From the Editor
Not so many years ago, no one seemed to discuss physician burnout.
Today, we speak much more about physician health and wellness.
In this week’s Reading, we consider a new American Journal of Psychiatry paper written by Dr. Erick Messias and Victoria Flynn of the University of Arkansas for Medical Sciences. In this highly readable Clinical Case Conference, the authors discuss the case of a mid-career psychiatrist – and then weigh the larger problem of burnout, and its overlap with depression.
Also, we consider the literature around burnout, and highlight a new JAMA Internal Medicine paper. “The pooled outcomes of the main analysis indicated that physician overall burnout is associated with twice the odds of involvement in patient safety incidents (OR, 1.96…).”
Burnout and Practice
“The Tired, Retired, and Recovered Physician: Professional Burnout Versus Major Depressive Disorder”
Erick Messias, Victoria Flynn
The American Journal of Psychiatry, 1 August 2018
Professional burnout is prevalent and consequential in health care today. Burnout is traditionally defined as an experience in response to chronic job stressors and as having three components: exhaustion, cynicism, and inefficacy. The prevalence of physician burnout was estimated at 54.4% in 2014, up from 45.5% in 2011. Similarly, 43.2% of nurses reported having levels of high emotional exhaustion in a large U.S. national sample, as did 50% of resident physicians. The consequences of burnout include increased patient mortality, reduction in work effort, increase in self-reported medical errors, and overall decreased satisfaction with work-life balance.
Although there are a plethora of instruments to measure burnout, the Maslach Burnout Inventory has been the most widely adopted in surveys in recent decades. The Maslach Burnout Inventory has U.S. national benchmarks, appears relevant to a variety of health professions, and has shown correlations with relevant outcomes. The Copenhagen Burnout Inventory, which was developed as part of the Danish Project on Burnout, Motivation, and Job Satisfaction, consists of three scales measuring personal, work-related, and client-related burnout. Its normative values for personal, work-related, and client related burnout, defined as a score ≥50, were 22.2%, 19.8%, and 15.9%, respectively. The scale has been shown to have high internal reliability and is associated with sickness absence, sleep problems, and intention to quit.
The driver dimensions of burnout among physicians include workload and job demands; efficiency and resources; meaning in work; organizational values and culture; control and flexibility; social support and community at work; and work-life integration.
So begins a “Clinical Case Conference” by Drs. Messias and Flynn.
It opens with a clinical summary of a physician. “‘Dr. A’ retired from the practice of medicine at the age of 49.” In describing the care, the authors note that Dr. A. had scored 50 or over for five out of seven items in the Copenhagen Burnout Inventory – but had scored zero in the Patient Health Questionnaire-9 (PHQ-9), indicating that he wasn’t depressed.
The paper notes a significant interest in the area, with organizations like the American Psychiatric Association starting to address these problems.
Yet the paper also notes the lack of depth of the literature:
- In a review of efficacy of interventions for physician burnout, there were just 52 studies – and most were observational.
- A Cochrane systematic review of interventions to prevent occupational stress also found “low-quality evidence” that CBT and other interventions reduced stress; there was “low-quality evidence” that changing work schedules is an effective strategy.
- The American Medical Association promotes a framework that includes seven steps for organizations to prevent or reduce burnout: establish wellness as a quality indicator; start a wellness committee or choose a wellness champion; distribute an annual wellness survey; meet regularly with leaders and staff to discuss data and interventions; initiate selected interventions; repeat the survey to reevaluate the situation; seek answers within the data, refine the interventions, and continue improvements.
The paper then considers the distinction between burnout and depression.
The debate about the boundaries of burnout and depression has similarities to that regarding the difference between depression and grief.
They go on to propose a DSM-5-style qualifier:
In distinguishing burnout from a major depressive episode, it is useful to consider that in burnout the predominant affect is feelings of exhaustion, cynicism, and inefficacy, whereas in major depressive episode it is persistent depressed mood and the inability to anticipate happiness or pleasure. The dysphoria in burnout is likely to correlate with fluctuations in workload demands, whereas the depressed mood in a major depressive episode is more persistent and is not tied to specific thoughts and preoccupations. The pain of burnout may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery seen in a major depressive episode. The thought content associated with burnout generally features a preoccupation with work rather than the self-critical or pessimistic ruminations seen in major depressive episode. In burnout, self-esteem is generally preserved, whereas in major depressive episode, feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in burnout, it typically involves perceived failings related to work.
For the record, Dr. A. returns to do a fellowship after a couple of years off, and then does some research training. He joins an academic medical centre where he continues to work, now 70 years of age.
- This is a good paper.
- The topic is very timely. (A google search of “physician burnout” yields over two million hits.)
- The distinction of depression and burnout is fair – and is the authors’ comment that burnout “should not be overlooked as a modifiable risk and aggravating factor for depression.” This seems like a nice compromise between acknowledging the distress of the workplace without pathologizing it.
- A new paper from JAMA Internal Medicine considers the impact on patient care. In “Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis,” the University of Manchester’s Maria Panagiotiand her co-authors note: “Despite consistent findings regarding the high prevalence of burnout and the detrimental personal consequences for physicians, research evidence about the outcome of physician burnout on the quality of care delivered to patients is less definitive.”
In this paper, Panagioti et al. consider 47 studies involving more than 47,000 physicians. Burnout was “evaluated with standardized measures, such as the Maslach Burnout Inventory (MBI) or equivalent.”
The pooled outcomes of the main analysis indicated that physician overall burnout is associated with twice the odds of involvement in patient safety incidents (OR, 1.96…). All dimensions of burnout were associated with significantly increased odds of involvement in patient safety incidents (emotional exhaustion: OR, 1.73; depersonalization: OR, 1.94; personal accomplishment: OR, 1.49).
The paper also weighed patient satisfaction. See the figure below.
The Panagioti et al. paper has gathered much attention; there was a lively discussion on social media.
That paper runs with an invited commentary by the University of Minnesota’s Mark Linzer. He writes: “Although a high degree of heterogeneity was seen, results consistently favored an association between burnout and patient outcomes. A study strength is that burnout was usually measured with the Maslach Burnout Inventory, which is widely considered to be the standard among burnout measurement instruments (internally consistent and validated against multiple personal experience metrics).”
He ends with a call for action:
In 2018, JAMA Internal Medicine published an editorial calling for more rigorous quality improvement studies. The editors emphasized that quality improvement projects are often local… Resonating with these concepts, I propose that for the burnout prevention and wellness field, we encourage quality improvement projects of high standards: multiple sites, concurrent control groups, longitudinal design, and blinding when feasible, with assessment of outcomes and costs.
The paper can be found here: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2698144; the invited commentary, here: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2698140.
- Interested in a self-assessment? Check out this APA link: https://www.psychiatry.org/psychiatrists/practice/well-being-and-burnout/assess-yourself.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.