1. How Can We, and Why Should We, Treat and Prevent Burnout?
February 4, 2011
Charles Meredith, MD
Interim Medical Director
Washington Physicians Health Program
Assistant Clinical Professor
Psychiatry and Behavioral Sciences
University of Washington School of Medicine

2. What is Burnout?
Burnout is a syndrome of depersonalization, emotional exhaustion, and low personal accomplishment leading to decreased effectiveness at work.
Burnout is a syndrome with three components…
Helping professionals
Differs from depression

3. Maslach Burnout Inventory
Developed in 1980, validated over the last 30 years.
22 item survey evaluates the 3 domains of burnout.
Respondents rate frequency on 7 point Likert scale.
3 Sub-Scales: Depersonalization, Emotional Exhaustion and Low Personal Accomplishment
Normative national samples of like professionals

4. Identification of Burnout
Overwhelming physical and emotional exhaustion
Feelings of cynicism and detachment from the job
A sense of ineffectiveness and lack of accomplishment
Over identification
Irritability and hypervigilance
Adapted from Kearney MK. Self-Care of Physicians Caring for Patients at the End Of Life. JAMA. 2009;301:

5. Identification of Burnout
Sleep problems, including nightmares
Social withdrawal
Professional and personal boundary violations
Poor judgment
Perfectionism and rigidity
Questioning the meaning of life
Adapted from Kearney MK. Self-Care of Physicians Caring for Patients at the End Of Life. JAMA. 2009;301:

6. Identification of Burnout
Questioning prior religious beliefs
Interpersonal conflicts
Avoidance of emotionally difficult clinical situations
Numbness and detachment
Difficulty in concentrating
Frequent illness—headaches, gastrointestinal disturbances
Adapted from Kearney MK. Self-Care of Physicians Caring for Patients at the End Of Life. JAMA. 2009;301:

7. Have you Seen the Following in Someone You Know?
physical exhaustion
repetitive cynicism
guilt
ineffectiveness
a sense of depersonalization in relationships with coworkers or patients
Here are some of the typical signs and symptoms

8. The “Physician Personality”
Maladaptive
Difficulty relaxing
Problem allocating time for family
Sense responsibility beyond what you control
Sense “not doing enough”
Difficulty setting limits
Confusion of selfishness vs. healthy self-interest
Difficulty taking time off
Adaptive
Diagnostic rigor
Thoroughness
Commitment to patients
Desire to stay current
Recognize responsibility of patients trust
-Gabbard JAMA 254:2926

9. What we typically do when we feel stress:
Intellectualize the stress: “I need to understand what is going on”
Minimize or deny: “I should not be feeling this way” or “I don’t feel this way”
Intensify our effort: “I just need to hunker down”

10. Physician characteristics associated with increased risk for burnout
Studies suggest high association with the following:
a hectic schedule
a strong achievement orientation
an inability to say “no”
One study suggested that the very traits that define a good physician—also place them at greater risk for burnout:
commitment to patients
attention to detail
recognizing the responsibility associated with patients’ trust
One of the tragic paradoxes of burnout is that the people more susceptible are the most dedicated, devoted, committed, responsible, highly motivated and energetic. Why? Partially because people with these traits are idealistic and perfectionist. They expect too much of themselves… and others. These individuals, many of whom would fit in a category of workaholics, “ type A” or obsessive-compulsive personalities, are marked by four characteristics: 1) a hectic schedule, 2) a strong achievement orientation, 3) an inability to say no, and 4) a tendency toward frequent cardiac problems (Minirth, 1986)
Traits: idealistic and perfectionist, highly motivated and energetic; individuals under constant pressure

11. Why Should We Care? Impact on Team (potential impairment!)
Disrupts collaboration, consultation, collegialism, and morale
High job turnover
Impaired job performance (decreased empathy, increased absenteeism)
Staff splitting and conflicting

12. What’s happening to physicians and surgeons?

14. Canadian National Physician Survey Sullivan, CMAJ 159:525 (1998)
>3500 physicians responding (RR 44%)
62% Workload too heavy
55% Family & personal life suffers because physician
65% Opportunities to change career limited
In 2008, 78% of surveyed US physicians reported their career had significantly decreased meaning; 49% of primary care physicians reported anticiapting reducing number of patients seen per day over the next 3 days, due to physical and emotional exhaustion

15. Burnout Among Surgeons Campbell, Surgery 130:696 (2001)
Surgeons in Michigan (RR= 44%; n=582)
Among practicing responders ~ 32% burned out
BO > among younger surgeons (p<0.01)
Sense of imbalance work/family/personal growth correlated with BO
A recent study of perioperative staff shows that among staff meeting criteria for burnout, core scores are higher for MDs, and highest for residents

16. 2008 ACS Survey Anonymous, cross-sectional survey
ACS members current (n=24,922)
61 item survey including standard tools assess:
Burnout
Mental and physical QOL
Symptoms of depression
Response rate 32% (n=7905)

17. Burnout Domains
% of Surgeons

18. Hours and Burnout
p<0.001

19. Factors Independently Associated with Burnout (ACS Survey; Multivariate Logistic Analysis)
Characteristic and Associated Factors
Odds Ratio1
P Value
Sub-specialty choice
All <0.013
Youngest child less than 21 years old
1.54
<0.0001
Compensation = incentive pay based entirely on billing
1.37
<0.001
Spouse works as other healthcare professional
1.23
0.004
# nights on call per week
1.05
Hours worked per week (each additional hour)
1.02
Age (each additional year older)
0.96
>50% time non-patient care
0.81
Recent extension of this study has shown that having co-MD or co- surgeon is significant risk factor for decreased quality of life
1 OR >1 indicate increased risk of burnout; OR<1 indicate lower risk of burnout

20. Factors Associated with Career Satisfaction (Surgeon)
Odds Ratio
P value
Absence of Burnout
4.12
<0.001
Higher academic rank
~1.3
<0.02
Age (each year)
1.03
Hours/week in OR (each hour)
1.01
0.033
# Nights on call/week (each night)
0.95
Private practice
0.71

21. Career Satisfaction 71% responders would become physician again
74% would become surgeon again
51% would recommend their children become physician/surgeon
36% work schedule leaves enough time for personal/family life

22. Again, Why Should We Care?

23. Self-reported Major Medical Errors in ACS Survey
OR Reporting Error p
Each 1 point increase EE
1.05
<0.0001
Each 1 point increase DP
1.11
Each 1 point decrease PA
0.97
Screen + depression
3.21

24. Emotional Exhaustion and Errors

25. Perceived Errors % Reported Error last 3 months 9%
Greatest contributing factor
Lapse judgment
32%
A system issue
15%
Degree of stress/burnout
13%
Lapse concentration
Fatigue 7%
Lack of knowledge 5%
Other
16%

26. However in addition to the professional consequences there is a tremendous personal cost of burnout for the individual physician
Who can experience….
These traits can also spill over into personal life and effect relationships with SO and children. Can lead to attrition from profession.
We need to care about it due its effects on colleagues in addition to the professional consequences.
JAMA 302:1294 (2006)
JAMA 296:1071 (2009)

27. Professional consequences of burnout
poor judgment in patient care decision-making
hostility towards patients
medical errors
adverse patient events
diminished commitment and dedication to productive, safe and optimal patient care
Diminished relations with colleagues
Approximately 15% of all physicians will be impaired
at some time in their career and will be unable to meet professional
responsibilities because of mental illness, alcoholism or drug dependency
(Boisaubin and Levine: Am J Med Sci 2001;322:31-36.

28. Professional consequences of burnout
Increased rates of malpractice events
Burn out in students is correlated with lower scores in empathy and professionalism
This is predictive of later trouble with the disciplinary board and significant boundary violations
Data suggests that burnout can precipitate chemical dependency and mood disorders
Approximately 15% of all physicians will be impaired
at some time in their career and will be unable to meet professional
responsibilities because of mental illness, alcoholism or drug dependency
(Boisaubin and Levine: Am J Med Sci 2001;322:31-36.

29. Depression
30% of responders in the ACS survey screened positive for depression
Suggest ~ 10% would meet criteria MDD

30. Suicidal Ideation Among Surgeons
501 (6.4%) surgeons thoughts suicide last 12 months
78% surgeons with SI had symptoms depression
26% surgeons SI sought psychiatric help
60% SI reluctant to seek help for treatment of depression due repercussions medical license
Only 22% used depression medication last 12 mo
26% self-prescribed or had prescribed by colleague
If you have had a colleague commit suicide you know how devastating this can be

31. Depersonalization and SI

32. Factors Associated with Suicidal Ideation on Multi-variable Analysisp
+ Depression screen
7.0
<0.001
Burnout
1.9
Perceived error last 3 mo
Youngest child age 19-22
1.6
0.004
Incentive pay only
0.8
0.035
Married
0.7
0.002
Practice academic medical center
0.6

33. Proportionate Mortality Ratio: Male Physicians vs Male Professionals
Figure. indicates human immunodeficiency virus. International Classification of Diseases, Ninth Revision. Error bars indicate 95% confidence intervals. Data from Frank and Dingle. 32 From:   Center: JAMA, Volume 289(23).June 18, –3166
The largest US study 4 of white, male physician deaths in 28 states during the years 1984 through 1995 found that, compared with white, male professionals, physicians' proportionate mortality ratio was higher for suicide than for all other leading causes of death L
Frank, JAMA.289:3161 (2003)

34. Burnout and suicidal ideation in U.S. medical students
50% of students met criteria for burnout over the past year
11% met criteria for SI in past year
Risk of Suicidal Ideation
Odds Ratio
Burnout
OR 3.46
P<0.001
High Emotional Exhaustion
OR 3.17
High Depersonalization
OR 2.10
Low Sense of Personal Accomplishment
OR 2.03
Drybye et al., Annals of Internal Medicine 2008;149:

35. Burnout and Professionalism in U.S. Medical Students
Dyrbye et al., JAMA 2010;304 (11):

36. What works, according to the experts?
Setting limits via self-regulation
Exercise
Cultivating relaxation
Connecting with friends/family
Humor
Interviewed 14 winners of the AMA annual foundation’s Pride in the Profession

37. Individual and Institutional Interventions for Burnout
Increase efficiency, autonomy, and meaning in work
Fostering self-awareness and self-reflection by writing a brief narrative about a personal experience while practicing
Process this “mindfulness” with other participants in small groups (increases attention, awareness, intention, and self-reflection)
Enhancing physicians’ attention to their own experience increases their orientation toward patients but also reduces their distress

38. *Measures That May Help Prevent Burnout
Mindful meditation
Reflective writing
Adequate supervision and mentoring
Sustainable workload
Promotion of feelings of choice and control
Appropriate recognition and reward
Adapted from Kearney MK. Self-Care of Physicians Caring for Patients at the End Of Life. JAMA. 2009;301:

39. *Measures That May Help Prevent Burnout
Supportive work community
Promotion of fairness and justice in the workplace
Training in communication skills
Development of self-awareness skills
Practice of self-care activities
Continuing educational activities
Adapted from Kearney MK. Self-Care of Physicians Caring for
Patients at the End Of Life. JAMA. 2009;301:

40. *Measures That May Help Prevent Burnout
Mindfulness-based stress reduction for team
Meaning-centered intervention for team
*Randomized trials have primarily shown
the effectiveness of mindfulness
meditation and reflective writing.

41. 10 month maintenance (2.5 hrs./mo.)
*Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians
70 PCPs
8 week intensive course of mindfulness meditation, self-awareness exercises, narratives of meaningful clinical experiences, appreciative interviews, didactics, discussions
10 month maintenance (2.5 hrs./mo.)
Krasner MS, Epstein RM, et. al. JAMA ; 302:

42. *Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes among Primary Care Physicians
Measured mindfulness (2 subscales), burnout (3), empathy (3), psychosocial orientation, personality (5), mood (6) at 2, 12, 15 mos.
Improvements in mindfulness statistically correlated with improvements in mood, empathy, burnout, conscientiousness, and emotional stability
The improvements were sustained throughout the duration of the study
Krasner MS, Epstein RM, et. al. JAMA ; 302:

44. How to contact me: Washington Physicians Health Program 206-583-0127
Call us to “discuss the situation”!