Thursday Review: “Correlates of physician burnout across regions and specialties: a meta-analysis”

This November, the Thursday Reviews will be dedicated to some of the literature available on Resilience and Burnout. We’ll be examining how storytelling and narrative are essential to healthcare providers’ well-being.

Nov. 2 | Nov. 9 | Nov. 16 | Wed., Nov. 22 | Nov. 30

Facets of Burnout

Quantitative research about burnout is usually traced back to Christina Maslach and Susan E. Jackson’s work in the late 1970s and early 80s. They began their work, pointing to their and others’ research that burnout can lead to a deterioration in the quality of care or service that is provided by the staff. It appears to be a factor in job turnover, absenteeism, and low morale. Furthermore, burnout seems to be correlated with various self-reported indices of personal distress, including physical exhaustion, insomnia, increased use of alcohol and drugs, and marital and family problems.1

Burnout is costly for patients, costly for healthcare systems, and, of course, costly to physicians and their families.

Raymond T. Lee, Bosu Seo, Steven Hladkyj, Brenda L Lovell, and Laura Schwartzmann set out to see if they could confirm our understanding of the different facets of burnout by a meta-analysis of different primary studies.

They ended up comparing 65 separate data sets on different factors which correlate with physician burnout. The researchers are always careful to use the word “correlate”, and never explicitly claim there is a causal relationship between the factors they study and burnout. Instead, they encourage Health Human Resources to use this data to “direct resources most needed to physicians of different regions and specialties.”

Maslach and Jackson’s research developed the idea that there are three interrelated aspects (“subscales”) to burnout, which we now call

  1. emotional exhaustion,
  2. depersonalization, and
  3. diminished personal accomplishment:

Burnout is a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do “people-work” of some kind. A key aspect of the burnout syndrome is increased feelings of emotional exhaustion. As their emotional resources are depleted, workers feel they are no longer able to give of themselves at a psychological level. Another aspect is the development of negative, cynical attitudes and feelings about one’s clients. Such negative reactions to clients may be linked to the experience of emotional exhaustion, i.e. these two aspects of burnout appear to be somewhat related. This callous or even dehumanized perception of others can lead staff to view their clients as somehow deserving of their troubles2, and the prevalence among human service professionals of this negative attitude toward clients has been well documented3. A third aspect of the burnout syndrome is the tendency to evaluate oneself negatively, particularly with regard to one’s work with clients. Workers feel unhappy about themselves and dissatisfied with their accomplishments on the job.4 [emphasis added]

Lee et al. only study Emotional Exhaustion and Depersonalization, and don’t explicitly say why. It may be that there are only large data sets available for the first two aspects of burnout.

Factors Involved in Burnout

In addition to the specific symptoms of burnout, the researchers also briefly discuss models of its causes:

The frameworks to explain the development of burnout in health professionals have ranged from personal characteristics to work organization variables or a combination of the two. […] Existing evidence supports models with personal and work characteristics. The three levels of change to reduce burnout risk are: (1) modifying the organizational structure and work processes; (2) improving the fit between the organization and the individual physician, including professional development programs to facilitate better adaption to the work environment; and (3) individual-level actions to reduce stress and poor health symptoms through effective coping and promoting healthy behaviors.

My purpose this month is mostly to highlight how individual-level actions and professional development programs help avoid burnout. I’ll also skip over most of the authors’ discussion of their statistical methods.

In 2001, Maslach proposed5 that Emotional Exhaustion, rather than Depersonalization or Diminished Personal Accomplishment, is the major culprit in burnout, although the other two factors contribute. The data that Lee et al. collect confirms this. They developed a weighted mean meta-correlation … corrected for within-sample measurement unreliability (ρc). That is, a statistical measurement of how closely a given factor correlates with either Emotional Exhaustion (“EE”) or Depersonalization (“DP”). The ρc values are significant for Depersonalization, but typically express a stronger correlation for Emotional Exhaustion:

Factor ρc for EE ρc for DP
Professional development -0.31 -0.18
Contributors to Poor Mental Health 0.62 0.34
Problem-focused Coping -0.29 -0.18
Ineffective coping 0.33 0.24

What is telling is what doesn’t correlate: Clinical Skills had a ρc of only -0.08 for EE, and -0.15 for DP. In other words, doctors have enough clinical skill to be good doctors. More clinical education won’t help health care providers deal with the stresses of clinical practice. Only the introduction of professional development, better coping mechanisms, and an emphasis on self-care can.

Maslach also proposed that because Emotional Exhaustion is the key issue involved in burnout, the implication is that while drivers are important, the management of constraints may be even more critical. In other words, it is more effective to remove stress than it is to add positive experiences. For example, it is more beneficial to help a physician cope with grief than it is to simply add a hobby to take their mind off of it.

To close, I’ll let Lee et al. summarize their own findings. Next week, we’ll review Yoon, Daley, and Curlin’s “The Association between a Sense of Calling and Physician Well-Being”.

EE was negatively associated with autonomy, positive work attitudes, and quality and safety culture. It was positively associated with workload, constraining organizational structure, incivility/conflicts/violence, low quality and safety standards, negative work attitudes, work-life conflict, and contributors to poor mental health. We found a similar but weaker pattern of associations for DP.

Physicians in the Americas experienced lower EE levels than physicians in Europe when quality and safety culture and career development opportunities were both strong, and when they used problem-focused coping. The former experienced higher EE levels when work-life conflict was strong and they used ineffective coping. Physicians in Europe experienced lower EE levels than physicians in the Americas with positive work attitudes. We found a similar but weaker pattern of associations for DP.

Outpatient specialties experienced higher EE levels than inpatient specialties when organization structures were constraining and contributors to poor mental health were present. The former experienced lower EE levels when autonomy was present. Inpatient specialties experienced lower EE levels than outpatient specialties with positive work attitudes. As above, we found a similar but weaker pattern of associations for DP.

Sources

The article reviewed: Lee, Raymond T, Bosu Seo, Steven Hladkyj, Brenda L Lovell, and Laura Schwartzmann. “Correlates of Physician Burnout across Regions and Specialties: A Meta-Analysis.” Human Resources for Health 11, no. 1 (2013): 48. https://doi.org/10.1186/1478-4491-11-48.

1 Maslach, Christina, and Susan E. Jackson. “The Measurement of Experienced Burnout.” Journal of Organizational Behavior 2, no. 2 (1981): 99–113. https://doi.org/10.1002/job.4030020205.

2 Ryan, William. Blaming the Victim. Vintage Books, 1976.

3 Wills, Thomas A. “Perceptions of Clients by Professional Helpers.” Psychological Bulletin 85, no. 5 (1978): 968–1000. https://doi.org/10.1037/0033-2909.85.5.968.

4 Maslach, Christina, and Susan E. Jackson. “The Measurement of Experienced Burnout.” Journal of Organizational Behavior 2, no. 2 (1981): 99–113. https://doi.org/10.1002/job.4030020205.

5 Maslach, Christina. “What Have We Learned about Burnout and Health?” Psychology & Health 16, no. 5 (September 2001): 607–11. https://doi.org/10.1080/08870440108405530.