________________________________________________________________________ Burnout in Physicians
lower rates of satisfaction and higher rates of burnout [29; 54]. Long hours, many of which are spent on nonclinical tasks, and unsatisfactory work-life balance are the key factors in feeling stressed or overextended. Physicians work an average of 51 to 63 hours per week, or 11 to 23 more hours per week than the mean for the general population [30; 34; 44; 48; 53; 55]. Approximately 60% of physicians have also noted time pressure associated with electronic documentation [56]. Physicians have reported that they spend an average of 9 to 11 hours per week on administrative (nonclinical) duties, with approximately 38% saying they work 11 hours or more each week on such duties [53; 57]. Thus, tasks such as billing, obtaining insurance approvals, financial and personnel management, and negotiat- ing contracts take up 14% to 23% of their work time [53; 57]. An excess of “bureaucratic” tasks was the highest ranked cause of burnout in the Medscape Lifestyle Reports, and long hours at work was the second leading cause [31; 47]. The time spent on administrative tasks takes away from time forming relation- ships with patients, the most satisfying factor about medical practice according to approximately 79% of physicians [53]. Long hours at work create conflicts between responsibilities at work and at home, and rates of work-life conflicts among physicians have been reported to range from 41% to 62%, and only 33% to 48% of physicians are satisfied with their work-life balance [11; 34; 40; 47; 48; 58]. Both long hours and work-life conflicts have been found to be significantly associated with burnout [34; 46; 48; 50; 51]. Physicians’ satisfaction with work- life balance has decreased since 2011 and is significantly lower than the rate among the general population (61% vs. 36%) [30]. Pooled multivariate analysis with adjustments for age, sex, relationship status, and hours worked per week showed that, compared with the general population, physicians had an increased risk of burnout and a decreased likelihood of being satisfied with work-life balance [30]. Electronic Environment The era of information technology in medical practice, most notably electronic health records (EHRs) and computerized physician order entry (CPOE), began in the 1990s, and the technologies have been slow in becoming embraced by the medical community because they are challenging and time- consuming to learn [37]. Approximately 85% of physicians currently use these technologies, and about 60% think that EHRs have improved the quality of care [37]. However, the technology has been slow to improve efficiency of care. Surveys have shown that approximately 43% to 75% of physicians think that EHRs decrease efficiency and 47% to 66% of physicians think that using EHRs detracts from patient interaction [37; 53; 59]. One study showed that physicians who used EHRs spent slightly more time on administrative tasks than physi- cians who used paper records (17% of work time vs. 15% of work time) [57]. In another study, emergency department physicians spent a mean of 43% of their time on data entry, a
significant difference from the time they spent on direct patient care (28%) [60]. In general, physicians are dissatisfied with the amount of time they spend using electronic documenta- tion systems, and stress levels increase and satisfaction levels decrease with increasing use of EHRs [56; 61; 62]. Physicians who use EHRs and CPOE are also at higher risk for burnout, and “increased computerization of practice” was the fourth most common cause of burnout in the Medscape Lifestyle Reports [31; 61; 47]. As more physicians become comfortable with using electronic systems, their satisfaction may improve. Loss of Control or Autonomy Physicians’ autonomy is defined as the ability to determine how they work and decide how much time to spend with patients, what kinds of tests to perform, and what treatments to plan [63]. Autonomy has been reported to be the most important determinant of career satisfaction, yet it appears to be slowly eroding [64; 65]. Approximately 50% to 69% of physicians say their clinical autonomy is sometimes or often limited and their decisions are sometimes or often compromised [53; 56]. Physicians report being frustrated with decision-making by third parties (insurance companies and government agencies) and restrictions imposed by formularies or guidelines [66]. This loss of physician autonomy has been found to be significantly associated with burnout; lack of clinical and administrative autonomy were both significantly correlated with burnout in emergency physicians, and low control over work was strongly associated with dissatisfaction and burnout among primary care physicians [29; 54; 66; 67; 68]. Subjective factors, such as a perception of lack of autonomy, have had a stronger correla- tion with burnout than objective factors [39]. Other Causes Many other factors have been noted to be risk factors for physi- cian burnout. According to Maslach, insufficient reward for one’s contributions is a risk factor for burnout, and this factor has been shown in studies of physicians. Insufficient income was fifth most commonly selected cause of burnout in the 2019 Medscape Lifestyle Report, and feeling unappreciated was a substantial contributor to burnout in a study of residents [47]. Poor working relationships with colleagues, analogous to Maslach’s absence of community, has been reported to be a risk factor for burnout among critical care physicians and nurses [19]. In contrast, good working relationships with other physi- cians and staff have been associated with a greater likelihood of job satisfaction [54; 69]. A factor unique to physicians was found in a 2010 study of U.S. surgeons, in which being sued for malpractice in the last 24 months was strongly associated with burnout [70]. Also unique to physicians is health policy; the impact of the Affordable Care Act was the fifth most common cause of burnout in the 2015 Medscape Lifestyle Report [31]. As many as half of physicians say their work environment is chaotic, and this factor has also been significantly associated with burnout [29; 37; 54].
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