Nearly half of medical residents report burnout during their second year of residency, and 1 in 7 report regretting their career choice, according to a prospective study published online last week in JAMA. However, not all specialties are equally affected by burnout or regret, the authors report.
Despite the high prevalence of burnout among residents, a systematic review published in the same issue finds that studies of physician burnout vary so greatly in their definitions and measurement tools that little can be concluded about the overall prevalence of burnout among physicians in general. The review of 182 studies worldwide found physician burnout rates range from 0% to more than 85%, depending on definitions and cutoffs of burnout measurement.
In the study on residents, Liselotte N. Dyrbye, MD, MHPE, of the Mayo Clinic (Rochester MN), and colleagues prospectively tracked 4696 US resident physicians from 49 medical schools for up to 6 years starting from their first year in medical school. First-year students filled out a baseline questionnaire between October 2010 and January 2011 and then two more questionnaires in their fourth school year and their second year of residency.
Dyrbye and colleagues suggest that “difficulties with work-life balance and work-home conflicts, sexism, stereotype threat and discrimination may play a part.”
The questionnaires collected information on participants’ demographics, clinical specialty, educational debt, and US Medical Licensing Examination Step 1 score. Students also answered questions about their levels of anxiety, empathy, and social support while in medical school; in later surveys, they were asked if they regretted their career choice. Of the 76.4% of participants who completed the second-year residency questionnaire, 45% reported burnout symptoms and 14% regretted their career choice.
Burnout prevalence was lowest in dermatology, at 29.6%, and highest in urology, at 63.8%. Rates of burnout were in the middle range among those in primary care specialties, including 42.6% in internal medicine, 37.2% in family medicine, and 43.2% in pediatrics. In multivariate analyses, compared to internal medicine residents, residents in urology, neurology, emergency medicine, and general surgery were significantly more likely to report symptoms of burnout, depending on their specialty. Women were 17% more likely to report burnout symptoms than their male counterparts. (Ref: Medscape)
After reading the above report on the extent to which burnout among physicians has now reached nearly half of those actively practicing medicine, something occurred to me. Yes, it’s tragic that the numbers describe a serious problem, spiraling apparently out of control, but we patients are putting our lives in the hands of our caregivers and it seems obvious that being treated by burned-out people isn’t only risky but, in some cases, possibly fatal.
What if half of all commercial airline pilots suffered symptoms of burnout? Would we be as likely to put our lives at risk that our flight from San Diego to San Francisco isn’t being flown by a burnout crew? Of course not. Many of us would stop flying and the industry would step in with a remedial strategy that ameliorated the obvious danger.
What I haven’t seen in connection with physician burnout is a definitive study showing the statistical correlation between rising burnout and patient mortality. Why is that, and how and why does physician burnout start as early as residency for so many newly minted doctors?
Steven Ross at Modern Healthcare writes that efforts to address physician burnout may need to start as early as residency, citing the new JAMA study referenced above. The results of one of two studies related on burnout in JAMA found 45% of second year residents surveyed reported having at least one symptom of the condition. (That’s really early; Didn’t know that.)
The survey of more than 3,500 second-year resident physicians found that 14% of those surveyed reported they would “definitely not” or “probably not” choose to become a physician again, while 7% of respondents indicated they definitely or probably would not choose the same medical specialty if given the chance to remake their choice.
“Burnout is really driven by work-related stressors, so perhaps medical students who are more empathetic just have a different perspective or are seeing things differently in terms of how they deal with those stressors and how they ultimately impact their experiences,” said study lead author Dr. Liselotte Dyrbye, a researcher at the Mayo Clinic.
Resident physicians in urology, neurology, ophthalmology, general surgery and emergency medicine specialties reported the highest prevalence of burnout, while dermatology, pathology, radiology and family medicine residents had the lowest prevalence.
Dyrbye said medical students who reported having higher levels of empathy and also higher levels of emotional support at the end of medical school were less likely to report regret about pursuing a career as a doctor or their choice of medical specialty.
“We need to sort of figure out ways to nurture empathy and to help trainees build their social support,” Dyrbye said. “But ultimately, the problem with burnout isn’t because the medical student, or resident or physicians in practice is somehow defective in personal coping strategies–it is ultimately coming from the work and the learning environment, and that’s really where attention should be focused in terms of strategies.”
Similar findings about the prevalence of burnout among younger physicians were found in a separate report (pdf) by the advocacy group, the Physicians Foundation, which backed a study conducted by Merritt Hawkins that found 78% of nearly 9,000 physicians surveyed reported experiencing burnout in their medical practices. When asked, “would you recommend medicine as a career to your children or other young people?” 48% of physicians ages 45 and younger answered they would not.
Dr. Gary Price, president of the Physicians Foundation, said issues involving increased administrative burdens and a loss of autonomy in the care of patients have left doctors with increased feelings of helplessness, which he said has led to lower morale and increased levels of burnout. He said addressing the problem though should focus more on making changes to the healthcare system rather than looking at ways of trying to make physicians more resilient.
“The whole problem is a serious wakeup call for the whole healthcare system,” Price said. “There are a number of factors that are making their (physician) work really difficult and affecting the quality of their output.”
Peter Grinspoon, MD, at Harvard Health Publishing, says burnout among doctors is generally described in terms of a loss of enthusiasm for one’s work, a decline in satisfaction and joy, and an increase in detachment, emotional exhaustion, and cynicism.
“It manifests in disproportionately high rates of depression, substance abuse, and suicide. Annually, approximately 400 physicians take their own lives in the United States,” Grinspoon asserts.
There is good evidence that physician burnout results in more expensive healthcare and less satisfied patients. Demoralized doctors can make mistakes, sometimes devastating. While this is a difficult phenomenon to measure, a 2014 study of intensive care doctors showed that emotional exhaustion among physicians predicted a higher mortality rate among the patients they cared for. And according to a research review in The BMJ from 2017, “there is moderate evidence that burnout is associated with safety-related quality of care.”
The problem of physician burnout is complex and there is no easy solution in sight. Dr. Grinspoon says that in his personal experience as a primary care physician over the last 20 years:
“The insurance companies won’t flinch at wasting a doctor’s time, even deliberately, if it will increase their profits. Hospitals will choose a medical record system that prioritizes their revenues, and which has the doctor facing the screen and pecking away, over one that allows for doctors and patients to speak with each other, comfortably, face to face. As with most things, it comes down to the bean counters, and the bottom line.”
Dr. Grinspoon asserts that, “The losers in all this, equally, are the doctors and the patients. If you are receiving substandard care from a seemingly burnt-out or distracted doctor, you obviously need to report it, and advocate for your own care. However, it is also critically important to remember that doctors are people too, not robots.”
I can’t say I agree that the losers in rising physician burnout are “equally, the doctors and patients.” There aren’t as yet clear and convincing data correlating rising physician burnout and patient mortality.
I’ve heard the Biblical axiom, “Physician, heal thyself (Luke 4:23) linked to physician burnout, as though providers are responsible for and thus should fix this systemic, growing condition. Frankly, I don’t agree that it’s the physicians who are the problem.
Organizations must take responsibility for constantly wringing the stress out of the systems of care, rather than just plonking every new regulatory and insurance mandate onto the back of the medical staff. It also falls on us patients whose health outcomes are very much at stake in this discussion to speak up and start being heard. I’ve also posted previously about some solutions to physician burnout.
Tell your congressional representatives to stop blaming the doctors for the burnout dilemma and focus on organizations, regulators and payers that also comprise the delivery system. The problem is now on center stage and out in the open. Let’s get moving!