HealthJuly 21, 2020

Physician burnout requires systemic solutions

By: Manoj Jain, MD, MPH

Despite interventions on an individual level, physician burnout persists. What would systemic solutions look like?

According to the most recent Medscape National Physician Burnout & Suicide Report, nearly 1 in 2 physicians report experiencing burnout, which is characterized by exhaustion, cynicism or low sense of efficacy. What more doctors are coming to recognize is that the causes of burnout are rooted, in large part, in the healthcare system, not in their individual behavior.

A look at physician burnout

For medical professionals, burnout and associated issues begins early in their careers. In fact, some research suggests that these issues reach a peak during medical school and residency and gradually diminish over the course of a medical career. In one 2014 study published in Academic Medicine, the journal of the Association of American Medical Colleges, depression, suicidal thoughts and a "low sense of personal accomplishment" were most prevalent during medical school, while "overall burnout, high depersonalization, and high fatigue" were most prevalent during residency and fellowship. That said, the study found that early-career physicians experienced "alarmingly high rates" of burnout, depression and fatigue, and the Medscape survey found especially high rates of burnout among Generation X physicians in the middle of their careers.

Each individual's experience and symptoms may vary, yet the general trends are common. When asked, physicians are clear about what's causing their burnout. Respondents to the Medscape survey identified the following contributors to physician burnout:

  • Over-regulation, including an excess of bureaucratic tasks, EHR requirements, government regulations and "feeling like a cog in a wheel."
  • Workload, including spending too many hours at work for insufficient pay and with decreasing reimbursements.
  • Lack of autonomy, including loss of control as well as disrespect from employers, colleagues and patients.

Physicians' responses to these broad systemic issues have been individual. According to Medscape, physicians primarily cope with burnout by isolating themselves from others, exercising, talking with family and friends and sleeping, among other personal - and potentially harmful - activities.

At the individual level, more formal interventions for burnout include self-assessment, self-motivation, seeking guidance and developing a wellness life plan. In practice, this can include everything from exercise classes to hobbies that enrich a physician's free time. Yet in a JAMA Internal Medicine meta-analysis of 19 controlled studies among 1,500 doctors, such interventions showed little impact.

Systemic solutions to burnout

To prevent physician burnout, we need to seek solutions at the systemic level. In their landmark paper published in Mayo Clinic Proceedings, Tait D. Shanafelt, MD, and John H. Noseworthy, MD, outline nine organizational strategies to reduce burnout. These begin with acknowledging and assessing the problem, harnessing the power of leadership and developing targeted interventions. An example of these steps playing out might start with a team meeting with work unit leaders, followed by conducting focus groups and then facilitating change and assessing impact.

Other organizational strategies include cultivating a feeling of community at work, using rewards and incentives wisely, aligning values, supporting work-life integration, promoting self-care and funding organizational science. Some examples of work-life integration include rethinking vacation policies and sick/medical leave and having role models who are balancing work and life successfully.

If organizations were to adopt the nine strategies described by Dr. Shanafelt and Dr. Noseworthy, doctors would have more motivation and psychological well-being through autonomy, competence and relatedness. This would reduce burnout, as Pamela Hartzband, MD, and Jerome Groopman, MD, discuss in the New England Journal of Medicine. When physicians have autonomy, they gain control over their time and how often they see patients. A sense of competence must go beyond checking a list of boxes. Meanwhile, if physicians feel a sense of relatedness, they feel a sense of belonging to an organizational structure.

According to Dr. Hartzband and Dr. Groopman, the many changes in the healthcare system, including EHRs and regulations, have made physicians "profoundly alienated and disillusioned." As one neurologist described it for an article in Neurology Today, the root cause of burnout is not the physician incapacity but healthcare "system incompetence," and physicians are having to compensate.

The COVID-19 pandemic has revealed the many seismic chasms in our healthcare system. While the public has shown appreciation for health providers, the physical and emotional stress has compounded the problem of burnout for select specialists like internists, pulmonologists and infectious diseases physicians. Systemic solutions have proven to be effective in the past - will they play a bigger role in healthcare's future?

Manoj Jain, MD, MPH