Burned out, but what does it all mean?

BURNOUT among clinicians is a troubling international trend, but the profession may be attempting to treat it without understanding it adequately, say experts calling for caution and further research.

In one of two research articles published on 18 September in JAMA, researchers set out to identify the international prevalence of burnout in a systematic review, but found such substantial variation in burnout definitions, assessment methods and study quality that no conclusions could be drawn.

The analysis of 182 studies from 45 countries found that most of the studies (85.7%) had used the Maslach Burnout Inventory, which measures three dimensions of burnout: emotional exhaustion, depersonalisation and diminished personal accomplishment. However, overall the researchers identified 142 unique definitions for meeting burnout criteria across all included studies.

They found overall burnout prevalence ranging from 0% to 80.5%.

In a second article, a study from the United States of more than 3500 resident physicians, researchers found that close to half of the participants (45%) reported symptoms of burnout, with about 14% reporting that they regretted their career choice.

An editorial accompanying the two articles stated that something “important and worrisome” was happening to physician wellbeing.

“The physician has become the patient, but the profession has started to act on the patient’s symptom before there is any actual understanding of its pathophysiology, origins, consequences, and effective approaches to prevention and treatment,” the editorialists wrote.

Michael Baigent, Professor of Psychiatry at Flinders University, said the term burnout was often inappropriately applied as a dichotomous concept.

“Researchers tend to suggest that doctors are burnt out or they are not, but the concept of burnout was never intended to be thought of in that way,” Professor Baigent told MJA InSight. “It’s more a term that should represent a spectrum, capturing people who have few symptoms of burnout through to people who have a lot.”

He said burnout was not a diagnosis or a syndrome.

“It’s really a description of a set of feelings that a doctor has in their workplace,” he said. “It’s supposed to capture [the way a doctor feels] when their work becomes overwhelming, whether that’s due to the volume of work or the characteristics of the work. Essentially, it’s a measurement of the match between the person and the work they are doing at the time. So, it’s a very subjective measure.”

Professor Baigent said the challenges in establishing the international prevalence of burnout were not surprising, considering the vast differences between medical systems across the globe.

“Comparing the work that a surgeon does in China with the work done in Africa, Spain or in the eastern suburbs of Sydney – it’s pretty hard to compare it globally,” he said.

Professor Baigent said Australia’s work climate was so different to that in the US that many concerns raised in the US cohort study were unlikely to apply here.

However, he pointed to the 2013 National Mental Health Survey of Doctors and Medical Students, funded by beyondblue as providing an important snapshot of the impact of burnout on Australian doctors.

The survey assessed burnout according to the three Maslach Burnout Inventory domains and found that 32% of Australian doctors had high levels of exhaustion, 35% had high cynicism, and 15% reported low professional efficacy.

“There were far higher percentages of younger doctors with high scores on emotional exhaustion, cynicism, low scores of professional efficacy compared with the older doctors, and there was a trend towards a reduction in those scores as time went by,” said Professor Baigent, who was involved with the research.

A spokesperson for beyondblue said the one-off doctors’ survey had paved the way for the creation of a guide for health sector managers about establishing mentally healthy workplaces.

Professor Baigent, who is one of the beyondblue Board of Directors, said although the survey was now 5 years old, the findings were likely to be similar today and it was too early to revisit it.

“I would be interested in doing it further down the track because as technology is weaving its way more and more into medical practice, the stresses are rising,” he said.

He said technology had often increased the time it took to see a patient.

“There are endless systemic risk management [tasks] that seem very relevant to administrators, perhaps, but less relevant to the clinical care of the patient.”

Professor Baigent said there was much interest and concern among doctors about burnout, and Australia needed to develop a more coordinated approach to reducing burnout.

“The existing approaches are rather piecemeal and vary from place to place,” he said. “There is a shared responsibility between workplaces and doctors to try and reduce burnout. I don’t think people need to be hysterical or alarmed about it, but if we are thinking that burnout is a risk factor for mental illness, it is certainly worth doing what we can to minimise it.”

Professor Baigent acknowledged the many hurdles in tackling a problem that varied enormously.

“Burnout varies not only from country to country but also from state to state, and even department to department,” he said. “But there are workplace and cultural strategies that can be put in place to alleviate it.”

Such strategies included realistic workloads for doctors, meaningful roles, some autonomy and an opportunity to practice patient-centred care, he said.

Professor Baigent also reiterated his position stated in the MJA earlier this year, that senior doctors should take on an advocacy role in supporting their younger colleagues who may be at a higher risk of burnout.

In related news, a Parliamentary Inquiry into Sleep Health Awareness in Australia was announced last week.

Professor Peter Eastwood, President of the Australasian Sleep Association, praised the move for recognising the importance of sleep as critical for good health.

“We now have a dire situation where millions of Australians are failing to get the sleep they need to live happy, healthy lives,” Professor Eastwood said. “With this inquiry, we hope to get a coordinated national strategy that enshrines sleep as the third pillar of good health, alongside regular physical activity and a healthy diet.”

In the National Mental Health Survey of Doctors and Medical Students, sleep deprivation was reported as a work stress by about 14% of respondents.

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