Provider Burnout

Aka: Provider Burnout, Physician Burnout

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II. Epidemiology

  1. Burnout affects up to 50% of U.S. physicians

III. Findings

  1. Emotional and physical exhaustion
    1. High patient morbidity and mortality
    2. Litigation risk
    3. Circadian rhythm disturbance (i.e. night shifts)
  2. Mental distance, cynicism or depersonalization
  3. Moral Injury
    1. Sense that provider is unable to deliver ethical, quality care in the context of system contraints
  4. Decreased personal accomplishment Perception or professional efficacy
  5. Decreased work-life balance satisfaction (i.e. general surgery, OB/Gyn, surgical specialties)
  6. Palliative Factors
    1. Symptoms improve with time away from work
  7. Exacerbating Factors
    1. Workplace discrimination
    2. Workplace Violence
    3. Insecurities about competency in role or imposter syndrome

IV. Risk factors: Specialty

  1. Positive risks (higher burnout rates)
    1. Family Medicine
    2. General Internal Medicine
    3. Emergency Medicine
  2. Negative risks (lower burnout rates)
    1. Dermatology
    2. Pathology
    3. Pediatrics

V. Pathophysiology

  1. Emotional Stress stimulates Corticotropin releasing Hormone to ACTH release
  2. ACTH stimulates adrenal release of Cortisol and Catecholamines (Epinephrine, Norepinephrine)
    1. Short-term adrenal Hormones work to succeed in serious fight or flight events
    2. Long-term Catecholamine and Cortisol release results in somatic symptoms and comorbidities

VI. Complications

  1. Decreased quality of patient care
  2. Decreased professionalism
  3. Decreased empathy
  4. Increased medical errors
  5. Self-destructive behaviors (e.g. Alcoholism or Drug Abuse)

VII. Management: Instituting Change despite Fear

  1. Create a mental model of what a positive change would look like
  2. Ask "what if I were to..."
  3. Make a list of the fears that are a barrier to change
    1. For each fear, address a preventive strategy to overcome that fear from coming true
    2. Identify a repair strategy, in case a worst fear does come true
  4. Identify the potential benefits of success
  5. Consider the costs of not making a change (status quo)
  6. References
    1. Herbert and Rosh in Herbert (2018) EM:Rap 19(2): 10-1

VIII. Prevention: Individual

  1. Self Actualization pyramid (Kurt Goldstein)
    1. Physiologic Needs
      1. Air, water, food, clothing, shelter and sleep
    2. Safety Needs
      1. Personal security, financial security, health security
    3. Love and Belonging
      1. Group embraces you and loves you for who you are
    4. Esteem
      1. Respect and Self Esteem
    5. Self Actualization (Wikipedia)
      1. https://en.wikipedia.org/wiki/Self-actualization
  2. Life balance strategy
    1. Plan pleasurable activities for yourself and with family and friends
    2. Schedule pleasurable activities on your life calendar
  3. Coping
    1. Vacation
    2. Make time for enjoyable activities and hobbies
    3. Stress Reduction (yoga, Mindfulness)
    4. Support groups among colleagues
    5. Socialize with colleagues
    6. Spend time with family and friends
    7. Healthy behaviors including regular Exercise and Healthy Diet
  4. Engage in adjunctive activities that increase job satisfaction
    1. Leadership roles
    2. Ensure job security and appropriate compensation (e.g. night shifts should receive fair pay)
    3. Encourage a supportive environment
    4. Teaching or consulting

IX. Prevention: Organization

  1. Job Satisfaction Surveys
    1. Use standardized surveys that can be compared to other regional and national organizations
    2. Prioritize change in low scoring areas relative to national benchmarks
    3. Repeat the survey on a periodic basis (e.g. yearly)
  2. Identify specific units in the organization that are at the highest stress and risk of burnout
  3. Keep clinicians working at the top of their license and delegating/off-loading non-clinical work to others
  4. Train and maintain competent and effective leaders within the organization
    1. Provides structural support for clinicians (working as a team)
  5. Encourage an environment for peer support and interpersonal connections
    1. Shared meals and outings
  6. Salary-based compensation and quality-based incentives may be less stressful than productivity-based models
  7. Incorporate work-life balance into the schedule (vacation, flexible hours, emergency time-off)
  8. Encourage healthy life styles (e.g. work benefit programs that discount fitness programs, access to healthy meals at work)
  9. References
    1. Gips and Welsh (2019) Crit Dec Emerg Med 33(3): 14

X. Resources

  1. Shawn Achor: The happy secret to better work | TED Talk
    1. https://www.ted.com/talks/shawn_achor_the_happy_secret_to_better_work?language=en

XI. References

  1. Orman, Herbert and Drummond in Herbert (2016) EM:Rap 16(8):8
  2. Kalantari in Herbert (2018) EM:Rap 18(8): 14-5
  3. Bright and Shoenberger in Majoewsky (2013) EM:Rap 13(6): 10
  4. Cydulka (2008) Ann Emerg Med 51(6): 714-22 [PubMed]
  5. Shanafelt (2012) Arch Intern Med 172(18):1377-85 [PubMed]

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