FEATURE
Features
Rethinking
Burnout
Will solving physician
burnout require sweeping
changes to the U.S.
health-care system?
About 15 years ago, during the first year
of his fellowship, Tait Shanafelt, MD,
was riding a bus when he heard a famous
radio broadcaster describing a small study
Dr. Shanafelt had conducted during the
last year of his residency. “I was shocked.
Paul Harvey came on the radio and actu-
ally said there was a new study from the
University of Washington showing physi-
cian burnout affects quality of patient
care,” Dr. Shanafelt said. “It was like an
out-of-body experience.”
The study, published in 2002, stemmed
from an observation Dr. Shanafelt made
during the third year of his residency:
Many of the residents he was working
with – people he’d considered exceptional-
ly altruistic and compassionate – seemed
to be growing cynical. 1 When his super-
visor asked why he cared, he answered,
“Because it’s affecting our patients.” With
those words, his supervisor greenlit the
study which, Dr. Shanafelt said, became
“a lightning rod.” “It was one of the first to
look at the links between physicians’ well-
being and quality of care.”
Dr. Shanafelt and coauthors asked
115 residents to assess their experiences
of burnout using the Maslach Burnout
Inventory, then to answer an additional
five questions to assess self-reported
behaviors that suggested suboptimal care
(for example, “I did not fully discuss treat-
ment options or answer a patient’s ques-
tions” and “I made … errors that were not
due to a lack of knowledge or inexperi-
ence”). Three-quarters of participants met
the criteria for burnout, and burned-out
physicians were more likely than non–
burned-out physicians to self-report at
least one suboptimal patient care practice
each month (53% vs. 21%; p=0.004).
Clinicians and researchers around the
world have begun taking notice and rais-
ing awareness of an issue that affects more
than half of all U.S. physicians. For years,
ASHClinicalNews.org
interventions have been focused on the
suicide were mood disorders, alcoholism,
stress or tiredness: emotional exhaustion,
idea that physicians need to build more
and substance abuse, but fear of stigma
personal accomplishment, and deperson-
resilience to thrive in stressful and de-
was a major obstacle to seeking treatment
alization (which manifests as a lack of
manding positions. Now, some physicians
for these issues. “Treatment interventions
empathy or cynicism).
are pushing back against that idea and
have not lowered the rates of physician
The consequences of burnout can be
turning their attention to interventions at
suicide,” the researchers reported, adding
dire – for both patients and physicians.
the organizational and systematic levels
that “there is little consensus on effective
Burned-out physicians are more likely
– such as offering more flexible hours,
means of preventing physician suicide.”
to make mistakes in patient care, and, as
increasing physicians’ autonomy, lighten-
When this problem entered the
reported in a recent meta-analysis review-
ing their workload, and encouraging their
mainstream consciousness, interventions
ing reports describing the occurrence and
meaningful interactions with patients.
typically focused on building physician
attempts to prevent physician suicide,
“Ultimately, we need happy, healthy
resilience, or the capacity to recover from
the suicide rate in among physicians is
physicians to take care of patients,” Nisha
difficulties or “bounce back” from the
more than that of any profession. Over
Mehta, MD, a radiologist at the W. G.
stress of the training and/or the clinical
the past 10 years, the suicide rate among
(Bill) Hefner Veterans Affairs Medical
environment. 4 According to the American
physicians is 28 to 40 per 100,000 – nearly
Center in Charlotte, North Carolina, and
double that of the general population. 3
Medical Association (AMA), a resilient
a wellness advocate, told ASH Clinical
doctor is better equipped to handle the
The most common psychiatric diag-
News. “If you look at things from a policy
many challenges of practicing medicine
noses among physicians who completed
standpoint, it’s scary
that physicians are
TABLE. CHARM Project’s Organization-Wide Recommendations to
not feeling happy or
healthy.”
Promote Physician Well-Being
ASH Clinical
Societal Commitments
News spoke with Drs.
Foster a trustworthy and
• examine the extent to which the culture of medicine, broadly and locally, facilitates
Shanafelt, Mehta,
supportive culture in
meaning, fulfillment in practice, and professionalism
and others about the
medicine
• practice and role model self-compassion and vulnerability as essential components of
physician practice
epidemic of physi-
cian burnout and the
Advocate for policies that • replace productivity-based reimbursement models with those that reduce excessive
enhance well-being
administrative work
shifting approaches
• advocate for processes that encourage physicians to seek routine mental health care
to its prevention and
without fear of licensing penalties
management.
Organizational Commitments
Where Do We
Start?
The Maslach Burnout
Inventory, a com-
monly used test for
measuring profes-
sional burnout, was
developed by psy-
chologist Christina
Maslach, PhD, in
1981, 2 It measures
three dimensions that
distinguish burnout
from run-of-the-mill
Build supportive systems • reduce administrative burden via automated prescription lines, or having medical assistants
enter information in EHRs
• ensure adequate rest and a manageable workload, with coverage systems and provisions for
family leave
Develop engaged
leadership • establish physician well-being as an organizational priority by including well-being
initiatives in strategic planning efforts
• integrate well-being measures into assessments of organizational performance
Interpersonal and Individual Commitments
Anticipate and respond
to inherent emotional
challenges of physician work • incorporate coping strategies for adverse experiences into training and continuing education
• normalize seeking support by integrating regular protected opportunities for debriefing
within the workday
Practice and promote
self-care • provide education, resources, and protected time for physicians to devote to enhancing
emotional awareness, mindfulness, and self-reflection
• encourage healthy choices by incorporating healthy food and exercise facilities at or near the
workplace and incentivizing participation in lifestyle initiatives
Source: Thomas LR, Ripp JA, West CP. Charter on physician well-being. J Am Med Assoc. 2018;319:1541-2.
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