Over the past 2 decades, work-related burnout, emotional exhaustion, depersonalization, and (perception of) reduced personal accomplishment have reached alarming levels among health care professionals. Several studies show that the extent and impact of burnout on the wellbeing of physicians and the quality of care is worrying.1,2,3 Due to a lack of focus and inconsistent adherence to robust methodological standards, there are concerns about the conceptualization and measurement of physician burnout in several of these studies. As a result, the outcomes from such studies are limited especially in their ability to inform the reader about the severity of the situation. A 2016 systematic review by West et al4 showed that the prevalence of burnout in physicians was a little more than 50% and that there was a need to understand the findings from the literature better, to prevent and reduce burnout in the healthcare workforce. They recommended that more attention should be given to promoting physician well-being and burnout prevention at individual and organizational levels.
The modern health care milieu is gradually becoming overpopulated with uncountable health improvement initiatives aimed at containing costs and expenditure but also meant to improve the quality and efficiency of health services. Unfortunately, most of these measures exert pressure on physicians resulting in the opposite effect of what they are meant to elicit, i.e. increased physician stress, decreased productivity, decreased quality of service, all of which negatively impacts individual patient care and that of the community at large. These inadvertent impacts ultimately have repercussions on patient access to care, affordability, safety, timeliness and the high quality of care the population has come to expect.
The study conducted by Rao et al5 fits into this new space of better understanding and trying to prevent burnout. It is a well-designed study with a high response rate from a sizeable number of respondents within a large academic center. The authors explored if engagement among physicians impacted their plans to stay in their current roles and whether it also influenced their job satisfaction. Factors that determined physicians’ engagement, their perceptions of burnout and the relationship between engagement and burnout were also investigated.
The major outcome of interest in this study is that physicians with low levels of burnout and low levels of engagement fared better than those who were burned out. Also, physicians who were not burned out but reported high levels of engagement, were twice as satisfied with their careers as those with low levels of both burnout and engagement. The application of a secondary analysis of administrative data, collected as part of a large, single, academic, health system’s quality initiative reflected a form of citizenship assessment initiative with mandatory requirements for response. Compared to identical, voluntary physician surveys that many health organizations embark on, the authors’ choice for this approach contributed to this study’s high survey completion rate. Given the context in which the data were collected, the analysis of the results provided an opportunity to identify important findings related to physician engagement and burnout.
As the survey was not voluntary and anonymity, even when implied, may not have been perceived as guaranteed by the respondents, there is the chance that the responses collected may have been guarded and the full validity influenced by how the information was solicited. Thus, while the high engagement rate may be a true reflection of the respondents’ commitment, the outcome may have been influenced by it being a compulsory exercise, hence explaining why the response rate was higher than expected.5 Furthermore, it is important to be mindful with the results of a cross-sectional study on engagement that captures a specific snapshot in time, as it may be reflecting the mood of the respondents and what is happening in the organization’s environment at that particular moment in time. For example, if such surveys occur during the implementation of new initiatives commonplace to the establishment of the affordable care act, any emergent environmental perturbation could add to the stress of the physicians. Likewise, initiatives such as the implementation of a new electronic medical record, which is a known common medical staff stressor, could also bias a single organizational survey similar to the one reported in this paper. This suggests that the generalizability of the findings of this paper to a general discussion on engagement and burnout may be situational and reflect bias. Alternatively, the responses of the medical staff could have been a way of sending a message to administrators and the organization’s leadership about the current climate of the work environment. Finally, the surveys reported in this paper were conducted in 2014 & 2017 (3-year interval) by the Massachusetts General Physicians Organization and a comparison of surveys over multiple years would indeed be very informative.6 It may not be fortuitous, therefore, that the authors saw an increase in burnout from 41% in 2014 to 45% in 2017.
Physician burnout and low-level engagement has resulted in higher frequency of changes in employment, attrition, early retirements, with many physicians opting for locum opportunities as opposed to traditional long-term practice. Physician engagement appears to be more highly correlated with better job satisfaction and increased likelihood of staying in current job in comparison to physicians experiencing burnout, probably because the risk factors associated with burnout are poorly understood or not as demonstrated in the current study. In our view, the incidence and prevalence of burnout in health care environments can (also) be seen as a growing social or moral phenomenon. Many physicians struggle with the realities of patients’ lack of access to specialist care and medication due to lack of affordability. They are frustrated regularly, and on a daily basis by the insurance and institutional prior authorization requirements for investigations and treatment that are necessary for their patients. The constant delays and frank refusals to approve medically-indicated procedures that result in denied access to care for patients are additional factors that contribute to physician dissatisfaction and burnout. An additional challenge is the requirement to invest time in conferences and CBT training on improving reimbursement or patient satisfaction scores when the evidence to support that such interventions actually improve access, cost or outcome of care for the patient is lacking. Therefore, physicians’ lack of engagement and increased burnout could possibly be the result of individual outrage or a social protest amongst providers and not necessarily dissatisfaction with the profession, per se, or the lack of energy to carry out medical training that providers have heavily invested in to provide optimal care delivery for their patients.
In conclusion, while burnout is often emphasized and given more prominence than engagement, this study showed that these two important factors may function divergently, and that engagement may even be a more important factor than burnout. Notably, the current study found that engaged providers have higher levels of career satisfaction and are more likely to stay in their current role regardless of their level of burnout.
Footnotes
↵† Current affiliation: Consultant Pediatrician, Horacio Oduber Hospital, Caya Punto Brabo 17, Aruba
- Received November 2, 2019.
- Revision received December 1, 2019.
- Accepted December 10, 2019.
References
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- 4↵WestCPDyrbyeLNErwinPJShanafeltTD. Interventions to prevent and reduce physician burnout : a systematic review and meta-analysis. Lancet 2016;388(10057):2272–2281.
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