Burnout in doctors
Authors: Marie Dahlin
Publication date: 29 May 2012
Burnout doesn’t have a negative effect on patient care or increase patient dissatisfaction, says Marie Dahlin
The concept of burnout was introduced in the late 1970s, mainly in a US context, and was used to describe a negative reaction of workers in client oriented occupations, such as social workers and doctors. In particular, individuals who engaged in idealistic work with people who had substance abuse or heavy social burdens were seen to react with fatigue and negative attitudes towards their clients. The most widely used instrument to measure burnout is the Maslach burnout inventory (MBI), a questionnaire of 27 items with three subscales. According to Maslach, burnout occurs when three criteria are met: high emotional exhaustion, high depersonalisation, and low personal accomplishment. Over time, the burnout reaction has been assumed to affect not only people who work with clients but all the working population; and revised MBI scales have been introduced, where, for example, the depersonalisation dimension is labelled “cynicism.”
In February this year BMJ Open published a paper on burnout among GPs in Essex who were found to have high levels of depersonalisation. The study authors found that of 564 GPs 46% had high levels of emotional exhaustion, 42% had depersonalisation characteristics, and 32% had low levels of personal accomplishment. Whether these numbers should be considered high or not depends on the interpretation.
The interpretation of the three dimensional concept on which the MBI scale is based is problematic, and the relation between the three dimensions is debated. Some researchers define burnout as a state of being, whereas others consider it a developing phenomenon. Maslach initially regarded the emotional exhaustion as a reaction to interpersonal demands, depersonalisation as a coping strategy, and reduced personal accomplishment as a consequence of non-adaptive coping. More recent work sees work engagement as the “opposite” of burnout, which indicates that depersonalisation or disengagement is the central component. In the Netherlands clinical burnout syndrome is a cause for sick leave from work. Burnout syndrome is associated with mental distress, mainly depression, but it is not an affective illness. It is important to note that the cut points of the MBI are not intended for diagnostic purposes or for detecting clinical burnout. Instead, they derive from statistical dispersions in occupational samples.
Many studies exist of burnout in doctors and medical students. Often such studies conclude that job distress and poor working conditions contribute to burnout among doctors. Medical students and junior doctors have been reported to be particularly at risk, but prevalence varies greatly, from 18% to 82%. It is sometimes stated that burnout in doctors is increasing, but the findings of most studies should be interpreted with caution. Detected predictors are individual and organisational, but most studies are considered weak.
Many studies enrolled convenience samples, were in different settings, and had different population characteristics—for example, stage of education, specialty, and nationality. These weaknesses make for limited generalisability and comparability.  In addition, revised or shortened versions of the MBI are often used,  and also measures other than the MBI may be used, limiting the applicability of findings.
Rarely, studies deal with the potential effects on the patients of doctors with burnout. Self reported medical errors are associated with burnout, but studying objective measures of effects on patients is a resource demanding endeavour. In the recent BMJ Open paper the authors studied how depersonalisation relates to practice and effects on patient care. The authors investigated how patients rated their doctor’s interpersonal skills; and in a subsample of the doctors they rated patient centredness during consultations. This was based on the assumption that depersonalisation would affect the way doctors relate to patients. The surprising and positive finding of this study was that high depersonalisation in doctors had no association with patient dissatisfaction or a lack of interpersonal skills. This is important.
In line with most research, male doctors were at greater risk of depersonalisation. Furthermore, depersonalisation was lower in doctors with more than 20 years of practice. This might be for several reasons. For example, doctors who are disengaged could perhaps leave their job, or with greater experience doctors may learn how to cope with stress.
High quality intervention studies on burnout are rare. Two Cochrane reviews concluded that there was insufficient support for interventions directed at stress and burnout among healthcare workers.  A review published in 2010 concluded that “there is insufficient evidence for the effectiveness of stress management training interventions to reduce job stress and prevent burnout among healthcare workers beyond the intervention period. Low quality evidence suggests that longer-term interventions with refresher or booster sessions may have more sustained positive effect, but this needs to be rigorously evaluated in further trials.”
Systematic reviews on burnout in undergraduate medical students are needed. An important research question relates to how burnout affects doctors’ health and wellbeing and the quality of care they deliver to patients. Future research on burnout in medical students and doctors should avoid case identification or prevalence estimates from self ratings on the MBI and should use validated and complete measures to enable comparisons and generalisability. Research should look into specific job or study factors that affect burnout; the effect of burnout on mental and physical health in doctors; the effect of burnout on the job (such as on patient care); and interventions that might deal with burnout.
Competing interests: None declared.
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Marie Dahlin senior lecturer, Karolinska Institute, Stockholm, Sweden
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