Physician Burnout Contrarians Prompt Reflection

While conceding more research is needed, physician wellness advocates say there are compelling justifications to move ahead with burnout interventions.

Physician burnout contrarians are drawing a skeptical response from physician wellness advocates.

On Sept. 18, a JAMA editorial claimed there is insufficient data about physician burnout to guide an effective response to the phenomenon.

"The term burnout has taken on meaning far beyond what is understood about it as an actual diagnosis or even a syndrome. The medical profession has taken a self-reported complaint of unhappiness and dissatisfaction and turned it into a call for action on what is claimed to be a national epidemic," the editorial says.

Jonathan Ripp, MD, MPH, senior associate dean for well-being and resilience at the Icahn School of Medicine at Mount Sinai, says the editorial has prompted reflection among physician wellness advocates.

"This editorial has had some reverberations in the community of individuals who are trying to take on and address the issue of well-being. … There are a number of things the editorial rightfully draws attention to. There is a lot of uncertainty about the best instrument to use to measure the well-being of physicians," Ripp says.

However, there is justified urgency to act, he says.

"There is a lot of suffering in our profession; and in some ways, to harp on the term that is used to describe the suffering or to focus on what measure you use lets the suffering continue without possible interventions that could help physicians."

Contrarian view
 

This week, a co-author of the editorial told HealthLeaders that terminology matters.

"We know that the general level of physician dissatisfaction and work misery seems to have increased, and physicians are certainly more vocal about their misery, with many suggestions for the source of that dissatisfaction. But labeling this as burnout implies a level of specificity and understanding of a defined clinical entity that I think is not justified," said Thomas Schwenk, MD, professor of family medicine and dean of the school of medicine at the University of Nevada in Reno.

Focusing on physician burnout, which is a relatively new diagnosis, could be dangerously misguided, Schwenk said.

"What is more important to note is the high level of depression as a criterion-based diagnosis, with a more clear understanding of pathophysiology and consequences including student, resident, and physician suicide. This would be a more worthy area of focus. It is possible that the use of the term 'burnout' has increased as a sort of more acceptable substitute for a diagnosis that still carries considerable stigma, namely depression," he said.

Schwenk singled out one intervention as problematic.

"I have particular concern about much of the attention on building resilience in students and physicians, as if we are simply not tough enough in a difficult world. Practicing medicine has always been exhausting, exhilarating, and demanding, but physicians never talked about burnout because they felt a greater reciprocity between the demands and the rewards of practice, and a stronger covenant with their patients and communities that energized them," he said.

Pressing ahead
 

Ripp says healthcare organizations have a duty to help suffering physicians even though there is incomplete information about burnout.

"We should not use the imperfection in how we measure well-being to say that we can't act. If you found an infection that affected 50% of the population, and you didn't have the best tools to diagnosis it, and you weren't exactly sure what to call it, but it was having real consequences, you would not wait to act until you had the perfect diagnostic tool," he says.

Ripp concedes more burnout research is needed but contends there is enough research to guide interventional approaches.

"We need more research, but we also have enough to act. The alternative would be to say, 'We don't have enough information, so we are not ready to look at interventions.' We have enough information to show that there is burnout and there are concerning consequences both to individual physicians and quality of care," he says.

Studies published in 2016 and 2017 demonstrate the causes of physician burnout and effective interventions, says Mickey Todd Trockel, MD, PhD, a clinical associate professor at the Stanford University School of Medicine in Stanford, California.

"Effective responses have already been crafted. Two good systematic reviews and meta-analyses demonstrate effectiveness of interventions.  Nevertheless, we have much room to improve. Physicians and those they serve will benefit from continued research on the causes of burnout and associated development of more effective individual and organizational level interventions," Trockel says.

There is little doubt that physician burnout exists as a serious problem, he says.

"A growing body of research demonstrates compelling relationships between burnout and adverse consequences to affected physicians and the quality of care they provide for their patients. In this light, the risk of understating seems greater than the risk of overstating the problem of physician burnout," Trockel says.