Burnout among physicians and nurses

Private practitioners are busy people between caring for their patients, recording and documenting data, going to meetings, keeping up with new treatment modalities, and running a practice group. They follow a tight schedule, have multiple sources of pressure, and suffer from burnout.

Stress occurs when a person is drained of energy, but can recover. In the case of burnout, the person is drained, but cannot recover.

The 3 core burnout symptoms can be measured by a standardized research survey tool called the Maslach Burnout Inventory. They include:

1. Exhaustion
2. “Depersonalization” showing up as compassion fatigue, sarcasm, cynicism, and blaming one’s patients.
3. “Lack of efficacy” presenting as thoughts such as “what’s the use?” doubting that one’s own work will make any difference and/or questioning the quality of one’s work.

In addition to being burdened by the incessant demand to see more patients in less time and with new Affordable Care Act (ACA) regulations, private practitioners face the mandate to implement electronic health records (EHR) and meaningful use in their practice. This has caused some “technophobic, resistant, and uncooperative” practitioners to become frustrated and even irate at the new regulations because the costs are not only monetary and time based, but also seem to lead nowhere. Transition to EHR has been traumatic for some and, at times, comical for others. One practitioner for example, prescribed a 39-fold overdose of Bactrim (sulfamethoxazole-trimethoprim) to a young patient—a near fatal error partially caused by an EHR. A critical care doctor who was “unable to identify new information in daily notes . . . beg[a]n printing them out and holding two superimposed pages up to the light to see what ha[d] changed.”

Patient safety incidents (PSI), from all causes, occur in one in 7 patients. Although many institutions, academics, and others have detailed the damages suffered by patients following a PSI, few have reported the impact, sometimes severe, of the same events on health care providers.

A recent paper by Van Gerven et al. published in the October 2016 issue of Medical Care detailed a study of 5,788 healthcare professionals (21% physicians, 79% nurses) working mostly in acute care units in Belgium. It found that 531 professionals (9%) were involved in a PSI during the six months prior to the survey. The incident caused temporary harm in 22% of the cases, permanent harm (2%) and death (2%). Physicians and younger health care providers reported more adverse incidents than nurses and older health care professionals. Involvement in a PSI was related to  greater risk of burnout, problematic medication use, greater work-home interference, and higher turnover intentions. Harm to the patient was a predictor of problematic medication use, risk of burnout, and work-home interference.

Another survey of 7,900 surgeons found that 9 percent reported having made a major medical error in the last three months. The worse the surgeon’s burnout, the more likely they were to report making a medical error. In a study of over 10,000 nurses, researchers found that increasing a nurse’s workload by one surgical patient was associated with a 7 percent increase in a patient’s odds of dying within 30 days of admission.

The impact of a PSI on the practitioner could be personal or professional, immediate or delayed. On a personal level, they may suffer from insomnia, loss of appetite, self-blame, or depression depending on the severity of the incident. There is nothing more distressing for a physician than to witness his or her “own” patient suffering from an adverse reaction, regardless of the source of error. Self-recrimination does occur in varying degrees and in worse cases lead to medication or alcohol abuse. A survey of more than 7,000 surgeons revealed that 15.4% of surgeons met diagnostic criteria for alcohol abuse or dependence. Suicidal ideation in the preceding 12 months was present in 7.9% of surgeons with alcohol abuse or dependence.  Career satisfaction and QOL were also lower in this subgroup.

On a professional level, the provider can suffer from loss of self-confidence or experience concentration difficulties. Some decided to leave practice while others committed suicide. A study of 479 primary-care doctors found that 30 percent of those aged 35 to 49 planned to leave their practices within five years. The rate jumped to 52 percent for those over 50. In a 2004 meta-analysis, the suicide ratio for male physicians compared to the general population was found to be 1.41. It was even higher for female physicians: 2.27.

Burnout is on the rise among physicians. Of 6,880 surveyed physicians using the Maslach Burnout Inventory, 54.4% (n=3680) reported at least 1 symptom of burnout in 2014 compared with 45.5% (n=3310) in 2011 (p<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%; p<.001). By its very definition, burnout is also associated with decreased empathy with resulting failure in delivering compassionate care.

Since the toll on health care workers is damaging for patients and healthcare workers alike, an appropriate and organized response (a “no blame, no shame” culture and recognizing the role of system errors) is needed to reduce PSIs and to reduce their negative effects on the involved physicians. Many groups across the nation are working on ways to infuse more humanity into health care to reduce this damage. The Schwartz Center for Compassionate Healthcare, for example, helps health care organizations set up meetings where care providers can speak openly about the feelings of distress triggered by their daily work. A time banking program has been set up to ease work-life conflict for ER physicians at Stanford hospital. They can “bank” the time they spend doing mentoring, serving on committees, and covering colleagues’ shifts on short notice and earn credits to use for work or home-related services. More work needs to be done to help health care workers heal and contribute efficiently to the complex and difficult problem of caring for patients.