Journal of Mental Health and Human Behaviour

REVIEW ARTICLE
Year
: 2018  |  Volume : 23  |  Issue : 2  |  Page : 78--85

Physician burnout: A review


Sandeep Grover, Himani Adarsh, Chandrima Naskar, Natarajan Varadharajan 
 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India

Abstract

The concept of Physician Burnout emerged in the 1960s. Over the last six decades or so, it has been recognized as a worldwide phenomenon. This brief review presents the evolution of the concept, risk factors, epidemiology, clinical manifestations, assessment, prevention, and management of physician burnout. Available data suggest that different theoretical models have been proposed and evaluated to understand the emergence of burnout at the workplace. The risk factors for the development of burnout can be understood as personal and organizational factors and interaction of these factors, determine the final experience of burnout. The incidence of burnout among medical professionals is generally reported to be higher than other professionals, and high rates of burnout are seen across all the stages of medical career, i.e., medical students, interns, postgraduates, and practicing physicians. There are some data to suggest rising trend in the prevalence of burnout among physicians. The common signs and symptoms of burnout include anger, irritability, impatience, increased absenteeism, decreased productivity, and decreased quality of care. However, many authors have categorized the symptoms into different stage models. Burnout among physicians is associated with multitude of negative consequences for the physicians, and patients, and the health-care system. Available data suggest that it is important to recognize burnout at the earliest and use preventive strategies for emergence of the same. At present, there are no clear-cut guidelines for the management of burnout, but some of the individual-level interventions, which are thought to be helpful for burnout, include cognitive-behavioral techniques, meditation and relaxation techniques, development of interpersonal skills, and development of knowledge and work-related skills. In addition to this, various interventions carried out at the level of organization and the physician–organization interface have also been proposed to address physician burnout.



How to cite this article:
Grover S, Adarsh H, Naskar C, Varadharajan N. Physician burnout: A review.J Mental Health Hum Behav 2018;23:78-85


How to cite this URL:
Grover S, Adarsh H, Naskar C, Varadharajan N. Physician burnout: A review. J Mental Health Hum Behav [serial online] 2018 [cited 2019 Dec 15 ];23:78-85
Available from: http://www.jmhhb.org/text.asp?2018/23/2/78/270991


Full Text



 Introduction



Physician burnout has recently received significant attention in the Western world. It has been linked to many of the poor health-care outcomes, besides the poor mental and physical health of medical professionals. There is a lack of consensus in the definition of the term burnout. According to one of the definitions, it is defined as “a persistent, negative, work-related state of mind in 'normal' individuals that is primarily characterized by exhaustion, which is accompanied by distress, a sense of reduced effectiveness, decreased motivation, and the development of dysfunctional attitudes and behaviors at work.”[1] The concept of physician burnout evolved in the 1960s and is now well recognized in the literature.

In this brief review, we discuss the evolution of the concept, risk factors, epidemiology, clinical manifestations, assessment, prevention, and management of physician burnout.

 Evolution of the Concept



The concept of burnout was first described by Freudenberger, a psychologist, in a paper titled “Staff Burnout,” while working with free clinics. He described it as a “state of mental and physical exhaustion caused by one's professional life.”[2] He recognized that people who develop burnout have gradual emotional depletion, loss of motivation, and reduced commitment. In fact, Freudenberger himself fell victim to burnout twice, which increased his credibility in spreading the message of burnout. Initially, the concept of burnout was considered as “pseudoscientific” or “fad.”[3] However, the concept became more acceptable with the development of an assessment instrument, Maslach Burnout Inventory (MBI), developed by Maslach and Jackson in 1981.[4] The various items of MBI are categorized into three components, i.e., emotional exhaustion, depersonalization, and a sense of low accomplishment.[4] Emotional exhaustion is understood as feeling “used up,” by the end of the day and in the context of medical profession, nothing to offer to patients from the standpoint of emotion. Depersonalization or compassion fatigue is understood as a feeling, in which a physician experiencing burnout end up treating their patients as objects rather than human beings and becomes careless or callous toward them. The sense of lack of personal accomplishment is characterized by feelings of ineffectiveness in taking care of patients and their problems.[3] With the availability of the MBI, there was a proliferation of research in this area and the concept was accepted and the three components of burnout were understood further. Thereafter, the concept of burnout was extended from physicians to any other professions or careers and the definition was further refined.[3]

 Theoretical Underpinnings



Different theories have been used to understand the concept of physician burnout. Many of these theories are based on the general stress theory, and these basically discuss the concept from the point of view of interaction of the person with the work characteristics.[5] Among the various general stress theories, one of the most important theories is that of person-environment fit theory, which considers the physician burnout to be an outcome of imbalance between the demands at the workplace, available opportunities, and skills and expectations of the person. When there is a wrong fit between these factors, the person finds himself as a wrong fit, which leads to psychological distress and/or strain, which finally leads to physical symptoms.[6],[7] Other authors have reported that additional factors, which contribute to burnout, include individual perception and evaluation of the situation.[8] Schaufeli and Enzmann[9] provided an integrated model of burnout, according to which coping plays an important role in determining “positive gains” or “negative loss spirals” at the workplace.[9] Other theories which have been proposed to understand burnout include job strain or the demand–control model[10],[11] and effort–reward imbalance model.[12] The job strain model suggests that burnout is an outcome of high demands at the workplace and low level of control. The effort–reward imbalance model considers burnout to be an outcome of a combination of putting in high efforts with low reward.[12],[13]

 Risk Factors for Physician Burnout



Physician burnout is considered to be an outcome of interaction of personal attributes and work-related stress [Table 1].[14],[15] The listed risk factors have been reported in one or more studies, and it is suggested that it is the combination and close interaction of various risk factors which determine the overall outcome.{Table 1}

 Epidemiology



Burnout affects physicians through all phases of education, training, and career practice. The incidence of burnout among medical students and residents has been estimated to be between 40% and 76%.[16] A meta-analysis of data from 24 studies, which involved 17,431 medical students, reported a prevalence of 44.2% (confidence interval [CI]: 33.4%–55.0%), with a prevalence of emotional exhaustion to be 40.8% (CI: 32.8%–48.9%), depersonalization to be 35.1% (CI: 27.2%–43.0%), and personal accomplishment to be 27.4% (CI: 20.5%–34.3%).[17] This meta-analysis further suggested that the main factors contributing to burnout among medical students include curriculum, stress related to the competition, examinations, cost of the studies, hospital conditions with workload, exposure to patients' suffering and death, style of management, and young age.[17] A meta-analysis, which evaluated the data for residents undergoing postgraduate training, reported the overall prevalence of burnout across various specialties to be 35.7%, with burnout rates higher for specialties such as general surgery, anesthesiology, obstetrics and gynecology, and orthopedics, when compared to other specialties. A recent study, which evaluated 3588 2nd-year residency trainees (median age = 29) using MBI, reported the prevalence of burnout to be 45.2%.[18] In terms of various specialties, this study showed that training in urology, neurology, emergency medicine, and general surgery was associated with higher relative risks (RRs) of symptoms of burnout (range of RRs, 1.24–1.48), when compared to training in Internal Medicine. The various characteristics which were found to be associated with a higher risk of symptoms of burnout included female sex, higher reported levels of anxiety during medical school. The features which were found to be associated with a lower risk of symptoms of burnout included a higher level of empathy during medical school.[18] A systematic review which evaluated 182 studies with 109,628 individuals in 45 countries, published between 1991 and June 1, 2018, reported the prevalence of burnout to vary from 0% to 80.5%, with the prevalence of emotional exhaustion to range from 0% to 86.2%, depersonalization to range from 0% to 89.9%, and that for low personal accomplishment to range from 0% to 87.1%.[19] A recent study evaluated the changes in the burnout and satisfaction with work–life balance among 6880 physicians in the United States using MBI. This study reported an increase in the prevalence of at least 1 symptom of burnout from 54.4% in the year 2011, when compared to prevalence figure of 45.5% in 2014, and this difference was statistically significant. During the corresponding period, there was a reduction with satisfaction with work–life balance from 48.5% to 40.9%. When these figures were compared with probability-based US adult samples, it was evident that physicians experienced an increasing disparity in burnout and satisfaction with work–life balance compared to general US working population. However, these changes were not associated with a significant change in the prevalence of depression and suicidal ideations. When the change in the prevalence of burnout was evaluated for various specialties, those specialties which were associated with more than 10% increase in the prevalence of burnout included family medicine, general pediatrics, urology, orthopedic surgery, dermatology, physical medicine and rehabilitation, pathology, radiology, and general surgery.[20]

 Signs and Symptoms of Burnout



There is some variation in the description of manifestations of burnout in the literature. The commonly reported features considered to be indicative of physician burnout include anger, irritability, impatience, increased absenteeism, decreased productivity, and decreased quality of care.[21] Others symptoms include fatigue (physical and mental), exhaustion, reduced immunity, change in sleep pattern, self-devaluation, helplessness, apathy, detachment from the others, lack of motivation, social isolation, and postponing the activities, i.e., procrastination and poor accomplishment of the professional tasks.[22] An exhaustive review of available studies divided the symptoms of burnout into seven clusters, which include warning symptoms in the early phase of burnout (in the form of increased commitment to goals and exhaustion), reduced commitment (toward patients, others, work and increased demands), emotional reactions (aggression and depression), reduction of performance (cognitive performance, motivation, creativity, and judgment), flattening of various aspects of life (emotions, social life, and intellectual life), psychosomatic manifestations, and despair.[23]

In terms of clinical features, some of the authors have given different stages of the development of burnout, i.e., 3-stage model, 5-stage model, 12-stage model, and so on. According to the 3-stage model, the 3 stages include stress arousal, energy conservation, and exhaustion. These stages are considered to occur sequentially, and intervention at any stage can stop further progression. The stress arousal stage is characterized by persistent anxiety, persistent irritability, brief period of raised blood pressure, bruxism, reduced sleep, forgetfulness, palpitations, unusual heart rhythms, difficulty in concentration, and headache. The energy conservation stage is characterized by being late for work, procrastination, need for long weekends, decreased sexual desire, persistent tiredness in the morning hours, social withdrawal, cynicism, resentfulness, increased consumption of beverages such as tea/coffee/cola, and increased alcohol intake. The final exhaustion stage is characterized by persistent sadness or depression, persistent gastrointestinal problems, persistent mental fatigue, persistent physical fatigue, persistent headaches, desire to drop out of society, desire to move away from everything (friends, work, and even family), and suicidal ideations. For each stage, the presence of any of the two symptoms is considered to be indicative of the presence of burnout.[24] The 12-stage model includes stages of (1) compulsion to prove oneself (i.e., ambitiousness); (2) working harder; (3) neglecting own needs; (4) displacement of conflicts and needs; (5) lack of time for nonwork-related needs; (6) increasing denial of the problem; decreased flexibility in thinking and behavior; (7) withdrawal, lack of direction, and cynicism; (8) behavioral changes/psychological reactions; (9) depersonalization; (10) inner emptiness, anxiety, and addictive behavior; (11) increasing feeling of meaninglessness and lack of interest; and (12) final stage of physical exhaustion.[25]

 Consequences of Burnout



Physician burnout is not only associated with poor mental and physical health outcomes for physicians but also has been linked with negative health-care outcomes. The adverse outcomes for physicians and medical professionals may include suicide, and for patients, this may amount to poor quality of care and poor treatment satisfaction [Table 2].{Table 2}

Some of the studies have evaluated the physical health outcome of burnout, and these studies suggest that high burnout scores are associated with higher cardiovascular risk factors (increased fasting blood glucose and cholesterol levels), increased risk of developing type 2 diabetes mellitus, increased inflammatory markers, increased leukocyte adherence, higher musculoskeletal pain, and higher risk of infertility.[26],[27],[28],[29],[30],[31],[32],[33],[34]

 Nosological Status of Physician Burnout



At present, physician burnout is not a recognized clinical entity as per the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The closest diagnosis in DSM-5, which could be considered as an equivalent of physician burnout syndrome, includes Acculturation problems (V62.4). The closest diagnosis in the International Classification of Diseases (ICD), 10th revision classification includes Problems related to life management difficulty,” which is described as a “state of vital exhaustion.” In ICD-11, burnout is going to be coded as QD-85, i.e., Problems associated with employment or unemployment. According to ICD-11, burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: (1) feelings of energy depletion or exhaustion, (2) increased mental distance from one's job or feelings of negativism or cynicism related to one's job, and (3) reduced professional efficacy. ICD-11 specifies that burnout refers specifically to a phenomenon in the occupational context and should not be applied to describe experiences in other areas of life.

 Barrier to Help-Seeking



Medical professionals work in an environment, in which they need to pretend to be supernaturally resilient, infallible, and omnipotent.[38] The work culture expects that “good doctors” do not complain, do not express pain, do not shirk work, and above all, do not develop signs or symptoms of mental illness, especially depression. Accordingly, those who express stress perception or mental problems are considered to be weak and not up to the job. Due to this, many a times physicians do not seek help for their mental health issues because of the fear that it might affect their reputation and ability to practice medicine.[38] Many studies, which have evaluated stress or physician burnout, have identified individual- and system-level barriers to seeking mental health care in the face of burnout.[39],[40] A study from India, which evaluated the resident doctors, reported various barriers to seeking mental health care. These include fear of being labeled weak or incapable of handling pressure; afraid of being stigmatized and labeled as having a mental illness; fear of being accused of shrugging work on the pretext of stress; fear that it will impact the attitude of faculty toward them; time constraint; inability to visit outpatient services to seek consultation; lack of confidentiality; unwanted sympathy from peers; fear that information will be sent to the department and family members; fear that it will lead to interference with postings and examination schedules; fear of impact on academic performance; and fear of side-effects of medications.[41] Various barriers in help-seeking acting at individual and institutional levels are summarized in [Table 3].{Table 3}

 Assessment of Physician Burnout



Because of lack of recognition of physician burnout as a recognized clinical entity, there are no clear-cut guidelines for the assessment and management of burnout. Various questionnaires which have been used to assess burnout include MBI, Burnout Measure, Oldenburg Burnout Inventory, and Burnout Clinical Subtype Questionnaire [Table 4].[4],[42],[43],[44],[45] All these questionnaires have their strengths and weaknesses. Among the various questionnaires used, MBI is the most commonly used scale in various studies which have evaluated burnout among medical professionals.{Table 4}

While assessing physicians for burnout, it is important to distinguish the same from depression, adjustment disorder, and other diagnoses such as neurasthenia. There is a significant overlap between burnout and depression, in terms of etiology, symptoms, course, cognitive biases, dispositional correlates, and allostatic load. It is important to remember that depression is primarily defined by anhedonia and dysphoric mood. Both the conditions differ from each other with regard to their links to job-specific (burnout) and generic (depression) factors. In persons with depression, the negative thoughts and feelings are not just limited to work but involve all areas of life, whereas in burnout, most of the problems are confined to work. Persons with burnout may report symptoms of depression, but usually, both the conditions differ from each other qualitatively and quantitatively.[46],[47] However, it is important to understand that burnout in physicians, if not addressed, can progress to depression.

Neurasthenia is characterized by mental exhaustion and fatigue. Burnout can be distinguished from neurasthenia by the attribution of fatigue to work instead of somatic factors.[48] Adjustment disorder can also have symptom overlap with burnout; however, it is important to remember that the stress among patients with adjustment disorder is not just limited to work but also can involve acute overwhelming stress involving various other aspects of life.

 Management and Prevention of Burnout



The prevention and management of physician burnout has not as extensively investigated as the prevalence of physician burnout. Most of the preventive programs focus mainly on efforts to increase physician “resilience,” rather than reducing the stressful situations. Some of the preventive strategies suggested to be implemented at the individual level include focusing on the relationships (family and workplace), spiritual practices, self-care (developing personal interests and self-awareness), openness to seek help and consultation, work–life balance, having a positive attitude toward work, with ability to say “no,” and having control over the schedule. However, some of the strategies which have suggested reducing the incidence of physician burnout include increasing vacation time, improving supervision, implementing more aggressive caps on patient census, decreasing the amount or duration of night rotations, increasing elective time, placing vacations or elective rotations adjacent to difficult rotations, and flexible work schedules.[49]

Building resilience is understood as a dynamic, evolving process of positive attitudes and effective strategies. Addressing all these factors promotes well-being and reduction in burnout. The four main issues involved in physician resilience include change in attitudes and perspectives (valuing the physician role, maintaining interest, developing self-awareness, and accepting personal limitations), addressing balance and prioritization (setting limits, taking effective approaches to continuing professional development, and honoring the self), practicing management style (sound business management, having good staff, and using effective practice arrangements), and developing supportive relations (positive personal relationships, effective professional relationships, and good communication).[50] Other measures which have been reported to promote resilience and prevent burnout include promoting emotional intelligence.[51] The preventive strategies which have been suggested to prevent physician burnout include having adequate number of staff, effective decision-making, authentic leadership, collaboration, and having skilled communication.[52]

The treatment of burnout is difficult because of the barrier to seek help and lack of awareness and acceptance about necessity of treatment/intervention. In terms of management, the interventions can be broadly understood as individual-level interventions, interventions at the organization–individual interface, and interventions at the organizational level [Table 5]. The important fact to remember is that individual-level interventions usually yield short-term benefits, up to 6 months, while those at the organizational level have longer benefit, more than a year. Further, the available evidence suggests that compared to physician-directed interventions, organization-directed interventions are more likely to lead to reductions in burnout, and the organization changes have a long-lasting effect on burnout reduction.[52] Among the various organization-level interventions, combined structural changes, fostering communication, sense of teamwork, and job control tend to be the most effective.[53]{Table 5}

 Conclusion



Burnout started as a sociocultural phenomenon in North America in the 1960s, but over the last half a century, the concept has been evaluated across the globe. Studies across the globe suggest that burnout is common among medical professionals, across the different stages of their career. However, despite progress in the understanding of physician burnout, still, there is a lack of a consensus definition for burnout. Although studies have reported the prevalence of burnout across the globe, cultural factors associated with the development of burnout have not been evaluated. In terms of intervention, there are limited data available in the form of randomized controlled trials to guide the clinicians to choose appropriate preventive and management strategies. Hence, there is a need to evaluate a wider range of techniques to assess the prevalence, etiologies, and interventions of burnout.

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Conflicts of interest

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