Burnout: Time to stop blaming the victims
Most surgeons today are familiar with professional burnout – in their colleagues, in surgical trainees, and perhaps, in themselves. But the understanding of burnout is evolving. The discussion is moving away from blaming physicians for their poor coping skills toward identifying the structural and organizational roots of burnout.
Burnout is a syndrome cause by work-related stress that features emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. A recent study of nearly 7,000 physicians using the Maslach Burnout Inventory found that 54.4% of those surveyed reported at least one symptom of burnout (Mayo Clin Proc. 2015 Dec;90[12]:1600-19). Other studies have found similar rates of burnout in the surgical specialties such as orthopedic, oncologic, cardiothoracic, and plastic surgery (JAMA Surg. 2014 Sep;149:948-53; Ann Surg Oncol 2011 May;18:1229-35; Internat J Cardiol. 2015 Jan 20;179:7-72; Aesthet Surg J. 2016 Sep 27. E-pub ahead of print).
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A new paradigm of burnout
The paradigm of burnout as a personal issue that can be managed by individual coping strategies is giving way to an understanding that the structural roots of burnout require the shared responsibility of individuals and their work organizations to solve the problem. A revised approach has emerged: Physician burnout as a symptom not of personal failure to cope, but of institutional failure to adapt to new circumstances in the health care milieu. The growing number of physicians employed in large group practices and medical centers has come with a whole array of management problems that are only beginning to be recognized, and burnout may be one of the most challenging.
Tait D. Shanafelt, MD, of the Mayo Foundation for Medical Education and Research, and John H. Noseworthy, MD, president and CEO of the Mayo Clinic, both in Rochester, Minn., have partnered to distill years of study and practice on the issue of burnout to a set of organizational strategies to tackle the problem and describe the Mayo Clinic experience. The study, “Executive Leadership and Physician Well-Being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout” (Mayo Clin Proc. 2016 Nov 18. doi. org/10.1016/j.mayocp.2016.10.004) reverses the conventional “blame the victim” approach and identifies instead institutional responsibility to address burnout.
“Increasing evidence over the last 10 years demonstrating links to quality of care, productivity, and turnover have raised appreciation … by organizations that they have a substantial stake in this issue and that they control many of the factors that contribute to this problem,” said Dr. Shanafelt in an interview.
Unintended consequences of the individual solution
The focus on individual responsibility can have unintended consequences. A physician suffering from burnout can take action by leaving his or her job or cutting back. Staff turnover, a phenomenon closely tied to burnout, is costly and damaging to productivity and patient care (Physician Leadersh J. 2015 May-Jun;2[3]:22-5); Health Care Manage Rev. 2004;29[1]2-7). These personal strategies may help individuals cope but can end up harming the institution and the work life of other staff members. Physicians experiencing burnout in their own lives can trigger the same condition in their colleagues.
The Mayo paper by Dr. Shanafelt and Dr. Noseworthy states, “Mistakenly, most hospitals, medical centers, and practice groups operate under the framework that burnout and professional satisfaction are solely the responsibility of the individual physician. This frequently results in organizations pursuing a narrow list of ‘solutions’ that are unlikely to result in meaningful progress (e.g., stress management workshops and individual training in mindfulness/resilience). Such strategies neglect the organizational factors that are the primary drivers of physician burnout and are correctly viewed with skepticism by physicians as an insincere effort by the organization to address the problem.”
Organizational strategies to reduce burnout
Dr. Shanafelt and Dr. Noseworthy developed a list of nine organizational strategies that have been shown to reduce burnout among doctors. A critical piece of this approach is the accumulated evidence of the financial burden of burnout among physicians in health care institutions. The approach is based on an informed leadership that recognizes the costs of inaction, without which a systemic solution is unlikely to be achieved.
1. Naming the issue and assessing the problem
Acknowledgment of burnout as an institutional problem and meaningful measurement of physician well-being are the initial steps in tackling the problem. This requires a sincere commitment at the highest level of management to listen and to recognize what staff physicians are saying. “At Mayo Clinic, we have incorporated town halls, radio broadcasts, letters, and video interviews along with face-to-face meetings involving clinical divisions, work units, and small groups as formats or [by using] the CEO to reach the staff.” Assessing physician well-being and quality of work life using one or more of the many available tools has to be an ongoing “a barometer of organization health,” and not just a one-off, crisis management activity.
