Burnout Basics – symptoms, effects, prevalence and the five main causes
This is the first in a series of three articles by Dike Drummond, MD, a Mayo-trained family physician, author, speaker and trainer on physician burnout. On Sept. 8, he will lead a five-hour workshop in Indianapolis to help physicians rediscover their joy in medicine. Sign up at www.ismanet.org/HappyMD.

   PREVENT PHYSICIAN BURNOUT - PART 1   

Burnout Basics – symptoms, effects, prevalence and the five main causes

By Dike Drummond MD 
CEO, www.TheHappyMD.com

There is an epidemic of physician burnout in the U.S. It has a pervasive negative effect on all aspects of medical care, including your satisfaction with your career. In this three-part article series, we will explore burnout’s symptoms and causes (Part 1), proven methods to lower physician stress levels (Part 2) and proven methods to recharge and create more life balance (Part 3). 

The prevalence of physician burnout
Burnout prevalence has been exhaustively studied in all major specialties and in most first-world nations over the last three decades. The 2015 Medscape Physician Lifestyle Survey (2) reported a burnout rate of 46 percent. This was up from 39.8 percent in the 2013 survey. 

Why is physician burnout important?
Burnout is directly linked to an impressive list of pervasively negative consequences. (3, 4, 5, 6, 7, 8)

  • Lower patient satisfaction and care quality

  • Higher medical error rates, malpractice risk

  • Higher physician and staff turnover

  • Physician alcohol and drug abuse and addiction, physician suicide
Burnout can be a fatal disorder. Suicide rates for both men and women are higher in physicians than the general population and widely underreported.

So, before we go on, let’s agree that physician burnout is bad on multiple different levels. Bad for the doctor and their family. Bad for their staff, patients and organization. And burnout is everywhere, all the time.

The origin of physician burnout
Burnout is a fundamental disorder of energy metabolism. This is not the Krebs cycle. It is more like “the force” in Star Wars. Before we go any further, we must debunk a common metaphor for burnout: The battery. Physicians often discuss exhaustion and burnout as a state where “my batteries are just run down.” This battery metaphor is at odds with reality for the following reasons. 

When a toy’s battery runs out, what does the toy do? Yes, it stops working. When did you ever stop working – ever? If you had stopped working – at any time in your med school, residency or practice – what effect would that have had on your career? 

A much more accurate and useful metaphor is the energetic bank account. This is just like the account at the bank that holds your money, but this one holds your life force. Just like a normal bank account, you can over draw it and find yourself in a negative balance. This is exactly what residency trains us to do. We are pushed beyond our limits and learn how to carry on even when our energy balance is below zero. We never stop no matter how exhausted we become.

Simply stated:

  • We use energy from this account for the activities of our life and medical practice

  • We recharge the account during times of rest and rebalance
Burnout is the constellation of symptoms that occur when your energy account is in a negative balance. You can continue to function in this depleted state; however, dozens of studies show you are a shadow of the doctor you are when your account is in a positive balance.

Burnout’s three cardinal symptoms
The accepted standard for burnout diagnosis is the Maslach Burnout Inventory, developed by Christina Maslach at the University of San Francisco and published in 1981. Her team was the first to describe burnout and name the syndrome. Here are the three main symptoms.

Exhaustion
The physician’s physical and emotional energy levels are extremely low and in a downward spiral over time. A common thought process at this point is, “I’m not sure how much longer I can keep going like this.”

Depersonalization
This is signaled by cynicism, sarcasm and the need to vent about your patients or your job. This is also known as “compassion fatigue.” At this stage, you are not emotionally available for your patients, or anyone else, for that matter. Your emotional energy is tapped dry.

Lack of Efficacy
You begin to doubt the meaning of your work. You might think. “What’s the use; my work doesn’t really serve a purpose anyway.” Or, you may worry that you will make a mistake if things don’t get better soon.

Gender differences
Recent research shows that men and women suffer from exhaustion and compassion fatigue equally. However, symptom three, lack of efficacy, is much less common in men. Male physicians are far less likely to doubt the quality of their work than women, no matter how burned out they are. (9)

Fast and slow and the role of trauma
Burnout can happen slowly over time in a chronic grinding fashion – the classic “death by 1000 paper cuts.” It can also crash down on you in a matter of minutes when it is triggered by a traumatic outcome, lawsuit, devastating medical error or equally tragic circumstance in your larger life. Trauma can drain your energy in mere moments, robbing you of the will to go on. The lifetime incidence of this level of trauma in practicing physicians is extremely high. In some specialties, repeated practice trauma is a constant feature of the physician’s professional life.

The 5 main causes of burnout
In more than 2,100 hours of one-on-one coaching experience with burned out physicians, here are the five causes of burnout I see most commonly.

  1. The practice of clinical medicine
    Being a physician has been and always will be a stressful job. This is a fundamental feature of our profession, for a simple reason. We are dealing with hurt, sick, scared, dying people and their families. 
    Our work takes energy even on the best of days. Our practice is the classic high-stress combination of great responsibility and little control. This stress is inescapable as long as you are seeing patients, no matter what your specialty. As you read on, note that this is the only one of the five causes of burnout we actually learn to deal with during the medical education process.

  2. Your specific job
    On top of the generic stress of caring for patients above, your job has a very specific set of unique stresses. Everyone’s matrix of job-specific stresses is unique. They include the hassles of your personal call rotation, your compensation formula, the local health care politics associated with the hospital(s) and provider group(s), the personality clashes in your department, your leadership and your personal work team and many, many more. 
    You could change jobs to escape your current stress matrix, and your next position would have all the same stressors, at different levels of intensity. It is also tempting to believe a different practice model would be less stressful. However, moving from an insurance-based practice model to concierge or direct-pay simply switches one set of stressors for another.

  3. Having a life
    In an ideal world, your larger life is the place where you recharge from the energy drain at work. Two major factors can prevent this vital recharging activity

    a) We are not taught life balance skills in our medical education. In fact, our residency training teaches us just the opposite. We learn and practice ignoring our physical, emotional and spiritual needs to unhealthy levels and then carry these negative habits out into our career. You work until you can’t go any longer, then you keep going. To do otherwise could be seen as a sign of weakness. (See cause 4 below.)

    b) Multiple situations could arise at home that eliminate the opportunity to recharge your energy account. Your life outside your practice then switches from a place of recharge and recuperation to an additional source of stress.

    The causes range widely from simple conflict with your spouse, to illness in a family member (child, spouse, parent), financial pressures and many more.

    This can lead to the common situation where you watch a colleague take on the downward spiral of burnout at work in the absence of any new work stress. If you reach out to a colleague who appears to be burned out, you must ask how things are at home  to reveal this burnout cause. (10)

  4. The conditioning of our medical education
    Several important character traits become essential to graduating from medical school and residency. Over the seven-plus years of our medical education, they become hardwired into our day-to-day physician persona, creating a double-edged sword. The same traits responsible for success as a physician simultaneously set us up for burnout down the road; here are the top five I see in my physician coaching practice.

    Workaholic
    Superhero
    Perfectionist
    Lone ranger
    Emotion-free

    In addition, we absorb two prime directives. One is conscious and quite visible: “The patient comes first.”
    This is a natural, healthy and necessary truth when we are with patients. However, we are never shown the “off” switch.  If you do not build the habit of putting yourself first when you are not with patients, burnout is inevitable.

    The second prime directive is never stated, deeply unconscious and much more powerful. It goes like this: “Never show weakness.”

    To show this programming in stark relief, please try a thought experiment. Imagine you are back in your residency. A faculty member walks up to you and says, “You look really tired. Is everything OK?” How would you respond – and how quickly would that response come out of your mouth? That is the essence of this deeper prime directive. This kneejerk defense makes it very difficult to help physician colleagues, even when their burnout is clear to everyone on the team.

    Put the five personality traits together with the two prime directives, and you have the complete conditioning of a well-trained physician. Combine this with a training process that is very much like a gladiator-style survival contest, and doctors become hardwired for self-denial and burnout.

  5. The leadership skills of your immediate supervisors
    Outside of health care, there is a management saying, “People don’t quit companies, they quit their boss.” There is wide acceptance that your work satisfaction and stress levels are strongly, powerfully affected by the leadership skills of your immediate supervisor.

    Now, we know this is true for physicians, too. A recent study shows a direct relationship between the quality of your boss and your burnout and job satisfaction levels. (11)  In this era, where physician groups are forming much more quickly than they can find trained doctors for leadership positions, it is very common to have either an unskilled – or worse, an absent – boss to report to. This fifth cause of burnout has only recently joined the classic four, above. It is a significant source of stress for many employed physicians. 
The pathophysiology of burnout
How does burnout work in the body of its victims? Let’s go back to two concepts discussed above – the energy account and the symptoms of the Maslach Burnout Inventory (MBI).
It is most useful to understand that we each have more than one internal energy account. There are actually three energy accounts inside each of us. They correspond to the three symptoms addressed in the MBI.

  1. Exhaustion = your physical energy account.
    You make energy deposits here by taking care of your physical body with rest, exercise and nutrition – all the things we learned not to do in our training.

  2. Compassion fatigue = your emotional energy account.
    You make energy deposits here by maintaining healthy relationships with the people you love – your friends and immediate family. Recharge here is essential if you are to have energy to be emotionally available for your patients and staff, family and friends.

  3. “What’s the use?” = your spiritual bank account.
    You make deposits here via a regular connection with your personal sense of purpose. In your practice, this occurs when you have an ideal patient interaction. This is the visit where you say to yourself afterward, “Oh yeah, that is why I became a doctor.” You can connect with purpose outside of work, as well. One example for me is when I coach my children’s youth soccer teams. If you go long periods of time without connecting with purpose, this account is drained, and you have a lot of trouble seeing a reason to carry on.
The physician’s ethical imperative
As physicians, we each have a moral imperative to keep our energy accounts in a positive balance. All good things flow from this positive energy state. Our leadership skills, quality patient care, empathy, our skills as a spouse and parent … all of these rely on a positive energy balance.

And, yet, you can see we are not trained to notice or care for our energy levels, and our job places us at very high risk for burnout.

How can we stop or prevent physician burnout? 
There are two fundamental mechanisms to drive a positive energy balance. 

  • Lower your stress levels and the drain they produce.

  • Improve your ability to recharge your energy accounts.
Most physicians will use a combination of both methods to treat and prevent burnout. We will discuss multiple tools in both categories in future articles. 

One more thing: Beware of Einstein’s insanity definition and the comprehension trap

Before we end this introductory article, let me show you two extremely common forms of “mind trash” that stop many physicians from preventing burnout in the first place. 

  • The comprehension trap: The tendency to study a concept until you understand it, then fail to put it into action.

  • Einstein’s insanity definition: “The definition of insanity is doing the same things over and over and expecting a different result.” (12)
Now that you have a better understanding of burnout, do not stop here.  You must take different actions to get different results in your practice and your life. In order to prevent or recover from burnout you must rise above the habits you learned in training and take new actions to lower stress and create more balance.

References:
(1) Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care, Shanafelt T, JAMA. 2009 Sep 23;302(12):1338-40.
(2) Medscape Physician’s Lifestyle Survey 2015, http://www.medscape.com/features/slideshow/lifestyle/2015/public/overview#2
(3) Shanafelt TD, West C, Zhao C, et al. “Relationship between increased personal well-being and enhanced empathy among internal medicine residents.” J Gen Intern Med 2005; 20:559-64
(4) Firth-Cousins J, Greehhalgh J. “Doctor's perceptions of the links between stress and lowered clinical care.” Soc Sci Med 1997; 44: 1017-22
(5) Shanafelt TD, Bradley KA, Wipf JW, Back AL. “Burnout and self-reported patient care in an internal medicine residency program.” Ann Intern Med 2002; 136: 358-67
(6) Williams ES, Skinner AC. “Outcomes of physician job satisfaction: a narrative review, implications and directions for future research.” Health Care Manage Rev 2003; 28: 119-40
(7) Gardiner M, Sexton R, Durbridge M, Garrard K. “The role of psychological well-being in retaining rural practitioners.” Aust J Rural Health 2005; 13: 149-55
(8) Wetterneck TB, Linzr M, McMurray J, et al. “Worklife and satisfaction of general Internists.” Arch Intern Med 2002; 162: 649-56
(9) Development of Burnout over time and the causal order of the three dimensions of burnout among male and female GP’s. A three wave panel study. Houkes I, Winants Y, BMC Public Health. 2011; 11: 240.
(10) A survey of U.S. physicians and their partners regarding the impact of work-home conflict. Dyrbye LN, et al, J Gen Intern Med. 2014 Jan;29(1):155-61. 
(11) Impact of Organizational Leadership on Physician Burnout and Satisfaction, Shanafelt, T, et. al, Mayo Clinic Proceedings April 2015, 90:4;432–440h
(12) There is no evidence Einstein ever said this. That does not make it any less powerful.