The lead author of a recent commentary on the elusive nature of burnout raised a few eyebrows with a provocative title, “Physician Burnout—A Serious Symptom, But of What?”1

“We received some feedback that was critical of us for seeming to suggest there was not a problem,” says lead author Thomas L. Schwenk, MD, dean of the school of medicine at the University of Nevada, Reno. “Truly something important is happening. There is clearly a problem. We need a better understanding of what it is.”

Schwenk has long been fascinated with the issue of burnout in physicians, linking some of it to the clinical depression famously described in Darkness Visible, a book by William Styron: “Depression is a disorder of mood, so mysteriously painful and elusive in the way it becomes known to the self — to the mediating intellect — as to verge close to being beyond description.”2 Schwenk corresponded with the late Styron and came to form a theory that a breakdown in the physician-patient relationship could be driving the widespread reports of burnout in the profession.

In a commentary, also published this year, Schwenk notes that physicians have lost a time-honored “deeply personal, reciprocal relationship with their patients. That caring relationship has been lost for many physicians in the current system of fragmented, rushed, dysfunctional, digitized, corporatized, and costly medical care — a system that prizes efficiency over relationships, profits over common good, and volume over value.”3

In his more recent commentary, Schwenk looked at the meta-analysis by Rotenstein et al.4 that found broad disagreement about definitions of burnout and widespread variation in assessing its prevalence. He offered more insights into this issue in the following interview.

HEH: Were you surprised at the wide variation of definitions and measurements of physician burnout in the Rotenstein study?

Schwenk: I was not. I have been following this work for a while, and it just never seemed to quite come together. We keep stabbing at this issue from many different perspectives, adaptations of different instruments, and I never could get to what the core is.

Our basic thesis in the editorial is that we have gotten too far over our skis here in terms of giving this condition a name that seems like a diagnosis. It sounds like it has clinical credibility, but it is really just a label for a very heterogenous group of dissatisfiers. It’s sort of a misery list of labels. There is misery and dissatisfaction, but it is not well-specified. It is not well-understood, and yet here we are racing down a path that says use massage, yoga, and scribes for electronic medical records. We are throwing all kinds of stuff at this. I wish we could take a step back and get a little better sense of what is actually happening.

HEH: The study found wide variations and approaches using the Maslach Burnout Inventory.

Schwenk: I think there are a couple of problems. One is that it was not designed for physicians. Initially, it was designed [to assess] the caregiving burden for social service professionals. It is used in quite a wide range of populations, but it has not really been validated for those [other] specific circumstances. At the very least, it is supposed to be used for people that have clinical or caregiving responsibilities. So when it is used for medical students in the first or second year — who don’t have clinical responsibilities — I don’t know what that means, exactly.

Medical practice has always been stressful and always will be. The fact that physicians would answer a question that I feel burned out from time to time in my work doesn’t surprise me too much. We all have our moments. I will say that there has been some work recently that will be interesting to see. That is the development of some instruments that are more specific to physicians and clinical work settings. That might be useful.

HEH: Rotenstein and colleagues suggested trying to develop clinical criteria similar to depression.

Schwenk: My bias is that at the very least we need to start out with all the physicians who score positively on depression questionnaires and burnout questionnaires. Pull them all out and label them more clearly as meeting criteria for depression. That would be a good start because that would be a clinical diagnosis. It has criteria and clear treatment approaches. A very high proportion who score positively on burnout questionnaires will naturally score positive on depression assessments. Let’s pull those out for starters, and then see what’s left in terms of all the other work dissatisfaction and try to figure out what that means.

HEH: As a practical matter, it is difficult to prevent something if you can’t define it and measure it.

Schwenk: That’s the main issue. I’ve been in medicine for 40 years, so I have seen a fair bit come and go. I keep trying to put this in perspective and trying to understand — has something changed? If so, what and why? That is of great interest to me. In older days, physicians would frequently talk about exhaustion, being on call, and the demands of patient care. But you just never heard anybody use the word “burnout,” and we didn’t talk about depression that much.

HEH: You mentioned some stigma associated with the term “depression” in physicians.

Schwenk: There has always been a stigma related to depression. I think one of the reasons we coined this word “burnout” is because it sounds like it is saying something, but it doesn’t have the stigma that the word “depression” has. I think we would be better off to just use the clinical nomenclature. Say it straight out, and talk about clinical diagnoses instead of burnout, which kind of trivializes the problem. It also causes physicians to feel like they are the victims. As if the system is doing something to me personally and I am the victim. I don’t really like to think of physicians as victims. We should be taking charge of the system and making it work for our patients. That would help a lot.

HEH: In one of your commentaries, you trace some of this to a breakdown in the traditional physician-patient relationship.

Schwenk: A lot of the things physicians complain about detract from the reciprocal nature of the physician-patient relationship. Physicians give a lot to patients, but they also get a lot back. If the system has disrupted that relationship — which I think it has — then it deprives the physicians of that energy return, if you will. We always give a lot. That has always been true, but we always got a lot back. Now the system may be disturbing those relationships and making them less satisfying, powerful, and reciprocal. It has harmed some of that, and we are not getting back that energy.

HEH: It’s tempting to say the changes in reimbursement, reporting demands, and the like are the cause, but even if that could be quantified, it wouldn’t explain all depression in physicians?

Schwenk: There are studies going back a ways in terms of depression in physicians. It’s pretty clear that the prevalence of depression of physicians has gone up, as it has in the general population. I’m really interested in the issue of being depressed as a physician vs. being depressed because of being a physician. We are taking in medical students who have a history of depression, who suffer recurrences, and they experience depression as a physician and some of the stigma attached to that. We also have physicians who have no history, yet they experience profound depression and suicidal ideation as physicians. And presumably, to some extent, because of being a physician — because they did not have prior episodes. I have a feeling those are two very different populations.”

REFERENCES

  1. Schwenk TL, Gold KJ. Physician Burnout — A Serious Symptom, But of What? JAMA 2018;320(11):1109-1110.
  2. Styron, William. Darkness Visible: A Memoir of Madness. New York: Random House, 1990.
  3. Schwenk, TL. Physician well-being and the regenerative power of patient care relationships. JAMA 2018;319(15):1543-1544.
  4. Rotenstein M, Torre M, Rosales RC, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA 2018;320(11):1131-1150.