Understanding Physician Burnout

The optometric care environment encompasses the majority of primary eye care in the United States, and we often see a continuum of secondary and tertiary care in our practice settings. Our schedules are packed, the pace and pressures of patient care are demanding, and encounters with our patients often involve a great deal of emotional intensity—something I can speak to personally after decades of treating people with chronic vision loss and special needs. These factors place doctors of optometry and our teams at high risk for physician burnout.

Burnout negatively affects physicians, our patients, and our practices. Factors such as short appointments times, complex patient cases, electronic health record (EHR) stressors, lack of control, and poor work-life balance can result in negative health outcomes and even lead physicians to abandon their practices.^1,2 Understanding burnout can help us face the challenges of an evolving health care landscape by continuing to deliver high-quality eye care and thriving in a happier, healthier care delivery environment.

What is burnout?

Burnout syndrome was described in 1981 in the Maslach Burnout Inventory as a measure of three dimensions: emotional exhaustion, depersonalization from work, and lack of sense of personal accomplishment.³ When this concept was first proposed, there was a widely held belief that burnout was a result of the natures of individual physicians. As burnout persisted, however, this perception fell by the wayside.^1,3

In 2019, the National Academy of Medicine (NAM) published a report that examined the safety, health, and well-being of clinicians.² The authors found that physician burnout is a multifactorial problem that cannot be easily solved. Changes related to technology, regulation, policy, and societal trends have a profound effect on modes of health care delivery, and, subsequently, the organizations and clinicians who deliver such care. As health care professionals, we take oaths pledging to ascribe to ideals and principles that put patients first. This shared promise to do what is in the best interest of the patient is challenged by changes occurring in our care delivery environments. As clinicians, we often experience a disconnect between available resources (eg, insurance coverage, staff or time limitations, administrative regulations) and care delivery demands. According to the authors of the report, the three dimensions of burnout mentioned above are detrimental to quality of care due to poorer interactions with burned-out clinicians.²

The Agency for Healthcare Research and Quality's (AHRQ)Minimizing Error, Maximizing Outcome study found that more than half of primary care physicians reported feeling stressed because of time pressures and other work conditions, such as chaotic environments, low control over work pace, and unfavorable organizational culture.⁴ In this study, a survey of more than 400 family physicians and general internists who worked in 119 ambulatory care clinics was accompanied by a review of the medical records of 1,795 patients from these clinics for information on medical errors and quality of care. More than half of the physicians reported experiencing time pressures when conducting physical examinations, and almost one-third felt they needed at least 50% more time than was allotted for this function. In addition, almost one-quarter of those surveyed said they needed at least 50% more time for follow-up appointments.⁴

The results of the AHRQ study reinforced the belief that existing working conditions were strongly associated with physicians’ feelings of dissatisfaction, stress, burnout, and intent to leave the practice. Interestingly, quality of patient care was not found to be consistently associated with the doctors’ reactions to working conditions.² Rather, the doctors were found to act as buffers between patient care and environment, and when lower quality of care was identified, the investigators found that it was the organizations causing burnout among the clinicians (not the burned-out doctors) that led to lower quality of care. Additional follow-up investigations are being conducted to delineate EHR-related findings contributing to burnout and further identify EHR-related stressors.²

EFFECTS OF THE PANDEMIC

The lingering COVID-19 pandemic has also affected the welfare of health care workers. A recent study showed physician burnout rates spiked to 63% in 2021, demonstrating how the pandemic has contributed to this problem.⁵ According to the study, at the end of 2021, almost 63% of physicians reported symptoms of burnout, up from a finding of 38% in 2020. Investigators found that providing care without adequate personal protective equipment and experiencing disruptive economic consequences due to COVID-19 were two factors independently associated with burnout risk.

Emotional exhaustion in health care workers, which was problematic prior to the pandemic, has become worse compared to prior years.⁶ The emotional exhaustion associated with burnout not only puts care quality at risk, but can necessitate additional support for members of the workforce delivering care. Physicians remain at increased risk for burnout relative to professionals in other fields,⁵ and one study suggested that some doctors were at a greater risk of burnout than others, including those in emergency and primary care, as well as female physicians in general.⁶

Another study of more than 70 hospitals found that burnout is often a local phenomenon, meaning there is a “social contagion” factor that places clinicians who are not yet burned out at higher risk of becoming so, simply by working with those who are burned out.⁶

RECOMMENDATIONS FOR REDUCING BURNOUT

The authors of the NAM report recommend a systems approach to reducing clinician burnout and fostering professional well-being.² The report shows that multiple factors produce imbalances in job demands and resources during all stages of a clinician’s career. Regulatory and institutional policies, payer requirements, and intrusive, difficult technologies all challenge the basic motivations that are essential to the professional fulfillment of clinicians delivering high-quality patient care.

The report proposes system transformation with meaningful, effective involvement of clinicians, describing the role health care organizations must adopt, as well as systems and principles to reduce clinician burnout and foster professional well-being.

Key burnout-related points made in the report include:

• Clinician burnout needs to be tackled early in professional development, and special stressors in the learning environment need to be recognized.
• Stakeholders in the external environment have an important role to play in preventing clinician burnout, as their decisions can result in increased burden and other demands; therefore, every attempt at alignment and reduction of requirements to reduce redundancy is essential.
• Technology can either contribute to clinician burnout (eg, poorly designed EHR technologies) or help reduce clinician burnout (eg, well-functioning patient communications).²

At that time, the authors of the AHRQ report found insufficient evidence to support strong recommendations for interventions, as the evidence for system interventions that significantly address clinician burnout is limited.⁵ However, they do make the following suggestions that directly address clinicians’ perceptions and concerns.

• Schedule monthly provider meetings focused on work-life issues or clinical topics, based on a survey of staff members on which topics to address
• Enhance team functioning through quality improvement projects to engage office staff, enhance teamwork, and reduce the pressure on physicians to be responsible for all aspects of care
• Have trained staff perform administrative duties, such as entering patient data into EHRs, tracking forms, and sending faxes, to give doctors more face time with patients

The need remains for greater attention to be paid to the mental health status of health care workers and for better access to be given to required resources to promote their well-being. A 2020 physician survey report found that 50% of physicians have experienced inappropriate anger, tearfulness, or anxiety as a result of pandemic effects.⁷ The AHRQ recommends that professional societies, state licensing boards, specialty certification boards, and clinical education and health care delivery organizations take steps to reduce the stigma of seeking help for psychological distress.

Another potential intervention involves recognizing the features of zero-burnout practices and translating them into our own professional environments. A 2021 study highlighted the importance of focusing on leadership and practice culture.⁶ Zero-burnout practices are those with higher levels of psychological safety and adaptive reserve, a measure of a practice’s capacity for learning and development.

Compared with high-burnout practices, zero-burnout practices reported using more quality improvement strategies and were more commonly solo and clinician-owned. They found lower burnout is associated with participatory decision-making and reported that facilitative leadership helps foster emerging leadership skills among all practice members, in contrast to traditional hierarchical leadership models that rely on command-and-control mechanisms. Facilitative leadership prioritizes fostering relationships, enhancing communication, attending to social influence and power imbalances, assuring psychological safety, and cultivating teamwork.⁸

TAKE SELF CARE SERIOUSLY

Just as large health care organizations are tasked with addressing the systemic complexities of burnout, you and your team can work to implement your own approach to reducing clinician burnout and its risk factors. Openly share your successes with colleagues and within your community, so that others can learn from your triumphs and mistakes. Pay attention to emerging information on clinician burnout, and adopt self-care approaches so that you and your team can look forward to a new year of delivering patient care in a happier, healthier environment.