, meetings, research, traveling to and from work, family life, travel, and hobbies. What is required for this renewal is a new way of thinking about one's personal energy—that work is not merely a domain of energy expenditure but also of energy renewal. Physicians can learn to receive support, healing, and meaning while giving of themselves in each activity of the day.^{52 - 53} This awareness of oneself as a locus of energy exchange can be promoted by simple but powerful practices such as mindfulness,^{54 - 56} which involves being fully present and attentive to the moment, to the person, and to the task at hand.

Burnout is characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. Preventing burnout, a responsibility of all physicians and of the health care systems and organizations in which they work, entails the explicit promotion of physician well-being. Physicians must be guided from the earliest years of training to cultivate methods of personal renewal,⁵⁷ emotional self-awareness,⁵⁸ connection with social support systems,⁵⁹ and a sense of mastery and meaning in their work.⁶⁰ Maintaining these values is the work of a lifetime. It is not incidental to medicine but is at the core of the deepest values of the profession to first, do no harm. Doing no harm begins with one's self.