"Physician burnout” is a catchphrase in employee health, but it turns out there is little agreement on how to define it, resulting in even less understanding of how to measure, treat, and ultimately prevent it.

A meta-analysis of 182 studies was literally all over the map, as 45 different countries were represented, but little common ground was found. This was all the more surprising because the authors reported 86% of the studies used a version of the Maslach Burnout Inventory for assessments.

“Studies variably reported prevalence estimates of overall burnout or burnout subcomponents: 67.0% (122/182) on overall burnout, 72.0% (131/182) on emotional exhaustion, 68.1% (124/182) on depersonalization, and 63.2% (115/182) on low personal accomplishment,” the authors noted.1

The devil emerged in the details, as the authors tallied “at least 142 unique definitions for meeting overall burnout or burnout subscale criteria, indicating substantial disagreement in the literature on what constituted burnout.”

One takeaway seems to be that because prevalence estimates are so broad, they almost are meaningless.

“Overall burnout prevalence ranged from 0% to 80.5%,” they reported. “Emotional exhaustion, depersonalization, and low personal accomplishment prevalence ranged from 0% to 86%, 0% to 90%, and 0% to 87%, respectively.”

Standardized Tools Needed

The findings underscore the need to develop standardized tools to assess the effects of chronic occupational stress on physicians, says lead author Lisa S. Rotenstein, MD, MBA, a resident physician in general medicine at Brigham and Women’s Hospital in Boston.

“We wanted to know how big of a problem this is across the world in attending physicians,” she tells Hospital Employee Health. “Ultimately, when we started doing the research needed for a meta-analysis, there was so much variation in how burnout was defined and measured, it was not possible.”

This conclusion is equally, if not more, important, she says.

“There really is not a consensus on how we define burnout, and that limits our ability to quantify it,” Rotenstein said. “On a very basic level, it’s difficult to understand how much of a problem you have. What really is the burden of what physicians are experiencing on their daily function and their interaction with the healthcare system?”

The findings do not question the legitimacy of what physicians are experiencing, she emphasized. “Burnout is a real feeling, and it is a response to stress on the job,” she says.

Indeed, it is possible that initial feelings of burnout may culminate in clinical depression and suicidal ideation. Whether that represents an overlap or a line of causation is another gray area. It is estimated that between 300 and 400 physicians take their lives annually. Male physician suicide rates are slightly higher than men in the general population, but female physicians die by suicide at a rate of two to three times that of other women. Importantly, male and female physicians have a very similar suicide rate, in contrast to the general population where men are four times more likely to die of suicide than women. (For more information, see the June 2017 issue.)

Baselines and Interventions

In addition to difficulty quantifying the problem, there also is little way to establish baselines and measure interventions without standardization. The Maslach Burnout Inventory has three subscales: emotional exhaustion, depersonalization, and personal accomplishment. However, the thresholds for defining these conditions varied widely between studies, Rotenstein says.

“We found significant variations in the cutoffs for each of the subscales and in definitions for overall burnout,” she says. “That has to do either with study author preferences or where in the world it was being studied. So even within that one [Maslach] metric, there was no standardization, which poses a big problem as we try to understand the magnitude of this issue.”

A lot of these problems can be traced back to burnout being more of a catchall phrase rather than a clinical syndrome with diagnostic criteria.

“This contrasts with depression, which has an agreed-upon definition and ways of measurement that correlate with a clinical diagnosis,” she says.

One way to bring burnout into focus is to determine where it overlaps with depression and correlates with its established clinical criteria.

“I think that would take us a long way toward understanding what we are trying to measure and subsequently measuring in the right way,” she says. That is being looked at in subsequent studies, with the hope of eventually achieving a “reset” on burnout that reflects clinical consensus.

“We know that there is already a big issue around mental health for healthcare providers,” Rotenstein says. “In a previous study, we showed that almost 30% of medical students were depressed and similar percentages of residents. We know this can have a downstream effect on patient outcomes, satisfaction, and quality of care. This is important for physician health and for health of the healthcare systems as a whole.”

REFERENCE

  1. Rotenstein M, Torre M, Rosales RC, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA 2018;320(11):1131-1150.