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Burnout in Doctors

 Burnout among doctors was first described in 1974.  It is a work-related syndrome.  It was initially ill-understood but over time has become increasingly accepted.  It is characterized by emotional exhaustion that results in decreased accomplishment at work1.  It is characterized by a cynical attitude to common-day activities and patients may be viewed in a detached manner.  Its causation is complex.  A key question is whether the institution makes the individual dysfunctional or whether he has an underlying susceptibility to begin with.  Stress and burnout can be generated by a combination of excessive workloads, excessive work hours, complaints from patients, and inadequate access to administrative supports.  There is data that suggests that there are gender differences in the response to stress over a long period of time.  Men show an increased level of physical deterioration, while women show more psychological symptoms.  Victims of burnout may adopt unhealthy lifestyles including excessive eating and increased alcohol intake.  Health-care systems are adversely affected by the reduction in the physicians’ work output.

Data on burnout is difficult to collect.  In 2011, the largest study to date, reported that 45% of 7288 physicians had at least one symptom of burnout2.  Also burnout was more common among doctors than among workers in other fields.  A common factor is that jobs with an intense level of interaction with people are more likely to precipitate burnout.  This may explain the higher rates in primary care specialties including family medicine and general internal medicine.  Burnout affects doctors at all stages of their careers from trainees through to experienced physicians.

Patricia Casey3 states that doctors are most concerned about the quality of healthcare management and the negative sociocultural environment.  The lifelong risk of depression among doctors is 10-20 per cent.  The mood change associated with depression may make the doctor appear brusque and antagonize the patient.  The overall patterns suggest that one third of doctors will suffer from burnout, the main challenge is what to do about it.

Blanaid Hayes4 says that psychosocial hazards have become the main workplace stressors nowadays.  Most people have peaks and troughs in their work, but for doctors there are unrelenting demands.  Being bullied or unfairly treated causes great anxiety.  Uncertainty such as an ill-defined job description is problematic.  Managers should have open communication, avoid making excuses, and be prepared to take criticism.

The non-clinical component of the job appears to be a contributory factor for many doctors.  The increased documentation in order to maintain registration is a challenge for doctors.  There are outcome measure data to be recorded and the findings acted upon.  Electronic health care records also add to the clerical burden of the doctor.  At a time when administrative chores are increasing, the secretarial support for doctors has decreased.  Previously the appointment of a new consultant was accompanied by a support package including a secretary.  In many cases this no longer happens, the new appointee being simply added to the existing secretarial services.  This is problematic.  One study has estimated that for every hour of clinical work, the doctor spends 2 hours on clerical activities.

There is time pressure and a lack of control over work processes.  Human conflict between individuals or group of individuals can have marked negative consequences.  Clinician burnout has been linked to increased medical errors and patient dissatisfaction.  The suicide rate among doctors is double that of the general population.  While it is accepted that clinical care is stressful, institutions must appreciate that they bear a responsibility if the governance structure is outdated or has negative policies.

To date, there has been little published literature on how to combat the problem of burnout.  The current burden of documentation following even the simplest clinical encounter needs to be reduced and streamlined.  Where possible, correspondence, billing requirements, should be undertaken by secretarial staff.  All future developments in electronic health care need to be vetted in relation to any potential increase in clinician administrative workload.  The maintenance of certification requirements need to be better integrated in the busy doctor’s work schedule.  The key message is to identify, reduce and delegate the clerical component of the job.

Doctors, on the other hand, have a duty to look after themselves.  The three important issues for any doctor are adequate sleep, adequate exercise, and attention to personal medical needs.

The National Academy of Medicine5 has developed a collaborative of more than 20 medical organisations to address the issue of stress in the workplace.  It wants to target burnout.  It states that physician well-being must a top priority in discussions on patient care.  Its remit is to assess and understand the causes of clinician burnout and to propose solutions to address the problem.  Both individual-focused and organization based solutions are required.

West et al6 have undertaken a meta-analysis on interventions to reduce physician burnout.  They identified 2617 articles of which 15 were randomised trials.  The useful strategies were mindfulness, stress management, and small group discussions.  Mindfulness is the practice of being fully present in the moment.  It helps the individual to identify how often they react rather than respond.   Duty hour limitation is less of an issue for trainees since the introduction of the EU working time directive.  However senior doctors are not protected in the same way. Effective interventions can reduce the burnout rate by 10%.  However, the intervention which offers the greatest value remains unclear.

There is widespread agreement that clinician burnout leads to significant morbidity for the affected individual.  It impacts on fellow healthcare workers and also interferes in patient care.  The reduction in effective clinical activity reduces hospital throughput.  Awareness of the condition and the institution of preventative measures can be very beneficial.

JFA Murphy

Editor

  1. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward.  JAMA 2017;317:901-2
  2. Shanafelt TD, Boone S, Tan L et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.  Arch Intern Med 2012;172:1377-1385
  3. Patricia Casey. The Independent 2016;Jan 26th
  4. Blanaid Hayes. The national study of wellbeing of hospital doctors in Ireland. RCPI
  5. National Academy of Medicine. Action collaborative on clinician well-being and resilience. http://nam.edu/initiatives/clinician -resilience-and-well-being
  6. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.  Lancet 2016;388:2272-81