Physician Stress and Burnout

VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA and the Health Sector >> ACA and Physicians >> Physician Stress and Burnout (last updated 11.6.17)

Overview 

Long before the ACA was implemented, the country faced a significant burnout problem in the medical community. The Studer Group predicted in 2012 that health reform would adversely affect morale and offered recommendations for improving physician satisfaction. Physician burnout “triggers” were described as: “Prohibitively heavy/intense workload; Industry pressures related to health reform mandates, technology changes, etc.; Lack of control at work; for example, feeling that there is inadequate time for patient visits; Inefficient or hostile work environments; Lack of support at work, in the community, or at home; Sense of isolation — lack of connection with colleagues; Feeling unappreciated and unrewarded; Perception that organization policies are unfair; Lack of alignment between physician’s personal value system and organization’s value system; Consistently putting patient care before self; Grief or guilt over negative patient outcomes; Financial stress.”

  • Physician Burnout: Preparing for a “Perfect Storm.” “All of these issues are putting tremendous pressure on doctors and other healthcare providers. Over the past quarter of a decade or so, research has found that up to 60 percent of all physicians and nurses suffer from burnout. The problem seems to be getting worse. In January of 2012, HealthLeaders Media published the results of a survey conducted by Physician Wellness Services and Cejka Search that found that 87 percent of 2,000 physicians were moderately to severely stressed, and 63 percent said the stress has increased ‘moderately to dramatically’ over the past three years…[A]s health reform changes kick in, it is likely to go even higher. Unfortunately, this burnout epidemic is occurring precisely at the time that alignment and collaboration between physicians and healthcare organizations are most critical.” (Studer Group, February, 2012)

Analyses

Physician Commentary

Items are in chronological order.

  • Physician Burnout – A Threat to Quality and Integrity. “Freudenburger, a clinical psychologist, first proposed the modern concept of burnout in 1974. This concept was clarified further by Maslach in her seminal work, published in 1982, in which she describes burnout as emotional exhaustion, feelings of being emotionally overextended and exhausted by one’s work, depersonalization, an unfeeling and impersonal response toward recipients of one’s service, care treatment or instruction, and a reduced sense of personal accomplishment. What Does Burnout Look Like in the Intensivist? Is burnout as obvious as an ‘Incredible Hulk’ transformation, with yelling, screaming and throwing objects within the intensive care unit? While it can present this dramatically in some cases, most often burnout expresses itself in a far less obvious manner. Burned-out physicians may be angry, irritable or impatient. They may seem to treat patients as objects or to be simply emotionally depleted. They may seem unable to leave work or may be persistently absent. Burnout differs from depression; burnout is less pervasive, and its symptoms decrease when the practitioner takes time away from work… Physician burnout is pervasive across specialties and has the potential to compromise our lives, the care we deliver and the system within which we practice. Our obligation is to understand burnout and the stressors from which it stems.” (Society of Critical Care Medicine, 4.2.13)
  • Reflections of a Medical Ex-Practitioner. “When it became increasingly difficult to work according to my principles, I closed my practice, first joining a ‘prepaid’ group for 15 years, and then leaving patient care altogether. As more physicians leave active practice, it must be appreciated that a focus on the economics of health care is not the only, and perhaps not even the most important, reason for their disillusionment. The glow of the personal relationship one might have with one’s patients is being extinguished.” (Marsh, Ed,MD., The Wall Street Journal, 4.7.14)
  • How Being a Doctor Became the Most Miserable Profession. “Nine of 10 doctors discourage others from joining the profession, and 300 physicians commit suicide every year… The end result is that the average face-to-face clinic visit lasts about 12 minutes. Neither patients nor doctors are happy about that. What worries many doctors, however, is that the Affordable Care Act has codified this broken system into law.” (Drake, Daniela. The Daily Beast, 4.14.14)
  • There was a Time When Doctors Were Doctors. “There was a time when doctors actually utilized their brains at work. There was a time when practicing medicine was not just about completing forms, checking boxes, navigating pathways, meeting core measures, and predicting — before patients actually arrive at the hospital — whether they would be inpatient or outpatient according to Medicare rules.” Ong, James. (KevinMD.com, 5.1.14)
  • Maine Physician Gives ACA Feedback to Senator Angus King (5.2.14). “Your interview so troubled me that I decided you needed to hear from someone who is ‘in the trenches.'”
  • The Importance of Sitting With Patients. “Reform must focus on understanding how best to ensure resident time is spent on direct patient care and meaningful clinical activities… On some level, though, efficiency-empathy trade-offs are an inevitable and inherent tension in medicine — a function of busy hospitals with complex patients and limited personnel and resources. But I wonder also if this is a trade-off we too readily accept and whether the pendulum has swung too far toward the altar of efficiency. Surely patients want to be seen and treated in a timely manner, but when we sacrifice empathy for efficiency we fuel what lays at the core of patient — and physician — discontent with modern medicine. We hide behind buzzwords like ‘patient-centeredness’ and ‘shared decision-making’ without being able to offer the time that gives these terms true weight. Ultimately, reconciling this tension may mean reconceptualizing ‘efficiency’ to include the tremendous value that exists in having more time to spend with our patients.” (The New York Times, 3.19.15)
  • Abraham Verghese: Hope for Hands-on Medicine in the EMR Era. “There are good data that 50% of primary care physicians are burned out. More than 50% are depressed, which makes you realize at once that it’s not an individual problem. It’s a systemic issue. The root of it is red tape. Our red tape equivalent is the EMR. I think organizations like the ACC should come out and say that the source of dysfunction and dysphoria among physicians, the source of frustration in the system, is that we are busy documenting something that has nothing to do with patient care. I’m not pessimistic about it; I’m a great optimist. I think that things will get better, but I think that you can’t make it better until you acknowledge the problem. It’s like a Dickens novel. There’s a point, an epiphany, where the big lie is revealed to the person who is carrying it. Then everything sorts itself out.” (theheart.org on Medscape, 4.6.15)
  • How Obamacare Demoralized Doctors and Degraded Care. “’My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.’… Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, ‘The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.’ That’s just the beginning of the losses. Consider the myriad small practices that, facing ruinous transition costs in equipment, software, training and time, have closed shop, gone bankrupt or been swallowed by some larger entity… Then there is the toll on doctors’ time and patient care. One study in the American Journal of Emergency Medicine found that emergency room doctors spend 43 percent of their time entering electronic records information, 28 percent with patients. Another study found that family practice physicians spend on average 48 minutes a day just entering clinical data.” Krauthammer, Charles, MD. (Chicago Tribune, 5.29.15)
  • In America, the Art of Doctoring is Dying. “Physicians are now insulated from knowing too much about their patients. It is all about the technology, the testing, the imaging, the electronic health record, the data — once collected by the doctor, but now so regulated and overwhelming that paramedical professionals have been enlisted to record the so-called minutiae, the often rote information in which may lie important clues. Some of these may remain forever buried, the patient not wanting to share sensitive details with just anyone, especially someone who no longer makes eye contact, whose face remains buried behind a computer screen, who seems uninterested or just unskilled in reading body language — that downward glance, that shift in the chair, that half-swallowed response.” Winakur, Jerald, MD. (Washington Post, 2.12.16)
  • MACRA, Stress, Brain Atrophy, and the End of Fee-for-Service Medicine. “Physicians who are in the Medicare system who are experiencing difficulty sleeping, weight gain, increased anxiety and worry about what will happen to their practice under MACRA, memory difficulties, increased difficulty making decisions, increased irritability, and depression over what the future will hold for them may be harming their brains by remaining in the Medicare system. Structural changes in the brains of excessively stressed physicians, including hippocampal atrophy and amygdala hypertrophy, may explain some of these underlying symptoms of chronic stress. If one complains of severe headaches because one is repeatedly hitting his head against a wall, the obvious cure is to stop hitting one’s head against the wall. The cure for brain atrophy and all of the symptoms that accompany chronic stress is to remove the causative stress from one’s environment. Medicare physicians have the opportunity to do that by opting out of Medicare. A recent survey revealed that 40 percent of physicians in solo and small-group practices are considering the healthy brain choice of leaving their abuser, Medicare. Given the punishing penalties of MACRA, more physicians are beginning to recognize that the only way to win is to not play the government’s game.” Huntoon, Lawrence, MD. (Journal of American Physicians and Surgeons, Fall 2016)
  • The Alienation Of America’s Best Doctors.The best and the brightest simply don’t want to become doctors anymore. Physicians are burning out. They are leaving the profession. They are going bankrupt. They are selling their private practices to big hospitals. They are retiring early. We are facing a growing doctor shortage. Doctors no longer want to be a part of a health care system that doesn’t value them after decades of sacrifice, debt, and brutal training. Physicians now have the highest suicide rate of all professions… Of course, we cannot deny that we need to focus on curtailing health care costs. But we absolutely cannot cut health care at the expense of alienating physicians. Our talent pool is rapidly shrinking. Nearly every month now, another one of my most brilliant physician colleagues (from Stanford, Yale, Johns Hopkins, UCLA, and Harvard) leaves his medical practice. This is real. This is palpable. These talented physicians are quitting to join startup ventures, concierge practices for the ultra-wealthy, pharmaceutical companies, or the ranks of corporate America where they feel they are better compensated and respected for their brain power and sacrifice.” Hakim, Melinda, MD. (Huffington Post, 11.13.16)

Other Analyses

Items are in chronological order.

  • Why Physicians Won’t Unite to ‘Rescue’ Medicine. “Plenty of physicians are feeling pretty miserable these days, and ‘it has a lot to do with loss of control,’ said Jordan Grumet, MD, an internist at Park Avenue Associates in Highland Park, Illinois… According to a 2013 poll by Deloitte Center for Health Solutions, majorities of physicians worry about an erosion of clinical autonomy and income. Dr. Grumet said he would add to that list all the paperwork physicians are required to fill out…Major impediments make it very difficult — perhaps impossible — for physicians to unite to save medicine. The following is a list of some of those barriers, and what might be done to bring physicians together, despite all the rifts.” (Medscape Business of Medicine, 9.4.14)
  • Four Steps to Eliminating Burnout. “When you give people a job they can’t be successful at, this can result in daily frustration that makes the job undoable — burnout. ‘We’ve got to make the job of the American physician doable,’ says Robert Pearl, Executive Director and CEO of The Permanente Medical Group. ‘To do that, we need to change the structure, change the reimbursement, change the technology, and change the leadership.’” (NEJM Catalyst, 2.1.16)
  • Mounting Frustration Among Gastroenterologists.The compensation report asked respondents about their satisfaction with their career; gastroenterologists ranked sixth, with an overall satisfaction rate of 57%. However, a comparison in metrics of satisfaction with the same poll conducted 5 years prior highlights the larger trend towards dissatisfaction (Table 1).

    Table 1. If You Had to Do It All Over…

     

    2016 Report

    2011 Report

    I would choose medicine as a career

    61%

    76%

    I would choose the same specialty

    60%

    80%

    I would choose the same practice setting

    27%

    53%

    Those interviewed were unanimous in attributing these declining numbers to the increased regulatory and administrative burdens being placed upon them. ‘The ability to just run your practice and be a good doctor has really become a fairly onerous task,’ said Dr Johnson, who has practiced gastroenterology for 36 years and attributes these new requirements to driving many away from private practice. ‘Despite this being a fantastic field, there’s clearly a burnout based on the administration of all of these tasks we never had to do before… Dr Johnson’s experience is borne out by the results of this year’s Medscape Lifestyle Report, in which the three most commonly reported causes of burnout were too many bureaucratic tasks, spending too many hours at work, and increasing computerization of practice. ‘In my experience, most innovations actually make us less productive,’ said Dr Reau. ‘Electronic medical records absolutely did.’” (Medscape Gastroenterology, 7.6.16)

Impact on Care Quality

  • Physician Burnout Is a Public Health Crisis, Ethicist Says. “A recent study from the Mayo Clinic showed that in 2011, 45.5% of doctors reported that they felt burned out, and that number has now risen to 54.4% in 2014. More than half of all doctors in this country are saying, ‘I really feel that some aspect of my work as a doctor is making me feel burned out.’ This is really trouble. It’s trouble because a doctor who feels this way can commit more errors. They suffer from compassion fatigue, or just not being able to empathize with others because they have their own emotional issues. They may retire early, thereby reducing the workforce. They may have problems managing their own lives; 400 doctors committed suicide last year, which is double the rate of the population average. There’s trouble for patients in having a workforce that’s burned out. There’s trouble for doctors in terms of their own health and well-being. We don’t talk about it much. We like to think that doctors can handle everything, but it’s clearly not true. It’s a problem and there ought to be some solutions.” (Medscape Business of Medicine, 3.4.16)
  • Burnout and Medical Errors Among American Surgeons. “Of 7905 participating surgeons, 700 (8.9%) reported concern they had made a major medical error in the last 3 months. Over 70% of surgeons attributed the error to individual rather than system level factors. Reporting an error during the last 3 months had a large, statistically significant adverse relationship with mental QOL, all 3 domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. Each one point increase in depersonalization (scale range, 0-33) was associated with an 11% increase in the likelihood of reporting an error while each one point increase in emotional exhaustion (scale range, 0-54) was associated with a 5% increase. Burnout and depression remained independent predictors of reporting a recent major medical error on multivariate analysis that controlled for other personal and professional factors. The frequency of overnight call, practice setting, method of compensation, and number of hours worked were not associated with errors on multivariate analysis.” (Annals of Surgery, June, 2010)

Burnout Surveys 

VITAL WorkLife & Cejka Search Physician Stress and Burnout Survey

Items are in chronological order.

  • 2011 Survey. “The majority—over 86%—of US physicians are moderately to severely stressed or burned out on an average day, according to a survey conducted by VITAL WorkLife (PWS) and Cejka Search… Physicians stated that their top four external stress factors are: the economy, healthcare reform, Medicare and Medicaid policies, and unemployed and uninsured patients. The top four work-related stress factors are: administrative demands of the job, long work hours, on-call schedules and concerns about medical malpractice lawsuits. The result of this cumulative stress is declining job satisfaction, a desire to reduce hours and a desire to retire or leave early, or leave the practice of medicine altogether. Fourteen percent of respondents indicated they had left their practice as a result of stress. The consequences of stress on respondents’ personal lives include fatigue, sleeplessness, irritability and moodiness, all of which result in physical and mental health issues, apathy and cynicism, and increased risk of medical errors, which impacts patient safety and could lead to medical malpractice lawsuits.” (Physician Wellness Services, September 2011)
  • 2015 Survey. “Stress and burnout are extremely prevalent, with 88.0% of all 2015 survey respondents identifying themselves as moderately to severely stressed and/or burned out on an average day using a 10-point Likert scale, and 45.6% specifying severe stress and/or burnout. The responses to the question regarding the work-related factors that caused stress and/or burnout were more broadly distributed… The top three external factors for the 2015 survey respondents were: Healthcare reform 47.6% of all respondents; Centers for Medicare and Medicaid (CMS) policies 47.4%; Consolidations in the healthcare industry 30.0%. The top work-related factors for 2015 respondents were: Paperwork and administrative demands 42.6%; Too many hours of work 28.0%; Personal compensation-related issues 27.6%; Electronic health/medical records 25.1%… an overwhelming nearly 60% of the physician respondents say they want to get out of medicine. Add the 42.4% who desire to work fewer hours, as another indicator of this growing crisis. The next factor was also related to change in their work situation: desire to switch jobs 17.8%. These responses point to an overwhelming desire by 2015 survey respondents to do something different from what they are currently doing with their medical careers.” (VITAL WorkLife, February 2015)

Mayo Clinic Surveys

Items are in chronological order.

  • Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. “From August 28, 2014, to October 6, 2014, we surveyed both US physicians and a probability-based sample of the general US population using the methods and measures used in our 2011 study. Results: 54.4% (n1⁄43680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.5% (n1⁄43310) in 2011 (P<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%; P<.001). Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty. In contrast to the trends in physicians, minimal changes in burnout or satisfaction with work-life balance were observed between 2011 and 2014 in probability-based samples of working US adults, resulting in an increasing disparity in burnout and satisfaction with work-life balance in physicians relative to the general US working population… More than half of US physicians are now experiencing professional burnout.” (Mayo Clinic, December, 2015)
    • Disturbing Trends in Physician Burnout and Satisfaction With Work-Life Balance: Dealing With Malady Among the Nation’s Healers. “The declining well-being of US physicians is documented empirically in the current issue of Mayo Clinic Proceedings… This burnout was apparent in all 24 medical specialties studied, and 9 of the 24 specialties showed a relative increase in burnout of more than 10%… Physicians had a risk of burnout that was twice as great as that of the broader US population (odds ratio=1.97; 95% CI, 1.80-2.16; P<.001), and physicians’ satisfaction with work-life balance was one-third less than that of the broader population (odds ratio=0.68; 95% CI, 0.62-0.75; P<.001). Of note, the research by Shanafelt et al also discovered that physicians’ rates of depression or suicidal ideation remained rather stable between 2011 and 2014; however, this consistency may simply signify that physicians’ baseline rates were already disturbingly high: For example, in 2011 and 2014, rates of depression were 39.2% and 39.8%, respectively (P=.04), and rates of suicidal ideation were 6.4% in both years (P=.98)… In our minds there are 3 main factors resulting directly from the recent changes to the medical environment that could disproportionately and adversely affect physicians’ well-being: asymmetrical rewards, loss of autonomy, and cognitive scarcity.” (Editorial, Mayo Clinic Proceedings, December, 2015)

  • One in Four Physicians Rethinking Clinical Practice. “Struggling to find joy in the practice of medicine, many physicians are planning to reduce their clinical work hours or leave their clinical practice, a study has shown. In a national survey of physicians across all specialties in the United States in 2014, nearly one in five respondents indicated their plan to reduce practice hours within 12 months, and one in four said they would likely leave their current practice within 2 years, Christine A. Sinsky, MD, from the American Medical Association, Chicago, Illinois, and colleagues report in an article published in the November issue of the Mayo Clinic Proceedings. The leading driver of physicians’ intent to reduce clinical work hours or leave their current practice was professional burnout, the authors write…. 19.8% planned to switch to a part-time clinical schedule within 1 year, and 26.6% planned to leave their current practice within the next 2 years through retirement (37.4%), pursuit of a different practice opportunity (35.2%), movement to an administrative position in healthcare (9.7%), or switch to a different career entirely (7.4%). Physicians aged 50 to 59 years were most likely to indicate their intention to leave medicine altogether in the next 24 months, the authors report.” (Medscape, 11.2.17)

Medscape Surveys

Items are in chronological order.

  • Burnout Rates Soar Among Family Physicians. “Nearly half of family physicians younger than 35 years feel burned out, according to a new survey conducted by Medscape. In the 2015 Family Physician Lifestyle report, which updates a previous report on physician lifestyle and burnout, 43% of family physicians in this age group responded that they had burnout, defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. This is a substantial increase over the rates documented in the 2013 report, in which fewer than 10% of the youngest family physicians said they felt burned out. Half (50%) of family physicians across all age categories reported burnout in the 2015 report, up from 43% in 2013. Compared with other specialties represented in the 2015 overall lifestyle report, the burnout rate among family physicians is on par with that of internists, general surgeons, and infectious disease specialists. It is lower than only two specialties: critical care (53%) and emergency medicine (52%). Physicians with the lowest rates of burnout in the 2015 report are dermatologists (37%), psychiatrists (38%), and pathologists (39%).” (Medscape Medical News, 1.28.15)
  • Medscape Lifestyle Report 2016: Bias and Burnout.This year’s Medscape survey, echoing other recent national surveys strongly suggests that burnout among US physicians has reached a critical level. Burnout in these surveys is defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment… [J]ust as the percentages of burnout have increased among all physicians compared with last year’s Medscape Lifestyle Report, so have the severity ratings. In this year’s Medscape lifestyle survey, as in previous years, more female physicians (55%) expressed burnout than their male peers (46%)… Physicians were asked to rate causes of burnout on a scale of 1-7, where 1 equals ‘Does not contribute at all’ and 7 equals ‘Significantly contributes.’ Top on the list, with an average rating of 4.8, was having too many bureaucratic tasks, followed by too many work hours (4.1) and increasing computerization at 4.0. These were the top three causes last year as well, but the rankings were slightly lower (4.7, 4.0, and 3.7, respectively). This year, the survey added the option ‘maintenance of certification requirements,’ which was tied for fifth place with ‘feeling like a cog in a wheel’ as a cause of burnout.” (Medscape, 1.13.16)
  • Medscape Otolaryngologist Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout. “In response to this year’s Medscape survey, 53% of otolaryngologists reported burnout, placing them in the upper third among all physicians. The highest percentage occurred among those practicing emergency medicine (59%), followed by ob/gyns (56%) and family physicians, internists, and infectious disease physicians, all at 55%. These groups all deal directly with patients, often in exigent circumstances. Emergency medicine physicians, family physicians, and internists ranked in the top five in Medscape’s 2015 and 2016 reports as well. Not surprisingly, other research has found high burnout rates in these groups. Otolaryngologists were asked to rate the severity of their burnout on a scale of 1 to 7, where 1 equals ‘It does not interfere with my life’ and 7 equals ‘It is so severe that I am thinking of leaving medicine altogether.’ Of the otolaryngologists who reported burnout, the average severity rating was 4.5, second highest among all physicians… Otolaryngologists were asked to rate the causes of their burnout on a scale of 1 to 7, where 1 equals ‘Does not contribute at all’ and 7 equals ‘Significantly contributes.’ Topping the list, with an average rating of 5.5, was “too many bureaucratic tasks,’ followed by ‘increasing computerization’ at 5.2 and ‘spending too many hours at work’ at 4.8.” (Medscape, 1.11.17)
  • Medscape Lifestyle Report 2017: Race and Ethnicity, Bias and Burnout. “Burnout rates for all physician respondents have been trending up since 2013, the first year that Medscape asked about it, when the overall rate was 40%. This year it is 51%, over a 25% increase in just 4 years. A recent major survey supports these findings, reporting that burnout and satisfaction with work-life balance had worsened between 2011 and 2014, with more than half of physicians reporting burnout. In this year’s Medscape report, the highest percentages of burnout occurred among physicians practicing emergency medicine (59%), followed by ob/gyns (56%) and family physicians, internists, and infectious disease physicians (all at 55%). The top four are all physicians who deal directly with patients with a range of complex problems. In Medscape’s 2015 and 2016 reports, emergency medicine physicians, family physicians, and internists were also within the top five. Not surprisingly, other research has found high burnout rates in these three professions… Topping the list, with an average rating of 5.3, was ‘too many bureaucratic tasks,’ followed by ‘spending too many hours at work,’ at 4.7. These two factors ranked highest the past two surveys as well. And the ratings have been trending up: In the previous report, they were 4.8 and 4.1, respectively, and in the one before that, they were 4.7 and 4.0. ‘Feeling like just a cog in a wheel’ and electronic health records (EHRs) also rated high as causes of burnout this year (4.6 and 4.5, respectively). In an October 2016 Medscape roundtable discussing EHRs and burnout, one of the panelists, Robert W. Brenner, MD, said, ‘If [EHR requirements are] implemented without a change in the workflow in the office, too much data entry falls on the physician. That is what is adding to the huge burden.’ Because ‘insurance issues,’ ‘threat of malpractice,’ and ‘family stress’ were mentioned frequently as important contributions to burnout in last year’s write-in responses to this question, the options were added to our survey. They rated 4, 3.9, and 3.1, respectively.” (Medscape, 1.11.17)

Geneia Surveys

Items are in chronological order.

  • Survey Finds Rising ‘Misery Index’ Among Doctors. “According to the survey, 87 percent of physicians say the ‘business and regulation of health care’ has changed the practice of medicine for the worse. It also found that 78 percent of physicians ‘say they frequently feel rushed when seeing patients.’ In addition, the survey found that 67 percent of physicians know other doctors who are ‘likely to stop practicing medicine in the next five years as the result of physician burnout.’ That figure includes younger and more experienced doctors, according to Geneia… ‘For most physicians, the ability to create meaningful relationships with their patients and truly impact health outcomes is why they entered the practice of medicine in the first place, and is critical to experiencing joy in their work. Yet 84 percent of respondents believe that quality patient time may be a thing of the past.’ A result of the survey, which canvassed 416 full-time physicians around the U.S., is Geneia’s ‘Physician Misery Index,’ which it says stands at 3.7 out of 5, ‘indicating that the scales are tipping from satisfaction to misery.’” (New Hampshire Business Review, 4.3.15)
  • Geneia Survey: Emergency Medicine Physicians are Miserable, Too. “This survey expands upon one earlier this year in which Geneia found that physicians as a whole score a 3.7 out of 5 on the Physician Misery Index, indicating the scales have tipped from satisfaction to misery. And the newly released results indicate that emergency medicine physicians are even less happy, scoring a 3.9 on the index. Additional findings include: 92% of emergency medicine doctors say the ‘business and regulation of healthcare’ has changed the practice of medicine for the worse; 67% say they have considered career options outside of clinical practice as the result of burnout compared with 51% of their colleagues.” (Geneia, 10.15.15)

Surveys of Medical Residents

Items are in chronological order.

  • 2015 Survey of Final-Year Medical Residents. “Though job offers are abundant for many new physicians, the stress of residency has taken its toll on some. One in four (25 percent) of respondents said they would choose a different career field if they had the chance to do it all again.” (Merritt Hawkins, 1.12.15)
  • Medical Resident Burnout Reaches Epidemic Levels.A survey conducted by investigators at the University of North Carolina, Chapel Hill, showed that approximately 70% of residents met criteria for burnout… Results revealed that general surgery (89%), radiology (85%), surgical subspecialties (82%), anesthesiology (81%), and internal medicine (79%) had the highest rates of burnout, whereas pediatrics (53%), family medicine (50%), and pathology (46%) had the lowest. However, Dr Holmes noted that even pathology, which at almost 50% had the lowest rate of resident burnout, still had a very high rate. ‘I want to point out that only one program had a rate of less than 50%,’ she said. At 70%, psychiatry residents were in the middle of the burnout range… Dr Holmes also looked at depression and found an overall rate of 17%. Demographic factors did not make a difference to these rates, although married residents were less likely to be depressed than divorced or separated ones. Suicidal ideation over the previous 2 weeks was reported by eight residents. One of them reported suicide ideation nearly every day. However, depression did not necessarily correlate with burnout. For example, pathology residents had a greater than average depression rate (23%), but the lowest rate of burnout, and anesthesiology residents had high rates of burnout, but low rates of depression (7%).” (American Psychiatric Association (APA) 2015 Annual Meeting, 5.16.15).
  • ‘Alarming’ Burnout Rate in General Surgery Residents. “More than two thirds of general surgery residents in a national survey meet the criteria for burnout, and many of them have considered leaving their residency program because of it, a study shows. Leisha C. Elmore, MD, MPHS, from the Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, and colleagues report their findings in an article published online May 27 in the Journal of the American College of Surgeons, as well at the American College of Surgeons 101st Annual Clinical Congress in October 2015. The study adds to a growing body of research suggesting that burnout among physicians in training has reached epidemic proportions, they write… Of those with complete data available, an ‘alarming’ 69% met the criterion for burnout on at least one subscale of the Maslach Burnout Inventory, the authors report. Of those who met burnout criteria, 57% scored in the highest tertile of EE, 50% scored in the highest tertile of DP, and 16% scored in the lowest tertile of PA. Further, nearly half (44%) reported that they had considered dropping out of their residency, and the same percentage would not choose general surgery again if they had the option. Forty percent would choose a career outside of medicine entirely, the researchers report.” (Medscape, 6.20.16)

Other Surveys

Items are in chronological order.

  • Predictors of Physician Career Satisfaction, Work-Life Balance, and Burnout (2007). “To explore factors associated with physician career satisfaction, work-life balance, and burnout focusing on differences across age, gender, and specialty… Both women and men report being highly satisfied with their careers (79% compared with 76%, P<.01), having moderate levels of satisfaction with work-life balance (48% compared with 49%, P=.24), and having moderate levels of emotional resilience (51% compared with 53%, P=.09). Measures of burnout strongly predicted career satisfaction (standardized beta 0.36-0.60, P<.001). The strongest predictor of work-life balance and burnout was having some control over schedule and hours worked (standardized beta 0.28, P<.001, and 0.20-0.32, P<.001, respectively). Physician gender, age, and specialty were not strong independent predictors of career satisfaction, work-life balance, or burnout. CONCLUSION: This national physician survey suggests that physicians can struggle with work-life balance yet remain highly satisfied with their career. Burnout is an important predictor of career satisfaction, and control over schedule and work hours are the most important predictors of work-life balance and burnout.” (Obstet Gynecol.  2007; 109(4):949-55)
  • Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. “Despite extensive data about physician burnout, to our knowledge, no national study has evaluated rates of burnout among US physicians, explored differences by specialty, or compared physicians with US workers in other fields… Characteristics of responding physicians with respect to burnout, symptoms of depression, suicidal ideation in the past 12 months, and satisfaction with work-life balance are summarized in Table 2. When assessed using the MBI, 37.9% of US physicians had high emotional exhaustion, 29.4% had high depersonalization, and 12.4% had a low sense of personal accomplishment. In aggregate, 45.8% of physicians were considered to be experiencing at least 1 symptom of burnout based on a high emotional exhaustion score or a high depersonalization score. The validated 2-item burnout measure, used for comparison with population controls (discussed in the ‘Comparison of Physicians With the General US Population‘ subsection), showed a strong correlation with the overall MBI (correlation with emotional exhaustion, 0.90; correlation with depersonalization, 0.85) but provided a more conservative estimated overall burnout rate of 35.2% relative to the gold standard MBI. Approximately half (48.2%) of the physicians thought their work schedule left enough time for personal or family life, with 14.4% responding neutral and the remaining 36.9% disagreeing with this assertion.” (Archives of Internal Medicine, 10.8.12)
    • Physician Burnout: An Urgent Call for Early InterventionWe read the study by Shanafelt et al1 with great interest. The authors surveyed 7268 US physicians for professional burnout in comparison with nonmedical US workers. They showed that physicians have a higher prevalence and a significantly greater risk for professional burnout compared with the general population. We are thankful to the authors for studying this extremely important topic. The major question that remains is why this happens, and more importantly, what we can do to prevent physician burnout?“ (JAMA Internal Medicine, 4.22.13)
    • Physician Burnout: An Urgent Call for Early Intervention—Reply. The thoughtful letters in response to our article1 each raise important questions regarding (1) why physician burnout develops and (2) what can be done do to prevent it? Factors contributing to burnout include lack of control and/or autonomy, loss of meaning from work, inefficient use of time, excessive workload, challenges with work-life balance, and poor career fit.2 There are certainly other contributors as well, as suggested in the letters. For example, compulsive personality traits are characteristic of many physicians.3 These qualities can cause physicians to have difficulty relaxing, have a sense of responsibility for things they do not control, and be constantly focused on work, even when away from the hospital. However, these traits are also part of what makes physicians good at what they do, resulting in dedication, attention to detail, and recognition of the trust patients place in physicians and the attendant responsibility.3 Accordingly, rather than ‘deselecting’ physicians with these traits, physicians should be taught to recognize both the constructive and destructive aspects of these qualities and to develop strategies to mitigate the negative aspects.” (JAMA, 4.22.13)
  • Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. The majority of sources of dissatisfaction identified in our study represent forms of delivery system dysfunction that many stakeholders would like to see solved: insufficient time per patient, EHRs with poor usability, regulations that require physicians to spend time on tasks that do not require their training, high turnover rates among allied health professionals and support staff, etc.
    • Sources within practices: Time pressure, lack of control over day-to-day decisions that affect patient care, and loss of collegiality are all causes of dissatisfaction that are within the purview of the practice to address.
    • External to the individual practice: Deficiencies in EHR technology, the cumulative burden of regulations, relationships between physicians and the hospitals and health systems that employ physicians, and physician payment policies.

“EHR usability represents a relatively new, unique, and vexing challenge to physician professional satisfaction. Few other service industries are exposed to universal and substantial incentives to adopt such a specific, highly regulated form of technology, which has, as our findings suggest, not yet matured. The current state of EHR technology appears to significantly worsen professional satisfaction for many physicians—sometimes in ways that raise concerns about effects on patient care.” Note: Paper also includes extensive pre-publication literature review on physician burnout. (RAND Health, 2013)

  • Doctor Burnout is a Rising Problem in Minnesota Medicine. “Physician burnout is on the rise in Minnesota and across the country, as the traditional strains of a medical practice — long hours and draining cases — are compounded by new challenges, such as computerized records and payment reforms that judge doctors by their patients’ health. A series of influential studies by Minnesota researchers suggest that burnout could aggravate the state’s shortage of primary care doctors by driving some into early retirement and undermine the quality of patient care by eroding doctors’ compassion and attention to detail. ‘There is an epidemic going on with respect to stressed and burned-out physicians,’ said Mitchell Best, executive director of Vital WorkLife, a St. Louis Park-based employee assistance program. In a national survey released this month, it found the share of physicians reporting severe stress increased from 38 percent in 2011 to 46 percent last year.” (Star Tribune, 5.24.15)
  • Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction.Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics… physicians’ satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.” (Mayo Clinic, July, 2016, Volume 91, Issue 7, Pages 836–848)
  • Leadership Survey: Why Physician Burnout Is Endemic, and How Health Care Must Respond. “For the first time since NEJM Catalyst began surveying our Insights Council members, there is overwhelming concurrence on an issue: 96% of executives, clinical leaders, and clinicians agree that physician burnout is a serious or moderate problem in the health care industry… Respondents rate ‘increased clerical burden,’ which is heavily influenced by expanded and more comprehensive use of electronic health records, as by far the biggest cause. In their current form, EHRs disrupt the workflow that many physicians have established over years in their practices, forcing them to carry their workload into off-hours, or ‘pajama time,’ as it is often termed… More than half of survey respondents say increased productivity requirements/expectations contribute to burnout. Untenable payment/reimbursement models and erosion of professionalism tie for third in the results at 21%. Although excessive metrics score less than 20% as a contributing factor, metrics could be considered a sub-dimension of the increased clerical burden.” (NEJM Catalyst, 12.8.16)

EHR and Impact on the Health Sector