How Can We, and Why Should We, Treat and

Prevent Burnout?

Charles Meredith, MDInterim Medical Director

Washington Physicians Health ProgramAssistant Clinical Professor

Psychiatry and Behavioral SciencesUniversity of Washington School of Medicine

February 4, 2011

What is Burnout?

Burnout is a syndrome of

depersonalization, emotional

exhaustion, and low personal

accomplishment leading to

decreased effectiveness at work.

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

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;301:1155-1164

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;301:1155-1164

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;301:1155-1164

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

The “Physician Personality”Adaptive

Diagnostic rigor Thoroughness Commitment to

patients Desire to stay

current Recognize

responsibility of patients trust

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

-Gabbard JAMA 254:2926

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”

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

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

What’s happening to physicians and surgeons?

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

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

2008 ACS Survey Anonymous, cross-sectional

survey ACS members current e-mail

(n=24,922) 61 item survey including

standard tools assess:BurnoutMental and physical QOLSymptoms of depression

Response rate 32% (n=7905)

Burnout Domains

40

13

32

26

0 10 20 30 40 50

"Burned Out"

Low PersonalAccomplishment

Hi EmotionalExhaustion

Hi Depersonal

% of Surgeons

Hours and Burnout

p<0.001

Factors Independently Associated with Burnout

(ACS Survey; Multivariate Logistic Analysis)

Characteristic and Associated Factors Odds Ratio1 P Value

Sub-specialty choice 1.2-1.6 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 <0.001

Hours worked per week (each additional hour) 1.02 <0.001

Age (each additional year older) 0.96 <0.001

>50% time non-patient care 0.81 <0.001

1 OR >1 indicate increased risk of burnout; OR<1 indicate lower risk of burnout

Factors Associated with Career Satisfaction (Surgeon)

Odds Ratio

P value

Absence of Burnout 4.12 <0.001Higher academic rank ~1.3 <0.02

Age (each year) 1.03 <0.001Hours/week in OR (each

hour)1.01 0.033

# Nights on call/week (each night)

0.95 <0.001

Private practice 0.71 <0.001

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

Again, Why Should We Care?

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 <0.0001

Each 1 point decrease PA

0.97 <0.0001

Screen + depression 3.21 <0.0001

4.85%

9.46%

14.69%

0%

5%

10%

15%

20%

25%

Low EE Int EE High EE

Emotional Exaustion

% M

ajor

Med

ical

Err

or in

Las

t 3

Mo

Emotional Exhaustion and Errors

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 13%

Fatigue 7%

Lack of knowledge 5%

Other 16%

JAMA 302:1294 (2006)

JAMA 296:1071 (2009)

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.

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.

Depression

30% of responders in the ACS survey screened positive for depression Suggest ~ 10% would meet

criteria MDD

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

Depersonalization and SI

OR p

+ Depression screen 7.0 <0.001

Burnout 1.9 <0.001

Perceived error last 3 mo 1.9 <0.001

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 <0.001

Factors Associated with Suicidal Ideation on Multi-

variable Analysis

Proportionate Mortality Ratio:Male Physicians vs Male

Professionals

Frank, JAMA.289:3161 (2003)

Burnout and suicidal ideation in U.S. medical

students

Risk of Suicidal Ideation Odds Ratio

Burnout OR 3.46 P<0.001

High Emotional Exhaustion OR 3.17 P<0.001

High Depersonalization OR 2.10 P<0.001

Low Sense of Personal Accomplishment

OR 2.03 P<0.001

50% of students met criteria for burnout over the past year

11% met criteria for SI in past year

Drybye et al., Annals of Internal Medicine 2008;149:334-341

Burnout and Professionalism in U.S. Medical Students

Dyrbye et al., JAMA 2010;304 (11):1173--1180

What works, according to the experts?

Setting limits via self-regulation Exercise Cultivating relaxation Connecting with friends/family Humor

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

*Measures That May Help Prevent Burnout

1. Mindful meditation2. Reflective writing3. Adequate supervision and

mentoring4. Sustainable workload5. Promotion of feelings of choice

and control6. Appropriate recognition and

reward

Adapted from Kearney MK. Self-Care of Physicians Caring for Patients at the End Of Life. JAMA. 2009;301:1155-1164

*Measures That May Help Prevent Burnout

7. Supportive work community8. Promotion of fairness and justice

in the workplace9. Training in communication skills10.Development of self-awareness

skills11.Practice of self-care activities12.Continuing educational activities

Adapted from Kearney MK. Self-Care of Physicians Caring for

Patients at the End Of Life. JAMA. 2009;301:1155-1164

*Measures That May Help Prevent Burnout

13.Mindfulness-based stress reduction for team

14.Meaning-centered intervention for team

*Randomized trials have primarily shown

the effectiveness of mindfulnessmeditation and reflective writing.

*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. 2009; 302:

1284-1293

*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. 2009; 302:

1284-1293

How to contact me:

Washington Physicians Health Program

206-583-0127

800-552-7236

Call us to “discuss the situation”!

cmeredith@wphp.org

www.wphp.org