Signs and symptoms of burnout
Signs and symptoms of burnout

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Putting out the fires of discontent: Managing physician burnout

Table of Contents

Dr. Richard Lander values positive working relationships with his staff. Lander owns a four-physician pediatric practice in Livingston, New Jersey

Everyone has the occasional bad day at work. We might feel stressed about having too much to accomplish in too short a time or simply feel unmotivated to do what is right in front of us. Frustration about situations or office policies over which we have little control is common. And who hasn’t become annoyed with their co-workers from time to time? But there is a significant difference between the everyday stresses that come with the territory in any job and the syndrome known as burnout.

What is burnout?

According to Christina Maslach, PhD, professor of psychology at the University of California Berkeley and author of several books on career burnout, the terms stress and burnout are often used interchangeably. Burnout, however, is a syndrome that consists of a unique set of three factors: exhaustion, cynicism, and negative feelings toward oneself.

Exhaustion from working long hours or simply trying to do too much in a day is a core part of burnout. Just going home to rest doesn’t always solve the problem, to which anyone who has ever been “too tired to sleep” can attest. “If you’re exhausted and don’t sleep well, you’re less able to handle the workload,” says Maslach.

Cynicism, the second component, tends to build up over time. This negative, hostile, or dehumanizing response to other people and situations can directly affect the quality of an employee’s work. “When people get into this mode,” says Maslach, “they shift their work behavior from doing their best to doing the bare minimum. This may begin because they’re overloaded and trying to cut corners, but eventually, it becomes ‘just do what I have to do to get my paycheck.’ ”

Feeling negative toward oneself is the third aspect of the syndrome. Individuals who don’t feel competent or proud of themselves and their work are candidates for burnout. Maslach says that such negative feelings can be a precursor to depression.

Having a sense of community within the practice doesn’t necessarily mean that everyone agrees on every topic. It simply means that the team works well enough together that employees are able to communicate and resolve conflicts as they arise.

necessarily mean that everyone agrees on every topic. It simply
means that the team works well enough together that employees
are able to communicate and resolve conflicts as they arise.

How to avoid burnout

In her book, Banishing Burnout: Six Strategies for Improving Your Relationship with Work (Jossey-Bass, 2005), Maslach addresses the factors that contribute to job burnout. “When we do assessments and work with organizations, we look at six areas to figure out what’s going on in the work setting that might be putting people at risk for burnout,” says Maslach. The six are workload, control, reward, fairness, community, and values. A look at each of these issues can reveal how they contribute to burnout and how employers can help to prevent it.

Workload: Simply put, an employee who is chronically overworked and overwhelmed by the sheer volume of work they have to accomplish will eventually experience exhaustion. Left unchecked, exhaustion can lead to burnout. If you notice that your employees are often behind on their work, if basic tasks are being left undone, or if patient satisfaction is slipping as a result of staff being unable to give patients adequate attention, it may be time to look at workload redistribution or hiring additional staff. Another issue to be on the lookout for is the “too many bosses” scenario. It’s not uncommon in medical offices for staff to be taking direction from several different physicians, plus an office manager. Too much work coming from too many directions without clear guidance on what the true priorities are can be a significant contributor to stress and burnout.

Shena Scott, MBA, is the executive director of Brevard Anesthesia Services in Melbourne, Florida. “As physicians, jobs become more administratively complex,
there is pressure on the staff to contain costs, but there is more work. They feel the squeeze,” says Scott. She says that a key factor in making sure the work gets done without putting her staff at risk for burnout is having people in the right jobs. “A person might be capable of a lot of things,” says Scott, “but they’ll fit well into a certain job while another might not be a good match for their skills.” She instructs her staff to come to her directly if they feel overwhelmed. “We can always shuffle duties.” Scott says she reassess assignments makes other adjustments if a staff member continues to feel overwhelmed or out of place in a position.

Control: According to Maslach, “Research shows that if people feel they lack control over what they have to do, if they’re being micromanaged or not able to be self-sufficient, then they are more likely to experience burnout.” This especially holds true for employees who work in a chaotic environment. To the degree possible, give staff members latitude when it comes to the details of doing their jobs. If someone can see a potentially better, smarter way to get her work done, let her experiment. In the big scheme of things, does it really matter if the filing gets done in the morning or the afternoon? Could changing staff meetings from bi-weekly to weekly improve communication? Would offering flexible work hours make for happier, more productive employees? Allowing staff to suggest
and participate in policy and procedure changes can go a long way toward creating a team.

Control over schedule is important. Scott sees great benefit in allowing employees as much flexibility as possible and offers staggered work hours with people coming to work anywhere between 7 a.m. and 9 a.m. and finishing their days between 4 p.m. and 6 p.m. “At different points in people’s lives different things are important to them,” says Scott. “If someone feels like they need to be at a child’s school play in the middle of the day, I’d rather them take the time off and go because they’ll work better before and after.”

Susan Britt-Roby is the administrator of Specialists in Dermatology, PLLC, in Tucson, Arizona, a group that boasts four physicians, four physician  ssistants, and more than 50 support staff. She is always on the lookout for ways to keep herself and her staff engaged to prevent burnout. “I had a couple of people whose jobs stopped being fun for them or didn’t match them anymore,” says Britt-Roby. “We talked about what wasn’t working and came up with new jobs for them.” Of course, in a smaller office, inventing a new job for a bored or frustrated staff member might not be possible, but don’t underestimate what people are capable of doing. A billing clerk might enjoy more patient interaction at the reception desk or a medical assistant might be reenergized by learning how to work with third-party payors for the benefit of the practice and patients.

Stress and burnout are often used interchangeably. Burnout, however, is a syndrome that consists of three factors: exhaustion, cynicism, and negative feelings toward oneself.

Reward: “Pay and benefits are important, but sometimes recognition and appreciation are more important,” says Maslach. The key with rewards is to make sure that they are meaningful to the employees. For many years, the faculty of her department at Berkeley “gave” the staff a picnic at the end of each academic year. A new department chair arrived and began asking questions about the traditional picnic. What she heard loud and clear was, “We don’t like the picnic.” What the group really wanted in the way of reward was new carpet for the staff lounge. “People make assumptions about what would be rewarding but haven’t checked it out,” says Maslach. So, before jumping to the conclusion that your employees want to dress up and bring their significant others to an annual holiday party at your country club year after year, ask them. You might find that they prefer a potluck at the office followed by the afternoon off instead.

Scott occasionally hires a massage therapist who comes to the office to give everyone a chair massage. If her staff is stressed due to an unusually heavy workload, Scott will spontaneously order in lunch. “It’s a reward and builds community at the same time,” she says.

Richard Lander, MD, owns a four-physician pediatric practice in Livingston, New Jersey. He also presents management seminars to physicians and residents through the American Academy of Pediatrics. Lander says he is fortunate that staff burnout doesn’t seem to be a problem in his practice. “We try to be very supportive,” he says, and offers a variety of rewards for employees to keep motivation high. “We always have a holiday dinner and give bonuses at that time. As a rule, everyone gets a raise every year, and someone can get two raises if they’re productive,” he says.

The practice also gives occasional unexpected rewards. “I’ll periodically bring in treats for the staff,” Lander says. When gas prices were headed for $4 per gallon, Lander slipped each employee a little extra cash to help offset that cost. Nonmonetary rewards are also part of  Lander’s program to keep employees happy. “In the summer, we slow down, and I’ll let them go home early but pay them for a full day,” he says.

Another kind of reward has nothing to do with pay or perks. People need to know they are recognized and valued for their efforts. Physicians and practice managers alike should make an effort to let staff members know they are appreciated. Specific feedback is better than a vague comment like “nice work,” according to Diane Brennan, a practice management consultant and coach based in Tucson, Arizona. She says praise such as, “You did a great job with that patient; I noticed how caring and concerned you were,” is the kind of feedback employees need and want to hear.

Richard Lander, MD believes in going to bat for his staff. “Occasionally someone will be so difficult that I’ll ask my staff if they’d like for me to dismiss the patient,” he says. On only one occasion did a staff member take him up on his offer, but simply making the offer goes a long way toward making staff members feel they are being treated with respect.”
Richard Lander, MD, believes in going to bat for his staff. “Occasionally someone will be so difficult that I’ll ask my staff if they’d like for me to dismiss the patient,” he says. On only one occasion did a staff member take him up on his offer, but simply making the offer goes a long way toward making staff members feel they are being treated with respect.”

Fairness: A perceived lack of fairness is one of the main factors that contributes to cynicism, one of the symptoms of burnout. “When someone is treated unfairly, they try to right the balance,” says Maslach. This attempt to “even the score” may range from not helping others to taking office supplies for personal use. At its most extreme, it can include workplace violence. It can be tricky to determine whether employees feel they are being treated fairly. Maslach suggests open communication as a place to start. “Check in with staff, take the pulse of things, invite feedback, ask what could management be doing better,” she says. Promote a sense of fairness in your practice by getting input when decisions are being made. “It gets people’s buy-in,” says Maslach. If you ask for feedback, though, don’t ignore it. Being asked and ignored is worse than not being asked at all. That doesn’t mean everything needs to go the employees’ way, of course. It means staff members need to feel they were heard, their suggestions were taken seriously, and their opinions matter to the decision-makers.

Lander’s group includes employees in monthly or bimonthly staff meetings. When necessary, he takes a stand on their behalf. For example, his practice is located in a fairly affluent area, and parents of his patients can be a bit demanding. “I can see where the front office staff could burn out,” Lander says. “People want what they want when they want it. Occasionally someone will be so difficult that I’ll ask my staff if they’d like for me to dismiss the patient,” he says. On only one occasion did a staff member take him up on his offer, but simply making the offer goes a long way toward making staff members feel they are being treated
with respect.

Community: Maintaining a harmonious workplace is a good deterrent for burnout. “The imbalance or mismatch comes when there is unresolved conflict, lack of trust, lack of support, or destructive competition,” says Maslach. Having a sense of community within the practice doesn’t necessarily mean that everyone agrees on every topic. It simply means that the team works well enough together that employees are able to communicate and resolve conflicts as they arise. The difference can be an office where people enjoy—rather than dread—coming to work. Maslach says that employees will often stay at a job where they have a “family” even when they could potentially earn more money elsewhere.

While burnout may not be contagious in the sense that the symptoms will be passed around like a flu bug, a staff member who is chronically unhappy at work can bring morale down. Physicians themselves can unintentionally contribute to burnout by slipping into a victim or blaming mode. “If they’re complaining and upset about the practice, the hospital, insurance plans, that can have a negative impact on staff,” she says. “In frustration they may say things like, ‘I can’t wait until I retire—three more years and I’m out of here.’ Those kinds of messages make it seem okay for the staff to complain, too.”

Maintaining a culture of trust within the dermatology practice she manages is a high priority for Britt-Roby. With the agreement of the physicians in the group, she instituted a policy of using the principles in Don Miguel Ruiz’s Four Agreements (Amber-Allen Publishing, 2001). The four agreements are: Be impeccable with your word; Don’t take anything personally; Don’t make assumptions; and, Always do your best. “We all agreed to this and we let anyone we hire know that we follow the Four Agreements,” says Britt-Roby. She says honoring the agreements helps keep gossip down and integrity high.

Lander says there is a strong sense of community among his staff members, many of whom have become friends with one another. Although he expects a lot from his employees, he says they know how to have fun. A few months ago, over a three-week period, every staff member of child-bearing age in the office came to Lander one by one to announce she was pregnant. “They expected me to get annoyed,” he says. When their joke didn’t rattle him into a panic, they finally confessed it was all in jest. “I’ve gotten one of them back already,” Lander says, “and I’m working on the others.”

Values: Burnout is less likely to occur in employees who work in jobs where the values they hold are not compromised. For example, if someone holds a strong belief that telling even “little white lies” is inappropriate, they will be worn down emotionally if they are asked to routinely tell patients “the doctor had an emergency” when, in fact, the doctor is running behind because she was late getting to work. According to Maslach, values can also be an issue when an organization “preaches one thing and does something else.”

One way to clarify and then manage in accordance with a practice’s most important values is by investing in an annual staff retreat. Many groups have partner retreats in which the doctors and administrators gather to discuss business goals and engage in strategic planning. A similar gathering for staff can be equally valuable to the long-term health and success of a practice. An annual daylong staff retreat is an excellent way to keep a team engaged, evaluate what’s working well and what needs to change, and set meaningful goals to keep everyone on the same page and excited about the possibilities for the practice and for their own careers.

Encouraging work/life balance to ward off burnout

Creating a culture within your practice that encourages work/life balance can help avert burnout and enhance the overall well-being of the team. The phrase work/life balance has been all the rage for at least a decade in human resource circles, but many organizations give the concept lip service and little else.

Practice administrators can and should set the tone for the office. “Managers get so attached to their work that they think they’re the only ones who can do the job,” says Brennan. “It’s not healthy for people to work 12 hours and then come back the next day.” Set a good example for what work/life balance is by practicing it and encourage others to do the same.

Britt-Roby agrees and encourages efficiency over long hours. She says staff members are often torn between being responsible to the practice and taking care of themselves. “There’s a lot of burnout when there is incongruence,” says Britt-Roby. For her own well-being, Britt-Roby believes that taking time away from work for professional networking and play and taking care of herself physically makes her better able to perform at work. “Being a medical manager is one of the most stressful jobs,” she says. “Dealing with doctors, insurance companies, employees— you’re like a psychiatrist and a mother.”

Employees who won’t take time off may be at higher risk for job burnout. “If they start bragging about all the vacation time they have saved up, that’s a sign,” says Brennan. “Encourage [employees] to take the time off that’s coming to them. Be aware, though,  that not everyone needs or wants an extended vacation. While one employee may indeed relish two weeks off, another might prefer to take a four-day weekend every other month or so. “Honor the differences in what people need,” says Brennan.

The high cost of burnout

The most obvious cost of staff burnout is high turnover. Lori Foley is a principal with Gates, Moore and Company, an Atlanta-based practice management consulting firm. She says it’s not unusual for turnover to cost a practice the equivalent of an employee’s annual salary. If you lose a staff member to burnout who earns $30,000/year, plan on spending roughly that amount to replace the individual. “You don’t write one big check,” says Foley, “so it’s not always visible.” But the costs do add up—and fast. Foley says the tangible costs of turnover include staff time to conduct exit interviews, review resumes, interview, hire, and then train a new employee. In the meantime, the practice may be paying for temporary help or overtime for staff members who are picking up the slack. There is also the cost of paying out accumulated vacation time and potentially an increase in state unemployment rates if too many employees leave and apply for benefits. (If you are curious about the cost of turnover for a specific position, Google “turnover cost calculator” to find online tools that do the math).

The intangible costs can also be high. “If you lose a valuable employee that everyone likes and is a contributor to the team, it’s a downer to other folks,” says Foley. “It puts their jobs in a different light.” Because personal relationships often continue among staff members after someone leaves a practice, Foley says doctors also risk losing additional valuable employees who follow the first person to her new office. ” A valued and trusted member of the group tells others what’s out there. You might lose one person to burnout and two more to the one who left,” says Foley.

Another cost of turnover is related to patient satisfaction. “It may be that an employee is the one who has the long-term relationships with patients,” says Foley. Physician productivity is also impacted when a staff member leaves. “If you lose someone who has been the physician’s right hand for 10 years, it can impact physician efficiency,” says Foley. “It’s not quantifiable, but it’s a cost.”

Burnout: signs and symptoms
Burnout: signs and symptoms

Relighting the fire

What can you do if you have an employee who is experiencing genuine job burnout? “Have a conversation with the individual,” says Brennan. “Sit down and ask her what’s happening. Give her specifics about the behavior you’re seeing. Be open and honest.” Chances are good the employee realizes at some level that she is suffering from burnout (or at least headed in that direction) and may appreciate the opportunity to talk about it. If job performance has become a problem, raise the issue and convey how the individual’s burnout symptoms are negatively affecting the practice or patient care. Brennan says it’s important to make expectations clear and create a performance plan that outlines what needs to change.

Burnout can sometimes be reversed. Suggestions for helping an employee reignite enthusiasm include:

  • Taking time off to rest, renew, and plan for what can be done to improve one’s relationship with work.
  • Building personal resilience by becoming physically healthier through regular exercise, proper nutrition, and adequate sleep.
  • Taking on new responsibilities, a special project, or a new role at work.
  • Reducing or changing work hours.
  • Engaging in a professional or personal development program.
  • Improving work/life balance by taking more time for family, friends, fun, and self-care.
  • Engaging a coach or finding a mentor.

Not every case of burnout can be solved. Sometimes, it’s a clear indicator that a new job or new career is in order.  If this turns out to be the case for an employee in your office, be sure to follow appropriate procedures if the ball is in your court to help the individual move on. Ideally, with proper support
and coaching from the practice manager or physician in charge, a genuinely burned-out employee will take the initiative to take a new position. If that’s the case, wish her well and base your reference letter on the work style and performance from the days beforethe burnout.

Karen Childress is a regular contributor to UO.

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Karen Childress

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