Burnout. If you work in health care, you’ve heard about it, but do you know how to spot burnout? Long before COVID, experts were sounding alarms about increasing rates of physician burnout. The pandemic only amplified those warnings.
Burnout has consequences for physicians, employers and patients alike. As a job-seeking physician, prioritizing your mental health isn’t just good for you. It’s also good for your career. Learning the causes and signs of burnout — as well as how to avoid and address it — will lead to a long, productive and satisfying career. That starts with choosing a practice that fits your needs.
Understanding risk factors
Residencies used to be so difficult that burnout was almost a given, according to Gary Price, M.D., FACS, president of The Physicians Foundation. “Our daily tasks were like trying to empty the ocean with a cup of water,” says Price, recalling his time as a chief surgical resident. “Everyone expected a chief resident in surgery to be burned out.”
Reflecting on that experience and reviewing current data convinced Price to act. In his role at the foundation, he works to combat burnout. Thankfully, he notes that residencies have changed a lot since the 1980s. But other contributing factors to burnout have increased in recent decades.
“Being a physician has always been a tough job,” he says. “The buck stops with the physician in health care. The hours are long. [Physicians] willingly expose themselves to infectious diseases that are potentially a threat to their families, and the time they’d like to spend with them is often encroached on. That’s always been there. What’s new, though, are some very obvious sources of burnout.”
The pandemic is the most recent and undeniable example. In The Physicians Foundation’s 2021 survey, 61 percent of physicians said they “often experience feelings of burnout.” That’s a substantial increase compared to 40 percent in 2018.
The pandemic is a “once in a hundred years” event, says Don Deep, M.D., of Central Ohio Primary Care in Columbus, Ohio. Physicians have had no control over it. They had to grapple with an outbreak they didn’t initially know how to treat or contain. On top of this, lockdowns meant their usual sources of relaxation were off limits.
“Connecting with people [outside work] and doing fun things just kind of went away,” he says. “It was almost literally impossible to travel, maybe even to go out to dinner in the last couple of years. When you don’t have that opportunity to recharge, that introduces factors that accelerate physician burnout.”
The pandemic spike in burnout is dramatic and unnerving, but it may also be transient. However, even if burnout rates return to 2019 levels once the pandemic recedes, there’s still cause for concern. The trends were alarming pre-pandemic. And many of burnout’s known causes have been slow to improve.
“Physicians are unanimous in saying the greatest satisfaction they get from their profession is the time and relationships they have with their patients,” Price says. “But part of their power to control outcomes for their patients has been taken away.”
Price cites insurance approval requirements as one major factor. Bureaucratic processes consume physicians’ time. All too often, they’re overruled on important decisions about prescriptions and testing. This means less control over patient outcomes, lower morale and higher rates of burnout.
Inefficient workflows also contribute to burnout. This is especially true of poorly implemented electronic health records (EHR) systems, according to Laxmi Mehta, M.D.,professor of medicine in the division of cardiovascular medicine and vice chair for wellness in the department of internal medicine at The Ohio State University Wexner Medical Center and chair of the American College of Cardiology’s physician wellbeing task force.
One big issue? Non-clinician stakeholders often add steps to EHR processes to gather data. They don’t realize the cumulative effect this has on physicians’ overlong to-do lists.
“People just think that it’s a click here, a click there,” Mehta explains. “But the clicks add up. We need to step back and ask, ‘Are these clicks and information really necessary?’” She adds that some of these inputs relate to quality and patient satisfaction programs. These in particular can undermine physicians’ sense of autonomy and influence over patient care.
“You’re doing all these things for ‘satisfaction,’ but is that even in the best interest of the patient?” she asks. “Sometimes this can lead to over-testing or overprescribing.”
Price agrees. “The time we spend documenting our care now has grown beyond double the time we spend caring for patients,” he says.
Physicians’ strengths may work against them
When it comes to fields with high burnout risks, medicine tops the list. That’s according to Cris Berlingeri, M.D., a dermatopathologist with U.S. Dermatology Partners. Berlingeri also works as a life coach. Her clients include physicians and others recovering from burnout. One common thread she sees in fields with high burnout rates? Overprioritizing others’ needs.
“We are trained in these professions, particularly as physicians, that everybody [else] comes first and you go last,” she explains. “You’re in a surgery, and it takes seven hours, and you don’t want to leave to use the restroom. We’re trained to deny our bodily necessities like sleep and rest. But we’re mammals. We’re animals,and we need to take care of ourselves. Burnout is a stress response. It’s like the brain is saying, ‘OK, we’re in danger. Let me take over.’”
Berlingeri adds that many physicians have spent their lives striving for exceptional performance. This only increases the risk of burnout. Self-criticism multiplies the stress of the job. For example, let’s say you procrastinate by scrolling social media instead of doing research or finishing charts. If you respond with internal criticism, it can radically amplify your stress.
“Let’s say that a stressor causes you a level three of stress on the scale from one to 10. Our judgment in response brings it up to a nine. It triples,” she explains. “If you say to yourself, ‘Look at you, being so lazy. You should be charting,’ you’ve added another stressor. But it’s coming from within you, and you cannot escape that.”
Mehta adds that trying to earn respect may also set physicians up for burnout. It’s not unusual for physicians in new jobs to offer to work late or take extra call. But repeatedly putting your own needs aside isn’t good for you or anyone else. Plus, the positive impression you make is unlikely to last. “If you want to impress people, impress them with your knowledge and intelligence and how you can take great care of patients,” she says. “Not by always being the one volunteering to do more call or weekends.”
Even more troubling, Mehta says some physicians feel a stigma around mental health care. They may try to be strong and ignore early symptoms of burnout instead of getting help. “People feel like it’s a mistake in them, even when the amount of work is just not sustainable,” she says.
Price agrees. “I think the biggest barrier to seeking help is physicians’ own perceptions that somehow seeking mental health care is a reflection of weakness or incompetence,” he says. “I don’t think they really feel they are being incompetent by seeking care. I think that they feel everyone else around them—patients, colleagues, administrators—will perceive it as a sign of weakness or incompetence, and that’s something we absolutely have to eradicate.”
Institutional barriers
Price says privacy concerns may also discourage physicians from seeking mental health care. The Physicians Foundation, in collaboration with Dr. Lorna Breen Heroes’ Foundation, has identified six privacy-related institutional barriers.
The first four are intrusive questions about mental health history on applications for state licensing, health plan and hospital privileging and credentialing, and malpractice coverage. The fifth is the fear of legal repercussions. Physicians worry about their mental health history being disclosed in a lawsuit discovery process. Finally, some employers require employees to access mental health care within their own systems. Physicians may reasonably doubt that their choice to seek care will remain confidential.
Importantly, Price notes, a nationwide push for licensing reforms has gained momentum. Several states have already reduced the intrusiveness of mental health questions, he says.
Pamela Wible, M.D., a family medicine physician, advocate and activist, has tracked this progress for several years. Her website,
idealmedicalcare.org, ranks state boards by the types of mental health questions they ask. She recommends physicians research board questionnaires in any stateswhere they’re considering practicing.
Specialty societies, medical associations and physician-led organizations are addressing barriers, too. They’re advocating for change and establishing confidential psychiatric helplines for physicians.
Knowing the signs
Another challenge to seeking care for burnout? Not recognizing the symptoms.
As Annie Wright, LMFT, explains, burnout “isn’t something that comes with clearly defined stages. And it certainly isn’t a diagnosis that appears in the DSM.” As a therapist based in Berkeley, California, she works with physicians and others experiencing burnout.
“But most people agree that burnout is a pervasive professional phenomenon that starts subtly—so subtly that you may not even be able to recognize that you’re dealing with it—and grows in intensity over a spectrum of severity to the point where it can negatively impact an individual across many sectors of their life.”
Berlingeri agrees. When she trained to become a life coach, she didn’t learn a clear continuum of stages for burnout. However, experts agree on several strong indicators. One is emotional distress even when you’re physically and chemically well. “One of the signs is you feel like crying every day and you don’t even know why,” she explains.
Deep echoes Berlingeri’s observation. He says not to ignore anxiety that’s unconnected to any obvious external stressor. This is a telltale burnout signal.
“I’ve had more than a handful of partners over the years who’ve described the sense of just being anxious about work, and I’ve said, ‘Well, was it because of something that happened?’ But no — they’re just anxious. Their day looks normal, but they’re anxious,” he says. “I think those are real signs that they hadn’t recharged the week before or the month before.”
“Normally, a stressor comes your way, and you bounce back,” Berlingeri explains. Over time, with more stress, you still bounce back, but [it’s like a] rubber band that gets very, very stretchy. It doesn’t bounce back like it did before. That’s what burnout is like. Our emotional resilience has been stretched so much we’ve completely depleted it.”
This can manifest as a feeling of exhaustion. For example, ordinary work tasks may make you want to give up. Or you feel unable to cope with everyday frustrations that wouldn’t normally derail you.
Understanding the patterns
“There is some argument about clinical stages and definitions,” says Price. “I think though that there is a very common agreement on the three elements that define burnout—no matter whose definition is in use.”
Price outlines these elements as exhaustion/fatigue, cynicism and depersonalization. Physicians may lose confidence that they’re making a difference. Then they may become overwhelmed and distanced. And in its final stages, burnout may affect a physician’s ability to do their job.
“You will have physical manifestations of burnout,” Deep says. “But it can be tricky [to spot] because you get physical manifestations of any high-stress, busy job. Things like ‘I’m not sleeping’ and anxiety. Headaches. They’re real [signs of possible burnout], but sometimes you don’t realize it until it’s been going on a while.”
Physicians may then go on to experience depersonalization. Deep explains this means feeling distanced and unable to recognize people as individuals.
“You might not be appreciating your staff,” he says. “You literally might not even be appreciating yourself for who you are. Patients seem to just kind of blur—like those pictures you commonly see of a human — but their head is blurred and is just a black cloud.” Finally, Deep says, “The last stage is the spiritual or emotional void and apathy. And obviously, that can be dangerous. It can lead to below-average health care and bad outcomes because you’ve lost your sense of purpose. You’re going through the motions.”
At that stage of apathy, Deep says, colleagues will likely notice. They may try to help by asking a physician what’s going on or speaking to their medical director.
“An important part of this is having the rest of us recognize when a colleague has this need and beginning that conversation,” Price says. “Learning how to recognize it in a colleague is a really important step to recognize it in yourself.” He acknowledges that it can be difficult to start the conversation. The Physicians Foundation’s Vital Signs initiative offers tips for talking about burnout and other prevention resources on their website.
Different people, different experiences
As Wright points out, the experience of stress and burnout varies from person to person. “Not everyone will experience profound negative consequences if they don’t attend to their feelings of burnout,” she says. “Some people can tolerate prolonged stress well with little impact to their biopsychosocial systems. But many cannot.”
Mehta adds, “I know a lot of people, even myself, that have had high levels of stress at different times throughout our careers.” And physicians don’t just experience stress at work. Like all human beings, they have other stressors in their lives. A very high-stress job may be manageable for a long time—right up until a sudden increase in workload or family demands tilt the balance.
Prevention and self-care
Taking steps to reduce burnout before it starts can help. So can preparing and responding quickly when you spot the signs.
“It’s very valuable if, before burnout happens, a physician has created a plan,” says Price. The Physicians Foundation offers a template: “A Personal Crisis Management Plan for Physicians.” It’s based on research with emergency medicine residents. A key component is identifying colleagues, friends and family to turn to if there’s a problem.
Spelling out available resources helps physicians overcome inertia, Price says. It also helps reduce their own resistance to seeking care. “Thinking about whatburnout is and how it happens and recognizing that you could someday need help, that’s part of knocking down that barrier that makes one so fearful of seeking it,” heexplains. In fact, after research participants created their plans, the foundation found that nearly a third sought help within just a few months.
In other words: knowing how to respond and making a commitment to do so can stop burnout from getting worse. And that prevents a whole host of related problems.
Physicians can also learn to spot trouble earlier. Berlingeri says this starts with examining their own feelings.
“One of the things I teach my clients is to process their emotions. It’s a multi-step process,” she explains. “First, you name the emotion because we are fearful of what we don’t know. So: ‘This is anger.’ Then you normalize it: ‘How human of me to experience anger.’ Physicians often feel like they can’t be human, right?”
Berlingeri compares this to caring for new patients.
“Residents will understand this very well. It’s kind of like when we interview a patient, and we go through the history of the present illness: Where does it hurt? In the same way, ask yourself: Do you have an associated symptom with your emotion? ‘ok, I feel angry.’ Is it burning in my throat? Is it like I’m tingling? Is it sharp? Is it dull? Where does it go? Then just get to know these emotions,” she says. “It sounds a little bit woo, but really, we all have emotions which are triggered by chemicals in our body. We can learn not to be afraid of them.”
In fact, Berlingeri explains that self-compassion is necessary to restore compassion for others. She recommends the framework and research of Kristin Neff, Ph.d., who has studied self-compassion for almost 20 years. “Whenever you have a stressor which is outside of you and start to feel a negative emotion because of it, check in with yourself,” Berlingeri suggests.
Being more aware of your own emotional wellbeing can help you spot and address burnout early. This can head off much worse problems. Conversely, not addressing burnout “risks a complex constellation of symptoms,” Wright explains.
These could include depression, physical pain, relational conflicts and maladaptive substances or behaviors. “In my therapy practice, in extreme forms of burnout, I’ve witnessed despair and even suicidal ideation,” she says.
Time off is essential self-care
Believe it or not, Wright says the solution can sometimes be as straightforward as taking time off.
“Every time I’ve seen my physician clients finally take time off—be it a sabbatical, fmla or designing extended time off for themselves— inevitably they make positive progress physically, mentally, emotionally and even logistically in their lives,” she says. “And when they return to work, nearly all of them self-report higher levels of psychological resilience and increased overall wellbeing.”
Newer physicians may not be able to afford to take time off or to leave one position before finding another. In that case, you can plan ahead by building up funds to keep your future options open. And if you want a more balanced work schedule or more time off, you might be able to negotiate it with your employer. Mehta says they may offer you a reduced workload in exchange for reduced compensation.
Reframing stressors as choices
Berlingeri urges her clients to reframe the way they think about stressful situations. “You cannot change this situation, but how can you support yourself through it?” she asks. “What can you do that empowers you?”
For example, let’s say you have a stressful thought like: “I cannot help all these COVID patients.” You can respond by asking yourself: “What is one thing that I can do today?” Berlingeri recommends, “Do for one person what you’d like to do for all your patients. ‘ok, I cannot change the whole thing. But what small thing can I do toward the immensity of the goal?’ Once you start seeing it that way, that’s empowerment.”
Physicians sometimes assume they are stuck. Berlingeri reminds them they may have more choice than they think they do.
“Let’s substitute the ‘should’ with ‘I want to’ or ‘I can’t’ with ‘I don’t want to.’ Because when you say ‘I should’ do this, you’ll be more resistant to doing it. That’s just human nature,” she explains. “But we don’t have to do anything. There are consequences, but it’s better to say, ‘I choose to come to work every day because I want to keep the house that I have and provide to my family the luxuries they have.’ Just that little shift changes the overall reaction in the body. It’s letting you know that you do have a choice, that you have a lot more control than you think you have.”
How employers are responding
Increasingly, employers recognize they need to help their physicians stay healthy. It’s crucial to serving their communities. This growing awareness is a welcome development.
“Burnout in the health care system is systemic,” says Liz Mahan, director of professional development and solutions with the Association for Advancing Physician and Provider Recruitment. “It’s not just one organization. We are still in a pandemic, and we thought burnout was bad before the pandemic.”
In-house physician recruiters can play a role in addressing burnout. “[Recruiters] are in a position where they can see the big picture,” Mahan explains. “They can see how many openings they have. They can see patterns unfolding within divisions or departments or practices. They’re making themselves subject matter experts in the area of physician retention.” This is directly connected to reducing burnout risk.
Mahan adds that employers are evolving and expanding support for physicians. This goes beyond resiliency programs. Health systems are recognizing the need for larger initiatives, such as developing physician leaders, expanding physician involvement in key decisions like EHR implementations, investing in staff development and retention, and helping physician families settle into their new communities.
Some organizations are even rethinking their business model. For the past five years, Deep says his large primary care group has been working to move away from fee-for- service and toward value-based care.
Job-seeking: How to ask about burnout
Fortunately, more people are talking about burnout these days — including prospective employers. As you consider job opportunities, be sure to ask about it during the interview process.
“We know that young physicians are not immune to burnout. We also know that burnout leads to a lower quality of care and medical errors,” Price says. “It’s a critically important topic we all need to talk about.”
If you’re uncomfortable posing pointed questions about burnout, you don’t have to ask directly. You can learn a lot by asking about efficiency, workload and models of care. For example, you can ask if there are ongoing efforts to analyze or streamline physician processes. You can also ask how involved physicians are in designing improvements.
EHR metrics related to physician efficiency and workload can also reveal a lot. “You might ask how much time people are spending on the EHR after hours,” Deep says. If physicians spend hours each night on charting, that suggests an unsustainable workload.
“Ask how they are making practices more efficient. How are they reducing unnecessary work and enabling physicians to work at the top of their licenses,” Mehtaadds. “Are they getting scribes? Are they being creative about what unnecessary work needs to be trimmed from electronic health records or other processes or policies?”
Staffing and teams
Sometimes, organizations are so motivated to hire a new physician, they forge ahead without planning for support staff, Mahan says. If you’re that new physician,this increases your risk for overwork right out of the gate. Ask about the support you’ll have and how it compares with that of more established physicians in the group.
Deep suggests researching staffing ratios in your specialty and asking employers how they compare. You may be able to find this data from your specialty society, your residency or fellowship program, or organizations like the MGMA and the AMGA.
Staffing is about more than numbers though. Mehta also advises asking about team roles and team dynamics. She recommends looking for employers who have embraced team-based care. She says this isn’t just a path to more satisfying and manageable work for team; it also serves patients better.
“In the American College of Cardiology, we really believe that there are certain strengths that everyone brings to the table, and that no one can individually succeed in delivering the best care for the patient. But together as a team, united, we can deliver the optimal care,” she says.
Mehta suggests asking specifically about patient flow and workplace dynamics.
“You want to know the intricacies of how the office works,” she explains. “When you’re looking at new practices, at first you’re looking at the window dressing—are people smiling and things like that. But you want to know the little intricacies of workflow, and you want to talk with the staff about their relationships with the physicians. Are they scared of them? Or do they feel like they can talk with them and ask questions? And do they know them personally as individuals? Or do they just know them as ‘doctor so and so’?”
It’s also good to ask about staff turnover and retention efforts. “The more trust you have in your staff, the less variables get introduced into your day,” Deep says. “But then, let’s just say there’s [staff] turnover every 30 days. That just becomes very stressful. Having a supportive environment for your staff to be able to practice team- based care reliably, minimizing unpredictability, that can certainly help decrease burnout.”
Other clues to culture
Similarly, high physician turnover may indicate an unsupportive culture. Deep suggests asking about new hire turnover in particular.
“Ask what their new employee turnover rate is. How many new employees are still with the organization after 30 and 90 days?” Deep says. “Oftentimes, a new employee will be less willing to tolerate a bad culture [than a longstanding employee].”
Questions about scheduling issues, such as on-call sharing, also provide insight. So do questions about the relationships between administrators, senior executives and physicians. For example, you can ask administrators and/or medical directors how the management team helps physicians succeed. You can also ask if physician voices are included in making decisions that affect them. “There’s a phrase physicians use: ‘No decisions about me without me,’” Mahan says. “It’s about making sure you’re getting physician input on things that affect them.” Another useful clue to an organization’s attitude aboutphysician wellness? Ask what metrics they track. Their answer will show which the trends they’re watching and what they’re working to understand.
Red flags
If you ask about mental health or burnout, watch out for red flags in employers’ responses. For example, employers who focus on resiliency may overlook systemic issues.
Mehta says, “I think there has to be a shift from ‘Let’s just keep doing more resiliency stuff and fix the employee’ to really focusing on creating a culture of wellness and inclusivity, so that people understand they are needed, they belong, their voices are heard and they’re valued.”
“To me, the biggest red flag would be to have this conversation immediately go to resiliency programs. I don’t think that any coal miners would want to work for a company whose response to canaries dying in the coal mine was to send out for tougher canaries,” Price adds. “Another red flag that I’ve heard is when people say, ‘Oh, [burnout] isn’t a problem for us. Everyone is very happy and content.’ That would be an even bigger red flag. Because I think for a long time the entire system had blinders on about this, and some people still do. And that would imply to me that there’s a perception within the organization that you only can get burnout if you’re not tough enough.”
Deep adds even an employee assistance program (EAP) can be a red flag of sorts. “It’s one thing to ask what resources they have for once you’re burned out, but whatare they doing to prevent you from getting there?” he says. “We often say: ‘We have a very robust EAP program.’ But really, ultimately, we want to do what we can so that our employees won’t have to go to the EAP program. So you want to ask: How do they prevent that? Because those are two different things.” •
September 1, 2017
Jeff Atkinson
