Physician burnout: Running on an empty tank

It is a freezing day and the bare trees are covered with a glistening coat of ice that reflects the early morning light. You should be enjoying this view as you drive into work, but instead, you are sitting in the car and staring at the icy pond where the local crew team practices.

Over and over in your head, you may be thinking, "I can't do this anymore." "What am I going to do?" "I have too many loans." "How will we pay our bills?"

If this is you, then don't ignore the signs; you may be experiencing physician burnout. Similar to any problem, recovery usually starts with recognition.

Medical school and clinical training is rigorous in ways that may be difficult for other professionals to comprehend. Self-care can easily slip to the bottom of the list of priorities in the face of the daily challenges of patient care and admin.

Medicine is known for a culture of "self-reliance and independence," and unfortunately it is common for physicians to feel that they're "not supposed to show signs of weakness or admit suffering," as Tom Murphy, M.D., explains in his book Physician Burnout: A Guide to Recognition and Recovery.

Burnout is bad for physicians, as evidenced by increased rates of alcohol and drug abuse, not to mention suicide. Burnout is also bad for your patients because it is associated with lower quality of care, lower patient satisfaction, higher rates of physician turnover, and increased chances of medical errors.

If you are feeling utterly exhausted and disconnected from your patients, perhaps even wondering if you still want to be a doctor, then rest assured - you are not alone. Chances are these days that your colleagues may be feeling the same.

Find out how to spot the early signs of burnout and the symptoms that you shouldn't ignore. We also bring you strategies to counter the destructive stress that leads to burnout.

Is physician burnout an epidemic?

Physicians at all stages of education and training are at risk for burnout. Studies have suggested that 25 to 50 percent of medical students experience depression and anxiety, with up to 50 percent reporting symptoms of burnout.

Sadly, up to 15 percent of medical students have reported suicidal ideation at some point during their medical school education.

The high demands of residency and fellowship training are reflected in the fact that more than 50 percent of residents report depression symptoms, with burnout rates as high as 75 percent.

According to a recent Letter published in JAMA Internal Medicine, 25 percent of family physicians self-reported signs of burnout. The data showed a strong correlation between work-related factors - such as stress, a chaotic working environment, or time spent on documentation - and burnout.

What causes physician burnout?

There are three factors that contribute directly to burnout. Below, we detail the main causes of physician burnout and give advice on how to counter them.

1. Time

The practice of medicine in the United States today is mostly volume-driven. More patients per day and shorter visits have eroded the relationship between physician and patient, which can prevent physicians from providing the type of care they went to medical school to do.

Furthermore, unrealistic call schedules can impact a physician's quality of life by allowing the work day to continue once at home.

With the advent of electronic medical records (EMRs) and smartphones, physicians are accessible 24 hours per day, and thus the workday potentially never ends.

2. Administration

While EMRs allow effective communication between the medical team and a patient's medical history at multiple locations, they can also be time-consuming and can interfere with the precious few minutes that a patient and physician have together.

With the use of EMRs comes the added concern of patients having direct access to the physician through messaging via the EMR.

Rather than answering questions during the office visits, physicians are also expected to provide information outside of scheduled clinic visits through these messaging systems.

3. Patients

Patient satisfaction scores are increasingly common in the U.S. medical system.

Physicians can easily be given a poor score for not giving a patient antibiotics (even if it is not indicated), for not providing a controlled substance at the patient's request, or for not ordering unnecessary laboratory tests.

Furthermore, physicians are expected to navigate situations in which patients are drug-seeking, noncompliant, or even threatening.

Lotte N. Dyrbye, M.D., associate chair of staff satisfaction, faculty development, and diversity in the Department of Medicine at the Mayo Clinic, told Medical News Today, "Between 2011 and 2014 the prevalence of burnout increased in U.S. physicians, even though work hours did not."

She went on to say, however, "During this time period, the prevalence of burnout among other U.S. workers did not increase. The drivers of burnout for physicians are factors within the practice environment."

The early signs and symptoms of burnout

The Maslach Burnout Inventory takes into account three factors for physician burnout. These are:

  • emotional exhaustion: a feeling of emotional and physical depletion
  • depersonalization: having a distant feeling toward patients that may lead to cynicism or sarcasm, also described as "compassion fatigue"
  • a low sense of personal accomplishment: a lack of efficacy or doubting the quality or meaning of your work as a physician

Other character traits and behaviors associated with burnout are:

  • perfectionism and obsessing over negative outcomes
  • being the "superhero" and having a misplaced level of responsibility for factors that are outside of your control
  • micromanaging situations and feeling that you need to do everything yourself
  • judging and self-labeling
  • responding to problems by working harder

Recognizing the signs and symptoms of burnout early on makes it easier to look for effective ways of preventing full-blown burnout.

Burnout intervention strategies

A systematic review and meta-analysis published in The Lancet by Colin P West, M.D. - of the Division of General Internal Medicine and Division of Biomedical Statistics and Informatics at the Mayo Clinic - and colleagues analyzed the outcomes of burnout intervention strategies.

Here, the authors showed that both individual-focused as well as organizational or structural interventions were associated with significant reduction in burnout.

1. Strategies at the individual level or self-care

Self-care means having a personalized strategy to look after yourself. It also means reflecting on the fact that life requires attention to multiple dimensions including family, career, community, spirituality, and the inner self.

There are many strategies that promote self-care, including having hobbies, making time for family and friends, focusing on a healthy lifestyle with exercise and adequate sleep, and practicing mindfulness.

In a recent Perspective article published in The New England Journal of Medicine, Adam B. Hill, M.D., shared his take on self-care and recovery.

A palliative care physician and associate program director for pediatric residency training at the Indiana University School of Medicine in Indianapolis, Dr. Hill is no stranger to this topic.

As a recovering alcoholic who has suffered suicidal tendencies, he uses "counseling, meditation and mindfulness exercises, exercise, deep breathing, support groups, and hot showers" in his self-care. He has also rearranged his own hierarchy of needs. "I learned that I must take care of myself before I can care for anyone else," he wrote.

2. Burnout at the work level

Dr. Murphy highlights in his book that "you can't be all things to all people." Recognizing this starts with learning to say no and creating appropriate boundaries with regard to your scheduling, your patient volume, your work week, and the size of your patient panel.

Furthermore, it is important to clearly define your "work-time" and your "off-time" to your colleagues, employers, patients, and, most importantly, to yourself.

Likewise, there are several researched methods of improving the work environment for physicians.

Adding a "float pool" to cover for life events, allowing physicians some control over their schedule, decreasing patient panel sizes, adjusting staff ratios, and lengthening visits, can all reduce stress levels.

Flexible and part-time physicians tend to be more satisfied with their career and are less likely to leave their position.

3. Administrative or institutional level strategies

Including physician well-being and satisfaction as a quality metric can help to shed light on the level of burnout in an organization and show which intervention strategies are most impactful.

Research also shows positive effects if administrators allocate time to allow practicing clinicians to incorporate teamwork, mindfulness, sharing of workload through Patient-Centered Medical Home models, and coaching for challenging experiences.

Finally, by adding charting slots throughout the day or increasing the length of visits to allow for charting time, the burden associated with EMRs could be decreased.

If physician burnout cannot be addressed at all three levels, it is clear that the U.S. healthcare system is steering headlong into a crisis.

"Interventions are needed that address factors within the practice environment that are contributing to burnout, rather than focusing primarily on individual strategies. That being said, all physicians have a responsibility for self-care."

Lotte N. Dyrbye, M.D.

She concluded, "Regularly assessing one's level of well-being and taking intentional steps to maintain and improve one's well-being is essential."

Looking after your own health and well-being, as well as finding a working environment that allows you to enjoy your work as a physician, are key to helping you avoid burnout.

For more practical tips, check out local American College of Physicians chapters, such as the New Mexico chapter, and Stanford Medicine. Both have great resources to help with burnout, stress, and physician wellness.