Causes and Consequences of Physician Burnout and the Importance of Well-Being

Physician burnout has emerged as a critical issue in healthcare over the past few years, with significant implications for the entire system. This multifaceted problem stems from a combination of individual factors and systemic concerns. By addressing this issue comprehensively, healthcare systems can work towards creating a more sustainable and supportive environment for physicians.

Introduction

The concept of burnout was conceived in the 1970s by the observations and experiences of two psychologists, Herbert Freudenberger and Christina Maslach. They observed the development of a triad of symptoms among professionals in human service sectors who worked with underprivileged populations. These symptoms included emotional exhaustion, detachment, and negative feelings, likely a response to the challenging work environments and high-stress interpersonal interactions inherent in these professions (Freudenberger 1974). The concept of burnout quickly gained mainstream popularity. Over the past 15 years, burnout has been used to characterise the poor well-being of physicians, helping to raise awareness of the multifaceted challenges to physicians' wellness and systemic issues within the healthcare industry. Burnout affects physicians across all career stages and affects many specialties. Poor well-being among physicians can lead to negative career and family consequences, ill health, substance abuse, and an increased risk of suicide (Hamidi et al. 2018). A physician’s distress can also affect the healthcare system through diminished quality of care, medical errors, high physician turnover, and attrition from the medical field (Shanafelt et al. 2017). In recent years, there has been a growing recognition of job-related stress among doctors, coupled with increased efforts to promote overall well-being. The COVID-19 pandemic further highlighted this issue, underscoring how crucial physician wellness is for providing quality patient care and enabling healthcare organisations to fulfil their objectives. This heightened awareness has brought the importance of physician well-being to the forefront of healthcare discussions and initiatives.

The objective of this comprehensive review is to examine the prevalence of burnout in physicians across various career stages, investigate the reasons contributing to burnout, and review the evidence-based strategies and interventions that can effectively mitigate burnout’s impact. The authors aim to provide a holistic understanding of the burnout epidemic affecting the medical profession and offer actionable insights to support physicians' mental health, job satisfaction, and overall well-being throughout their careers.

Background

The World Health Organization (WHO) defines burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed (WHO 2019). The risk of burnout is higher amongst physicians because of unique occupational challenges, including demanding workload, emotional intensity, administrative burdens, and high-stakes decision-making. Furthermore, data from cross-sectional studies showed an independent relationship between burnout and work hours: every additional hour worked increased the odds of burnout by 3%, night shift by 3%, and weekend shifts by 9% (Shanafelt et al. 2009a).

The leadership, organisational environment, and ethics of the workplace also influence burnout rates. Understanding and respect among leadership and colleagues decreases burnout rates, lowers reported stress, and increases workplace satisfaction (Salvagioni et al. 2018). Individual factors related to burnout include age, gender, sleep deprivation, and home support and stress (partner, spouse, children). Contrary to prior understanding, burnout is not a phenomenon of older late-career physicians; it is now thought to start as early as residency and medical school (Salvagioni et al. 2018).

A nationwide survey conducted by West et al. (2018) showed that 54.4% of US physicians reported at least one symptom of burnout, and satisfaction with work-life balance had declined from 48.5% in 2011 to 40.9% in 2014. While burnout is prevalent across various professions, physicians exhibit a markedly higher susceptibility, with studies indicating approximately double the risk compared to the general population. A Medscape physician lifestyle report from 2015 indicated that critical care physicians have the highest prevalence of burnout compared to other medical specialties (Peckham 2015). Again, in 2021, critical care burnout rates continued to be the highest compared to other specialties. In a recent Medscape survey in 2024, multiple medical specialties were investigated for rate of burnout. Table 1 summarises the findings from the survey (Kane 2024).

The emergence of the global health crisis brought by the COVID-19 pandemic thrust the pre-existing challenges faced by physicians to the forefront, bringing long-standing issues of burnout and professional dissatisfaction into sharp focus. John Hopkins University documented nearly 100,000,000 COVID cases with 1 million deaths in the United States. Healthcare workers were expected to work during the pandemic with an extraordinary level of stress. Since the start of the pandemic, healthcare workers have battled with the fear of being at risk of daily exposure to COVID-19 whilst working with limited resources, PPE shortage, and helping severely sick patients with high mortality rates, leading to increased rates of burnout (Burrowes et al. 2023).  In a survey regarding the effect of the pandemic on mental health in general, 55% of healthcare workers reported worsening mental health after the COVID-19 pandemic, and 43.6% reported insufficient mental health support at work (Burrowes et al. 2023).

Discussion

The prevalence and impact of burnout prompted the development of multiple assessment tools to quantify burnout. The Journal of Occupational Behavior published an article in 1981 where the authors introduced The Maslach Burnout Inventory (MBI) (Maslach and Jackson 1981), which was later adapted as a gold standard assessment tool for burnout (Rotenstein et al. 2018). The MBI is a three-dimensional test which evaluates three major endpoints of burnout: emotional exhaustion, personal accomplishment, and depersonalisation (Rotenstein et al. 2018). Other burnout scales, such as the Copenhagen Burnout Inventory (CBI) and the Oldenburg Burnout Inventory (OLBI), focus on a two-dimensional assessment of burnout, including exhaustion and disengagement (Restauri and Sheridan 2020). Although most published works on burnout have used MBI as a burnout assessment tool, the MBI originated as a multi-dimensional research instrument. It includes separate subscales for each dimension, and it was not structured to be an individual assessment tool, which prompted the need for more specific assessment tools. The Burnout Assessment Tool (BAT) has been designed, utilising a multi-dimensional structure and increased scoring complexity. BAT includes four core dimensions (BAT-C): exhaustion, mental distance, and cognitive and emotional impairment, and two secondary burnout dimensions (BAT-S), including distress symptoms and depression symptoms. BAT is considered a valuable alternative when it comes to studying burnout, and it is advised that further research uses it to assess burnout between individuals (Kristensen et al. 2005).

In general, high-stress professions, including firefighters, police officers, and healthcare professionals, have higher burnout syndrome (BOS) rates compared to less stressful professions, with emergency medicine and critical care medicine having the highest rates of BOS in healthcare (Moss et al. 2016a). Multiple factors contribute to higher rates of burnout among healthcare workers, including but not limited to continued stress, exhaustion, lack of appropriate sleep hours, depression, anxiety, high workload with understaffed conditions, and relative lack of community support (Peckham 2015). Comparing severe burnout rates among ICU nurses and physicians, 25-30% of ICU nurses reported severe BOS and about 45% of ICU physicians reported severe BOS. Furthermore, comparing paediatric ICU to adult ICU, working with sick children increased burnout rates to 71% in paediatric ICU physicians (Moss et al. 2016b).  

Further investigation of BOS epidemiology reveals significant differences by gender, with female versus male physicians having different BOS rates. The higher prevalence reported by female physicians reached 56%, while male physicians reported a burnout rate of 41%. Multiple reasons contribute to this difference. On average, female physicians spend 10% more time with new patients; they tend to provide more psychological support to patients and spend more time reviewing medical records than male physicians. Female physicians report a lack of control of autonomy as a contributor to burnout (Lyubarova et al. 2023). Although gender disparities have improved over the years, it persists in medicine. For example, in leadership roles, male physicians have a higher likelihood of promotion opportunities than female physicians, contributing to feeling rewarded, appreciated, and valued at work (Li et al. 2021). A cross-sectional study published by the Journal of the American Medical Association in July 2017 focused on discrimination experienced by female physicians with children and highlighted both gender and maternal-related discrimination resulting in higher burnout rates. It also promoted a further focus on gender equality, providing longer maternity leaves, lactation support, and backup childcare (Patel et al. 2018).

Burnout syndrome in the healthcare system negatively affects patient care. While most research focuses on patient safety, limited literature focuses on healthcare workers' wellness and the root cause of burnout. In the United States, there are more than 10,000 critical care physicians and 500,000 critical care nurses providing patient care, and it stands to reason that improved provider wellness will reflect positively on patient care (Moss et al. 2016b). BOS can impair physicians' cognitive function, critical thinking, and performance, and it leads to less compliance with treatment guidelines. As a consequence, more medical errors are reported, which further leads to more medical malpractice suits. This not only affects patients but also directly impacts entire healthcare system outcomes. Further ramifications of BOS demonstrated earlier rates of retirement among physicians. BOS increases musculoskeletal disorders, obesity, insomnia, and a higher risk of alcohol and drug abuse (Shanafelt et al. 2009b). A call for action was developed by the Critical Care Societies Collaborative (CCSC) and sought to significantly reduce the prevalence of BOS by shifting focus to recognising burnout, encouraging ICU health workers to be more vocal about critical issues, while striving to create a healthy work environment in the ICU (Moss et al. 2016b).

The substantial impact of physician burnout on the healthcare system reinforces the importance of quantifying, managing and preventing it. After a comprehensive review of the literature, we summarised the two perspectives with significant impact on reducing physicians' burnout: physician-directed strategy and organisation-directed strategy (Adriaenssens et al. 2015). Physician-directed intervention emphasises the importance of positive physician coping mechanisms, which can be applied by increasing mindfulness and cognitive behavioural techniques, ideally increasing coping and improving communication between physicians, nurses, and healthcare workers. Though this intervention can have a positive impact on reducing BOS, BOS is mainly considered a system-level defect, and putting resources and efforts into making changes at the systemic level is expected to be favourable over individual physicians' intervention. On an organisation-directed strategy, a systematic review identified 50 studies evaluating the effect of organisation-directed workplace interventions on physician burnout. Out of the 50 studies, 38 studies focused on factors that reduce and alleviate burnout or improve associated indicators, such as emotional exhaustion, stress, job satisfaction, or fatigue. The interventions were classified into four categories: teamwork, technology, transitions, and time (Panagioti et al. 2017).

Teamwork interventions focused on increasing, encouraging, and supporting communication between physicians, having scribes, who aided by entering electronic health records (EHR) data and expanding medical assistants' roles to include between-visit care and EHR documentation. In the technology category, EHR was found to play a key role in burnout rates. It is reported by male sex, older age (>55 years), surgical specialties, and clinic physicians the dissatisfaction with EHR and its negative effect on patient-centred communication. Ambient artificial intelligence (AI) scribes use smartphone microphones to transcribe encounters and is already showing promising results as it is expected to reduce the documentation burden and, most importantly, enhance physician-patient interaction (Shanafelt and Noseworthy 2017). Time-based interventions have a different approach depending on the physicians' career level. Residents working hours have already improved significantly since the work hours limitation; however, attending physicians do not have work hours. On an organisational level, monitoring work schedules and working hours per week may be beneficial (Shanafelt et al. 2023). While attending shift work is difficult to control, having a fully staffed ICU with proper support and safe sign-outs between shifts also contributes positively to decreasing burnout. Lastly, transition impacted burnout through quality improvement QI projects that pivot on the most time-consuming, burdensome tasks for physicians, like medication reconciliation (Morrow et al. 2014).

Well-being is the experience of positive perceptions and the presence of constructive conditions at work that enable workers to thrive and achieve their full potential. Well-being can be further explained from professional, objective, and subjective perspectives. Professional well-being includes job satisfaction, high-quality work experience, a feeling of fulfilment and engagement at work (National Academies of Sciences, Engineering and Medicine Report 2019). Objective well-being covers physical needs satisfaction, shelter, food, and clothing. Lastly, subjective well-being includes psychological and emotional support (Chari et al. 2018). A systematic review summarised the effects of a positive psychology intervention (PPI) on the well-being of healthcare workers (Watanabe et al. 2023). The two most evaluated PPIs in this systematic review were gratitude-based and mindfulness-based interventions. Gratitude-based intervention is simply applied by expressing gratitude to self and to others, which is thought to positively improve well-being and decrease both anxiety and depression, which could lead to decreased burnout (Komase et al. 2021). Mindfulness-based interventions include mindfulness meditation, body scans with awareness focused on different areas of the body, and slow breathing practices. The latter increased the connection between the central nervous system and the parasympathetic system, which improves cognitive control (Kabat-Zinn 2003). As stress is known to cause the upregulation of inflammatory markers, mindfulness interventions were demonstrated to counteract this inflammatory process by downregulating inflammatory proteins. It was proven on structural MRIs that mindfulness practices diminished the amygdala response activity to stress. In other words, people who practice mindfulness have less arousable fear and emotion centres in their brains (Tang et al. 2015).

Conclusion

Physician burnout has reached epidemic proportions, with prevalence rates exceeding 50% among medical students, physicians-in-training and practicing physicians. This alarming trend poses a significant threat to healthcare quality, patient safety, and the longevity of the physician workforce.

The consequences of burnout are far-reaching, impacting not only physicians' personal well-being but also patient care outcomes. Addressing physician burnout requires a multifaceted approach that targets both individual and systemic factors. Healthcare organisations must prioritise physician wellness, investing in evidence-based interventions to improve working conditions, reduce administrative burdens, and foster a supportive organisational culture. Simultaneously, individual physicians should be empowered with tools and resources to enhance their resilience and maintain work-life balance. As the healthcare landscape continues to evolve, it is crucial to recognise that physician well-being is inextricably linked to the quality and efficiency of patient care. By prioritising physician wellness and implementing comprehensive strategies to combat burnout, we can create a healthier, more sustainable healthcare system that benefits providers and patients.

Conflict of Interest

None.