Enhancing Meaning in Work: Title and subTitle BreakA Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care

Burnout is a pervasive problem among physicians.¹ The burnout syndrome is characterized by losing enthusiasm for work (emotional exhaustion), treating people as if they were objects (depersonalization), and having a sense that work is no longer meaningful (low personal accomplishment).² Numerous global studies involving nearly every medical and surgical specialty indicate that approximately 1 of every 3 physicians is experiencing burnout at any given time.¹

The prevalence of burnout among physicians is cause for concern. Burnout appears to alter both the physician-patient relationship and the quality of care physicians provide. Physicians' degree of burnout and professional satisfaction are related to physician empathy and compassion, prescribing habits, referral practices, professionalism, and the likelihood of making medical errors.^{1 ,3 - 5} Physician burnout also appears to influence patient adherence to recommended therapy, the degree of trust and confidence patients have in their physician, and patients' satisfaction with their medical care.^{6 - 7} In addition to these professional repercussions, burnout can have profound personal consequences for physicians, including substance abuse, intent to leave medical practice, and suicide.^{1 ,8}

Factors that contribute to physician burnout are complex. Most studies find loss of autonomy, decreased control over the practice environment, and inefficient use of time due to administrative requirements to be central factors.¹ Other surveys implicate workload, specialty choice, practice setting, sleep deprivation, lack of work-life balance, medical errors, risk of malpractice suits, characteristics of treated patients, and the methods physicians use to deal with patient death and illness as contributing factors.¹ These variables interact in unique ways depending on each physician's personal responsibilities, personality, coping strategies, and other factors, which likely account for variation in burnout among physicians in similar professional circumstances.⁹

Despite the prevalence of burnout and its potential for serious consequences, few studies have tested interventions to address the problem. Most analyses have focused on individual interventions, such as stress reduction training, rather than organizational interventions. Although these studies have suggested possible benefits, they are limited by small sample sizes, short follow-up, nonrandomized study designs, and failure to incorporate intent to treat analysis.^{10 - 11} Few studies have evaluated organizational interventions to reduce clinician distress. For instance, a multisite, primary care clinic was established with the organizational value that physician well-being is of equal importance to care quality and financial viability. The clinic leadership aimed to promote physician well-being by cultivating efficiency, autonomy, and meaning in work through a continuous improvement process along with longitudinal monitoring of physician well-being.¹² This strategy was associated with an increase in physician satisfaction and lower physician burnout at the organizational level over a 4-year interval.¹²

Other studies have suggested that fostering self-awareness can help physicians identify what they value and connect with what is most meaningful in their work.¹³ A variety of methods can be used to help promote awareness and reflection. For example, physicians may be asked to privately reflect on or write a brief narrative about a specific personal experience in their practice (eg, being with a patient at the end of life, making a medical error, recall of a particularly meaningful encounter) with a focus on how they reacted to and worked through the situation.¹⁴ Participants may then share their experience (and listen to those of others) with a small group of colleagues who listen with the intent of understanding the speaker's experience rather than interpreting or judging.¹⁴ Although the goal of such “mindfulness training” is to increase attention, awareness, intention, and self-reflection, it is hypothesized these traits may also reduce physician distress.¹¹

In this issue of JAMA, Krasner and colleagues¹⁵ report the results of a single-group cohort study that evaluated the effect of a mindfulness and self-awareness curriculum on primary care physician burnout, empathy, and mood. Participants engaged in an intensive mindfulness education program that involved a 52-hour curriculum administered over a 1-year interval that included training in appreciative inquiry, narrative medicine, and mindful meditation. The study used a before-and-after intervention design and comprehensively measured changes in mindfulness, burnout, mood disturbance, and patient orientation using standardized instruments.

The results were striking. Participants had large increases in mindfulness skills and orientation that were immediately detectable and were sustained for up to 15 months.¹⁵ The physicians also had large, durable improvements in burnout, mood disturbance, and empathy. These changes correlated with the improvements in mindfulness, suggesting that enhancing physicians' attention to their own experience not only increases their orientation toward patients but also reduces physician distress.¹⁵

As acknowledged by the authors, the study has several limitations. First, only 70 of 871 invited physicians (<10%) participated in the study. It is unknown whether these participants are representative of physicians in general or whether those who did not volunteer would have derived equal benefit. Second, the before-and-after study design provides less strength of evidence than a randomized trial. The improvements observed could be due to the Hawthorne effect or simply spending time with colleagues. However, the large improvement in mindfulness (the focus of the curriculum) suggests that additional time spent with colleagues was not the sole benefit of the intervention. Third, because the study was limited to primary care physicians, it is unknown whether the intervention would be beneficial for physicians in other specialties, particularly surgical disciplines or specialties with minimal direct patient contact (eg, radiology, pathology). Despite these limitations, the study evaluated a well-conceived, comprehensive, and portable intervention that was appropriately executed, longitudinally evaluated with standardized metrics, and included long-term follow-up investigating the durability of effect.

The study by Krasner and colleagues is part of a growing body of research suggesting that enhancing meaning in work increases physician satisfaction and reduces burnout. A recent study of academic physicians demonstrated that physicians' ability to focus on the aspect of work most meaningful to them (eg, patient care, research, education) had a strong inverse relationship with burnout.¹⁶ Qualitative studies suggest that physicians primarily derive professional satisfaction from relationships with patients, relationships with colleagues, and the day-to-day rewards of practice such as intellectual stimulation.¹⁷ The most meaningful professional role varies from physician to physician but often centers on being a healer, developing expertise, being a teacher, or making scientific discoveries.¹⁸ Physicians may also derive different degrees of meaning from specific aspects of their work and may be able to tailor their practice accordingly. For primary care physicians, this may include focusing on geriatric care, hospital medicine, palliative care, health education, or administration.

Can promoting physician well-being truly improve quality of care? In one of the few studies to evaluate the effect of a clinician-based intervention on quality outcomes, a large medical malpractice insurer developed and tested a stress reduction program for hospital employees that focused on individual training in stress management and organizational control of factors that produced stress. A pilot study found a reduction in medication errors after implementation of the program at a single hospital.¹⁹ The investigators subsequently conducted a controlled trial that evaluated the longitudinal effect of the program on malpractice claims at 22 participating hospitals relative to 22 control hospitals matched for size, practice scope, geography, and baseline frequency of malpractice claims. Malpractice claims over the ensuing year were reduced by 70% at intervention hospitals compared with a 3% reduction at control hospitals (P < .01).¹⁹ Additional studies evaluating the effect of organizational interventions to promote physician well-being on quality of care are needed.

Physicians in the United States will face a host of new challenges over the next decade as the nation reforms its health care system. This restructuring will likely result in reduced physician compensation and autonomy, increased time pressure, and myriad new administrative challenges. These changes have the potential to increase the already epidemic levels of burnout among physicians and to overwhelm those currently near their limits. Although many physicians may be tempted to respond to this challenge by retreating from work (eg, more time off, reduced scope of practice, retirement), the study by Krasner and colleagues¹⁵ demonstrates that training physicians the art of mindful practice has the potential to promote physician health through work. Physicians continue to control the most sacred and meaningful aspect of medical practice—the encounter with the patient and the reward that comes from restoring health and relieving suffering. Reminding physicians of this fact and helping them recognize and enhance the meaning they derive from the practice of medicine may help protect against burnout and promote patient-centered care for the benefit of both physicians and their patients.