Physician Burnout: Overview
Physician burnout is a critical issue within the healthcare sector, characterized by emotional and physical exhaustion, depersonalization, and feelings of ineffectiveness. Initially recognized as a significant concern prior to the COVID-19 pandemic, burnout among physicians has intensified due to heightened pressures and expectations in the profession. Studies indicate that over 50% of U.S. physicians reported experiencing burnout symptoms, a trend worsened by systemic challenges such as bureaucratic red tape, the complexity of healthcare delivery, and the demands of electronic health records. These factors collectively contribute to diminished patient care quality and increased physician turnover, potentially exacerbating a looming physician shortage. Experts attribute burnout to a combination of long work hours, high educational debt, and a perceived loss of professional autonomy. The COVID-19 pandemic further amplified these stresses, with reports showing a notable increase in burnout rates among healthcare workers from 2018 to 2022. Addressing physician burnout requires multifaceted solutions that consider both systemic changes and individual self-care strategies.
Physician Burnout: Overview
Introduction
Burnout among physicians is an ongoing issue that has been further exacerbated by certain factors in recent times. Made worse by the COVID-19 pandemic that began in 2020, physician burnout had previously been identified as a major concern in the healthcare industry. In March 2017, the leaders of ten major US health care institutions issued a stark warning on the blog of the journal Health Affairs. The headline read, “Physician Burnout Is a Public Health Crisis: A Message to Our Fellow Health Care CEOs,” and the article went on to cite a study published in Mayo Clinic Proceedings (2015) that found that over 50 percent of the US physicians surveyed reported experiencing at least one symptom of burnout in 2014. The authors described the costs to the health care system, patients, and doctors themselves of rising physician burnout, characterized by emotional and physical exhaustion, lack of connection with patients (known as depersonalization), and intense feelings of failure and ineffectiveness. This article has been one of many to call for changes to the way physicians experience their work life. Though the symptoms of burnout are not restricted to the medical field, it appears more common and severe than in other professions in the United States, and as these roles are crucial to public health, the negative impact on patients is considered especially serious. These existing issues were worsened by the COVID-19 pandemic, which placed immense strain on healthcare workers on the front line of the global health crisis.
Experts debate the causes of and solutions for physician burnout, but as the authors of the Health Affairs article pointed out, there is a consensus that, overall, physicians are fit for their professions, having been through demanding educational and training experiences. There is also consensus that the causes of burnout are a combination of external and internal expectations and frustrations, including overwhelming bureaucracy and the increasing complexity and commercialization of health care. Just as the causes for physician burnout are variable, proposed solutions are as well, with some experts advocating for changes to the system at the national and institutional level, some focusing on individual physicians improving their self-care, and some seeing a need for both to make a difference.
Understanding the Discussion
Cognitive behavioral therapy: A psychotherapy treatment that focuses mental energy on problem-solving and changing faulty thought patterns.
Electronic health record (EHR): A digital version of a patient’s medical history that allows information to easily be shared among health care organizations and providers and may include clinical data, notes, medications, and more.
Maslach Burnout Inventory: The industry standard for testing individuals for signs of occupational burnout, developed by Christina Maslach and Susan E. Jackson in 1981.
Patient Protection and Affordable Care Act: Enacted in 2010 under the administration of President Barack Obama, a comprehensive health care reform law also known as the Affordable Care Act or Obamacare that mandated affordable health insurance coverage to most Americans.
History
Burnout as a recognized, measured, and widely studied syndrome began in part with the notorious “Stanford prison experiment” at Stanford University in 1971. Psychology professor Philip Zimbardo recruited twenty-four students for the experiment and assigned them roles as either prisoners or guards. The assigned guards quickly became brutal and sadistic, and Zimbardo himself noted that he quickly took on the role of superintendent and failed to see the implications of the cruelty inflicted on the students who were assigned to be prisoners. Recent PhD graduate Christina Maslach came to observe and, horrified at the way the students were treating each other, demanded that the experiment be stopped. Zimbardo agreed, but the way that the stress of the situation had turned ordinary college students into brutish thugs stayed with her.
What she witnessed focused her professional life, and she stated in a 2011 interview for Stanford magazine that it “raised some really serious questions about how people cope with extremely emotional, difficult situations, especially when it’s part of their job—when they have to manage people or take care of them or rehabilitate them.” Maslach began to interview emergency room workers. She recalled one of them describing their experience as “burnout,” and the term stuck (the term “burnout” used in the clinical context is often attributed to the psychologist Herbert Freudenberger, who used it in the early 1970s). In September 1976, Maslach published an article titled “Burned-Out” in the journal Human Behavior, followed by studies of lawyers, daycare workers, and other professions. In 1981, her findings were published as a series of questions, the Maslach Burnout Inventory (MBI), that could identify professionals in need of help. The MBI assessed responses in the areas of emotional exhaustion, depersonalization, and decreased sense of personal accomplishment. These measures continued to be widely used as a tool to assess physician burnout.
Though physician burnout was certainly present to some extent in the United States before the 1980s, due to the emotionally taxing nature of such a human service profession, it is believed that its prevalence began to worsen with the growth of health maintenance organizations and associated increases in productivity expectations. Physician burnout steadily climbed after the publication of the 1999 US Institute of Medicine report To Err Is Human: Building a Safer Health System. This report exposed the prevalence of medical mistakes in the United States and spelled the end of what some saw as a less stressful period in medical history—not because mistakes were made with impunity, but because the variable, personalized relationships that many doctors had with their patients was replaced by safeguards, matrixes, and reporting that has contributed significantly to physician burnout.
Physician Burnout Today
In addition to the 1999 Institute of Medicine report, some experts identify the widespread implementation of electronic health records (EHRs) as mandated by the American Reinvestment and Recovery Act in 2009 and the enactment of the Patient Protection and Affordable Care Act (also known as the Affordable Care Act) in 2010 as key contributors to physician burnout as millions of people signed up for health insurance and reporting and paperwork became more complicated. A study initiated by the Physicians Foundation and completed in 2018 reported that burnout remained a significant issue in the medical profession, with 78 percent of physicians surveyed experiencing burnout sometimes, often, or always. The cost of burnout to the mental and physical health of physicians is staggering, with suicide rates greater than that of the rest of the population. Burnout also has a serious impact on patient care, contributing to lower patient satisfaction and quality of care and, ironically, since much of the required reporting that is contributing to burnout was intended to prevent mistakes, reduced patient safety.
As patient tracking and documentation increased, insurance and billing requirements further reduced the time that doctors spend practicing medicine and added hours of paperwork. An additional concern expressed by individuals and organizations in the health care industry was that as physicians suffer from burnout, they are more likely to leave the profession, exacerbating a growing shortage of physicians and adding to the workload and stress of other practitioners. In 2019, the Association of American Medical Colleges (AAMC) predicted, based on recent data, a shortage of as many as 122,000 physicians by 2032. Additionally, it can be costly to replace a physician who leaves the field.
As experts have continued to debate the best ways to combat physician burnout, they have agreed on common stressors that include long work hours, crippling debt for many recent graduates, and mountains of reporting and billing paperwork. A 2015 Mayo Clinic study identified three main contributors to physician burnout, linked to the changing medical profession: loss of autonomy, asymmetrical rewards, and cognitive scarcity. Autonomy loss occurs when physicians are so constrained by institutional structures that they are no longer able to use their judgment and creativity to help their patients. Asymmetrical rewards are the result of the high stakes involved in treating human beings, particularly patients whose data is now recorded at every turn. Cognitive scarcity is the stress brought on by constantly having too little time and the consequences of organizing that time.
These existing issues were compounded by the onset of the COVID-19 pandemic in March 2020, which placed immense strain on global healthcare systems and healthcare workers as the world mobilized to respond to the global health crisis. Following years of increased pressure and stressors, the Centers for Disease Control and Prevention (CDC) reported on a study that compared data between 2018 and 2022 that showed 46 percent of examined health workers reported feeling burned out often or very often in 2022, compared to 32 percent in 2018. The study also found that turnover intention, or the desire to look for a new job, among health care workers increased from 33 percent in 2018 to 44 percent in 2022, while reports of experiencing harassment increased from 6 percent to 13 percent during that same period.
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