Burned out

Practicing medicine has never been an easy profession. But it’s also not getting any easier.

Perhaps that’s what makes burnout not only a reality, but also on the rise—and rising fast. Tait Shanafelt, M.D., chief wellness officer of Stanford Medicine, has found that burnout rates among physicians are now twice as high as that of professionals in other fields.

In the most recent data from a national research study, Shanafelt found that nearly 49 percent of physicians reported burnout, as opposed to 28 percent for other professionals.

Although physicians of all ages and time in practice can and do suffer from burnout, it’s actually the younger physicians who seem to be particularly at risk.

“Residency is the peak time for burnout,” Shanafelt says. One factor is the long hours required of training.

Female physicians report burnout at higher rates than male physicians. In one survey from Medscape, 48 percent of female respondents reported burnout symptoms vs. 38 percent of male respondents.

Specialty can also play a role. One Medscape survey cites the following specialties have the highest reported rates of burnout: critical care, neurology, family medicine, Ob/Gyn, internal medicine, emergency medicine and radiology.

Additional issues also contribute. For example, working emergency department shifts can contribute to “a distortion in circadian rhythm,” says David A. Farcy, M.D., who practices at Mount Sinai Medical Center in Miami Beach and is president of the American Academy of Emergency Medicine (AAEM). Likewise, “Emergency departments are the safety net of America, social issues are mounting and resources are getting less.”

The two factors most often cited in the Medscape survey as contributing to burnout are “too many bureaucratic tasks” (cited by 56 percent of survey respondents) and “spending too many hours at work” (cited by 39 percent of respondents).

Shanafelt notes another factor: complying with the demands of electronic health records.

“About 37 percent of a physician’s time in an examination room is spent entering EHR data into a computer,” says Shanafelt—time that could be spent with the patient, and time that still often requires data entry on nights and weekends.

Bringing burnout to light

As recently as the late 1990s and early 2000s, the idea of physician wellness was rarely addressed as part of med school curriculum. Instead, the focus was on strength and resiliency.

The message was this: physicians should do whatever was necessary to deal with the challenges of a career in medicine. That mindset created even more stress.

It took an increase in physician suicides to bring the matter to the forefront.

In 2012, the suicides of two residents in New York City shone a light on the issue of physician suicide. “As a result, the emergency community as a whole came together in 2016 to form a coalition of all emergency medicine groups to address wellness,” says Farcy.

Goals of the coalition included defining the problem of burnout and determining ways to identify and prevent it.

Benefitting from the focus

For Farcy, the topic was deeply personal.

“During my medical school, emergency medicine and critical care fellowship training, physician burnout and wellness was never addressed,” he says. “We were taught to just press on.”

But while in residency at Maimonides Medical Center in Brooklyn, Farcy was a first responder on 9/11—an experience with memories that he put “in a box” and didn’t speak about to others.

Then, during a moment of silence paying tribute on the one-year anniversary, Farcy’s experiences hit him hard.

Farcy’s program director took notice and invited him to her office to talk. She suggested he get help and referred him to a representative from the ACGME. From there, he visited a psychologist trained in PTSD and survivor guilt—and got the help he credits with changing his life.

“I am grateful that my institution had a program in place and a plan to address the issue without fear of repercussion,” Farcy says.

Antonia P. Francis, a maternal fetal medicine fellow at NYU Langone Health Center, reports that while she hasn’t personally known any physicians who have committed suicide, “I trained at an institution that experienced two suicides of house staff within a three-week period, yet I can honestly say that during my medical training, the topic of suicide was not heavily stressed.”

Francis, who works a fairly typical 80-hour a week, says, “I experienced depression and burnout during my residency training and first year of fellowship,” she says. The first step was recognizing she had a problem. Then, she took action.

“I visited counselors and a therapist who specifically works with physicians who had mental exhaustion,” she says. “I also learned to practice mindfulness, started journaling for stress relief, and exercised more.”

Physician suicide: A serious threat

Untreated burnout can lead to suicidal ideation and suicide. The AMA and Steps Forward offer a downloadable module available in PDF and PowerPoint called “Preventing Physician Distress and Suicide.”

The module, produced by the University of Colorado Physician Health Program Research Committee, outlines four steps to identify at-risk physicians and includes warning signs with sample scripts for approaching doctors who may be at risk for suicide.

See it at stepsforward.org/modules/preventing-physician-suicide

When help doesn’t come

Untreated burnout can lead to medical errors, substance abuse, depression and even death.

“About 300 to 400 physician suicides are reported each year,” Farcy says, “but suicide in doctors is under-reported and often hidden, because a physician can make a suicide look like an accident.”

The AMA and STEPS Forward module (stepsforward.org) on physician depression and suicide reports that female physicians commit suicide at a 130 percent higher rate, and males at 40 percent higher rate, than that of the general population for each gender.

Those statistics alone make burnout a problem in dire need of fixing.

Fixing the problem

Alleviating physician burnout is a complex challenge. Survey respondents cited more pay, fewer hours and patients, and fewer government regulations as key.

Early detection can also help. Farcy, who has been supervising residents in emergency medicine for 12 years, has seen and addressed depression and burnout in others.

The early signs, he says, are “less involvement, less caring, and negative comments in a person who used to be very positive.”

Addressing physician burnout, however, comes with its own land mines. Sometimes when a physician who is depressed or approaching burnout speaks to their supervisor about the issue, the physician is forced to stop working or see a psychiatrist in order to be cleared to go back to work.

“Too often, this adds to the stress by causing a new burden on the physician,” Farcy says.

And when a colleague has moved beyond burnout to something deeper, expressing concern may not be enough. “By the time a doctor is in the early stages of depression, it is harder to get them involved in resilience,” says Farcy.

“Telling them you need to go work out, do yoga, drink less, spend more time with your loved ones, etc., too often falls on deaf ears. The physician may hear it but won’t change or do these things because of their underlying depressive state.”

The best answer may be in fostering a community that’s open to discussing burnout. Farcy says physicians need to feel free to talk openly, in a safe place, without being labeled as weak.

“We have a wellness program where I work, and I have an open-door policy for anyone to be able to talk and share, without risk or fear of repercussion,” Farcy says.

“Once the person begins speaking, most important is listening and creating a plan,” he says.

Clif Knight, M.D., is senior vice president for education for the American Academy of Family Physicians (AAFP). He’s worked in private practice, as a hospital administrator, and as director of a family medicine residency program. As a residency program director, he witnessed resident burnout and tried to help his physicians recognize their symptoms and consider counseling and coaching.

Knight stresses that burnout is not due to a lack of physician resiliency, as was once commonly thought.

“It’s important to recognize that the majority of burnout is related to problems in the health care system and outside the physician’s control most of the time,” he says. “We need to fix the system’s problems instead of addressing only the resiliency and coping skills of individual doctors.”

Francis agrees. “Physician wellness isn’t only about individual and personal efforts, but about change on a broader level.” She suggests that institutional support and a change in our medical culture would go a long way to support physician wellness.

The path ahead

Now, medical education institutions are addressing burnout head-on. And there appears to be more help for physicians in the throes of burnout.

“Cultural and environmental changes are necessary to combat physician burnout,” says David A. Rothenberger, M.D., who advises on physician burnout at the University of Minnesota. “At our institution, we have a multi-year, major commitment from the top of the organization to devote time, talent and treasure to take on this problem.”

Rothenberger is also helping to build a coalition of those who want to address the issue of physician burnout. Currently, close to 80 individuals belong to the coalition, including academic and clinical leaders and staff.

Though progress is being made, Rothenberger says it will take a decade or two to fully address the issue.

“Achieving the needed transformation of the workplace culture to overcome the current physician burnout epidemic will take many years, and sustaining physician wellbeing is dependent on continuous effort to meet the future needs of physicians and other health care professionals,” he says.