Anesthesiologists: Battle Burnout and Rediscover Meaning

The developers of the Maslach Burnout Inventory define physician burnout as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”  Some suggest its relative absence should be considered a measure of quality.  No matter how one defines it, it is not a good thing—for physicians, care teams, practice management professionals, patients or healthcare organizations.  As the data show, anesthesiologists unquestionably suffer from it right alongside their peers in other specialties.

U.S. Surgeon General Vivik Murthy, MD puts it well in explaining why physician burnout is a serious problem:  If healthcare providers aren’t well, it’s hard for them to heal the people for whom they are caring.”

While the phenomenon is far from new and has been extensively studied, recent research confirms that physician burnout is widespread and growing.  In a Mayo Clinic survey of more than 6,200 physicians, 54.4 percent reported at least one symptom of burnout in 2014, compared with 45.5 percent in 2011.  Physicians also reported significant declines in satisfaction with work-life balance (48.5 percent in 2011 versus 40.9 percent in 2014), despite the fact that comparable changes did not occur in the U.S. population as a whole. 

Followed by choice of specialty, putting patients first, thriving outside of the office and dealing with electronic health records, burnout also heads the American Medical Association’s (AMA’s) list of the medical community’s top five topics of interest for 2015.

Prevalence in Anesthesiology

The Medscape Lifestyle Report 2016 reveals that anesthesiologists are not immune. The survey of 15,800 physicians in 25 specialties suggests physician burnout has reached a critical level, ranging from 40 percent to 55 percent, depending on specialty.  Burnout rates for all specialties rose in 2016 from 2015, including among anesthesiologists, who landed in the high middle range at 50 percent, an increase from 44 percent the previous year. Male and female anesthesiologists reported equal rates of burnout.

Symptoms and Causes

Varying widely in severity, physician burnout has three hallmarks:  1) physical and emotional exhaustion; 2) depersonalization, marked by the development of a negative, callous and cynical attitude toward patients and their concerns; and 3) a reduced sense of personal accomplishment, including a tendency to see one’s work negatively, without value or meaning.

Considering the multitude of pressures facing physicians today, the condition’s pervasiveness does not come as a huge surprise.  Our March 14, 2016 eAlert highlighted the role of the growing burden of measuring quality in anesthesiology and other medical practices.

Add to these stresses the broader pressure on clinicians to produce better outcomes in less time at lower cost, and a constellation of other contributors, ranging from long work hours and insufficient income stemming from regulatory changes to the demands of moving to a digital environment, and it’s no wonder physician fatigue and disillusionment have mushroomed.

Impact on Quality

As Dr. Murthy stated, physician burnout does more than take a toll on clinicians; it also affects the quality of care.  A 2009 review in The Lancet (Physician Wellness:  A Missing Quality Indicator) of work stresses among physicians and the challenges they face in attending to their own wellness suggests that health systems should routinely measure physician well-being because a burned out medical staff leads to suboptimal health system performance.

Clinicians themselves report that feelings of burnout impede the quality of their work.  In a February 2015 study in Psychiatric Services of 120 clinicians participating in a burnout intervention trial, more than half (58 percent) described burnout as having a negative impact on the quality or amount of their work.  Burnout also reduced their patience and energy, diminished their communication and listening skills, and increased their tendency to withdraw from others.  Some participants described how burnout was affecting their personal lives, though the study was focused on the work environment.  One participant stated, “I try not to allow the way I feel impact the veterans.  I take it out on my family.”

In a Mayo Clinic longitudinal study of physicians at a large institution, burnout and satisfaction scores correlated strongly with actual reductions in professional work effort over a two-year period.  Each one-point increase in a seven-point emotional exhaustion scale was associated with a greater likelihood of reducing full-time equivalent (FTE) work over the following 24 months, and each one-point decrease in a five-point satisfaction score was also associated with a greater likelihood of reducing FTE. 

“These findings run counter to some of the usual tropes about the increasing interest in part-time work.  Some have tied the trend to the increasing number of female physicians wanting to spend more time with family, or to the influx of younger physicians into the workforce seeking more work/life balance,” comments Nicole Clarke, MSM, PhD, in Practice Notes, a blog of the Advisory Board.  “However, this relationship between burnout and FTE reduction is independent of age, sex, practice site and specialty.  For the medical group executive, this highlights the importance of looking beyond demographic factors when trying to diagnose, and address, burnout among your physicians.”

Other research in Annals of Surgery found a strong correlation between major medical errors and mental health.  More than 70 percent of surgeons who reported making a major medical error in the previous three months attributed the error to individual rather than system factors.

In an article in the November/December 2014 issue of The Annals of Family Medicine, Thomas Bodenheimer, MD, of the Center for Excellence in Primary Care at the University of California at San Francisco, contends that care team well-being can be seen as a prerequisite for health care’s Triple Aim (enhancing the patient experience, improving population health and reducing costs).  He argues for expanding the Triple Aim to the Quadruple Aim by adding a fourth goal of improving the life of clinicians and healthcare staff.

In an ironic twist, efforts to support the Triple Aim can themselves contribute to burnout, making the achievement of Triple Aim goals even more elusive.  “Higher scores on a patient-centered medical home assessment may be associated with greater clinician burnout in safety-net clinics. More EHR functionalities—email with patients, physician order entry, alerts and reminders—intended to promote the Triple Aim are associated with more burnout and intent to leave practice,” he writes.

In a June 2016 post in the Harvard Health Blog, Steven A. Adelman, MD, director of Physician Health Services, Inc., a subsidiary of the Massachusetts Medical Society, posits a connection between lack of physician well-being and another serious quality and safety issue—the opioid epidemic.  The possible connection is something anesthesiologists should keep in mind, since they are among the most frequent prescribers of opioids. 

Answering to a “growing cadre of masters,” including managed care professionals, IT consultants, administrators and patients, physicians “may not possess enough time or the requisite emotional fortitude to fully explore non-opioid alternatives when, for example, a patient with chronic lower back pain reports that 80 mg of oxycodone (Oxycontin) per day has allowed him to continue working and providing for his family,” Dr. Adelman writes.  “Until our society and the medical profession begin to address this crisis in a vigorous and meaningful way, our quest to put an end to the opioid epidemic remains daunting.” 

Warning Signs and Strategies

What can physicians do to identify burnout and address it before it takes a serious toll on their personal and professional lives?

Physicians should never ignore the following risk factors, according to Mark Linzer, MD, of Hennepin County Medical Center in Minneapolis, who has studied physician burnout for 20 years: 

• A high tolerance to stress.  Physicians who consistently operate under high stress are at least 15 times more likely to burn out, according to Dr. Linzer’s research.
• An exceptionally chaotic practice.  “Caring for patients keeps doctors motivated.  What burns them out is caring for patients in a high-stress environment,” he says.
• Conflicting values and leadership.  Physicians need to feel as if the people leading them also share their values for medicine and patient care. 
• Acting as the emotional buffer.  Physicians will often buffer the patient from their own stressful environment, and that can eventually have an impact.
• Allowing work to interfere with family events.  Dr. Linzer cites work-life imbalance as one of the most common predictors of burnout.
• Self-neglect.  Physicians who continually neglect their own mental and physical well-being may begin to neglect their patients, too.  They must take time for self-care.
• Lack of control over work schedule and free time.  If physicians must work a long standardized set of hours each week, practices should customize their schedules to flexibly accommodate changes in physicians’ daily lives.

Dr. Linzer has developed a program for the AMA called Steps Forward™ that recommends seven steps for combating physician burnout:

• Establish wellness as a quality indicator for your practice
• Start a wellness committee and/or choose a wellness champion
• Distribute an annual wellness survey, such as the 10-item Mini Z Burnout Survey
• Meet regularly with leaders and/or staff to discuss data and interventions to promote wellness
• Initiate selected interventions
• Repeat the survey within the year to re-evaluate wellness
• Seek answers within the data, refine the interventions and continue to make improvements

In a presentation on burnout, experts offered the following simple tips for physicians:

• Take a look at your schedule and take 1 or 2 items off your daily to-do list
• Take daily time-outs for exercise, yoga or meditation
• Connect with friends and family in a meaningful way
• Find something to laugh about every day
• Have a mantra that you can turn to when feeling stressed
• Try 4-4-8 breathing:  relax and inhale through your  nose for a count of 4, hold for a count of 4, and exhale through your mouth for a count of 8
• Use relaxation and mindfulness techniques to lessen stress and progression to burnout
• Make sure you get enough sleep

Addressing burnout begins by recognizing that it exists and giving it the attention it deserves as a metric for practice and organizational effectiveness, Dr. Linzer says in Medical Economics.  “I hear people say, ‘we can’t afford to deal with this.’ I say you have to listen and understand what’s hurting people.  Preventing burnout in the long run will save the system money.”

Dr. Linzer and his colleagues have implemented solutions at their institution such as a “reset room” where clinicians can go for a brief respite to listen to music, a wellness center with exercise and meditation spaces, and float pools that provide coverage for physicians for sick days and personal days so that they do not have to dump their workloads on peers.

Stanford University has developed a time bank that allows clinicians to earn credits for doing the kinds of work that are typically unrewarded, including serving on committees, mentoring or covering colleagues’ shifts.  They can use these credits to pay for time-saving services, such as home-delivered gourmet meals, housekeeping services and help writing research grants.

As Dr. Linzer said in a Stanford presentation, “Give people control of the work environment, give them support and all of a sudden they are back in balance.  It’s not easy, but it can be done.”

With best wishes,

Tony Mira
President and CEO