Emotional exhaustion. An increase in detachment. Lower productivity. These are not experiences physicians and other clinicians should have to cope with on a regular basis. Yet these and other symptoms of burnout are all too common.
Not only is the rate of occupational stress among clinicians increasing, but research also shows its effects lead to more expensive healthcare and less satisfied patients. One study found burnout was linked to a higher incidence of physicians self-reporting medical errors.
As clinicians feel worsening symptoms of career dissatisfaction, they are more likely to leave medicine mid-career, resulting in an increase in healthcare costs and a shortage of qualified professionals. Replacing a physician can cost an organization from $250,000 up to $1 million and take 6 – 12 months to find a culturally-aligned individual.
At the same time, the latest data from the Association of American Medical Colleges estimates a projected shortage of 37,800 to 124,000 physicians by 2034. This includes deficits in both primary care physicians as well as specialists across the board.
So, where did this all start? How did we get here? Below is a brief history on clinician burnout.
1974: The first published mention of burnout
Clinical psychologist Herbert Freudenberger used the word burnout to describe, “excessive demands on energy, strength, or resources” accompanied by symptoms including “malaise, fatigue, frustration, cynicism, and inefficacy” during his work as a volunteer at a free clinic.
1981: An official measurement of burnout published
The Maslach Burnout Inventory to assess burnout, named after its creator Christina Maslach, was introduced. The scale measures emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. The model is still used by researchers to assess burnout today.
Mid-1980s/early 1990s: The growth of HMOs
Some physicians believe the rise of HMOs in the mid-1980s and into the early 1990s resulted in pressure for physicians to spend less time than they wanted with patients.
2009: “Meaningful use” of EHRs put into legislation
The American Reinvestment and Recovery Act included incentives for hospitals that adopted EHR technology. Many researchers and healthcare professionals point to the time-consuming administrative burdens resulting from EHR requirements as a contributor to burnout.
2013: Report reveals severity of burnout by specialty
Medscape surveyed physicians from 27 specialties and found the highest percentage of burnout was for physicians in emergency medicine or critical care. Almost 40% of all respondents indicated experiencing at least one symptom of burnout.
2014: Expanding from the triple aim to a quadruple aim
The healthcare community widely uses the triple aim — enhancing the patient experience, improving population health, and reducing costs — to guide health system performance. Researchers recommend expanding to a quadruple aim, adding the goal of improving the work life of healthcare professionals.
2015: Over half of U.S. physicians report symptoms of burnout
The Mayo Clinic published research that investigated work-life balance among physicians between 2011 and 2014. More than 54% reported at least one symptom of burnout in 2014, up from 46% at the start of the study in 2011. The study also found depression rates at 40%, and suicidal ideation at 6%.
2016: Major health system CEOs call burnout a public health crisis
Ten CEOs declared that “the issue of burnout is a matter of absolute urgency” in HealthAffairs, citing the above research from the Mayo Clinic.
2017: IHI publishes Framework for Improving Joy in Work
In response to increasing levels of burnout, the Institute for Healthcare Improvement published a whitepaper intended to help healthcare leaders better understand the barriers to joy in work and how to create strategies to foster an engaged workforce.
2017: The National Academy of Medicine launches a burnout network
In response to increasing levels of clinician burnout, more than 60 organizations joined the Action Collaborative on Clinician Well-Being and Resilience to use evidence-based strategies to improve clinician well-being.
2017: Work hour restrictions are established
The Accreditation Council for Graduate Medical Education (ACGME) established the Maximum Hours of Clinical and Educational Work per Week requirement, stating clinical and educational work hours must be limited to no more than 80 hours per week to foster “the best outcomes for our patients, and the well-being of our residents, fellows, and faculty members.”
2018: Burnout increases for all specialties
Medscape published updated research on burnout by specialty. The number of respondents who indicated experiencing at least one symptom of burnout increased from 40% to 42%. Critical care remained the specialty with the highest rates of burnout at 48%, tied with neurology (48%), followed by family medicine (47%), OB/GYN (46%), internal medicine (46%), and emergency medicine (45%).
2018: Conversations around moral injury start to appear
STAT published an article about physicians suffering from moral injury. There is an ever-widening gap between the care clinicians want to provide and the care they find that they can provide. Navigating these competing demands can lead to moral injury, where clinicians feel symptoms of burnout from the inherent structures of the system. Therefore, the authors assert the symptoms of burnout can’t be combated by simply working harder or smarter.
March 2019: Major medical organizations call burnout a public health crisis
The Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society and Massachusetts Health and Hospital Association called burnout a public health crisis.
April 2019: Spok survey
Spok conducted a survey to learn more about the prevalence of clinician burnout. Major findings: 92% of clinicians call burnout “a public health crisis,” and 90% believe increased and ineffective technology contributes to risk of clinician burnout.
May 2019: Burnout becomes a medical condition
The World Health Organization added burnout to its handbook as a recognized medical condition.
June 2019: Research estimates the cost of physician burnout at $4.6 billion
The Annals of Internal Medicine released research that estimated “approximately $4.6 billion in costs related to physician turnover and reduced clinical hours is attributable to burnout each year in the United States.”
March 2020: COVID-19 pandemic accelerates burnout levels
The WHO declares COVID-19 a pandemic and the U.S. declares it a national emergency. Hospitals across the country began seeing an influx of patients.
November 2020: From burnout to ‘burnover’
STAT noted the third wave of COVID-19 had moved many clinicians from feelings of burnout to those of ‘burnover’ in the face of staffing shortages, long hours, and intense pressure.
January 2021: Death by 1000 Cuts
Medscape releases its latest findings on physician burnout, calling it ‘Death by 1000 Cuts.’ Critical care physicians lead the list of burnout by specialty at 51%. Twenty percent of all respondents said they are clinically depressed.
May 2021: Clinicians need a recovery period
Although the pandemic is far from over, a Harvard Business Review article calls for a recovery period for clinicians in light of the trauma they’ve experienced due to the pandemic.
July 2021: Spok conducts second survey on burnout
Spok revisited the topic of burnout by adding several burnout-related questions to its annual State of Healthcare Communications Survey. Eighty-three percent of respondents (including 100% of clinical executives) agreed that the risk of clinician burnout is a public health crisis today. Burdensome or increased workload not related to direct patient care and poor integration into clinical workflows were the most common clinical technology contributors to alarm fatigue or clinician burnout.
Major medical journals, healthcare news, thought leaders, and healthcare organizations alike have called clinician burnout a public health crisis. But as more healthcare administrators begin to understand the challenges and costs of burnout, positive changes will happen. I hope this brief history of clinician burnout will help us better understand how we got here, and drive conversations and ideas for how to move forward.
Editor’s note: This post was originally published in August 2019 and has been updated for relevance and accuracy.