OVERVIEW

• Burnout has been defined by Maslach and Jackson as a sustained response to chronic work stress involving the 3 dimensions of emotional exhaustion, depersonalisation and a perceived lack of personal accomplishment
• World Health Organization International Classification of Diseases (ICD-10) defines burnout as a “state of vital exhaustion.”
• Burnout us not a recognized disorder in The Diagnostic and Statistical Manual of Mental Disorders
• Physicians and other healthcare workers are believed to be particularly susceptible to burnout compared with the general public

FREQUENCY

• Estimated prevalence of burnout among US residents, regardless of the year of training, is as high as 50%
• in some studies >50% of physicians reported that they felt that tiredness, exhaustion or sleep deprivation had a negative effect on the care they delivered
• Emergency medicine has burnout levels in excess of 60% compared with physicians in general (38%). Despite this, most emergency medicine physicians (>60%) are satisfied with their jobs
• Approximately half of the intensivists and a third of ICU nurses report a high level of burnout

MASLACH BURNOUT INVENTORY

The Maslach Burnout Inventory (MBI) is the standard research tool used to study burnout.

Three dimensions

• emotional exhaustion (e.g. feeling unable to care for others as ‘nothing is left’)
• depersonalization (e.g. compassion fatigue, cynical comments and impersonal or dehumanising response toward patients or coworkers)
• perceived lack of personal accomplishment (e.g. negative self evaluation)

Categories are based on compilation of overall scores from these 3 dimensions

• low risk
• medium risk
• high risk

CONTRIBUTING FACTORS

These include

• work overload
• quality of teamwork
• lack of control
• insufficient rewards
• lack of community (social and peer support)
• lack of fairness
• conflicting values (work vs family)

Critical care practitioners are at risk as they have work that is physically demanding, allows limited rest and is associated with sleep deprivation and objective markers of physiologic stress (e.g. ketonuria, arrhythmia or heart rate abnormalities))

FEATURES OF BURNOUT

Classical stages described by Maslach, 1982:

• over-commitment (no healthy distance from work, individual gives everything)
• beginning exhaustion (insidious onset; feeling of emotional and physical exhaustion; a sense of alienation, cynicism, impatience, negativism and feelings of detachment to the point that the person begins to resent the work he or she is involved in and the people who are a part of that work)
• increased exhaustion (hostile feelings and a negative attitude develop towards their profession and their patients; personal engagement at work is reduced; emotional reactions such as feelings of guilt, self-pity and helplessness)
• feeling burned out (feeling of depleted energy; shutdown numbness, mood swings, helplessness, and desperation; formerly caring individuals insulate themselves to the point that they no longer care about others)

The classical stages may not occur, and not all features may be present. Early stages of burnout mayappear asymptomatic or be occult:

• physical symptoms (e.g. insomnia, fatigue, headaches, gastrointestinal upset)
• psychological symptoms (e.g. irritability, cynicism, guilt, decreased concentration, poor judgement, feelings of ineffectiveness)

Complications

• can lead to anxiety (a so-called “nervous breakdown”), depression, substance abuse, addiction, psychosomatic disorders and suicide (rare)
• disrupted personal and family life
• impaired patient care and increased medical error
• decreased productivity and job satisfaction
• increases in absenteeism, health care costs, and personnel turnover

MANAGEMENT AND PREVENTION

Evidence-based approaches to managing burnout are lacking

• evidence that reducing work hours improves quality of life is lacking – some studies suggest burnout worsens when hours are simply reduced
• mindfulness and meditation may play a protective role
• cognitive behaviour therapy leads to the improvement of emotional exhaustion in the majority of the studies
• evidence is inconsistent for the efficacy of stress management (e.g. relaxation, stress inoculation training) and music therapy
• time spent away from active clinical duties (e.g. research) and time spent in continuing professional development might reduce burnout

Common-sense preventative measures

• engage in self-care (e.g., exercise, healthy eating, meditation)
• take regular vacations
• take breaks from email
• learn how and when to say no
• time management and set limits for yourself rather than letting someone else set them for you
• learn to recognize the symptoms of burnout and to ask for help
• strengthen personal and workplace relationships (e.g. team-building and use of effective communication strategies)

CONTROVERSIES

• the acceptance of burnout as a condition
• the definition and ‘diagnostic critieria’ of burnout
• appropriate management
• are high rates of burnout in medicine due to the nature of the profession, or due to the traits of the individuals who enter medicine or a result of their training?

References and Links

Journal articles and textbooks

• Arora M, Asha S, Chinnappa J, Diwan AD. Review article: burnout in emergency medicine physicians. Emerg Med Australas. 2013 Dec;25(6):491-5. doi: 10.1111/1742-6723.12135. Epub 2013 Oct 9. PubMed PMID: 24118838.
• Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007 Oct;13(5):482-8. Review. PubMed PMID: 17762223.
• Fralick M, Flegel K. Physician burnout: Who will protect us from ourselves? CMAJ. 2014 Jul 8;186(10):731. doi: 10.1503/cmaj.140588. Epub 2014 Jun 2. PubMed PMID: 24890102.
• Felton JS. Burnout as a clinical entity–its importance in health care workers. Occup Med (Lond). 1998 May;48(4):237-50. Review. PubMed PMID: 9800422.
• Korczak D, Wastian M, Schneider M. Therapy of the burnout syndrome. GMS Health Technol Assess. 2012;8:Doc05. doi: 10.3205/hta000103. Epub 2012 Jun 14. PubMed PMID: 22984372; PubMed Central PMCID: PMC3434360.
• Maslach C (1982) Burnout. The cost of caring. Prentice-Hall, Englewood Cliffs, New Jersey
• Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav 1981;2:99−113
• Regehr C, Glancy D, Pitts A, LeBlanc VR. Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. J Nerv Ment Dis. 2014 May;202(5):353-9. doi: 10.1097/NMD.0000000000000130. Review. PubMed PMID: 24727721.
• Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012 Oct 8;172(18):1377-85. PubMed PMID: 22911330.
• Small GW. House officer stress syndrome. Psychosomatics. 1981 Oct;22(10):860-9. PubMed PMID: 7313046.