During the COVID-19 pandemic, hospital employee turnover increased to 19.5%. Compare that to labor turnover of about 4% in the general US workforce. Burnout is a major factor driving the increased turnover rate and a dire issue affecting physicians more than ever.
Before the pandemic, 27% of US physicians stated that they felt burned out. In 2022, almost double (45%) the rate of physicians said they have personally experienced burnout in the last 2 years. These percentages are variable depending on location in the country and specialty; however, these trends are headed in the wrong direction. The next frontier must be addressing the organizational and systemic drivers of burnout.
What Is Burnout?
The American Medical Association defines burnout as: “A long-term stress reaction characterized by depersonalization, including cynical or negative attitudes toward patients, emotional exhaustion, a feeling of decreased personal achievement, and a lack of empathy for patients.” For someone who goes to school for at least a decade after high school to even qualify to practice medicine independently, this definition seems to be the opposite of what a physician should be and feel.
You may wonder why I’m defining burnout — after all, many of you have likely experienced it firsthand. But as Dike Drummond, MD, says, “Burnout is everywhere, but you can’t fight an enemy unless you recognize it.”
What Causes Burnout?
The inability to recharge: Oftentimes, the difference between a medicine and a poison is the dose. People who decide to become physicians have a burning passion and driving curiosity to heal the human condition, they are motivated and ready to work extremely hard to make a difference. So why then does this type of individual experience burnout? Too much of a good thing can be harmful.
Microaggressions in the work environment: Microaggressions are “subtle behaviors and attitudes toward others that arise from conscious or unconscious bias.” Becoming a physician is already difficult enough: learning and relearning endless amounts of knowledge, working long hours, and being exacting in every action. Add on top of that marginalization from other healthcare workers through “hostile, derogatory, or negative” communication, and training to be a physician or practicing medicine becomes all the more challenging.
Do-it-all compassion: Physicians see the most gruesome, life-altering, and catastrophic patient cases, and then must move on to the next patient with the same level of compassion. The “do-it-all” mentality that physicians are superheroes creates a false narrative and sets providers up for compassion fatigue: giving your emotional best to each person you meet, until you have nothing to give yourself.
Isolation: Over the years, physicians have transitioned from being leaders in their communities and practice owners to employed skilled workers for large hospital systems. Although physicians have benefited, this transition has led to professional loneliness since physicians are becoming more attached to their electronic health record (EHR) systems and efficiency metrics rather than being able to seek companionship from colleagues in or outside of the workplace. The long hours at the hospital don’t help either, as physicians report levels of loneliness 25% greater than survey respondents with bachelor’s degrees.
Workload: Thankfully, medicine is advancing and the “US life expectancy at birth has increased from 70.9 years to 78.7 years” over the last 40 years (note this was as of 2015 and trends have shifted as a result of COVID-19). But even pre-pandemic, patients 65 and up were two times more likely to visit physician offices than other age groups and significantly more likely to be hospitalized. Furthermore, patients are much sicker now with multiple chronic conditions; moreover, there is an expected 37% increase (an additional 46 million) Americans to be affected by chronic conditions by 2030, as compared to 2000.
What Actually Works to Fix Burnout?
The Accreditation Council for Graduate Medical Education (ACGME) recognized the principle of burnout, and in 2003 the landmark 80-hour work week was implemented. This was an introductory idea to address burnout, but more is needed to treat the systemic causes of burnout induced by medical education.
Medical education and residency is highly structured, helping to enhance consistency of training and advancement through years of training. However, it does not allow medical trainees to take breaks when they feel the onset of burnout.
Many professional jobs now allow employees to take days off for mental health. These “mental health” days are differentiated from vacation, sick, and holiday time off. A similar concept could be applied in healthcare to help prevent burnout. Currently, medical trainees can only take extended periods off through leaves of absence. This is usually unpopular because it can require extensive effort to get approval from administration and can significantly delay training length. Additionally, there is the potential of stigma from future employers due to gaps in employment history.
While mental health days for medical trainees or professionals could help in the short term, it won’t solve the problem of burnout as the stress and emotional burden will likely resume when the person returns. Of course, physicians can, and do, work on prioritizing self-care through nutrition, good sleep habits, socialization, exercise regimens, spiritual revitalization, reducing obligations by saying no, and so on. However, organizational level changes are needed to create a more supportive and manageable work environment.
Some suggest that simply hiring more physicians will decrease the workload per physician. But will this actually decrease the rate of burnout?
Based on the World Bank data, the number of physicians per thousand people does not seem to significantly impact the burnout percentage. The US has about half the number of physicians per 1,000 people as the UK; however, it has a similar burnout percentage level among physicians. Of course, patient demographics, comorbidities, insurance coverage, medical training practices, access to resources, and more vary greatly by country. But going by the sheer numbers, there is no linear association between the number of physicians and the collective level of burnout.
Thus, we need to focus on improving the organizational drivers of burnout. The physician executive council states that the main three organizational burnout drivers are: workload, autonomy and control, and loss of meaning in work. To address these, organizations can provide physicians resources to streamline EHR workflow, use advanced practice providers to allow physicians to work consistently at the top-of-license, give physicians clarity and decision-making capacity in their schedules, and allow physician leadership roles to be sustainable and fulfilling. Through investing in physician burnout at an organizational level, we can decrease this epidemic and start to focus on prevention of burnout so physicians are able to provide the best care for their communities.
Rafid Rahman, MD, is a physical medicine and rehabilitation resident at the University of Missouri School of Medicine. He is a member of MedPage Today‘s The Lab.