What makes doctors great also drives burnout: A double-edged sword

A physician burnout expert from the Mayo Clinic explained earlier this month at the 2016 AMA Annual Meeting how physicians in the current health care system often have an intrinsic risk of burnout. Learn about the role that the “physician personality” can play in burnout and ways Mayo has found to help address burnout as a system-wide issue.

What’s happening to physicians?

“If I told you we had a system issue that affected quality of care, limited access to care, and eroded patient satisfaction, that affected up to half of patient encounters,” said Tait Shanafelt, MD, a hematologist and physician burnout researcher at the Mayo Clinic, “you would immediately assign a team of systems engineers, physicians, administrators at your center to fix that problem rapidly.”

That’s what burnout is, he said. It’s a system issue. “And we have not mobilized the way we would to address other factors affecting quality access and patient satisfaction,” Dr. Shanafelt said.

“On a societal level folks would look at us and think we have a recipe for great personal and professional satisfaction,” he said. “We engage in work that society values and thinks is meaningful work. And yet our own literature has been telling a different story about the experience of being a physician.”

A recent study published in Mayo Clinic Proceedings took a look at how physician burnout compares to the general population and found that physicians displayed almost double the rate of emotional exhaustion as the general working population and reported lower satisfaction with work-life balance (36.0 percent for physicians, versus 61.3 percent of the general working population).

Dr. Shanafelt said that burnout is often the result of three components:

Depersonalization: Treating people as though they’re objects rather than human beings
Emotional exhaustion: Losing enthusiasm for your work
Low personal accomplishment: Feeling you’re ineffective in your work, whether or not that is an accurate perception

“All of us have those feelings to some frequency and some severity,” he said. “But when they come too often and to too severe an extent, they can begin to undermine your effectiveness in your work.”

“This syndrome differs from the global impairment of depression,” he said. “It primarily relates to your professional spirit of life, and it primarily affects individuals whose work involves an intense interaction with people—so professions such as teachers, social workers, police officers, nurses and physicians.”

The survival mentality and the physician personality

“I think we all remember that survival mentality of residency,” Dr. Shanafelt said. “‘I’ve just got to make it through; things will get better when I’m done with residency.’ But what we find is that physicians perpetuate that framework throughout their whole career.”

Dr. Shanafelt said that in one study, 37 percent of physicians reported looking forward to retirement as an effective wellness strategy. “This is the same thing as the survival mentality … and what was notable was that it was equally common to report that strategy for those under the age of 40 as those who were older,” he said. “It’s not just those who were actually getting closer to retirement.”

It’s a mentality of “work now, when I retire I’ll get to personal life,” he said.

Dr. Shanafelt said that one suggestion many researchers have found to be a possible cause of physician burnout is “that we are also at inherently higher risk due to what they’ve coined the ‘physician personality,’” he said. “Now, this is where if I wasn’t a physician myself you would start throwing rotten fruit.”

“They say … that the characteristics that define many doctors are doubt, guilt and an exaggerated sense of personal responsibility,” he said. “But these are the qualities that make you a good physician. They lead you to be thorough, committed, leaving no stone unturned, to always be thinking about Mrs. Jones and what else I could do, what am I missing? How could we do a better job taking care of her?”

“The qualities that make people good physicians are a double-edged sword,” he said. “It’s those who are most dedicated to their work who are at greatest risk to be most consumed by it.”

A strategy to examine work-life balance

If you’re experiencing burnout, identifying values—both personally and professionally—is an important factor in addressing what causes burnout, Dr. Shanafelt said. One way to do that is to engage in a series of questions to examine the two sides.

The first set of questions:

What are the things you care about in your personal life?
What does it look like for you to live in a way that demonstrates those are the things you care about?

The second set of questions:

What are the things you care about in your professional life?
How are you devoting and spending your time to align with those things?

“Physicians usually are relying on things around being a healer, teacher, making discoveries or operating a successful practice,” Dr. Shanafelt said. “The thing I can guarantee you is that your two lists are incompatible and that you cannot achieve everything on those lists.”

“If I think that I’m going to be a world expert in my field,” he said, “but never miss a soccer game to be away at study section, presenting at a meeting, to be writing a grant or manuscript, that’s an unrealistic expectation. I will miss soccer games to make a difference for the patients with this disease that I care about.”

“The question is,” he said, “how many soccer games is it OK to miss to still have the relationship with my kids that I want and the impact professionally that I aspire to? It’s this integration of these two spheres that’s really where the rubber meets the road.”

Addressing isolation

Due to some of the changes to the medical profession over the past few decades that have resulted in busier schedules, higher productivity expectations and more time spent documenting, physicians have less time to interact with each other.

“That interaction has always been part of the fabric of the profession,” Dr. Shanafelt said. “We have amazing colleagues, and getting to work with those people is what makes this profession great. But we have less of that interaction now than we did in the past.”

In a study at the Mayo Clinic, Dr. Shanafelt and colleagues randomized 75 physicians and “bought” an hour of their time. One-half of them used the hour every other week however they wanted for nine months—for instance, to catch up on administrative tasks or get home early. The other one-half used it to meet with a group of colleagues to engage a curriculum largely around sharing their experience of the challenges and virtues of being a physician.

“We measured a variety of personal and professional characteristics,” he said. Both groups saw a reduction in physician-reported burnout symptoms, but the group who met with their colleagues also had an improvement in meaning of work, “and we came back a year after the intervention ended.”

“The group who had that hour to catch up on admin went immediately back to baseline with respect to burnout as soon as they stopped getting an hour,” he said, “but those who had met with their colleagues every other week for nine months, the burnout and meaning in work remained improved a year after the intervention ended.”

As a result, Mayo conducted a second study during which physicians met for happy hour, breakfast, lunch or dinner. Mayo would buy the meal and send five questions the physicians could choose from to talk about as a group. The study saw the same outcomes as the previous study in improvement in burnout and meaning in work just from that interaction.

The Mayo Clinic’s board approved the program, which they now offer to all physicians. As a standard practice, Mayo pays for groups of colleagues every two weeks to go out to a restaurant in town with their colleagues. Dr. Shanafelt said about 1,000 physicians have signed up.

One physician in the audience who teaches in a residency program noted, “One of the questions that I got once—that I still don’t know how to answer—is: ‘Aren’t you just teaching us how to trick ourselves into being happier when we really are in this horrible situation?’”

“I look at it just like clinical skills,” Dr. Shanafelt answered. “You as an individual want to do your [continuing medical education] and keep yourself current and refine your art as best you can. And the system in which you plug into is also going to make you a better or less effective physician.”

“The answer is: ‘Yeah, I get it, this isn’t all yours and the organization has to do its part,’” he said. “But you want to be as good as you can at navigating the choppy water and knowing it’s going to come. And we’re trying to give you that skill set.”