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Burnout in United States Healthcare Professionals: A Narrative Review

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Thomas P Reith
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Abstract

Burnout has reached rampant levels among United States (US) healthcare professionals, with over one-half of physicians and one-third of nurses experiencing symptoms. The burnout epidemic is detrimental to patient care and may exacerbate the impending physician shortage. This review gives a brief history of burnout and summarizes its main causes, effects, and prevalence among US healthcare workers. It also lists some strategies that physicians, organizations, and medical schools can employ to counter the epidemic.
Received 11/26/2018
Review began 11/27/2018
Review ended 12/03/2018
Published 12/04/2018
© Copyright 2018
Reith. This is an open access article
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Burnout in United States Healthcare
Professionals: A Narrative Review
Thomas P. Reith
1. School of Medicine, Medical College of Wisconsin, Milwaukee, USA
Corresponding author: Thomas P. Reith, treith@mcw.edu
Disclosures can be found in Additional Information at the end of the article
Abstract
Burnout has reached rampant levels among United States (US) healthcare professionals, with
over one-half of physicians and one-third of nurses experiencing symptoms. The burnout
epidemic is detrimental to patient care and may exacerbate the impending physician shortage.
This review gives a brief history of burnout and summarizes its main causes, effects, and
prevalence among US healthcare workers. It also lists some strategies that physicians,
organizations, and medical schools can employ to counter the epidemic.
Categories: Medical Education, Quality Improvement, Other
Keywords: burnout, wellness, well-being, stress, fatigue
Introduction And Background
What is burnout?
Broadly speaking, burnout is a combination of exhaustion, cynicism, and perceived inefficacy
resulting from long-term job stress. It was first described in 1974 by the clinical psychologist
Herbert Freudenberger, who often volunteered at a free clinic in the then drug-ridden East
Village of New York City. Over time, Freudenberger observed emotional depletion and
accompanying psychosomatic symptoms among the clinic’s volunteer staff. He called the
phenomenon “burnout,” borrowing the term from drug-addict slang. Freudenberger defined
burnout as exhaustion resulting from “excessive demands on energy, strength, or resources” in
the workplace, characterizing it by a set of symptoms including malaise, fatigue, frustration,
cynicism, and inefficacy:
There is a feeling of exhaustion, being unable to shake a lingering cold, suffering from
frequent headaches and gastrointestinal disturbances, sleeplessness and shortness of
breath. … The burn-out candidate finds it just too difficult to hold in feelings. He cries
too easily, the slightest pressure makes him feel overburdened and he yells and
screams. With the ease of anger may come a suspicious attitude, a kind of suspicion and
paranoia. The victim begins to feel that just about everyone is out to screw him. … He
becomes the ‘house cynic.’ Anything that is suggested is bad rapped or bad mouthed.
… A sign that is difficult to spot until a closer look is taken is the amount of time a
person is now spending in the free clinic. A greater and greater number of physical
hours are spent there, but less and less is being accomplished. He just seems to hang
around and act as if he has nowhere else to go. Often, sadly, he really does not have
1
Open Access Review
Article DOI: 10.7759/cureus.3681
How to cite this article
Reith T P (December 04, 2018) Burnout in United States Healthcare Professionals: A Narrative Review.
Cureus 10(12): e3681. DOI 10.7759/cureus.3681
anywhere else to go, because in his heavy involvement in the clinic, he has just about
lost most of his friends [1].
In addition, Freudenberger noted that burnout often occurred in contexts requiring large
amounts of personal involvement and empathy, primarily among “the dedicated and the
committed.”
Over the next decade, the social psychologist Christina Maslach built upon Freudenberger’s
work. At the University of California, Berkeley, Maslach developed a model of burnout
consisting of three dimensions: emotional exhaustion, depersonalization, and a diminished
sense of personal accomplishment [2]. In 1981, she proposed the Maslach Burnout Inventory
(MBI), which consists of three subscales to measure the extent of an individual’s symptoms
along each dimension [2]. The MBI remains the most commonly used instrument to assess
burnout to this day [3].
Why should we care about burnout?
The consequences of burnout are not limited to the personal well-being of healthcare workers;
many studies have demonstrated that provider burnout is detrimental to patient care. For
example, the number of major medical errors committed by a surgeon is correlated with
the surgeon's degree of burnout [4] and likelihood of being involved in a malpractice suit [5].
Among nurses, higher levels of burnout are associated with higher rates of both patient
mortality [6] and dissemination of hospital-transmitted infections [7]. In medical students,
burnout has been linked to dishonest clinical behaviors, a decreased sense of altruism [8], and
alcohol abuse [9]. High rates of physician burnout also correlate with lower patient satisfaction
ratings [10].
At an institutional level, burnout results in greater job turnover and increased thoughts of
quitting among physicians [11] and nurses [12]. It also results in decreased workforce
efficiency: a recent Mayo Clinic study estimated the loss of productivity due to physician
burnout as the equivalent of eliminating seven entire medical school graduating classes [13].
Consequently, burnout may contribute to an already impending physician and nursing
shortage.
Review
How prevalent is burnout?
Attending Physicians
Over half of physicians in the United States (US) experience symptoms of burnout, a rate nearly
double that of workers in other professions after controlling for hours worked, age, sex, and
other factors [14]. Furthermore, burnout among physicians has shown signs of increasing. The
2013 Medscape Lifestyle Report – based on the surveyed responses of over 20,000 physicians –
reported a nationwide burnout rate of 40% [15], yet the 2017 Report found a rate of 51% [16],
representing a 25% increase in four years. Another recent study supports the Medscape
findings, reporting a 9% increase in burnout between 2011 and 2014 [17]. Physicians working
the front lines of care (emergency medicine, family medicine, internal medicine and
obstetrics/gynecology (OB/GYN)) are at especially high risk for burnout, and female physicians
are more likely to experience burnout than their male colleagues [16].
Nurses & Physician Assistants
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Burnout is not limited to physicians. A 2001 study found that 43% of nurses working at US
hospitals experience symptoms of emotional exhaustion [18], and a 2011 study reported
burnout prevalences of 37% among nurses providing direct patient care in nursing homes, and
33% among hospital nurses [19]. While burnout in physician assistants is less studied, initial
reports suggest it may be similarly high [20].
Residents & Medical Students
Burnout is especially prevalent among physicians in training. A 2016 study of residents of all
specialties at a tertiary academic center reported an overall burnout rate of 69%, with a 78%
rate among surgical residents and a 66% rate among non-surgical residents [21]. A 2009 review
supports these findings, reporting overall rates of resident burnout up to 75% [22]. In medical
students, burnout levels are not much better. A 2013 review estimated that at least half of
students at US medical schools experience symptoms [23], and a 2018 meta-analysis of over
16,000 students worldwide found that 44% suffered from burnout [24].
What causes burnout?
Although burnout is caused by a myriad of factors, surveys of physicians have helped to identify
common themes. As part of its annual Physician Lifestyle Report, Medscape gives physicians a
list of possible burnout causes and asks them to rank their significance. Over the last five years,
“too many bureaucratic tasks (e.g., charting, paperwork),” “spending too many hours at work,”
and “increasing computerization of practice (electronic health records (EHRs)),” have
consistently been ranked as three of the top four factors [15, 16].
Too Many Bureaucratic Tasks
Today’s physicians spend a large amount of time on documentation required for a growing
number of quality programs initiated by Medicare, Medicaid, and private insurance companies.
Such programs cause burnout by impeding physicians from spending time with their patients
[17]. On average, US physicians spend 2.6 hours per week complying with external quality
measures; in an outpatient setting, this is enough time to see approximately nine additional
patients [25]. Moreover, for each hour of clinical face time that physicians spend with patients,
an additional two are consumed by administrative and clerical work [26]. The former president
of the American Medical Association (AMA), Robert M. Wah, attempted to summarize the
collective feelings of US physicians in the following statement:
Physicians want to provide our patients with the best care possible, but today there are
confusing, misaligned and burdensome regulatory programs that take away critical time
physicians could be spending to provide high-quality care for their patients [27].
Too Much Time at Work
The average US physician works 51 hours per week, with one quarter of US physicians working
more than 60 hours per week [28]. When surveyed by the AMA, one half of physicians
responded that they would prefer to work fewer hours [29]. Inverse correlations have been
found between hours worked and job satisfaction. Physicians working in specialties requiring
more hours report lower job satisfaction, and physicians working in specialties requiring fewer
hours report higher job satisfaction [30].
Increasing Computerization of Practice
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When EHRs were first introduced, they were touted as a way to streamline workflows and
reduce the clerical burden on physicians. In this respect, however, EHRs have had the opposite
effect of creating more work. In one recent study, primary care physicians spent nearly six
hours out of an 11.4-hour workday on EHR tasks, including around 1.5 hours at night after the
clinic was closed [31]. Such tasks included documentation, order entry, billing and coding, and
inbox management. Put another way, physicians spent more time in the EHR than they did
treating patients. In a recent interview, Steven Strongwater, CEO of Massachusetts-based
Atrius Health, summarized the impact of EHRs on Atrius’s physicians as follows:
The electronic medical record has clearly added work to a physician’s day, and people
who are so dedicated and committed are working late into the evenings in what we
would call ‘pajama time.’ In general, what seems to happen is that our docs will work
during the day — they’ll work a full day, sometimes 8 or 10 hours or longer — they’ll go
home for a brief period of time, and then they’ll get back on their record in order to
finish the work of the day that evening [32].
Is burnout a distinct disorder?
The validity of burnout as an independent diagnosis remains controversial. While the majority
of studies use the MBI for measurement, the scales and cutoff values employed are often
arbitrary. Indeed, one recent review concludes that the measurement of burnout in the
literature is so heterogenous that it is impossible to conclude anything about its prevalence [3].
Another criticizes the MBI as being “neither grounded in firm clinical observation nor based on
sound theorizing” [33]. A third calls it “unrealistic”:
The three-dimensional structure of the burnout syndrome is unrealistic [and] the mere
fact of defining burnout as job-related is not nosologically discriminant. … The
arbitrariness surrounding the elaboration of the MBI constitutes a fundamental
problem, especially given the central role of the instrument in the definition of the
burnout phenomenon [34].
Furthermore, the symptoms of burnout seem to overlap with those of depressive disorders. In
one study, over 90% of participants assessed as “burned out” by the MBI also met diagnostic
criteria for depression and scored 15 or greater on the Patient Health Questionnaire-9 (PHQ-9)
[35]. In another study, depressed and “burned out” participants displayed similar attentional
and behavioral alterations [36].
Burnout is also not recognized in the 5th edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), the official classification of psychiatric disorders in the United States
[37].
How can we combat burnout?
Regardless of burnout’s nosological classification, an epidemic of unhappy and demoralized
physicians seems worthy of acknowledgement. Unfortunately, there remains a relative paucity
of evidence on how to address the problem. Still, recent research indicates that efforts at both
the individual and organizational levels can prove effective; indeed, the best way forward likely
involves a combination of the two [38]. To that end, major health organizations have begun
developing guidelines aimed at decreasing burnout and increasing well-being. Last year, the
Mayo Clinic described nine strategies that, when implemented, resulted in a 7% decrease in
2018 Reith et al. Cureus 10(12): e3681. DOI 10.7759/cureus.3681 4 of 9
burnout over a two-year period [39]. In April 2018, a number of physician educators and
wellness experts published a Charter on Physician Well-being [40], which presents guiding
principles that individuals and groups should use when addressing burnout. Some suggestions
for addressing burnout are listed below.
Involve Leadership
There is an ancient saying that the fish begins to stink at the head. In other words, problems
within any organization often stem from its executive leadership. Evidence suggests that
greater leadership qualities in physician supervisors decreases burnout and increases job
satisfaction among the physicians they oversee [41]. Consequently, healthcare administrators
must acknowledge burnout as a systemic problem and promote a culture of self-care among
their employees, starting from the top down. To help accomplish this, some hospitals, such as
Stanford and Mount Sinai, have created the administrative position of chief wellness officer
[42]. If leadership is inadequate, however, organizations must be willing to make changes. In
most companies, the board of directors has no problem ousting a CEO who is not delivering
profits. Similarly, a healthcare executive overseeing a majority of unhappy physicians may need
to be replaced.
Choose Incentives Wisely
Many healthcare systems motivate physicians with financial rewards, either adjusting
physicians’ salaries based on productivity (i.e., revenue generation) or handing out
performance-based bonuses [43]. Yet productivity-based compensation often leads to overwork
and/or shortening the time spent per patient, which in turn leads to increased burnout. Such
consequences are by no means a modern phenomenon. In The Wealth of Nations, the
18th century economist Adam Smith offered the following warning:
Workmen, … when they are liberally paid by the piece, are very apt to overwork
themselves, and to ruin their health and constitution in a few years [44].
To avoid these problems, organizations may want to consider performance-independent salary
models or offer alternative rewards such as greater schedule flexibility or time off [39]. They
may also want to incorporate measures of well-being into performance assessments [40].
Encourage a Work-Life Balance
Physicians often find it difficult to balance long hours at work with their personal lives.
Organizations can help mitigate this problem by allowing physicians to work fewer hours in
exchange for reduced compensation, or by granting them greater flexibility. For example,
physicians could choose to start the work day earlier or later, or work longer hours on certain
days and shorter hours on others. Organizations can also let physicians devote more time to
their favorite aspect of work (e.g., patient care, education, administration, or research).
Physicians who spend at least 20% of their time on the part of work they find most fulfilling
significantly lower their chances of burning out [45]. On an individual level, physicians can
work to improve their time management skills. Eliminating time used inefficiently at work
allows more time to be spent at home.
Encourage Peer Support
Recent years have seen diminished personal interaction between physicians. Increased
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documentation requirements and the rise of EHRs have caused physicians to spend increasing
amounts of time on computer systems. Moreover, doctors’ lounges – where physicians
historically relaxed and discussed cases – have disappeared from many hospitals, resulting in a
loss of camaraderie and an increased sense of isolation [42]. Yet evidence suggests that
encouraging physician solidarity reduces burnout: when Mayo physicians engaged in one hour
of small group discussions every other week, they experienced significant reductions in
depersonalization and emotional exhaustion [46]. One small way for hospitals to promote
physician interaction might be providing coffee and snacks at gathering spots analogous to the
office “water cooler.” Recently, Stanford has taken a more creative approach, paying for small
groups of doctors to dine together at local restaurants [42].
Furnish Resources for Self-care and Mental Health
Mental health remains a taboo subject among physicians, and many are reluctant to pursue
treatment due to potential shame, income loss, or licensure actions [47]. Organizations can
counter this stigma by helping physicians seek treatment in ways that minimize repercussions.
Examples include extending the hours of confidential mental health services to include times
that physicians are not at work, and/or providing coverage to allow physicians to attend
appointments [40]. Organizations can also furnish resources encouraging individual physicians
to practice self-care; examples include offering healthy food in cafeterias, providing
mindfulness or exercise programs at the hospital or clinic, and facilitating memberships to local
gyms. Furthermore, physicians can be equipped with protected time to devote to these
practices.
Target Burnout from Day One of Medical School
Finally, burnout must be addressed from the onset of medical training. This problem cannot be
addressed at the resident and attending levels if students are already burned out by the time
they get there. Recent efforts addressing burnout at select schools have been met with success.
Vanderbilt University's School of Medicine has implemented a wellness program where
students promote healthy habits by holding each other accountable [48]. At
Northwestern University's Feinberg School of Medicine, second-year medical students are
tasked with improving their self-care by choosing a personal health behavior to change and
tracking their progress towards it [49]. Perhaps the most drastic changes, however, have been
made at the Saint Louis University (SLU) School of Medicine, where the curriculum has been
redesigned over the past decade to reduce student stressors and “produce a less toxic
educational environment.” Changes included the implementation of a pass/fail grading system,
reducing unnecessary detail in coursework, and introducing electives throughout the
preclinical years. As a result, SLU students experienced reductions in depression, stress, and
anxiety while maintaining similar levels of academic performance [50].
Conclusions
Burnout has emerged as a major problem plaguing 21 st century American medicine. If not
addressed, the burnout epidemic may continue to worsen, to the detriment of patients and
physicians alike. Experts have identified good starting points to confront this problem, and it is
time for healthcare institutions nationwide to put their suggestions into practice.
Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors
declare the following: Payment/services info: All authors have declared that no financial
2018 Reith et al. Cureus 10(12): e3681. DOI 10.7759/cureus.3681 6 of 9
support was received from any organization for the submitted work. Financial relationships:
All authors have declared that they have no financial relationships at present or within the
previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or
activities that could appear to have influenced the submitted work.
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... Considering that serious medical errors [43,82] occur under Burnout Syndrome it is paramount to attend to the risk factors of individual medical specialties, particularly those at a higher risk. ...
... Health professionals with higher levels of Burnout Syndrome present a higher percentage of medical error in clinical practice [2,36,42,85,86] which compromises the quality of the service provided [22,26,48,57,84,87] the level of patient satisfaction and safety [13,23,24,43,47,67,70,83] as well as interpersonal relationships [38,55,88]. It should be mentioned as well that there is a positive correlation between Burnout levels among nurses and the mortality rate of patients [82] and nosocomial infections [66]. Besides this, health professionals also present a decrease in productivity [13,42,66] and effectiveness of their work [7] which together with absenteeism [48,56,57,72,79] and the increase in the number of referrals to other specialties, contribute to a negative net balance for their institutions [23,27]. ...
... Besides this, health professionals also present a decrease in productivity [13,42,66] and effectiveness of their work [7] which together with absenteeism [48,56,57,72,79] and the increase in the number of referrals to other specialties, contribute to a negative net balance for their institutions [23,27]. Also, as discussed above, Burnout Syndrome can lead to substance use disorders, particularly, but not only, alcohol [7,29,48,49,79,82] and suicidal ideation [43,47,56,61,67,86] with or without suicidal behaviours [79]. ...
Reappraising Burnout Syndrome in Healthcare under Sars-Cov-2 Pandemic
Article
Full-text available
  • Jan 2021
Background: Burnout Syndrome consists of a set of physical and psychological symptoms, resulting from an excessive workload and can be divided in three main dimensions: Emotional Exhaustion, Depersonalization and Lack of Personal Achievement at Work. It is a prevalent and extremely relevant health problem, affecting over half the health professionals.
... Inefficacy, described initially as a reduced personal accomplishment, is a state of low morale affecting productivity and the ability to cope. 2 First described in the scientific literature in 1974 by Freudenberger, followed by Maslach in 1981, 2 the prevalence of this syndrome has since reached 'epidemic' levels in the USA. 3 Previous to the COVID-19 pandemic, nearly 50% of physicians reported living with burnout. 3 Similar prevalence rates were also observed among nurses and physician assistants. ...
... Inefficacy, described initially as a reduced personal accomplishment, is a state of low morale affecting productivity and the ability to cope. 2 First described in the scientific literature in 1974 by Freudenberger, followed by Maslach in 1981, 2 the prevalence of this syndrome has since reached 'epidemic' levels in the USA. 3 Previous to the COVID-19 pandemic, nearly 50% of physicians reported living with burnout. 3 Similar prevalence rates were also observed among nurses and physician assistants. 3 The COVID-19 pandemic imposed significant challenges to the healthcare system, and in turn, burnout prevalence among qualified healthcare professionals (QHP) has skyrocketed globally. ...
... 3 Similar prevalence rates were also observed among nurses and physician assistants. 3 The COVID-19 pandemic imposed significant challenges to the healthcare system, and in turn, burnout prevalence among qualified healthcare professionals (QHP) has skyrocketed globally. [4][5][6][7][8] As a multidimensional syndrome, the clinical manifestation of burnout spirals down to a cascade of adverse outcomes affecting QHP, patients and healthcare systems. ...
Implementing complex interventions to mitigate burnout among qualified healthcare professionals: a realist review protocol
Article
Full-text available
  • Jan 2023
Introduction Reported burnout rates among qualified healthcare professionals (QHP) are alarming. Systematic reviews evaluating the effectiveness of burnout interventions for QHP exist; however, findings are contradictory. In addition, to date, there is no indication of how these interventions work and what specific intervention elements mitigate burnout. This review aims to explain how burnout interventions work and the contextual factors that mediate the intended outcomes. Our ultimate goal is to formulate actionable recommendations to guide the implementation of complex burnout interventions for QHP working in the hospital setting. Methods and analysis In light of the heterogeneity and complexity of the interventions designed to address burnout, we will conduct a realist review using Pawson’s five iterative stages to explore and explain how burnout interventions work, for whom, and in what circumstances. We will search PubMed, CINAHL, Scopus, PsycINFO and Web of Science from inception to December 2022. Grey literature sources will also be considered. The results will be reported according to the Realist and Meta-Narrative Evidence Syntheses—Evolving Standards quality and publication standards Ethics and dissemination Findings will be disseminated in a peer-reviewed journal, conference presentations and through the development of infographics and relevant educational material to be shared with stakeholders and key institutions. This study is a secondary data analysis; thus, a formal ethics review is not applicable. PROSPERO registration number CRD42021293154.
... Burnout can have serious consequences, it can have enormous effects both on the individual and the society due to personal and interpersonal disturbances [8][9][10]. It can also lead to serious health issues, such as insomnia, increased anxiety and depression and can also be closely associated with cardiovascular complications, chronic pain syndromes and increased sudden mortality in the young (< 45 years) [11][12][13][14]. Considering the adverse effects of burnout as seen above, it can negatively impact all domains of life and can be associated with lower quality of life, although this connection has rarely been studied among "blue-collar" workers [2,[15][16][17][18]. ...
... In our study, the prevalence of overall burnout was 50.8%, which is a surpsisingly high rate, much higher than among healtcare professionals who are amongst the most vulnerable ones [3,15,[31][32][33]. Burnout can have serious mental and physical consequences including mental issues as insomnia or mood disorders and can also be closely associated with cardiovascular complications, chronic pain syndromes and increased sudden mortality in the young (< 45 years), which underlines the importance of proper screening [11][12][13][14]. However, this rate is comparable to the results of our previous Hungarian studies focusing on different population of workers [26,34,35]. ...
... It is estimated to become the leading cause of disability and one of the leading causes of death by 2030 because of increased suicide rates [45]. It is a matter of debate whether there is a significant ovelap between burnout and depression [14]. On the other hand, a recent metaanalysis including a moderation analysis showed different pathways, which is in concodance with our result as neither the history of depression nor the presence of a mood disorder were significantly associated with burnout in a multivariate analysis [15]. ...
The prevalence and risk factors of burnout and its association with mental issues and quality of life among hungarian postal workers: a cross-sectional study
Article
Full-text available
Background Burnout is one of the most extensively studied phenomena of the twenty-first century; which has been extensively studied among helping professions, although it can be broadened to several other types of occupation. Based on our knowledge and literature search, no similar studies have been carried out among postal workes to date. Methods This cross-sectional questionnaire-based epidemiological study was carried out between May 2021 and January 2022 in five counties in Hungary with the recruitment of postal delivery workers focusing on (1) the prevalence of burnout among postal delivery workers; (2) including the role of demographic parameters, duration of employment as well as the presence of secondary employment; (3) and also analyzed the role of several risk factors and medical conditions; (4) and we also examined the possible association between depression, insomnia and quality of life and burnout. Results Overall 1300 questionnaires were successfully delivered and 1034 responses received (response rate of 79.5%). Three hundred sixty-eight males (35.6%) and six hundred sixty-six females (64.4%) participated in our study. The prevalence of burnout was 50.8% (525/1034) in this study population (mean score 2.74 ± 0.33). Logistic regression analysis showed that female gender [OR = 2.380, 95% CI: 1.731 to 2.554], first workplace [OR = 1.891, 95% CI: 1.582 to 2.162] and working more than 30 years [OR = 1.901, 95% CI: 1.608 to 2.326] have significantly increased the likelyhood of burnout as well as the history of muscoskeletal pain [OR = 1.156, 95% CI: 1.009 to1.342], current quality of life [OR = 1.602, 95% CI: 1.473 to 1.669] and the presence of sleep disturbance [OR = 1.289, 95% CI: 1.066 to 1.716]. Conclusion This is the first study in Hungary to investigate the prevalence of burnout among postal workers and to explore the relationship between burnout and mental health problems. Our study underlines the clinical importance of burnout and draws attention to the need for appropriate prevention and treatment strategies.
... 50% of clinicians (physicians, nurses, pharmacists, and other professionals) report feeling burned out. 4 A large body of research has emphasized and evaluated self-care activities as potential coping-strategies for burnout, with considerable focus on mindfulness, meditation, and meditative practices. [5][6][7][8][9] Meditation, as defined by the National Institutes of Health Center on Complementary and Alternative Medicine, is "a mind and body practice that has a long history of use for increasing calmness and physical relaxation, improving psychological balance, coping with illness and enhancing overall health and well-being." 10 Meditation has been shown to have a number of benefits, including improvements in perceived stress and burnout. ...
Journey Mapping Healthcare Worker Experience With Heart Rhythm Meditation
Article
  • Jan 2023
Background Levels of stress and burnout continue to rise amongst healthcare workers. In addition to systemic and institution-level changes to healthcare practice environments, well-being interventions, resources, and support to assist healthcare providers are necessary. Meditation practices like Heart Rhythm Meditation (HRM) may provide benefits to healthcare workers, but healthcare worker experiences with HRM are not well understood. Objective To explore healthcare worker experiences with HRM using a journey mapping approach. Methods An exploratory cross-sectional online survey was administered between May and July of 2020 to a purposeful sample of 25 healthcare workers currently practicing HRM. Surveys consisted of 5 open-ended and 36 multiple-choice items mapped to five journey mapping domains: Discover, Search, Assess, Decide, Assist. Descriptive statistics for survey items were generated in addition to a visual representation of a Persona and associated journey map for HRM. Content analysis was performed on open-ended responses using a general inductive approach to code responses and identify representative quotes. Results Twenty surveys were completed for a response rate of 80%. The majority of respondents identified as women (n = 14). From the journey mapping output, the overall emotional experience score was an 8.2/10, suggesting respondents had positive experiences with HRM. Open-ended comments suggest that HRM provides important benefits to the personal and professional lives of healthcare workers. A small number of participants reported challenges like feeling difficult emotions during HRM practice. Conclusion Mapping the healthcare worker journey with HRM identified generally positive experiences with personal and professional benefits. While experiences were largely positive, HRM elicited difficult emotions from some individuals, suggesting that appropriate resources and support are required when considering HRM and other meditation forms.
... Bu çalışmanın yöneticilere ve çalışanlara da katkıları bulunmaktadır. Örneğin, Amerika Birleşik Devletleri'nde özellikle sağlık çalışanlarının yarısının, hemşirelerin de üçte birinin tükenmişlik semptomları ile karşılaştığı ve tükenmişlik semptomları yaşayan sağlık çalışanlarının hasta ölüm oranlarını olumsuz yönde etkilediği, düşük hasta memnuniyeti yarattığı ve cerrahi hatalara yol açabildiği gösterilmiştir (Reith, 2018). Benzer bir şekilde diğer sektörlerde de tükenmişliğin olumsuz etkilerini gösteren birçok veri mevcuttur (Alarcon, 2011). ...
... A disheartening finding in this study was lesser emphasis on well-being. This is of concern as physician burnout is rampant [57]. This finding is not aligned with one purpose of education-a fulfilled meaningful life-that includes personal well-being. ...
A framework for residents’ pursuit of excellence based upon non-cognitive and cognitive attributes
Article
  • Jan 2023
Purpose Excellence, although variably conceptualized, is commonly used in medicine and the resident excellence literature is limited. Both cognitive attributes (CAs) and non-cognitive attributes (NCAs) are essential for academic and clinical performance; however, the latter are difficult to evaluate. Undergirded by an inclusive and non-competitive approach and utilizing CAs and NCAs, we propose a criterion-referenced behavioral framework of resident excellence. Methods Perceptions of multiple stakeholders (educational administrators, faculty, and residents), gathered by survey (n = 218), document analysis (n = 52), and focus group (n = 23), were analyzed. Inductive thematic analysis was followed by deductive interpretation and categorization using sensitizing concepts for excellence, NCAs, and CAs. Chi-squared tests were used to determine stakeholder perception differences. Results All stakeholders had similar perceptions (P > .05) and 13 behavioral attributes in 6 themes undergirded by insight and conscientiousness were identified. The NCAs included: interpersonal skills (works with others, available, humble), professional (compassionate, trustworthy), commitment to profession (visible, volunteers), commitment to learn (proactively seeks feedback, creates learning opportunities), and work–life balance/integration (calm demeanor, inspirational). The CA (medical knowledge and intellect) included: applies knowledge to gain expertise and improves program’s caliber. Conclusion Resident excellence is posited as a pursuit. The attributes are non-competitive, inclusionary, potentially achievable by all, and do not negatively affect freedom of choice. However, contextual and cultural differences are likely and these need validation across societal equity segments. There are implications for learners (adaptive reflection and learning goal orientation), faculty (reduced bias and whole-person feedback), and system leaders (enhancing culture and learning environments) to foster excellence.
Evaluation of a Pre-clinic Diabetes Assessment and Mapped Care Planning Intervention: a Multi-Centre Randomised Controlled Trial
Preprint
Full-text available
  • Oct 2021
Introduction: Existing therapeutic interventions to treat diabetes are well known, yet the majority of people with diabetes do not consistently achieve blood glucose targets (even individual therapy targets) for optimal health, despite the large range of treatment options available. Such outcomes have remained stubbornly poor for decades with <25% adults with diabetes achieving glycaemic targets. Patient behaviour, individually supported in routine clinical care, is an important missing component to improved outcomes, in a medical healthcare model not ideally suited to supporting successful diabetes management. Participants: Adults with type 1, type 2 or pre-diabetes attending routine care outpatient appointments. Design: A multi-centre, parallel group, individually randomised trial comparing consultation duration in adults with type 1, type 2 or pre-diabetes using the Spotlight Consultations pre-clinic assessment compared to usual care in the Spotlight-AQ study. Intervention: An outpatient pre-clinic intervention delivered within one week prior to scheduled routine outpatient appointment. Sample size: 200 recruited across up to 10 sites. Primary outcome measure: Duration of routine outpatient consultation. Secondary outcome measures: · Functional health status · diabetes distress · depression · treatment satisfaction · impact on self-care behaviours · HCP burnout · HCP treatment satisfaction and burden · hypoglycaemia (time less than 70mg/dL) · hyperglycaemia (time above 180 mg/dL) · Change in weight · Change in HbA1c · Cost effectiveness of intervention Ethics and dissemination: The trial was approved by the Wales REC7 Research Ethics Committee (21/WA/0020). Results will be disseminated through national and international conferences, scientific journals, newsletters, magazines and social media. Target audiences include consultants and other clinicians in diabetes, and medical professionals or scientists overall. Trial Registration: ISRCTN15511689
Patient Enrollment Growth and Burnout in Primary Care at the Veterans Health Administration
Article
  • Jan 2023
Background Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown.Objective Estimate associations between patient enrollment and burnout.DesignIn this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA’s annual All Employee Survey provided burnout estimates.ParticipantsA total of 82,421 responses to the 2014–2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members.Main MeasuresIndependent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently.Key ResultsOverall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3).Conclusions Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.
Work-Life Integration in Medicine: Unlearning Medical Culture and Establishing Boundaries
Chapter
  • Jan 2023
As defined by the International Classification of Diseases 11th revision, burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion, feelings of negativism or cynicism related to one's job, and reduced professional efficacy. Multiple studies using the most widely accepted standard for burnout assessment—the Maslach Burnout Inventory—reported an increased incidence of burnout amongst all healthcare workers, particularly physicians. The most reported factor leading to burnout is the lack of appropriate work-life integration (WLI). WLI is a complex issue that requires prioritization, value alignment, boundary setting, and lifelong work. This chapter highlights a few of the many barriers to WLI in medicine, the impact of burnout on the delivery of quality care, and strategies to achieve a goal-based WLI for healthcare workers offering direct patient care during and after training.
Ensuring Emotional Fitness of Healthcare Workers Through Employee Champion Role of Human Resource Management
Article
Full-text available
  • Jan 2023
Objective: The study examines Human Resource champion approach in combating the emotional health problems of healthcare workers. The objectives of the study include identifying the different emotional needs of Health care workers; mapping the various Human Resource Champion roles towards each of the identified emotional needs of the healthcare workers and the different levels of emotional well-being. Methods: Based on a mini review the purpose of the paper is to create a unique synthesis and proposal for utility of healthcare organizations The exploration included terms of search in combination and in particular related to emotional fitness of healthcare workers, COVID-19, HR role in managing employee stress, , workplace stress, employee champion and HR champion. The potential chances of subjectivity in selection of the papers cannot be overlooked though the various databases used for review include Google scholar, Web of Science, Semantic Scholar which provides the most cited work. Results: The study reports a negative influence of pandemic on HCW’s mental health. The identified needs of Healthcare workers during the pandemic include caring, protecting, hearing, preparing and supporting them. The identified needs have been mapped towards the various HR champions ie physical, social, financial, emotional, work-life integration and meaning in work champion. The various practices that were available and were considered feasible have also been evaluated. The fulfillment of the specific emotional needs of HCW’s can lead to emotional well- being at different levels including essentials, belonging, purpose and flourishing. Conclusions: The findings of the study reveal that different employee champions can nurture the specific emotional needs of healthcare workers thereby leading to fulfillment of their emotional well-being at different levels. Some champion roles are more visible (Physical and financial champion) as compared to Work- life integration, Social, Emotional, Meaning in work champions in the healthcare organizations.
Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties
Article
Full-text available
  • Sep 2016
Background: Little is known about how physician time is allocated in ambulatory care. Objective: To describe how physician time is spent in ambulatory practice. Design: Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours). Setting: U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington). Participants: 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries. Measurements: Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work. Results: During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks. Limitations: Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics. Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. Primary funding source: American Medical Association.
Burnout in Rural Physician Assistants: An Initial Study
Article
Full-text available
  • Apr 2016
Purpose: To assess the prevalence and causes of burnout in rural physician assistants. (PA in this article refers to personal accomplishment. To avoid confusion, we will spell out physician assistant throughout the article, instead of using PA to refer to both physician assistant and personal accomplishment.) METHODS: Physician assistants who practice in rural communities were asked to complete the Maslach Burnout Inventory. A preliminary assessment of burnout was determined using the 3 Maslach Burnout Inventory subscale scores: emotional exhaustion, depersonalization, and personal accomplishment, as well as causes of burnout assessed for a correlation to personal and professional factors. Results: Burnout within the rural physician assistant population responding to this survey (response rate = 11.3%) was measured to have high to moderate emotional exhaustion and depersonalization subscores (64% each) and a low to moderate personal accomplishment subscore (46%). Conclusions: The rural physician assistant population who responded to this survey exhibited burnout correlating to feelings of professional isolation and various workplace conditions such as the adequacy of administrative support and control over workload. To begin addressing burnout within this community, we suggest adjusting rural physician assistant workload and support, enhancing professional communications, and addressing burnout prevention techniques within physician assistant training programs.
Burnout in medical students before residency: A systematic review and meta-analysis
Article
  • Jan 2019
Background: Applying the concept of burnout to medical students before residency is relatively recent. Its estimated prevalence varies significantly between studies. Our objective was to estimate the prevalence of burnout in medical students worldwide. Methods: We systematically searched Medline for English-language articles published between January 1, 2010 and December 31, 2017. We selected all the original studies about the prevalence of burnout in medical students before residency, using validated questionnaires for burnout. Statistical analyses were conducted using the OpenMetaAnalyst software. Results: Prevalence of current burnout was extracted from 24 studies encompassing 17,431 medical students. Among them, 8060 suffered from burnout and we estimated the prevalence to be 44.2% [33.4%– 55.0%]. The information about the prevalence of each subset of burnout dimensions was given in nine studies including 7588 students. Current prevalence was estimated to be 40.8% for ‘emotional exhaustion’ [32.8%–48.9%], 35.1% [27.2%–43.0%] for ‘depersonalization’ and 27.4% [20.5%–34.3%] for ‘personal accomplishment’. There is no significant gender difference in burnout. The prevalence of burnout is slightly different across countries with a higher prevalence in Oceania and the Middle East than in other continents. Conclusions: The results of this meta-analysis suggest that one student out of two is suffering from burnout, even before residency. Again, our findings highlight the high level of distress in the medical population. These results should encourage the development of preventive strategies.
Prevalence of Burnout Among Physicians: A Systematic Review
Article
Importance: Burnout is a self-reported job-related syndrome increasingly recognized as a critical factor affecting physicians and their patients. An accurate estimate of burnout prevalence among physicians would have important health policy implications, but the overall prevalence is unknown. Objective: To characterize the methods used to assess burnout and provide an estimate of the prevalence of physician burnout. Data sources and study selection: Systematic search of EMBASE, ERIC, MEDLINE/PubMed, psycARTICLES, and psycINFO for studies on the prevalence of burnout in practicing physicians (ie, excluding physicians in training) published before June 1, 2018. Data extraction and synthesis: Burnout prevalence and study characteristics were extracted independently by 3 investigators. Although meta-analytic pooling was planned, variation in study designs and burnout ascertainment methods, as well as statistical heterogeneity, made quantitative pooling inappropriate. Therefore, studies were summarized descriptively and assessed qualitatively. Main outcomes and measures: Point or period prevalence of burnout assessed by questionnaire. Results: Burnout prevalence data were extracted from 182 studies involving 109 628 individuals in 45 countries published between 1991 and 2018. In all, 85.7% (156/182) of studies used a version of the Maslach Burnout Inventory (MBI) to assess burnout. Studies variably reported prevalence estimates of overall burnout or burnout subcomponents: 67.0% (122/182) on overall burnout, 72.0% (131/182) on emotional exhaustion, 68.1% (124/182) on depersonalization, and 63.2% (115/182) on low personal accomplishment. Studies used at least 142 unique definitions for meeting overall burnout or burnout subscale criteria, indicating substantial disagreement in the literature on what constituted burnout. Studies variably defined burnout based on predefined cutoff scores or sample quantiles and used markedly different cutoff definitions. Among studies using instruments based on the MBI, there were at least 47 distinct definitions of overall burnout prevalence and 29, 26, and 26 definitions of emotional exhaustion, depersonalization, and low personal accomplishment prevalence, respectively. Overall burnout prevalence ranged from 0% to 80.5%. Emotional exhaustion, depersonalization, and low personal accomplishment prevalence ranged from 0% to 86.2%, 0% to 89.9%, and 0% to 87.1%, respectively. Because of inconsistencies in definitions of and assessment methods for burnout across studies, associations between burnout and sex, age, geography, time, specialty, and depressive symptoms could not be reliably determined. Conclusions and relevance: In this systematic review, there was substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods, and study quality. These findings preclude definitive conclusions about the prevalence of burnout and highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools to assess the effects of chronic occupational stress on physicians.
Charter on Physician Well-being
Article
  • Mar 2018
Dedication to serving the interest of the patient is at the heart of medicine’s contract with society. When physicians are well, they are best able to meaningfully connect with and care for patients. However, challenges to physician well-being are widespread, with problems such as dissatisfaction, symptoms of burnout, relatively high rates of depression, and increased suicide risk affecting physicians from premedical training through their professional careers. These problems are associated with suboptimal patient care, lower patient satisfaction, decreased access to care, and increased health care costs.
Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations
Article
  • Sep 2017
Purpose: Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. Methods: We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours. Results: Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%). Conclusions: Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation.
Executive Leadership and Physician Well-being
Article
These are challenging times for health care executives. The health care field is experiencing unprecedented changes that threaten the survival of many health care organizations. To successfully navigate these challenges, health care executives need committed and productive physicians working in collaboration with organization leaders. Unfortunately, national studies suggest that at least 50% of US physicians are experiencing professional burnout, indicating that most executives face this challenge with a disillusioned physician workforce. Burnout is a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Physician burnout has been shown to influence quality of care, patient safety, physician turnover, and patient satisfaction. Although burnout is a system issue, most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician. Engagement is the positive antithesis of burnout and is characterized by vigor, dedication, and absorption in work. There is a strong business case for organizations to invest in efforts to reduce physician burnout and promote engagement. Herein, we summarize 9 organizational strategies to promote physician engagement and describe how we have operationalized some of these approaches at Mayo Clinic. Our experience demonstrates that deliberate, sustained, and comprehensive efforts by the organization to reduce burnout and promote engagement can make a difference. Many effective interventions are relatively inexpensive, and small investments can have a large impact. Leadership and sustained attention from the highest level of the organization are the keys to making progress.
Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis
Article
Background: Physician burnout has reached epidemic levels, as documented in national studies of both physicians in training and practising physicians. The consequences are negative effects on patient care, professionalism, physicians' own care and safety, and the viability of health-care systems. A more complete understanding than at present of the quality and outcomes of the literature on approaches to prevent and reduce burnout is necessary. Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO, Scopus, Web of Science, and the Education Resources Information Center from inception to Jan 15, 2016, for studies of interventions to prevent and reduce physician burnout, including single-arm pre-post comparison studies. We required studies to provide physician-specific burnout data using burnout measures with validity support from commonly accepted sources of evidence. We excluded studies of medical students and non-physician health-care providers. We considered potential eligibility of the abstracts and extracted data from eligible studies using a standardised form. Outcomes were changes in overall burnout, emotional exhaustion score (and high emotional exhaustion), and depersonalisation score (and high depersonalisation). We used random-effects models to calculate pooled mean difference estimates for changes in each outcome. Findings: We identified 2617 articles, of which 15 randomised trials including 716 physicians and 37 cohort studies including 2914 physicians met inclusion criteria. Overall burnout decreased from 54% to 44% (difference 10% [95% CI 5-14]; p<0·0001; I(2)=15%; 14 studies), emotional exhaustion score decreased from 23·82 points to 21·17 points (2·65 points [1·67-3·64]; p<0·0001; I(2)=82%; 40 studies), and depersonalisation score decreased from 9·05 to 8·41 (0·64 points [0·15-1·14]; p=0·01; I(2)=58%; 36 studies). High emotional exhaustion decreased from 38% to 24% (14% [11-18]; p<0·0001; I(2)=0%; 21 studies) and high depersonalisation decreased from 38% to 34% (4% [0-8]; p=0·04; I(2)=0%; 16 studies). Interpretation: The literature indicates that both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians. Further research is needed to establish which interventions are most effective in specific populations, as well as how individual and organisational solutions might be combined to deliver even greater improvements in physician wellbeing than those achieved with individual solutions. Funding: Arnold P Gold Foundation Research Institute.
Taking Care of Our Own: A Multispecialty Study of Resident and Program Director Perspectives on Contributors to Burnout and Potential Interventions
Article
  • Jul 2016
Objective: Rates of resident physician burnout range from 60 to 76 % and are rising. Consequently, there is an urgent need for academic medical centers to develop system-wide initiatives to combat burnout in physicians. Academic psychiatrists who advocate for or treat residents should be familiar with the scope of the problem and the contributors to burnout and potential interventions to mitigate it. We aimed to measure burnout in residents across a range of specialties and to describe resident- and program director-identified contributors and interventions. Methods: Residents across all specialties at a tertiary academic hospital completed surveys to assess symptoms of burnout and depression using the Maslach Burnout Inventory and the Patient Health Questionnaire-9, respectively. Residents and program directors identified contributors to burnout and interventions that might mitigate its risk. Residents were asked to identify barriers to treatment. Results: There were 307 residents (response rate of 61 %) who completed at least one question on the survey; however, all residents did not respond to all questions, resulting in varying denominators across survey questions. In total, 190 of 276 residents (69 %) met criteria for burnout and 45 of 263 (17 %) screened positive for depression. Program directors underestimated rates of burnout, with only one program director estimating a rate of 50 % or higher. Overall residents and program directors agreed that lack of work-life balance and feeling unappreciated were major contributors. Forty-two percent of residents reported that inability to take time off from work was a significant barrier to seeking help, and 25 % incorrectly believed that burnout is a reportable condition to the medical board. Conclusions: Resident distress is common and most likely due to work-life imbalance and feeling unappreciated. However, residents are reluctant to seek help. Interventions that address work-life balance and increase access to support are urgently needed in academic medical centers.