Professional burnout, with its attendant detrimental effects on career satisfaction and success, is an issue of concern for many practicing psychiatrists. Burnout is a work-related syndrome distinct from depression. In the professional literature, burnout is characterized by 3 adverse characteristics: emotional exhaustion, depersonalization (or cynicism), and a sense of personal inefficiency or impeded accomplishment.1 These characteristics manifest as loss of enthusiasm for work and feeling that one has nothing to contribute; developing negative attitudes toward work; treating others, including patients, as if they were objects; and feelings of incompetence or inadequacy. In terms that capture more of the actual subjective experience of burnout, some have referred to “compassion fatigue”; deterioration of dignity, values, spirit, and will; an “erosion of the soul.”2
Although the potential for emotional exhaustion that is central to burnout has been long recognized, the topic emerged as one of professional focus in the mid-1970s. The term “burnout” was first used in the literature by a psychiatrist who described the gradual loss of motivation and commitment he observed in volunteers in a human services agency.3 At about the same time, burnout became a subject of empirical investigation. Since then it has been studied extensively and has been found to occur in a large proportion of doctors: as many as 30% to 60% of practicing physicians have been reported to have burnout when measured with validated instruments.4,5
Findings from a literature review indicate that a variety of factors may contribute to physician burnout.6 These include personal traits, such as perfectionism or obsessive worrying; the culture of medicine that promotes unbalanced lifestyles, expectations for personal invulnerability, and denial of personal needs; and recurring exposure to emotionally intense experiences, such as patient pain, suffering, and mortality.
Social exchange theory may also explain physician burnout.7 The lack of reciprocity in the physician-patient relationship, in which the relationship exists for the benefit of the patient, can create an imbalance between emotional investments and outcomes. This, in turn, can lead to fatigue and emotional drain. Work pressures have also been suggested, including excessive clinical loads, medicolegal concerns, lack of collegial support, and a perception of inadequate resources for accomplishing expected tasks. A perception of excessive career demands and inadequate resources have been identified as particularly important in predicting burnout.8
■ Burnout is often associated with experiencing a lack of control; finding ways to increase one’s sense of control improves resilience.
■ Setting professional and personal limits can be keys to maintaining positive attitudes.
■ Sharing feelings and responsibilities can be an important ingredient to overcoming burnout; support can be found in interpersonal relationships and in group settings.
■ Age and experience may be positive protective factors against burnout.
Not all findings about burnout are intuitive. For example, a recent comparison of burnout between family medicine and psychiatry residents that used the Maslach Burnout Inventory and Work Environment Scale found that being female, having children, and being from another culture appeared to be protective factors.9 Psychiatry residents reported less burnout than family medicine residents on the Depersonalization and Emotional Exhaustion Scales (respectively: t = 2.49, P = .014; t = 2.05, P = .042) and higher physical comfort on the Work Environment Scale (t = 22.60, P = .011). Family medicine residents reported higher peer cohesion, supervisor support, and autonomy (respectively: t = 3.41, P = .001; t = 2.38, P = .019; t = 2.27, P = .025). These data suggest possible differences in burnout experiences by specialty, but current literature is inadequate to fully define the differences.
Patient and physician outcomes
Spickard and colleagues10 noted that burnout is associated with numerous adverse outcomes. It negatively alters both the nature of the physician-patient relationship and the quality of care physicians provide. Burnout can lead to an increase in medical errors. This is obviously detrimental to patient care but also fuels a sense of incompetence that only perpetuates and exacerbates burnout. Escalating burnout has also been associated with additional problems—such as reduced physician empathy, reduced patient trust and satisfaction with care, impaired professionalism, increased risk of physician substance abuse and depression, career changes, and physician suicide.11
As a group, psychiatrists may have unique experiences that make them vulnerable to burnout. Kumar12 notes that psychiatrists, more than physicians in other specialties, use themselves as “tools” in the execution of their professional activities. This use of self is challenging and requires special diligence to remain emotionally responsive while protecting boundaries. Physician-patient relationships in psychiatry may be particularly delicate. The nature of patient problems and the stigma associated with mental health problems increase the burden of confidentiality for psychiatrists. While all physicians must confront the reality of patient death or other adverse outcomes, the increased emotional load associated with patient suicide may be especially hard on psychiatrists.
The stresses of medicine are not new and are likely to persist and possibly increase as pressures intensify to provide more care to more patients. So how do some doctors maintain a positive attitude and joy while others find themselves becoming cynical and discouraged?
There is limited literature on this topic, and even more limited research, but some effort has been made to identify protective factors and strategies. Several studies surveyed or interviewed physicians to determine successful coping strategies.13-16 In addition, innovative programs have been created to strengthen physician resilience.17,18 A number of themes emerge from these studies.
Seek control. A central theme in much of the burnout literature is that burnout is often associated with experiencing a lack of control. Finding ways to increase one’s sense of control improves resilience. With the increasing demands on physicians, control may seem a more and more elu-sive goal; however, certain strategies that increase a sense of control have been identified.
An innovative approach to enhancing control was designed by the leaders of a group practice in Oregon. Dunn and colleagues17 describe a program intended to enhance physician well-being. One of the core principles was to increase physician control over his or her practice. Strategies included soliciting physician input during group meetings and accommodating scheduling wishes (eg, length of sessions) and other practice preferences (eg, case mix). The program also allowed flexible work schedules, such as part-time and job share options. Physician satisfaction improved and burnout scores decreased after interventions increased physicians’ influence over their work environment.
Setting limits is another way to exert control. Many physicians are reluctant to say no to requests from others and consequently may find themselves drained or resentful. Giving oneself permission to set limits without guilt can be an important ingredient in achieving balance.
Another study interviewed 17 physicians who had a reputation within their community for being resilient.14 These physicians identified the importance of setting limits both professionally and personally as keys to their positive attitudes. Within the professional arena, this may mean changing the way they practice or reducing their hours. On the personal level, setting limits may include making healthy behaviors a priority, such as scheduling time off, exercising, and relaxing. Recognizing that by setting limits one is saying yes to healthy behaviors (and not just saying no to a request) may help physicians understand the choices they face and adopt self-care behaviors.
It is important to remember that the perception and interpretation of circumstances in large part determine how stressful those circumstances become. Physicians can fall prey to cognitive errors, such as catastrophizing, all-or-nothing thinking, and discounting positive events.
Perfectionism is a trait that is shared by many in the field of medicine. Resistance to acknowledging personal limits and fallibility can lead to impossible expectations or defensive behavior. It may also lead to an unforgiving response when mistakes inevitably occur. Correcting these cognitive distortions can improve flexibility; decrease feelings of victimization; and improve problem solving, self-esteem, and professional relationships—all of which protect against burnout and increase one’s sense of control.
Interpersonal support. Another element that is often cited as a source of strength and resilience is having adequate support from others. The practice of medicine is often a lonely one, and many doctors find that over time they become isolated. This isolation may be especially pronounced for physicians who begin to feel down or burned-out. A “conspiracy of silence” has been described among physicians, in which a “macho mentality” leads doctors to the implicit assumption that they must always be strong and care for others and that they would be perceived as weak if they were to acknowledge their own vulnerabilities.6
Sharing feelings and responsibilities can be an important ingredient to overcoming burnout. Support can be found in personal relationships with friends, family, spouses, and in group settings (eg, church groups or clubs). Professional organizations may provide much-needed support, whether for general professional collegiality or, for example, help with alcohol and drug problems (as with Caduceus Club meetings for physicians). Most states have health programs that offer support for physicians who struggle with substance abuse or with emotional problems. This support can include professional intervention and advocacy.
Attitude/meaning. Recapturing empathy with patients and regaining a sense of meaning from medicine is another important strategy for overcoming burnout. A recently published study describes an effort to combat the loss of meaning that often occurs in those who experience burnout in medicine.18 In this study, a continuing medical education course focused on enhancing mindfulness, communication, and self-awareness among primary care physicians.
Mindfulness refers to the quality of being fully present and attentive in the moment during everyday activities. A study of internists that indicated the capacity of “being present” with their patients correlated more strongly with finding meaning in their work than with diagnostic and therapeutic victories.19 In that study, doctors were asked to write and discuss meaningful experiences in medicine. The participants described the process of writing these narratives and talking about them as both profound and helpful.
Journal writing is a useful method that anyone can use to encourage reflection. In addition, many persons find that their spirituality is a source of renewal and strength and helps them to preserve the sense of meaning in their work.
Age and experience. A recent study done in Australia surveyed 158 physicians with both the Maslach Burnout Inventory and the Kessler Psychological Distress Scale and included a semistructured interview about issues related to burnout for a subsample.15 Older and more experienced doctors had lower burnout scores; this group qualitatively described themselves as experiencing less psychological distress than they did when they were younger. They attributed this change to the development of protective defenses in their relationships with patients as well as to accumulated experience and changed work conditions. These doctors were encouraged to pass on such lessons to their younger colleagues.
Although external stressors themselves cannot always be changed, healthy approaches to lessen the stresses of medicine and avoid burnout can be learned at any age (Table). The protective defenses that may be helpful include such strategies as learning to compartmentalize so that work can be left behind when there is time to relax. Use of such healthy defenses may help doctors avoid lapsing into depersonalization and distancing behaviors that are characteristic of burnout.
Dr Miller is professor and chair and Dr McGowen is professor in the department of psychiatry and behavioral sciences at the James H. Quillen College of Medicine of East Tennessee State University in Johnson City. The authors report no conflicts of interest concerning the subject matter of this article.
1. Maslach C, Jackson S. The measurement of experienced burnout. J Occup Behav. 1981;2:99-113.
2. Maslach C, Leiter MP. The Truth about Burnout: How Organizations Cause Personal Stress and What to Do About It. San Francisco: Jossey-Bass; 1997:13-15.
3. Freudenberger HJ. Staff burnout. J Soc Issues. 1974;30:159-165.
4. Maslach C, Schaufeli WB. Historical and conceptual development of burnout. In: Schaufeli WB, Maslach C, Marek T, eds. Professional Burnout: Recent Developments in Theory and Research. Philadelphia: Taylor & Francis; 1993:1-16.
5. Shanafelt TD, Sloan JA, Habermann TM. The well-being of physicians. Am J Med. 2003;114:513-519.
6. Miller MN, McGowen R. The painful truth: physicians are not invincible. South Med J. 2000;93:966-973.
7. Bakker AB, Schaufeli WB, Sixma H, et al. Patient demands, lack of reciprocity, and burnout: a five-year longitudinal study among general practitioners. J Organiz Behav. 2000;21:425-441.
8. Schaufeli WB, Bakker AB. Job demands, job resources, and their relationship with burnout and engagement: a multi-sample study. J Organiz Behav. 2004;25:293-315.
9. Woodside JR, Miller MN, Floyd MR, et al. Observations on burnout in family medicine and psychiatry residents. Acad Psychiatry. 2008;32:13-19.
10. Spickard A Jr, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288:1447-1450.
11. Shanafelt TD. Enhancing meaning in work: a prescription of preventing physician burnout and promoting patient-centered care. JAMA. 2009;302:1338-1340.
12. Kumar S. Burnout in psychiatrists. World Psychiatry. 2007;6:186-189.
13. Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med. 1990;150:1857-1861.
14. Jensen PM, Trollope-Kumar K, Waters H, Everson J. Building physician resilience. Can Fam Physician. 2008;54:722-729.
15. Peisah C, Latif E, Wilhelm K, Williams B. Secrets to psychological success: why older doctors might have lower psychological distress and burnout than younger doctors. Aging Ment Health. 2009;13:300-307.
16. Kearney MK, Weininger RB, Vachon ML, et al. Self-care of physicians caring for patients at the end of life: “Being connected . . . a key to my survival.” JAMA. 2009;301:1155-1164.
17. Dunn PM, Arnetz BB, Christensen JF, Homer L. Meeting the imperative to improve physician well-being: assessment of an innovative program. J Gen Intern Med. 2007;22:1544-1552.
18. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302:1284-1293.
19. Horowitz CR, Suchman AL, Branch WT Jr, Frankel RM. What do doctors find meaningful about their work? Ann Intern Med. 2003;138:772-775.