________________________________________________________________________ Burnout in Physicians
MEASURING BURNOUT The criterion standard for measuring burnout is the MBI, a self-assessment tool first published in 1981 by Maslach and Jackson [7]. The MBI was originally developed for the human services industry [121]. Since then, four additional versions have been developed, including a general survey, surveys for educators and students, and a medical personnel-specific survey [8]. The tool has been shown to be reliable, valid, and easy to administer and has been translated into several languages for use around the world. The MBI is often used in conjunction with other assessments to evaluate the relationship between burnout and organizational policies, productivity, and social support [7]. The MBI addresses the three defining aspects of burnout syndrome with 22 statements in three subscales [6]: • Emotional exhaustion: Nine statements to measure feelings of being emotionally overextended and exhausted by one’s work • Depersonalization: Five statements to measure an unfeeling and impersonal response to the recipients of one’s services, care treatment, or instruction • Personal accomplishment: Eight statements to measure feelings of competence and successful achievement in one’s work Each statement in the MBI expresses a particular feeling or attitude; for example, one statement in the depersonalization subscale is “I’ve become more callous toward people since I took this job” [6]. For each statement, the respondent indicates how frequently he or she experiences that feeling by using a fully anchored scale ranging from 0 (never) to 6 (every day). Higher scores on the emotional exhaustion and depersonali- zation subscales indicate higher degrees of burnout. A lower score on the personal accomplishment subscale corresponds to a lower degree of burnout. A separate score is determined for each subscale, and a scoring key provides threshold scores to indicate a low, average, or high degree of burnout on each subscale. Because the length of the MBI may limit its use, research- ers have explored the use of single-item measures from the instrument. Studies of healthcare professionals have shown that responses to one statement in the emotional exhaustion subscale (“I feel burned out from my work”) and one state- ment in the depersonalization subscale (“I have become more callous toward people since I took this job”) correlate well with the results of the full inventory [21; 22]. More recently, a nonproprietary single-item measure has been shown to be a reliable substitute for the emotional exhaustion subscale of the MBI [23]. The use of tools to assess well-being or psychological status in conjunction with the full MBI can help professionals gain a bet- ter understanding of the sources of stress for individuals. The Mayo Clinic Physician Well-Being Index is often used in studies of burnout among physicians [24]. In addition, the General
Health Questionnaire, developed by Goldberg, is designed to measure common mental health problems (domains of depres- sion, anxiety, somatic symptoms, and social withdrawal) and was developed as a measure to identify individuals who are likely to have or be at risk for the development of psychiatric disorders [25]. BURNOUT AMONG PHYSICIANS Physicians certainly fall into the category of human services professionals and so are especially vulnerable to burnout [6]. The 2024 Survey of America’s Physicians, conducted by the Physicians Foundation, found that 6 in 10 physicians reported often feeling burnout at work, a number which has remained consistent since increasing from 4 in 10 in 2018 [123; 127]. Multiple factors have contributed to this number, including burnout related to the COVID-19 pandemic, as well as a trend in healthcare towards consolidating facilities, leaving physicians navigating change and often dealing with staff shortages [123; 124; 126]. In addition to the emotional strain of dealing with people who are sick or dying and who have extreme physical and/or emotional needs, features unique to medical practice and the evolving state of health care create additional stress for physicians [26]. Somewhat novel stressors contributing to burnout emerged at various points during the pandemic. These range from the initial uncertainty regarding COVID transmission, shortages of personal protective equipment, lack of effective treatments, and an overwhelming workload (in some settings) to later-stage factors, such as the politicization of social distancing, masking, and vaccination; incivility; and the multiple, frequent waves of disease [124]. Many physicians (49% overall, though markedly higher among surgeons) saw their incomes drop significantly early in the pandemic and many dealt with a reduction in staff (32%), while some shifted to working outside their area of expertise or had to adopt standards of care that were suboptimal [123; 124]. As noted earlier, stress and job dissatisfaction play a role early in the development of burnout, and studies have confirmed that job or professional dissatisfaction is associated with burnout among physicians [27; 28; 29]. In 2023, the Survey of America’s Physicians found that 71% of physicians believe financial gain to be the top priority of the hospitals they work for; many also believe that mergers and acquisitions have impacted patient outcomes negatively and will continue to do so [126]. These findings highlight the need to understand and address causes of stress and job dissatisfaction among physicians in order to prevent burnout. Burnout has been studied among physicians in general, as well as across the span of their careers (medical students, fellows) and across specialties. The rates of burnout vary among these subgroups, but in general, the rates are higher than among workers in the general population and have increased over the past few years [11; 30; 31].
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