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The current framework for addressing burnout, including burnout among physicians and other healthcare professionals, tends to be one that attempts to ‘fix’ the individual, but burnout is really a warning sign to the organization that it needs to make improvements in the social and psychological environment. We offer highlights of a presentation by Dr. Christina Maslach at ANESTHESIOLOGY® 2018.

November 5, 2018

Attendees at ANESTHESIOLOGY® 2018 had the opportunity to absorb some of the current thinking and research on physician burnout from an esteemed source—social psychologist Christina Maslach, PhD, developer of the highly regarded and widely used Maslach Burnout Inventory™ (MBI) for measuring burnout in individuals and organizations.

In a featured session, Dr. Maslach highlighted some of the misunderstandings about the true nature and causes of burnout, and explored how correcting these misunderstandings might enhance efforts to address an issue that not only impacts individual clinicians and whole healthcare organizations, but also impedes the quality of patient care. 

Physician burnout, in and of itself, is not the problem, said Dr. Maslach, who is professor emerita of psychology at the University of California, Berkeley. Rather, it should be viewed as a red flag. “That means it’s a warning that other things in the workplace are not working well. That warning is telling you to think about and look at better solutions. What is happening here that people are not dealing well with this environment?”

Burnout is indicated on the MBI by high negative scores on three dimensions: exhaustion, cynicism and feelings of professional inefficacy. Counting a high score on only one or two of these dimensions as burnout may not provide an accurate picture of the problem. A physician may be overworked and exhausted, but not necessarily experiencing burnout. “It may be fine to say that people are beginning to show some signs and we should pay attention to that. But I also think we need to be careful about how we lump these [dimensions] together,” she said.

In addition, the lack of confidentiality and supportiveness with which some organizations handle burnout assessments, as well as the faulty attitudes and beliefs surrounding the phenomenon that often manifest when burnout is identified, can stymie attempts to tackle the problem.

People often fear they will be stigmatized by saying that they’re experiencing burnout, so many people deny they’re having a problem and report that they’re okay. “People look around and everyone else seems fine, so they think ‘Am I the only one who’s having this problem?’” she said. “That’s what we call ‘pluralistic ignorance,’ because all of us are putting on a happy face to protect ourselves. It distorts the reality of what’s going on.” That potential for distortion also “raises the question of whether you can actually trust some of the data” yielded by burnout questionnaires and tools.

The current framework for dealing with the chronic stress that is burnout’s hallmark tends to be one of disability, in which the ‘solution’ is for the individual to quit or work less to escape from the work. The common approach taken by many organizations is to essentially encourage the individual to ‘fix’ themselves by advising them to get more sleep, exercise more, eat a healthier diet or take a resilience workshop, the implicit message being that it’s the individual’s fault. “It’s not that those aren’t good things to do, but they don’t solve the problem of burnout,” Dr. Maslach said.

Similarly, while periodic assessments of burnout prevalence might be valuable, burnout scores are not the key issue, Dr. Maslach said. To make lasting improvements, organizations must focus instead on identifying the elements of the work environment that can be modified to make it a healthier place that allows people to thrive rather than beating them down.

“You have to look at the things that are causing burnout and how to make changes. It’s a mistake to keep measuring it at an individual level and to assume, therefore, that it’s an individual problem, and not to look at the environment in which people work.”

Organizations often focus on fitting the person to the job by helping them take better care of themselves, build resilience and cope with stress. “These are all good solutions, but they don’t make the job any less toxic or stressful. So how about fitting the job to people?” she said.

She described six areas of job-person fit that organizations can use as a guide for asking questions and identifying ways to improve the social and psychological “ergonomics” of the work environment. Extensive research has shown that these six areas—workload, control, reward, community, fairness and meaning or values—correlate strongly with burnout.

Dr. Mashlach describes these six areas in more depth in an article, “Finding solutions to the problem of burnout,” published in the June 2017 issue of Consulting Psychology Journal. “The six areas of work life can be used as a kind of diagnostic tool to identify important job-person mismatches, thus providing a clearer picture of what the goals of an effective intervention might be,” she writes. “By ‘customizing’ an intervention to take into consideration more probable causes, rather than relying on more standard, one-size-fits-all approaches, practitioners would have a better chance of preventing burnout and building engagement throughout the workplace.”

The six positive “fits” that promote engagement and well-being are: 1) a sustainable workload; 2) choice and control; 3) recognition and reward; 4) a supportive work community; 5) fairness, respect and social justice; and 6) clear values and meaningful work.

Beyond merely identifying problems in these six areas, organizations should also assess their progress regularly to determine which interventions are working and how to fine-tune them.

The “fit” between person and job can be understood in terms of certain core psychological needs that have been shown to support motivation and well-being:  autonomy, belongingness, competence, psychosocial safety, positive emotions, fairness and meaning. “Thus, the challenge will be to figure out how to design and modify workplaces in ways that will support the satisfaction of these needs through the performance of the job,” she said.

In a 2017 review article in Medical Teacher, Dr. Maslach and Michael P. Leiter, PhD, discuss research showing that improving the balance of civil, respectful social encounters during the workday can lead to an enduring reduction in burnout among healthcare providers.

Improvements in social work environments with an emphasis on reciprocal relationships between colleagues can help prevent burnout and build engagement, she said. “It has to be more of a ‘we’ process rather than just ‘me’ alone.”

In our view, consideration of issues related to job-person fit as a means of preventing or addressing burnout may be advisable from a practice management and staff retention standpoint as well. A 2016 longitudinal study of 1,800 physicians by Mayo Clinic found that for each one-point increase on a seven-point emotional exhaustion scale, there was a 43 percent higher likelihood that the physician would reduce their full-time employment over the next 24 months. Each one-point decrease in a five-point satisfaction score led to a 34 percent higher likelihood that a physician would reduce their hours.

With best wishes,

Tony Mira
President and CEO