Avoiding Burnout

JAMA had a great article this month on burnout.  As far as I (or the authors know) this is the only scientific study of burnout among physicians.  They used validated instruments that measure burnout (who knew they even existed) and then surveyed doctors in many specialties.  The results are illuminating, depressing, and even a little scary.

Results

46% of physicians have at least one symptom of burnout.

Compared to other working adults, physicians are more likely to have symptoms of burnout (38% vs 28%) and to be dissatisfied with their work-life balance (40% vs 23%).

Compared to a high school graduate, a person with an advanced degree was less likely to have symptoms of burnout, UNLESS that degree was an MD or DO!

Here’s the most important chart from the article:

 

 

 

 

 

 

 

 

 

 

 

So much for emergency medicine being a “lifestyle specialty”!  Burnout has often been discussed with regards to emergency medicine, but those of us in the specialty have always scoffed, saying something to that effect that EM’s reputation as a burnout specialty came from those who, decades ago, migrated to the ER after flunking out of other specialties.  No wonder they burned out of EM!  They were never trained in it and didn’t ever really want to do it.  But this survey gives us all pause that perhaps there is more to it than that.  At least we still score above average in “satisfaction with work-life balance.”  Work hard, play hard, right?

It is interesting to see that the “burnout specialties” are not only “front-line specialties” such as EM, IM, and OB-GYN, but also include the “lifestyle specialties” such as anesthesiology and radiology.  In fact, the only thing I see that the specialties that are above average in burnout have in common is that most of them often work at night.  How ENT and PM&R landed that high on the list is beyond me.

What is Burnout?

The article defines burnout as

a syndrome characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. Although difficult to fully measure and quantify, findings of recent studies suggest that burnout may erode professionalism, influence quality of care, increase the risk for medical errors, and promote early retirement. Burnout also seems to have adverse personal consequences for physicians, including contributions to broken relationships, problematic alcohol use, and suicidal ideation.

Preventing Burnout

Here are my completely non-scientific suggestions for preventing burnout.

1) Frugal Lifestyle  Eliminate your NEED to work.  Any job is more fun when you don’t absolutely have to do it, just ask my kids when they’re doing chores.  What causes us to need to work?  Servicing large debts (including a mortgage or two), high spending habits, and lack of an “F.U. Fund” (AKA emergency fund) are at the top of the list.  Guess what?  The less you spend each month the less you need your job.

2) Early Retirement  On that same note, being in a position to retire early does two things for you.  First, it allows you to retire early if you become burned out.  Taking a sabbatical or working part-time can do wonders for burnout and are options available to those who save early and often.  Second, if you are independently wealthy, you no longer HAVE to go to work.  That by itself makes work more enjoyable.

3) Work Less  There are a myriad of pressures to get us to work more.  Residents who work a mere 80 hours a week are often looked down upon, especially by those who worked 100+ hours a week as residents.  There are always more patients to be seen, more people to help, and more money to be made.  Whatever your motivation to practice medicine at your career stage (and for most of us it is some combination of the above), there is always pressure to spend more time working.


I do not find it surprising at all that working more than, say, 60 hours a week easily leads to burnout.  There is nothing in life that I enjoy enough to do for 60+ hours a week.  That includes my job and each of my many hobbies.  The enjoyment of life comes from the variety of experiences available to us.  Or maybe I just have an undiagnosed case of ADHD. At any rate, I’m quite confident that the best way to avoid burnout is to work less.  There’s a reason the average emergency doc only works something like 1500 hours a year (<30 hours a week).  It’s because after just a few months of trying to work 50+ hours per week rotating shifts in a busy emergency department, you realize it just isn’t possible to sustain that kind of pace long-term.  Now, depending on your specialty and practice, you might not feel burnt out at 50 hours a week or even 70 hours a week.  But there is a limit at which you will feel burnt out and it won’t take you long to figure out what it is.  Respect it!

4) Sleep More  I learned a long time ago while mountaineering that if you can just get a decent night’s sleep, you can do anything all day long.  Unfortunately, many of us either work rotating shifts including nights, weekends, or holidays or take frequent call, either in-hospital or at home.  We have two wonderful neurologists at my hospital, but it is a pretty unusual night in our ED when the one on-call isn’t woken up at least once.  That takes a toll after a while.  You must find a balance that works for you.  In our EM group, many doctors accept lower compensation in order to avoid night shifts.  You may be able to do the same to avoid weekends or call responsibilities.  Yes, you have an obligation to help patients, but you cannot help them if you are burnt out all the time, and certainly not if you have to end your career after a mere decade.  Moderation in all things.  Sometimes it isn’t work that’s keeping us from sleeping more.  I often find myself burning the candle at both ends for reasons that have nothing to do with work.  Prioritizing sleep makes for a happier life.

5) Choose Longevity over Income  Whenever you have to make a decision about your practice, don’t just consider which decision will lead to a better income.  Perhaps more importantly, choose the option that will allow you to practice longer.  I know an older primary doctor who loves his practice…because he’s fired all the patients that wear him out.  Now he spends his entire day with friends!  An emergency medicine group that chooses to staff at a level that allows them to see less than 2 patients per hour is promoting longevity compared to a group running a skeleton crew trying to see 2.5-3 patients an hour.

6) Develop a Life Outside of Medicine

Spending time with family or friends and developing a hobby or two provides a lot of balance to your life.  When all there is to life is work, it’s much easier to get despondent when work sucks.  If there’s something else going on that night, the next day or this weekend, then it’s easier to overlook your crappy EMR, drug-addicted patients, and abusive administrators.

Beware of burnout.  It’s real.  It’s common.  Take steps early on in your career to allow you to enjoy work for decades.

Image Credit: Steve Jurvetson, via Wikimedia, cc-by-sa

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Comments

Avoiding Burnout — 16 Comments

  1. I burned out my 4th year of medical school, and it continued until the last day of my residency. Now that I am an attending, work 40 hours a week or less, barely take call, and sleep as many hours a night as I need to, all the burnout symptoms are gone and life is good again.

    It’s amazing how well some people can function on very little sleep. Unfortunately, I was never one of those people.

  2. good article.

    i agree all those things can help you avoid burnout. I don’t know what it’s like to have to work all those crazy hours like the med people do because there’s nothing like that in dentistry… however my sisters are in medicine and i’ve seen them go through that.

    Only one problem with the article… frugal lifestyle and large emergency fund (both of which I have) also serve to kill any drive that you might have to really succeed.

    I have little debt, no expensive hobbies, and enough money that if zero patients came in the door that i could make bills for the next 15 months… and the results are that I feel pretty lazy at work and no real “drive” to succeed and take my practice to higher highs because the money wouldn’t really do anything for me that I want.

    Whereas I have friends with much much higher debt loads and a real craving for expensive stuff and it pushes them to succeed… and their practices are more lucrative because of that drive.

    So… I’m sure there’s a balance between those somewhere but i haven’t found it.

  3. i like how you add in these alternative or somewhat related topics. I think the problem however is that the cause of “burn out” probably isnt the same for the different specialties (comparing individuals would be even harder). Some may bc of the unusual hours of that specialty, some bc of pay for the amount of work, some bc the type of medical problems are hard to help/cure. One of the problems with all jobs is that you never know what its gonna be like day in and day out until you have been doing the job for years. Many of one’s previous ideas on what your job/marriage/children/etc will be like, will wind up being wrong. Given that medicine is such a long road to become an attending, it can get dissapointing if it isnt what you thought it should be.

  4. I don’t love going to work, I’d rather play with my baby or do my hobbies. Perhaps I’m burnt out. That said, I can’t think of another career that would be anything other than “work.” Regarding this paper, I find any survey with a 27% response rate essentially worthless. Plus I do not see a breakdown of responses. Perhaps of the 6 EM guys who responded, they all hated their lives (maybe they were sitting at work, taking a break from CPOE and the new EMR), whereas the 2000 EM guys who didn’t respond were out enjoying themselves. The authors undoubtedly put a lot of effort into their study–and it gives some food for thought–but this paper does not even qualify as pseudoscience. JAMA is reaching with this one.

  5. And I was just talking to my friend today about how EM seemed to be a lifestyle specialty because of the great hours…. ha! I guess we’re just stupid med students

  6. I could not agree more about #1 and #2. I really hope to retire early, but more importantly, I want the option to walk away if I want to. I do not love my job, but I like it most days. I am not sure how I will feel about it years down the road though. Personally, having the feeling that I NEED to go to work adds a level of stress to my life.

  7. I am shocked General Surgery measured (just) below the ‘burnout average’. I would definitely consider it to be among the top 3-5 burnout specialties based on my own observations.

  8. i think it has to do with the issue mentioned above (response rate). I also wouldnt be surprised if some people put down what they wanted people to read and then given the low n, it has a bigger effect.

  9. The response rate is a pretty big issue, I agree. But what response rate do you expect to get from surveying a bunch of docs? The only way to get a really high response rate is to pay them, which most academic studies obviously can’t afford, and that would bias the results in a different manner anyway.

    It’s not the best science, but that’s the problem with any of the social sciences. You can’t compare something like this to a physics paper.

  10. A reader wrote in with this comment:

    An excellent article, WCI.

    About 9 months ago, I started to incorporate many, if not all, of the ‘solutions’ brought up here.

    I’m a month shy of being 62. I’m working about 20-25 hours of family practice a week. No hospital work.

    This shorter work week has brought the joy back into practicing medicine.

    No debt, more than enough investments to hang it up tomorrow if I wanted to.

    I love the feeling of my F.U. fund !

  11. Another reader wrote in with this:

    As to the notion that the author can not understand how ENT can be high on the burnout list speaks for itself, indeed he does not understand that many ENT surgeons and others in small rural groups or solo like me are always on call with a very short leash for our patients that we treat and operate on.

    We cannot turn off the work and sign off to the next doctor coming into the next shift. We are it, there is no shift, which can wear you out physically and mentally with time. Every doc in any specialty is potentially prone to burnout.

  12. that gets back to what i mentioned earlier that the cause is likely different for those ent physicians and then of course the solution probably is different. As a mohs surgeon i feel that exact pain about always being on call but the truth is that if i or they wanted to we could hire someone to do the call work. It would be costly and there would be additional issues about feeling comfortable doing it that way but it could be done. Many of us (me included) suffer some sort of pride problem where we cant allow it to happen.

  13. Medicine is tough enough on a good day. Add to this all of the peripheral bull like CPOE, EMR, EMTALA, JCAHO, managed care, RAC audits, etc. and things become more frustrating. Then when you get on the internet or watch the news and you hear things like doctors make too much money….or we don’t pay enough taxes……and I think a lot of us start thinking about doing something else. Thanks for the ideas to make things better.

  14. I echo the importance of sleep. I used to do full time family practice and worked ER shifts on nights and weekends, oftentimes going several days with little sleep or disrupted sleep. Quitting the ER, I rediscovered the importance of adequate sleep.

  15. Many neurosurgeons work insane hours, even as attendings yet they are relatively low on the list. My guess is that many who do neurosurgery do so because they love it and really enjoy the satisfaction they get from using the skill sets they’ve acquired over years of hard training to help people (???). Most of the tips are spot on in this article, except I disagree with the “working less” tip – if you truly love what you’re doing, working less is not the answer; perhaps finding a speciality that you truly enjoy is??? It is important to remember that we as physicians have a front row seat in life, and we should try hard to never take that for granted.

  16. As a neurosurgeon in practice, I can say that the majority of my colleagues (myself included) are absolutely in love with the job and feel that the 80-120 hours/week is okay given the enjoyment and satisfaction of most of the cases/patients we treat. However, everyone needs a break and thus, having a schedule that cycles between busy and relaxed, if carved out appropriately, provides a needed respite from the inevitable grind.

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