Clinical Professor of Psychiatry, New York University School of Medicine, New York, NY
Dr. DiLallo has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Are you burnt out? This seemingly casual question may not be as easy to answer as you might think. Being burnt out can easily be mistaken for feeling tired, stressed, or depressed. But according to a growing body of research on physicians, recognizing and addressing this work-related syndrome may help protect your well-being, along with that of your patients and colleagues.
What is burnout? “Burnout” likely originated as a slang term to describe substance abusers, and it generally connotes ideas of being demoralized, used up, or spent. In the 1970s, mental health researchers applied this term to the “compassion fatigue” they were studying among human service professionals. Defined as a “prolonged response to chronic emotional and interpersonal job stressors,” burnout is measured in 3 domains: 1) Emotional exhaustion, or the sense of having nothing left to give; 2) Depersonalization, or a sense of detachment from others; and 3) A lost sense of personal effectiveness and accomplishment (Maslach C et al, Annu Rev of Psychol 2001;(52):397–422).
Vignette: Burnout or depression? A 55-year-old psychiatrist had worked for 25 years in private practice, doing primarily medication management along with some psychotherapy. Over a period of several years, he had become increasingly frustrated with both the administrative and clinical burdens of the job, including the preauthorization paperwork required by insurance companies, patient requests for letters, calls from patients’ families, and difficulties with a cumbersome electronic medical record system. He found that he was exhausted, especially when he thought about going to the office—which gave him a feeling of dread. When he greeted his patients in the waiting room, he did so without any spark or interest, and he felt that most visits had become rote exercises in asking questions and writing prescriptions.
The psychiatrist increasingly doubted that he was really helping patients and wondered if there was anything meaningful to what he was doing. He thought more and more about quitting. When he shared these feelings with his wife, she encouraged him to see a clinician to check for signs of depression—but he rarely felt demoralized during the weekends or during his day off during the week.
On the advice of a colleague, he took 3 weeks of vacation from his practice, and decided to make a number of adjustments to his schedule and his procedures. He stopped using the electronic medical record system for anything other than transmitting prescriptions, and he scheduled more appointments for 30 minutes or longer, as opposed to the 15- to 20-minute visits that had become the norm. He also joined a monthly journal club of local psychiatrists. Within a few weeks, he found that he was again looking forward to work and enjoying his contact with patients.
Symptoms and effects of burnout As the vignette illustrates, burnout can be mistaken for depression. Although doctors who report burnout do not have higher rates of mental illness than unaffected doctors, burnout has been associated with suicidal ideation in medical students. More ominously, U.S. physician suicide rates are approximately 4 times higher than the general population, and the highest among any profession. Several physician risk factors are identical to those in the general population: Caucasian race; higher age; being unmarried, divorced, or separated; and having medical or mental health problems. However, physician suicides appear unique in that they are more common following job problems than relationship problems, they also sometimes occur after lawsuits or the perception of having made an error (Gold KJ et al, Gen Hosp Psychiatry 2013;35(1):45–49). In many published vignettes, suicide victims appear to have endured their professional pain in profound emotional isolation and without interruption to their professional responsibilities, such that most others did not notice that anything was wrong.
Physician burnout affects patients as well. It is associated with increased medical errors, decreased professionalism, decreased patient satisfaction and treatment adherence, and less communication with collateral providers (Shanafelt et al, JAMA 2009;302(12):1338–1340). Burnout also may cause physicians to leave clinical practice, or to avoid disadvantaged patient groups, as indicated by a recent study of psychiatry residents whose responses to an emergency room rotation made them less likely to consider future jobs involving the Medicaid population (Dennis NM and Swartz MS, Psychiatr Serv 2015;66(8):892–895).
How common is physician burnout? One recent study estimated that 50% of U.S. physicians have “work-related distress” (Shanafelt TD et al, Mayo Clin Proc. 2015;90(12):1600–1613). The authors report a roughly 10% increase between 2011 and 2014 in rates of at least 1 burnout symptom (54.4% versus 45.5%) and of work-life balance dissatisfaction (48.5% versus 40.9%) among surveyed physician members of the American Medical Association (AMA). In contrast, a matched control group of nonphysician workers had no such increase in burnout symptoms over that time period.
How do psychiatrists compare with other physicians in terms of burnout? They appear to be doing somewhat better than their peers. In the AMA survey, psychiatrists ranked in the lower third of physicians reporting at least 1 symptom of burnout, at approximately 48%.
Causes of burnout In 2013, the AMA commissioned the RAND Corporation (a California think tank) to study the factors leading to physician workplace satisfaction and dissatisfaction. The researchers interviewed nearly 700 physicians from 30 practices across 6 states. The final report’s conclusion emphasized 2 points. First, what doctors find most rewarding is being able to use their clinical skills to help patients. On the other hand, the biggest barriers to work enjoyment are things that limit face-to-face contact with patients, especially electronic health records and their time-consuming data entry demands. The respondents also complained about administrative tasks that don’t require a medical degree to perform—such as prior authorizations and appeals.
Another factor is the so-called “fictive schedule.” This piece of jargon, originally coined by anthropologic studies of primary care doctors, refers to a schedule in which more patients are assigned than it is possible to see. If you are in a clinic with a high no-show rate, you may double-book to account for such no-shows—which makes sense, until the day when everybody you’ve booked shows up. This leads to a nightmare scenario with limited meal or bathroom breaks, and with evenings spent on deferred data entry and paperwork at the expense of personal time—a recipe for burnout.
Added together, pressures on doctors’ time and clinical resources can cause “cognitive scarcity,” in which decision-making suffers as a result of constantly needing to do more with less. Like a traveler who has only a small suitcase for a long journey and must spend extra effort considering what to pack and what to leave, doctors often must make tradeoff decisions in anticipation of the many imperatives that will come to their attention on a given day. In experiments, the effects of cognitive scarcity can be so large that, according to one paper, “they are comparable with the cognitive toll of completing the task after losing an entire night of sleep, being an alcoholic, or losing approximately 13 IQ points” (Ariely D, Mayo Clin Proc 2015;90(12):1593–1596). Aside from the factors that may affect all physicians, studies of burnout among psychiatrists have identified stressors that are particularly common in our practices, such as patient suicide, violence, and hostile patient family members (Kumar S et al, Int J PsychiatryMed 2005;35(4):405–416).
Treating and preventing burnout Given that burnout is defined by a triad of emotional exhaustion, detachment, and self-perceived ineffectiveness, one way to push back is to promote their antidotes: vitality, engagement, and self-efficacy.
The most robust clinical trial of a specific anti-burnout treatment was conducted with primary care physicians in Rochester, New York (Krasner MS and Epstein RM, JAMA 2009;302(12): 1284–1293). All primary care doctors in the Greater Rochester area were invited to participate in the program, and 70 (50%) of them agreed. The program was structured as a CME activity emphasizing skills in self-monitoring, limit setting, and cognitive reappraisal. It was intensive, with 8 weekly 2.5-hour sessions, an all-day meditation retreat, and a subsequent maintenance phase of 10 monthly 2.5-hour sessions.
Participants were given a variety of scales before the intervention and again after 15 months, and the results were impressive. On the Maslach Burnout Inventory, the doctors showed medium improvements in all 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. They also became significantly more empathic toward their patients.
Most of us will not have access to such a comprehensive intervention. However, some primary techniques employed in the study are widely available and potentially helpful for psychiatrists coping with professional challenges:
Mindfulness meditation consists of observing present events inside and outside of oneself using a non-judgmental stance. Regular meditation practice helps us to respond thoughtfully rather than automatically to stress. Models such as mindfulness-based stress reduction are associated with positive effects on mood, anxiety, and health outcomes (Geary C and Rosenthal SL, J Altern Complement Med 2011;17(10):939–944). Experienced meditators explain that mindful attention is like a muscle that grows stronger with practice, and that practicing regularly with a group can be even more beneficial.
A second technique is to write down stories about one’s personal experiences in clinical practice. This helps to foster reflection, personal meaning, and re-engagement with clinical work. Doctors in this study also shared their clinical narratives with peers in a non-judgmental format.
Psychiatrist peer groups are common just after our training, though we tend to participate less in such groups as we approach mid-career, which is when burnout rates are highest. Two established group models explicitly prevent burnout by processing workplace stress and revitalizing the doctor-patient relationship. The mindfulness-based consultation team format at the heart of Dialectical Behavior Therapy helps to validate a clinician’s emotional response when dealing with chronically suicidal patients. (Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guildford Press; 1993). In a similar vein, “Balint groups” consist of clinicians who meet periodically to process a “difficult” clinical situation by considering it from the perspectives of both the patient and the doctor (Balint M. The Doctor, His Patient and the Illness. New York, NY: International University Press; 1957). The value of these approaches is supported by a randomized controlled trial in which a 9-month physician group curriculum of mindfulness, reflection, shared experience, and group learning during working hours resulted in sustained improvement in work engagement and morale (West et al, JAMA Intern Med 2014;174(4):527–533).
Steps you can take to prevent burnout If you just can’t face another day of work, don’t quit—at least not yet. Here are some practical suggestions:
Talk to colleagues about it. This can be in the setting of a regularly scheduled group, or simply informal conversations about the stresses of work.
Learn how to meditate, and schedule at least 5–10 minutes of meditation into your day.
Minimize administrative work. This may involve a financial investment in an assistant, but the cost can be minimal, especially if you hire a virtual assistant, who can work a few hours a week from a remote location.
Develop new professional skills, such as teaching, consultation, or business management.
Make a conscious effort to get reengaged with your clinical work. Rediscover the idealism and intellectual curiosity that got you into psychiatry in the first place.