December 2018

NEWS & OPINION

Part I: The weariness, the fever, and the fret


by J.C. Noreika, MD, MBA


J.C. Noreika, MD, MBA

Physician burnout is purported to be a serious crisis. What is it? Who’s at risk? What are its ramifications for doctors and patients?

An epidemic afflicts our nation. It affects patient safety, the delivery of care, what drugs are prescribed, patient satisfaction, even when patients are discharged from hospitals. USA Today cited a study reporting that nearly 50% of the country’s physicians suffer burnout symptoms. Two recent publications in the Journal of the American Medical Association attempt to interpret the landscape. Harvard’s Lisa Rotenstein, MD, and co-authors seek to assess its prevalence.1 Mayo Clinic’s Liselotte Dyrbye, MD, investigates determinants affecting resident physicians.2
Mental health professionals have bandied about burnout for more than 50 years. In 1981, Christina Maslach, PhD, University of California, Berkeley, proposed a methodology to quantify it. She and co-author Susan Jackson published “Measurement of Experienced Burnout” in the Journal of Occupational Behavior. This introduced the Maslach Burnout Inventory (MBI). The MBI-HSS (Human Services Survey) focuses on the service sector and is used to quantitate stress affecting social workers, educators, and healthcare professionals. A veritable burnout industry has emerged.
Three subsets comprise the MBI symptom complex: emotional exhaustion or the loss of enthusiasm for work, depersonalization or treating people as if they were objects, and low personal accomplishment or having a sense that work is no longer meaningful. Symptoms of burnout and clinical depression overlap. Using the term burnout instead of depression “avoids pathologisizing workers’ emotional response to their jobs.”
The importance of physicians’ mental health cannot be overstated. Schaufeli’s recent writing summarizes burnout’s history; an article by Agerbo in Psychological Medicine in 2007 showed that among 55 occupations, the profession of medicine had the highest rate of suicide.3 Being a physician is demanding and stressful. Doctors are at risk for substance abuse or abandoning their profession. Factors contributing to symptoms of burnout are complex. Some relate to workload, loss of autonomy, diminished control of practice environment, time inefficiencies caused by administrative demands, lack of work-life balance, and malpractice liability. Mandates perceived as meaningless are a major cause of physician dissonance.
The topic “burnout” begs the questions: What is it? Who’s at risk? What can be done about it?
Rotenstein conducted a meta- analysis of 182 studies involving 109,628 subjects across 45 countries. These studies were published between 1991 and 2018. More than 85% of them employed some version of the MBI. Of the 67% of studies that reported on overall burnout, results of its prevalence ranged from 0% to 80.5%. Findings of depersonalization ranged from 0% to 89.9%. Academic literature and the popular media have glommed onto a figure of 50%. The authors found “at least 58 unique ways of labeling individuals as experiencing burnout.” One hundred forty-two definitions were used to meet criteria for burnout or one of its components. Channeling Humpty Dumpty in Lewis Carroll’s Through the Looking Glass, “burnout” seems to mean whatever investigators choose it to mean.
How does one diagnose a disease that has no normative definition? How is treatment formulated? Rotenstein states, “These findings preclude definitive conclusions about the prevalence of burnout and highlight the importance of developing a consensus definition of burnout and of standardizing tools to assess the effects of chronic occupational stress on physicians.” Back to square one.
Dyrbye’s work focuses on medical students and residents. She and her co-authors attempt to correlate symptoms of burnout with medical students’ personality traits and their career and subspecialty choices. Abridging the MBI to two statements—“I feel burned out from my work” and “I’ve become more callous toward people since I started this job”—the two studies’ shortcomings nonetheless converge. An affirmative response occurring at least once per week constituted evidence of burnout. A JAMA editorial opined, “It may be surprising to some that the prevalence of burnout is not higher based on that criterion.”
In the Mayo Clinic study, 76.4% of 4,696 resident physicians responded. Only 95 ophthalmology residents representing 2.6% of total respondents participated. In the 2017 Residency Match report, 468 ophthalmology positions were offered. Thus, the survey had an approximate response rate of 20% among ophthalmologists. Ranking third behind urology (63.8%) and neurology (61.6%), Dyrbye reported a 55.8% prevalence of burnout symptoms in ophthalmology PGY-3s. Dermatology had the lowest prevalence at 29.6%. The overall rate of burnout symptoms among residents mirrored that of practicing physicians (48.8%) and was far higher than other U.S. workers (28.4%).
Other interesting findings? Being female or Hispanic was independently associated with risk. Students who scored higher for anxiety in medical school were at increased risk while those who scored higher in empathy had lower risk. Household income or educational debt did not seem to affect the prevalence of symptoms. Residents enjoying top-quintile household incomes greater than $250,000 per year exhibited career choice regret nearly twice as high as lower quintiles. Residents with families and small children showed fewer symptoms and regrets.
In a 2008 study by Shanafelt et al. involving 7,905 surgeons, ophthalmologists and orthopedic surgeons were twice as likely to be satisfied with their career choice as general surgeons.4 Government has brought radical change and decreased compensation. Do ophthalmologists sustain that level of professional fulfillment?
Crisis? I’m skeptical. Yes, many physicians are unhappy. Depression is a tragic occupational hazard, its pervasiveness increasing as medical practice changes. But the hype surrounding burnout is not supported by studies.
Medical educators are initiating innovative programs to prepare physicians for the challenges of tomorrow’s practice. In January, I’ll probe these efforts in Part II.

References

1. Rotenstein LS, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320:1131–1150.
2. Dyrbye LN, et al. Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians. JAMA. 2018;320:1114–1130.
3. Schaufeli WB. Burnout: A Short Socio-Cultural History. Burnout, Fatigue, Exhaustion. 2017:105–127.
4. Shanafelt TD, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250:463–71.

Editors’ note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years.

Contact information

Noreika: jcnmd@aol.com

Part I: The weariness, the fever, and the fret Part I: The weariness, the fever, and the fret
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