Provider burnout: How’s your relationship with work?

Provider burnout: How’s your relationship with work?

Burnout has been associated with medical errors, longer patient recovery times and lower HCAHPS scores.

April 2016
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physician-burnout

Published in the April 2016 issue of Today’s Hospitalist


Author David A. Frenz, MD, provides a method of assessing one’s personality and propensity for burnout in his July 2017 article “Know yourself.” 


PROVIDER BURNOUT continues to receive a lot of attention. Tait Shanafelt, MD, and colleagues threw the latest log on the fire in the December 2015 issue of Mayo Clinic Proceedings. They found that 54.4% of U.S. physicians had at least one symptom of burnout and that its prevalence had increased 8.9% in just three years.

As an executive responsible for roughly 200 providers, this worries me more than a little. Burnout has been associated with all sorts of bad things like medical errors, longer patient recovery times and lower HCAHPS scores. But what, exactly, is burnout? How is it measured, and how can you address it if you have it?

Background
Herbert Freudenberger, PhD, is credited with the first systematic description of burnout. In the 1970s, he reported physical signs such as “a feeling of exhaustion and fatigue” and behavioral manifestations including anger, irritability, low frustration tolerance and deep cynicism. In the Winter 1974 issue of the Journal of Social Issues, he further observed that the burnout “victim begins to feel that just about everyone is out to screw him, including other staff members.” Finally, he noted, “the person looks, acts and seems depressed.”

Michael Leiter, PhD, and Christina Maslach, PhD, both big names when it comes to burnout, describe it as a “chronic state of being out of sync with your job.” They noted that burnout occurs when there is a “poor fit” or “major mismatch” between work and you, resulting in lost energy, enthusiasm and confidence.

Measurement
The Maslach Burnout Inventory (MBI), which was published in 1981, is considered the gold standard for assessing burnout. It consists of 22 Likert-type questions dealing with emotional exhaustion, depersonalization and sense of personal accomplishment. Here is a representative item from each area:

    • I feel used up at the end of the workday.
    • I’ve become more callous toward people since I took this job.
    • I feel I’m positively influencing other people’s lives through my work.

Response options range from “never” to “every day.” Like all good psychological tests, numbers can be aggregated, categorized and compared to normative data.Emotional exhaustion and personal accomplishment are pretty straightforward. Depersonalization, on the other hand, is the sense of being disengaged from or having an impersonal response to the people you work with or treat.The MBI is available online for $15 through Mind Garden, a psychological testing vendor. Do yourself a favor: Get tested.

Getting inside my head
I love my job and have decent work-life balance. Even so, I racked up 23 points on the emotional exhaustion subscale, placing me in the middle of the “moderate” range (17–26 points). I’m doing OK on the other subscales with low depersonalization (2 points) and high personal accomplishment (41 points).

Compared to the general population, my emotional exhaustion score is at the 59th percentile—meaning roughly two-thirds of people are doing better in that department than I am. This isn’t too surprising: Dr. Shanafelt found that doctors have higher rates of burnout than the general U.S. working population. For example, 14% of physicians reported daily emotional exhaustion, compared to only 6.4% of nonphysicians.

But how do I compare to other doctors? Dr. Shanafelt’s data suggest that I’m pretty average. The median emotional exhaustion score in his study was 25, with 19% of physicians falling in the moderate range. The remainder skewed low (34.1%) or high (46.9%).

But average isn’t normal. After all, the mean hemoglobin in the ICU is probably 8 or 9. I’d love to have a better (lower) emotional exhaustion score.

Your relationship with work
Burnout is probably the final common pathway for various work-related problems. Drs. Leiter and Maslach identified six domains that can either promote burnout or protect against it:

  • workload
  • control
  • reward
  • community
  • fairness
  • values

Take workload, which encompasses your amount of work as well as the burdens of job demands and their impact on your personal life. A poor fit in this domain tends to contribute to burnout, whereas a better match is neutral or potentially protective.So is your sense of autonomy and your job’s social and financial rewards. The people with whom you work and your company’s overall culture are also major factors.All of this can be measured via the Areas of Worklife Survey (AWS), a 28-item psychological instrument (also available from Mind Garden). Like the MBI, responses are categorized and put into the context of a large compare group. Here are some representative questions:

  • I have enough time to do what’s important in my job.
  • I have control over how I do my work.
  • My work is appreciated.

Response options for each item range from “strongly disagree” to “strongly agree.”

Back inside my head
My AWS looks great for everything except workload, where I’m sitting at just the 4th percentile. (See “My own score,” below.) In this test, higher numbers are better. In the general population, 96% of people have a better fit between their actual and their ideal workload than I do. This suggests that workload is the primary cause of my emotional exhaustion.Fortunately, AWS data come with a 25-page report with strategies for addressing problems. Workload solutions include resilience, uninterrupted time, improved time management and reducing workload.

I’m working hard on uninterrupted time: closing my office door, ruthlessly declining meeting requests and protecting desk time with a daily “No Meeting Zone.” This helps me get work done during the day so it doesn’t encroach (as much) on my nights and weekends.

This is a little harder on the wards, where providers are often sitting ducks for drive-by questions and requests. Again, closing doors and periodically making yourself unavailable can give you the space you need. I generally complete my charts in my administrative office far, far away from the original point of care.

David A. Frenz, MD, is vice president and medical director for North Memorial Health Care in Robbinsdale, Minn. You can learn more about him and his work at www.davidfrenz.com or LinkedIn.

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