|Year : 2017 | Volume
| Issue : 3 | Page : 1-12
What's new in academic medicine: Can we effectively address the burnout epidemic in healthcare?
Julia C Tolentino1, Weidun Alan Guo2, Robert L Ricca3, Daniel Vazquez4, Noel Martins5, Joan Sweeney6, Jacob Moalem7, Ellen L. T Derrick8, Farhad Sholevar9, Christine Marchionni9, Virginia Wagner9, James P Orlando10, Elisabeth Paul5, Justin Psaila5, Thomas J Papadimos11, Stanislaw P Stawicki1
1 Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
2 Department of Surgery, The State University of New York, Buffalo, NY, USA
3 Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, USA
4 Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
5 Department of Internal Medicine, St. Luke's University Health Network, Bethlehem, PA, USA
6 Center for Neuroscience, St. Luke's University Health Network, Bethlehem, PA, USA
7 Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
8 Department of Vascular and General Surgery, Providence Regional Hospital, Everett, WA, USA
9 Department of Psychiatry, St. Luke's University Health Network, Bethlehem, PA, USA
10 Department of Academic Affairs, St. Luke's University Health Network, Bethlehem, PA, USA
11 Department of Anesthesiology, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
|Date of Web Publication||21-Apr-2017|
Stanislaw P Stawicki
Department of Surgery, St. Luke's University Health Network, Bethlehem, PA
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Tolentino JC, Guo WA, Ricca RL, Vazquez D, Martins N, Sweeney J, Moalem J, Derrick EL, Sholevar F, Marchionni C, Wagner V, Orlando JP, Paul E, Psaila J, Papadimos TJ, Stawicki SP. What's new in academic medicine: Can we effectively address the burnout epidemic in healthcare?. Int J Acad Med 2017;3, Suppl S1:1-12
|How to cite this URL:|
Tolentino JC, Guo WA, Ricca RL, Vazquez D, Martins N, Sweeney J, Moalem J, Derrick EL, Sholevar F, Marchionni C, Wagner V, Orlando JP, Paul E, Psaila J, Papadimos TJ, Stawicki SP. What's new in academic medicine: Can we effectively address the burnout epidemic in healthcare?. Int J Acad Med [serial online] 2017 [cited 2020 Nov 30];3, Suppl S1:1-12. Available from: https://www.ijam-web.org/text.asp?2017/3/3/1/204959
| Introduction: Burnout in Healthcare|| |
Burnout is a complex syndrome that involves depersonalization (DP), a diminished sense of accomplishment, and emotional exhaustion (EE) [Figure 1].,,,,, Burnout has become an epidemic that, depending on specialty, is thought to affect between 40% and 60% of practicing physicians [Figure 2].,, In addition, substantial proportion of physicians in training, at various stages of their education, experience burnout.,,,, The authors will demonstrate throughout the current manuscript that burnout is present across all levels of training, specialties, and practice patterns [Figure 2] and [Figure 3].,,, Medical education is among the most challenging, stressful, and emotionally taxing experiences. It is therefore not surprising that signs and symptoms of burnout first emerge at this stage, and medical students are susceptible to numerous psychological conditions, from neurotic symptoms to overt depression.
|Figure 1: Burnout represents a confluence of numerous factors that cumulatively result in the syndromic manifestation systematically defined by Freudenberger in the 1970s|
Click here to view
|Figure 2: Percentage of physicians reporting burnout in the U.S., listed by specialty area. Each bar represents mean and standard deviation based on data available in the literature. Note that both physicians in medical and surgical subspecialties (highlighted in red) reported lower rates of burnout than their counterparts in each respective primary specialty area|
Click here to view
|Figure 3: Dyrbye et al. demonstrated that as physicians progress in their career, the prevalence of depression, burnout, and suicidal ideation decrease. Medical students, residents and fellows, and early career physicians completed the 22-item Maslach Burnout Inventory. The Maslach Burnout Inventory is composed of three subscales: Emotional exhaustion (EE), depersonalization (DP), and a sense of personal accomplishment. Color-coded bar graphs show the percentage of medical students, resident and fellows, and early career physicians who had high scores on the emotional exhaustion and depersonalization scales and the percentages of the same groups who had positive burnout, symptoms of depression, and suicidal ideation. Of note, the same source also compared the scores of each group of trainees and early career physicians with age-matched participants in the general population. The authors found statistically significant differences in burnout, emotional exhaustion, and depersonalization subscales, but not in depression and suicidal ideation domains|
Click here to view
Compared to the U.S. college graduates between the ages 22 and 32 years, medical students experience a significantly higher prevalence of EE, DP, and burnout. This fact is concerning in that medical students begin their professional education with mental health profiles that are similar to their age-matched peers, suggesting that the demands of medical training are a significant contributing factor to the development of burnout., Burnout is not limited to any particular stage of training (e.g., pre-clinical or clinical years). In a recent study, approximately 20% of the 1st year class, over 40% of the 2nd and 3rd year classes, and nearly one-third of the medical school seniors experienced burnout. An alarming associated finding is that as many as 10% of students with burnout also reported suicidal ideation. In another report, nearly one-third of medical students met diagnostic criteria for alcohol abuse or dependence. It has been shown that organizational approaches and/or focused individual interventions can reduce burnout among medical professionals. It is incumbent upon all levels of healthcare leadership to recognize the significance of burnout and ensure that appropriate resources are in place to recognize, treat, and prevent this destructive phenomenon.
| Burnout: History and Definition|| |
The currently accepted definition of “burnout” was first put forth by Freudenberger in the early 1970s. Burnout is a complex syndrome that results from a confluence of a person's sense of dedication and commitment to a task or job, need to “prove oneself,” gradual “depletion of energies,” and eventually “feelings of being overwhelmed” (e.g., lack or resiliency) [Figure 1] and [Figure 4]. Over time, burnout impacts judgment, attitudes, perceptions, and results in a variety of psychosomatic manifestations. Physical signs may include insomnia, somatic complaints, chronic fatigue, and gastrointestinal symptoms. Psychological and behavioral signs include the following: (a) compulsion to prove oneself (excessive ambition); (b) working incrementally harder; (c) displacement of conflicts and needs; (d) neglect of one's own/nonwork-related priorities; (e) increasing denial of the problem; (f) decreasing flexibility of thought and behavior; (g) withdrawal, lack of direction, and cynicism; (h) behavioral changes/psychological reactions; (i) loss of contact with self and own needs (e.g., DP);” (j) inner emptiness, anxiety and behavioral patterns of addiction; (k) increasing feeling of meaninglessness and lack of interest; and (l) escalating physical exhaustion.
| Burnout Occurs Early in Medical Education|| |
As stated previously, burnout tends to manifest early in medical education, being particularly prevalent during the 1st year of medical school. This may be a reflection of the steep learning curve associated with the highly regimented, intellectually demanding, and competitive (to the point of being “unforgiving”) environment which many recent undergraduate alumni are simply unprepared to face. Thus, it is important for schools to develop mechanisms for screening/identification and proactive interventions that collectively reduce the probability of progression to more serious manifestations along the “burnout continuum.”,, Medical students should be educated regarding signs and symptoms of burnout and should be encouraged to seek help as soon as potential signs of burnout are identified. Among the earliest signs indicative of the need for intervention are depressive symptoms. Activities that focus on promoting wellness and mindfulness during medical education are of great importance in lessening the impact of burnout [Figure 5]. A number of medical schools have implemented programs that promote mind-body focus and stress prevention in an effort to decrease burnout. Among such initiatives, curricular changes centered around the first and second year of school have received favorable reviews. Targeted education on metacognitive skills may also be helpful in this domain. While the use of formal training has been beneficial, peer-to-peer interaction and the use of shared experiences have also been helpful in reducing psychological stress among students. For example, the University of Heidelberg implemented a peer-led stress prevention program that focuses specifically on the period of transition to formal medical training. This program was well received by participants, including positive feedback from enrolled students. Cumulatively, the above-described approaches can benefit medical students who are preparing for the transition to residency training.
|Figure 4: Resiliency is an important component in the “burnout equation,” and represents the end-result of the highly complex interplay between one's intrinsic value system, the degree of self-awareness, and the ability to effectively care for oneself. Other domains are also involved in the genesis of burnout, as outlined earlier in the current manuscript|
Click here to view
|Figure 5: Simplified conceptual representation of the positive effects of mindfulness on the ability to modulate one's responses and the reduction of reactive behaviors. Note that mindfulness is strongly associated with awareness of self and others. It is also an important component of the meta-cognitive skill development|
Click here to view
| Burnout Across Medical Specialties|| |
Burnout may be associated with medical errors and has been shown to adversely affect patient satisfaction. In recent years, burnout among U.S. physicians has reached a critical level, with highest rates reported among specialties at the front line of access to care (e.g., emergency medicine, primary care) [Figure 2].,, The 2015 survey published in the Mayo Clinic Proceedings  reported that specialties with highest burnout rates, in the decreasing order, include emergency medicine, urology, physical medicine and rehabilitation, family medicine, radiology, orthopedic surgery, general internal medicine, neurology, dermatology, and anesthesiology. The study also observed that burnout rates increased an additional 10%–20% between 2011 and 2014. Similarly, in the 2016 Medscape physician lifestyle report, the highest percentages of burnout were noted among practitioners of critical care, urology, and emergency medicine – the majority of physicians (55%) in these specialties reported loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. Fifty-four percent of physicians in family medicine and internal medicine also reported similar complaints. Of concern, burnout rates for most specialties have once again increased between 2015 and 2016 in the Medscape survey. Escalating rates of physician burnout over the years, especially in the so-called “front line” specialties raise a concern whether enough is being done to reverse this trend.
Training and practice of a surgical specialty are stressful endeavors, making surgeons especially prone to burnout. In a review of quality life and burnout across various surgical specialties, plastic surgeons and vascular surgeons were among those reporting lowest career satisfaction. The review also revealed that residents have a much higher risk for burnout than attending surgeons across multiple specialties. Of interest, 50% of physicians and 70% of the general public believe that surgical errors are often attributable to surgeons being overworked, stressed, and sleep deprived. Expanding on this, a recent study showed that being involved in an error during the previous 3 months had a significant adverse effect on mental quality of life, all three domains of burnout, and symptoms of depression. Furthermore, each one point increase in DP was associated with an approximate 10% increase in the likelihood of reporting an error while each one point increase in EE (scale range, 0–54) was associated with a 5% increase. Similar findings have been reported for residents , and nurses.
| Predictors of Burnout|| |
There are numerous factors associated with burnout and psychological morbidity among medical students, resident trainees, and other health-care professionals [Table 1]., Specifically, being younger, unmarried, and carrying significant educational debt were all strongly associated with EE and burnout., Burnout was also associated with alcohol abuse/dependence.,, Dyrbye and Shanafelt point out that burnout among students/trainees may be more attributable to the learning and work environments than personal factors specific to the affected individual. Other characteristics, such as impulsivity, depressive symptoms, the amount of time spent studying or working, and the presence of a co-existing psychiatric diagnosis play a role in burnout.,, Of interest, older medical students tend to have greater overall personal accomplishment scores, which in turn is associated with reduced risk for burnout. This suggests that students with more life experience and maturity may be equipped with better coping strategies. In addition, the availability of dedicated support and emphasis on stress-lowering strategies are both important in decreasing burnout. Finally, an important, yet often under-appreciated factor that contributes to burnout is the presence of significant personal life events and stressors. It is not uncommon for medical students to “hide” significant events in their personal lives to avoid disruptions in the professional domain, often due to a misconception that personal events may adversely affect academic competitiveness and the resident match process. In summary, there is strong rationale for the use of targeted education, peer-led seminars, and support groups to prevent burnout.,,
As a professional community, we must also recognize that various stressors associated with burnout and depression may change during each year of medical school (and thereafter). Unique stressors include the United States Medical Licensing Exam during the 2nd year of medical school, the transition to clinical years, and ultimately the residency match process. Each of these events occurs at a unique time in medical training and may require different stress management strategies by the student. For residents, in-training examinations and specialty-specific board examinations can be a source of significant stress and may contribute to burnout in conjunction with the heavy demands of busy clinical rotations., In fact, it has been shown that surgical residents have a significantly higher risk of burnout than attendings within the surgical specialties. If not promptly identified and appropriately remedied, the negative cycle of burnout and underperformance can result in a gradual transition to maladaptive coping, followed by overt professional failure and even unplanned abandonment of medical career.,,,
| Burnout and Sleep Deprivation|| |
It has been reported that ability to effectively cope with stress can be negatively affected by sleep deprivation among medical trainees and professionals alike.,, This correlation is particularly relevant to the more rigorous specialties which involve night call, such as obstetrics and surgery. In addition, “night float” assignments, used to limit duty hours by having a student, resident, or practitioner work evening hours for multiple days in a row, have a deleterious effect on the trainees' sleep/wake cycle.,, It is important to note that the appearance of depressive symptoms tends to be associated with either sleep disturbances or decreased amounts of sleep., Pathologic sleepiness and inadequate sleep were noted to be significant risk factors for the development of burnout in one study of medical students, where <7 h of night-time sleep was strongly associated with burnout. Poor sleep quality was also noted to be associated with lower level of academic performance.
Pagnin and de Queiroz examined the quality of life of medical students, including correlations with the student's own health status. Despite the overarching professional goal to promote their patients' health, it appears that medical students' well-being is often neglected. In fact, there seems to be an overall decrease in physical health due to EE and low sleep quality. This further impacts the student's psychological health, leading to a negative spiral that affects multiple aspects of personal and academic life. To minimize the occurrence of sleep deprivation and poor sleep quality, including the associated health consequences, institutions should implement efforts directed at encouraging regular exercise, good sleep hygiene, mindfulness, and promoting “time out” activities (e.g., meditation or retreats).,,
| Burnout: Effect on Training and Career|| |
Effects of burnout on medical education and subsequent professional career are profound [Table 2]., Furthermore, there may be an even stronger association between burnout and lower empathy scores among the more technical medical specialties, such as general surgery. It is critical for the medical community to support targeted outreach efforts that promote both education and dissemination of information on resilience and coping skills. This is of special importance today because of the ever-increasing professional demands on health-care providers, which in turn leads to greater stress, lower quality of life, and ultimately burnout. The looming physician shortage does not make things easier, with the U.S. Department of Health and Human Services estimating that in 2025 there will be an acute shortage of 45,000–90,000 physicians, mostly in general surgery and primary care. Burnout has been identified as one of the main reasons physicians will reduce their work effort in the coming years. In fact, projections suggest that there will be a 1% decrease in overall physician effort in the U.S. by 2025; the staggering effect of this will be equivalent to abrupt closure of several large medical schools. Moreover, these estimates do not consider physicians choosing either early retirement or the pursuit of new careers outside of medicine. After burnout and professional dissatisfaction are first identified, a “palpable” reduction in work effort among affected physicians can be appreciated in as little as 24 months.
As highlighted above, targeted educational and interventional efforts should be considered and implemented early because burnout tends to start at the beginning of the medical education journey and has the tendency to continue throughout one's career if not adequately addressed. Equipping medical students with the right tools will ultimately lead to the development of a more resilient, well-adapted, and better performing medical workforce. Educators must understand that medical students have a fear of being perceived as depressed or “burning out” because of how it may affect their evaluations and hence their future careers. Almost half of the students in a recent study felt that program directors would not consider their application if aware of the student having sought help for burnout or related problems. This status quo must change, and seeking help must be viewed as a sign of self-awareness and maturity, not as a manifestation of weakness.
| Effects of Burnout on Clinical Care Delivery|| |
In addition to profoundly affecting individual providers personally and professionally, negative effects of burnout frequently extend into the realm of clinical care delivery and physician-patient interaction dynamics., Studies have demonstrated associations between provider burnout and important aspects of medical practice, such as patient satisfaction, clinical outcomes, and care quality/safety-related issues.,, In addition, distress among physicians has been linked to changes in fundamental clinical behaviors including patterns of prescriptions and orders. Of interest, provider burnout may affect areas as diverse as malpractice risk and patient compliance with prescribed treatment(s)., This, in turn, highlights the pervasiveness of the issue and the magnitude of its impact on multiple domains at individual, institutional, and health-care system levels.
| Barriers to Seeking Assistance|| |
It is concerning to note that despite extensive education and years of training, many medical professionals who exhibit signs of burnout tend to avoid seeking appropriate medical care or assistance.,, For example, a recent study of burnout among U.S. medical students at several large medical schools revealed that a smaller percentage of medical students would actively seek medical care for burnout and depression than comparable age-matched individuals. The reasons for this discrepancy are many, including a perceived stigma associated with burnout, fear of reprisal from colleagues or supervisors and a concern for potential violations of privacy., It is important to mention that only about one-third of medical students with burnout and associated problems were reportedly willing to seek help. In addition, poor awareness of available health-care resources has also been cited as a reason for not seeking appropriate care. Given the heavy debt burden of graduating medical students, it should be emphasized that student well-being has been negatively correlated with the level of indebtedness.
The long list of deleterious effects of burnout, from declining provider well-being to increase in patient safety events, mandates system-wide, coordinated action.,,, As masterfully summarized by Dyrbye and Shanafelt, “…multi-pronged efforts, with an attention to culture, the learning and work environment and individual behaviors are needed to promote trainees' wellness and to help those in distress.” While each individual circumstance may vary, it is clear that there is a need for continued education for supervisors and development of adequate resources to effectively treat burnout without the negative and unjustified stigma. In the past, most medical school programs referred struggling students to counseling and psychological services as the primary intervention tool. All too often, this intervention was implemented already after a long period of frustration and professional turmoil. It is therefore essential for the health-care community to focus on more proactive personal resilience skills training from the very beginning of the medical education. Addressing coping mechanisms early in each provider's career is important to improving quality of life measures across the entire medical community. Finally, we must consider and actively address the counterphobic nature of some of the behaviors not infrequently exhibited by medical professionals.,, In this context, individuals tend to deny the struggles they are facing but that denial may lead to the unintentional self-harm and professional underperformance. Our role in health care is to heal but we are increasingly at the risk of failing those we care for.
| Strategies to Prevent Burnout|| |
Several strategies have already been proposed to reduce burnout among medical professionals [Table 3]. These strategies focus on early intervention, peer interactions, and stress reduction. It should be pointed out that general approaches that are effective in the 1st year of medical school may be ineffective after the transition to the clinical years, or after completion of residency training. Saint Louis University School of Medicine successfully instituted multiple changes to their curriculum in the preclinical years to reduce the stress placed on students. These interventions included a transition to a pass/fail grading system, implementation of a mindfulness curriculum, and the creation of a confidential tracking system to allow for early mental health intervention. These efforts led to 30% reduction in the number of students with moderate to severe depression symptoms at the end of the 1st year. Many schools have also begun implementation of mindfulness or mind-body medicine curricula. Such courses emphasize meditation, journal writing, and other techniques that promote self-awareness and constructive self-reflection. A recent study showed the benefit of a 7-week course in mind-body medicine that helps students better cope with stress. Similar programs have been proven to be effective in increasing empathy, ultimately leading to decreased burnout among medical students., Other studies have shown benefits of mindfulness training for practicing physicians. One investigation showed sustained improvements in empathy among primary care physicians who completed an educational program on “mindful communication”. Teaching physicians to be more self-aware and “in the moment” when interacting with patients can lead to improved empathy and create the added benefit of better physician-patient relationship.
Another way to reduce burnout is to establish strong support from professional and institutional groups that can advocate for the well-being of their constituents. One example may be the establishment of provisions protecting mental health record confidentiality for residency applicants to reduce the stigma for those who proactively and constructively sought treatment. Another example is the introduction of integrative self-care initiatives for medical students. Such programs incorporate resiliency training into their curricula, with a separate set of competency goals. Specific skills fostered within these initiatives include mindfulness meditation, guided imagery, creative expression, journaling, laughter yoga, biofeedback, appreciative inquiry, and social support. Sessions are led by attending physicians and are incorporated into the curriculum to encourage both self-awareness and self-compassion.
One of the most effective interventions to help facilitate the achievement of the above-mentioned goals, and potentially an instrumental part of structured curricula in the area of burnout prevention, is the practice of yoga.,, Yoga training is widely accepted and readily available in most communities. It is highly recommended for students with demanding work and study schedules. Barnes notes that “…yoga is one form of exercise popular amongst U.S. and Caribbean medical students.” The physical, emotional, and psychological benefits assist not only the future physicians' health but also serve to guide their patients' emotional well-being. An attractive option for those with very busy lifestyles, yoga can be practiced in organized group classes or individually at home with many free programs offered through web-based options.
| Burnout and the Evolving Health-Care Landscape|| |
With the increase in burnout among medical professionals, it is critically important to identify what has changed in the learning and work environments to cause the emergence of this unwanted trend. Principal causes of physician burnout are not new and hence the question must be asked, “why and how was the current state of affairs allowed to happen?”. One poorly addressed cause of burnout is sleep deprivation associated with strenuous on-call demands. Although residents and medical students are more protected following system-wide efforts to reduce resident work hours following the Libby Zion case, a surgical resident survey performed before and after implementation of duty hour regulations in 2003 showed that although responding trainees logged significantly fewer hours, there was no statistically significant decrease in burnout as measured by EE and DP. Clearly, the problem is not yet solved and requires further attention.
One factor affecting physicians' well-being in the workplace may be the fear of litigation. In a study of surgical oncologists, an association between lawsuits and burnout was clearly demonstrated. Moreover, malpractice claim frequency and severity continue to be - a major concern among physicians. To further compound the problem, the increasingly rapid accumulation of new medical knowledge places additional strain on providers who are forced to keep up with this “information overload”. Because standards of care follow developments in research, providers have no option but to “embrace change” or “become obsolete”.
Previously, learning how to treat a condition may have entailed two steps such as asking a more experienced provider for instruction and perhaps reading about a topic in a textbook. Today, this process is far more complex in that the “best way” to treat a wide variety of health conditions is constantly evolving. Approaching a new clinical problem today for a resident or student entails tracking down the relevant publications concerning the topic at hand, critically appraising these studies, applying these results to the clinical scenario in question, and in some instances applying the scientific method in determining the optimal management of the individual patient. As outlined in the previous paragraph, the fact that the “correct answer” is constantly changing requires physicians to revisit topics at an increasing frequency to stay up-to-date. This, in turn, may contribute to a low sense of personal accomplishment.
While burnout remains a significant issue related to training of the next generation of physicians, it is promising to see more widespread implementation of programs aimed at reducing the incidence of burnout at all phases of medical training and career. Critical to the success of this global approach is better preparation of trainees and physicians for their subsequent career expectations, including education on the evolution of healthcare itself. Over the past decade, there have been remarkable changes in the way students, trainees, and attending physicians practice medicine. There has been a dramatic shift toward the use of clinician provider order entry (CPOE) and the use of electronic medical records (EMRs). There is evidence that the more physicians use CPOE and EMR, the more likely they are to experience burnout. In one study, physicians who used CPOE and EMR were less satisfied with the amount of time spent on clerical tasks and were more likely to develop burnout. Another study found that physicians who use highly advanced EMR systems were particularly susceptible to time pressures during office visits. Further research is needed to optimize the ways our health information systems can improve physicians' workflow without increasing redundant and/or unnecessary work and tasks that are associated with increased risk of burnout.
There has also been a striking change in the way physician practices are structured. There are fewer physicians in solo practices and small group practices now than ever before, and increasing number of physicians are employed by large health-care organizations. Recent data suggest that about 75% of U.S. physicians are now employed by academic medical centers, large physician groups, hospitals and health maintenance organizations., Keeping this in mind, the impact of an organization's leadership on physician mental health and burnout can be substantial [Table 1] and [Table 3]. A recent study showed that leadership ratings, after adjustment for age, sex, duration of employment, and specialty area, are strongly associated with burnout and satisfaction, accounting for 11% of the burnout variation and 47% of the satisfaction variation. Nonetheless, the direct effect of good leadership on ndividual provider professional satisfaction and burnout remains poorly understood and warrants further investigation.
Mid-career physicians are generally considered to be at the most influential stage of their “professional career cycle”. They are neither “just out of residency” nor “ready to retire.” This group of providers has largely established their field of expertise, mentoring style, and leadership positions in their workplace. However, this segment of health-care workforce is also more likely to experience increased work hours, more on-call duties, administrative meetings, etc. All of these priorities compete with work-life balance, and significant added uncertainties related to ongoing health-care reform may add to the perception that “things are beyond one's control”. It is therefore this subset of health-care professionals that may be most likely to consider leaving the field of medicine prematurely due to burnout, professional disappointment, and work-life imbalance.
| Conclusion|| |
Efforts to understand burnout among medical trainees and practitioners, its causes and its remedies, are of primary importance to the U.S. population in general. The threat of fewer physicians and lower physician availability has the potential to adversely affect the future of health-care delivery. The large proportion of physicians dealing with burnout is inextricably tied to a less effective and disengaged medical workforce. This, in turn, may lead to increases in medical errors, poor quality of care, and decreased patient satisfaction. Consequently, the burnout epidemic in healthcare should be considered a national priority and therefore urgently addressed at all levels of our health-care system.
The potential for the disruption in the delivery of essential health-care services, the impact on the quality of services rendered, as well as the associated risks to patient safety should prompt institutional and political leadership to act swiftly and to ensure that those whose primary mission is to care for others also receive the required care and support.
The relationship between burnout, the escalating debt of new medical graduates, and substance abuse represents a symptom of an unacceptable status quo. Approaches to solve the problem of burnout should be multifaceted, with emphasis on early identification and aggressive intervention. Appropriate screening and prevention measures should begin during medical school and subsequently continue throughout the practice years. Early resiliency education including personal self-awareness, meditation, stress relief techniques, and empathy training are among some of the approaches that can help practitioners withstand the demands and stresses of the modern day practice of medicine.
The very reason that physicians have answered the call to their noble profession can easily be lost in the sacrifice of long hours, lack of sleep, denying of own personal needs, especially without institutional or systemic support. It is incumbent on teachers, administrators, and physicians in all stages of their careers, and across all organizational levels, to become involved in formulating specific solutions, and to actively engage their organizations in addressing the ongoing “burnout epidemic” that puts practitioners, patients, and institutions at unacceptable levels of potentially preventable risk.
The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Dr. Robert L. Ricca, Jr., is a U.S. military service member. This work was prepared as part of his official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis. Lancet 2016;388:2272-81.
Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al.
Burnout and suicidal ideation among U.S. medical students. Ann Intern Med 2008;149:334-41.
West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA 2011;306:952-60.
Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, et al.
Burnout and career satisfaction among American surgeons. Ann Surg 2009;250:463-71.
Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al.
Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377-85.
Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al.
Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015;90:1600-13.
Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J, et al.
Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med 2014;89:443-51.
Guthrie E, Black D, Bagalkote H, Shaw C, Campbell M, Creed F. Psychological stress and burnout in medical students: A five-year prospective longitudinal study. J R Soc Med 1998;91:237-43.
Miller PM, Surtees PG. Psychological symptoms and their course in first-year medical students as assessed by the Interval General Health Questionnaire (I-GHQ). Br J Psychiatry 1991;159:199-207.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006;81:354-73.
Brazeau CM, Shanafelt T, Durning SJ, Massie FS, Eacker A, Moutier C, et al.
Distress among matriculating medical students relative to the general population. Acad Med 2014;89:1520-5.
Santen SA, Holt DB, Kemp JD, Hemphill RR. Burnout in medical students: Examining the prevalence and associated factors. South Med J 2010;103:758-63.
Jackson ER, Shanafelt TD, Hasan O, Satele DV, Dyrbye LN. Burnout and alcohol abuse/dependence among U.S. Medical Students. Acad Med 2016;91:1251-6.
Freudenberger HJ. Staff burn-out. J Soc Issues 1974;30:159-65.
Kaschka WP, Korczak D, Broich K. Burnout: A fashionable diagnosis. Dtsch Arztebl Int 2011;108:781-7.
Dahlin ME, Runeson B. Burnout and psychiatric morbidity among medical students entering clinical training: A three year prospective questionnaire and interview-based study. BMC Med Educ 2007;7:6.
Stawicki S. Short timers syndrome among medical trainees: Beyond burnout. OPUS 12 Scientist 2008;2:30-2.
Ishak W, Nikravesh R, Lederer S, Perry R, Ogunyemi D, Bernstein C. Burnout in medical students: A systematic review. Clin Teach 2013;10:242-5.
Uchino R, Yanagawa F, Weigand B, Orlando JP, Tachovsky TJ, Dave KA, et al
. Focus on emotional intelligence in medical education: From problem awareness to system-based solutions. Int J Acad Med 2015;1:9. [Full text]
Bugaj TJ, Mücksch C, Schmid C, Junne F, Erschens R, Herzog W, et al.
Peer-led stress prevention seminars in the first year of medical school – A project report. GMS J Med Educ 2016;33:Doc3.
Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al.
Burnout and medical errors among American surgeons. Ann Surg 2010;251:995-1000.
Pulcrano M, Evans SR, Sosin M. Quality of life and burnout rates across surgical specialties: A systematic review. JAMA Surg 2016;151:970-8.
West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al.
Association of perceived medical errors with resident distress and empathy: A prospective longitudinal study. JAMA 2006;296:1071-8.
Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al.
Rates of medication errors among depressed and burnt out residents: Prospective cohort study. BMJ 2008;336:488-91.
Garrett C. The effect of nurse staffing patterns on medical errors and nurse burnout. AORN J 2008;87:1191-204.
Prins JT, Gazendam-Donofrio SM, Tubben BJ, van der Heijden FM, van de Wiel HB, Hoekstra-Weebers JE. Burnout in medical residents: A review. Med Educ 2007;41:788-800.
Chin W, Guo YL, Hung YJ, Yang CY, Shiao JS. Short sleep duration is dose-dependently related to job strain and burnout in nurses: A cross sectional survey. Int J Nurs Stud 2015;52:297-306.
Dyrbye LN, Thomas MR, Huntington JL, Lawson KL, Novotny PJ, Sloan JA, et al.
Personal life events and medical student burnout: A multicenter study. Acad Med 2006;81:374-84.
Dyrbye LN, Thomas MR, Shanafelt TD. Medical student distress: Causes, consequences, and proposed solutions. Mayo Clinic Proceedings 2005;80:1613-1622.
Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ 2016;50:132-49.
Boudreau D, Santen SA, Hemphill RR, Dobson J. Burnout in medical students: Examining the prevalence and predisposing factors during the four years of medical school. Ann Emerg Med 2004;44:S75-6.
Lashley PM, Campbell MH, Emmanuel MK. Psychological stress and burnout among medical students at the university of the west indies. West Indian Med J 2015. pii: wimj.2014.311.
Dudley HA. Stress in junior doctors 1 – Stress and support. BMJ 1990;301:75-6.
Slavin SJ, Chibnall JT. Finding the why, changing the how: Improving the mental health of medical students, residents, and physicians. Acad Med 2016;91:1194-6.
Reamy BV, Harman JH. Residents in trouble: An in-depth assessment of the 25-year experience of a single family medicine residency. Fam Med 2006;38:252-7.
Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med 2001;76:142-50.
Bittner IV JG, Khan Z, Babu M, Hamed O. Stress, burnout, and maladaptive coping. Looking Forward. Bulleting of the American College of Surgeons 2011; 96:17-22.
Kravitz RL. Physician job satisfaction as a public health issue. Isr J Health Policy Res 2012;1:51.
Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: Promoting resilience and preventing burnout. Acad Psychiatry 2008;32:44-53.
Wolf MR, Rosenstock JB. Inadequate sleep and exercise associated with burnout and depression among medical students. Acad Psychiatry 2016;41:174-179.
Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med 2006;81:82-5.
Luks AM, Smith CS, Robins L, Wipf JE. Resident perceptions of the educational value of night float rotations. Teach Learn Med 2010;22:196-201.
Mansukhani MP, Kolla BP, Surani S, Varon J, Ramar K. Sleep deprivation in resident physicians, work hour limitations, and related outcomes: A systematic review of the literature. Postgrad Med 2012;124:241-9.
Henning MA, Hawken SJ, Hill AG. The quality of life of New Zealand doctors and medical students: What can be done to avoid burnout? N
Z Med J 2009;122:102-10.
Ghoreishi A, Aghajani A. Sleep quality in Zanjan university medical students. Tehran Univ Med J 2008;66:61-7.
Pagnin D, de Queiroz V. Influence of burnout and sleep difficulties on the quality of life among medical students. Springerplus 2015;4:676.
Hassed C. Sleep that knits the ravelled sleeve of care. Aust Fam Physician 2003;32:945.
Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: Outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ Theory Pract 2009;14:387-98.
Shanafelt TD. Enhancing meaning in work: A prescription for preventing physician burnout and promoting patient-centered care. JAMA 2009;302:1338-40.
Chen D, Lew R, Hershman W, Orlander J. A cross-sectional measurement of medical student empathy. J Gen Intern Med 2007;22:1434-8.
Shanafelt TD, Mungo M, Schmitgen J, Storz KA, Reeves D, Hayes SN, et al.
Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc 2016;91:422-31.
Shanafelt TD, Dyrbye LN, West CP, Sinsky CA. Potential impact of burnout on the US physician workforce. Mayo Clin Proc 2016;91:1667-8.
Dyrbye LN, Eacker A, Durning SJ, Brazeau C, Moutier C, Massie FS, et al.
The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout. Acad Med 2015;90:961-9.
Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: Results from the MEMO study. Health Care Manage Rev 2007;32:203-12.
Halbesleben JR, Rathert C. Linking physician burnout and patient outcomes: Exploring the dyadic relationship between physicians and patients. Health Care Manage Rev 2008;33:29-39.
Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med 1998;47:1611-7.
Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 2017;92:129-46.
Shanafelt T, Dyrbye L. Oncologist burnout: Causes, consequences, and responses. J Clin Oncol 2012;30:1235-41.
Skovholt TM, Trotter-Mathison M. The Resilient Practitioner: Burnout Prevention and Self-care Strategies for Counselors, Therapists, Teachers, and Health Professionals. New York, New York: Routledge; 2014.
George S, Hanson J, Jackson JL. Physician, heal thyself: A qualitative study of physician health behaviors. Acad Psychiatry 2014;38:19-25.
Menon V, Sarkar S, Kumar S. Barriers to healthcare seeking among medical students: A cross sectional study from South India. Postgrad Med J 2015;91:477-82.
Olkinuora M, Asp S, Juntunen J, Kauttu K, Strid L, Aärimaa M. Stress symptoms, burnout and suicidal thoughts in Finnish physicians. Soc Psychiatry Psychiatr Epidemiol 1990;25:81-6.
Teng CI, Shyu YI, Chiou WK, Fan HC, Lam SM. Interactive effects of nurse-experienced time pressure and burnout on patient safety: A cross-sectional survey. Int J Nurs Stud 2010;47:1442-50.
Penson RT, Dignan FL, Canellos GP, Picard CL, Lynch TJ Jr. Burnout: Caring for the caregivers. Oncologist 2000;5:425-34.
Vettor SM. Predicting Work Stress Burnout in Rural and Urban Emergency Medical Technicians Through the Use of Early Recollections; 2002.
Rolland JS. Working with illness: Clinicians' personal and interface issues. Fam Syst Med 1994;12:149.
de Vibe M, Solhaug I, Tyssen R, Friborg O, Rosenvinge JH, Sørlie T, et al.
Mindfulness training for stress management: A randomised controlled study of medical and psychology students. BMC Med Educ 2013;13:107.
Chen AK, Kumar A, Haramati A. The effect of mind body medicine course on medical student empathy: A pilot study. Med Educ Online 2016;21:31196.
Solhaug I, Eriksen TE, de Vibe M, Haavind H, Friborg O, Sørlie T, et al.
Medical and psychology student's experiences in learning mindfulness: Benefits, paradoxes, and pitfalls. Mindfulness (N
Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, et al.
Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009;302:1284-93.
Nedrow A, Steckler NA, Hardman J. Physician resilience and burnout: Can you make the switch? Fam Pract Manag 2013;20:25-30.
Lerner BH. A Case that Shook Medicine. Washington, DC: Washington Post; 2006:HE01.
Gelfand DV, Podnos YD, Carmichael JC, Saltzman DJ, Wilson SE, Williams RA. Effect of the 80-hour workweek on resident burnout. Arch Surg 2004;139:933-8.
Balch CM, Oreskovich MR, Dyrbye LN, Colaiano JM, Satele DV, Sloan JA, et al.
Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg 2011;213:657-67.
Danzon PM. The frequency and severity of medical malpractice claims: New evidence. Law Contemp Probl 1986;49:57-84.
Guyatt GH. Evidence-based medicine. ACP J Club 1991;114:A16.
Shanafelt TD, Dyrbye LN, Sinsky C, Hasan O, Satele D, Sloan J, et al.
Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc 2016;91:836-48.
Babbott S, Manwell LB, Brown R, Montague E, Williams E, Schwartz M, et al.
Electronic medical records and physician stress in primary care: Results from the MEMO study. J Am Med Inform Assoc 2014;21:e100-6.
Epstein RM, Privitera MR. Doing something about physician burnout. Lancet 2016;388:2216-7.
Shanafelt TD, Gorringe G, Menaker R, Storz KA, Reeves D, Buskirk SJ, et al.
Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc 2015;90:432-40.
Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc 2013;88:1358-67.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||An Examination of Burnout Predictors: Understanding the Influence of Job Attitudes and Environment
| ||Katelyn J. Cavanaugh,Hwa Young Lee,Diane Daum,Shine Chang,Julie G. Izzo,Alicia Kowalski,Courtney L. Holladay |
| ||Healthcare. 2020; 8(4): 502 |
|[Pubmed] | [DOI]|
||Whatęs new in academic medicine? Things we wish were taught during our medical training
| ||HarryL Anderson III,DavidP Bahner,MichaelS Firstenberg,SagarC Galwankar,Manish Garg,SonaM Garg,Donald Jeanmonod,Rebecca Jeanmonod,Lorenzo Paladino,ThomasJ Papadimos,StanislawP Stawicki |
| ||International Journal of Academic Medicine. 2019; 5(1): 1 |
|[Pubmed] | [DOI]|
||Self-Reflected Well-Being via a Smartphone App in Clinical Medical Students: Feasibility Study
| ||Elizabeth K Berryman,Daniel J Leonard,Andrew R Gray,Ralph Pinnock,Barry Taylor |
| ||JMIR Medical Education. 2018; 4(1): e7 |
|[Pubmed] | [DOI]|