Institutional factors in the medical burnout epidemic.

Physician burnout is being widely discussed in the literature as an epidemic phenomenon. In 2014, 54.4% of U.S. physicians reported at least 1 symptom of burnout, compared with 45.5% in 2011, despite increasing recognition of the problem.1,2 Medical students are also at great risk for developing burnout, as well as other psychiatric disorders.3 According to a systematic review and meta-analysis published in this journal, this is also the case in Brazil.4 The incidence of burnout among U.S. medical students and residents has been estimated at 40-76%.5 Some risk factors are known, such as female gender, presence of physical illness, medication use, and dissatisfaction with one’s academic curriculum or career, among others. Many authors are additionally suggesting that institutional factors also play a role, and should be evaluated and addressed as an essential path for effective solutions.6 Contemporary physicians are faced with the challenge of delivering high-quality care that is increasingly patient-centered, while also keeping pace with rapid shifts in the economy, technology, and regulatory areas, raising expectations of physician availability. In fact, in the United States, burnout in physicians appears to increase as a direct result of increasing expectations regarding the electronic medical record. Instant messaging tools, e.g., WhatsApp, which is widely used in Brazil, can also raise the demand of being accessible both day and night to promptly respond to patients’ concerns. Together with the current information overload and other ongoing demands, this expectation may lead to feelings of guilt that physicians often have about not doing enough or not being good enough.7

When it comes to medical students and professors, high levels of competitiveness inherent to academic settings may complicate the scenario even further. The traditional model of the physician tends to be a paternalistic, omnipotent, and authoritarian figure. Physicians often carry some of the typical obsessive-compulsive personality traits of those who choose the medical profession, such as perfectionism and excessive devotion to work, which may significantly contribute to the process.8 Seemingly positive character traits, including dedication, responsibility, and motivation, may also place physicians at greater risk for burnout. A high demand for perfection comes from both intrinsic characteristics of physicians themselves and from features of the social milieu.2,9 Furthermore, medical professionals tend to feel they are falling short of expectations if they need help, creating a stigma that prevents them from speaking up about the impact of burnout on their health, their relationships, and their career. There are several external aspects that cannot be changed in the short run, but there are also many institutional factors that can and should be addressed to improve well-being and work-life satisfaction.

Research projects aimed at evaluating the dynamics inside the halls of the institutions that may contribute to this context are essential. Psychiatrists may have a leading role to play in addressing the problem. The focus should go beyond the absence of psychiatric disorders and evaluate professional fulfillment as well. We are well aware, however, that projects of this nature may be met with longstanding resistance. The frequent refrain of “We’ve always done it this way and don’t see a reason to change” can be a formidable obstacle. Indeed, this type of attitude is probably a key driver of the perpetuation of a toxic environment from one generation of physicians to the next. Institutions must face their reluctance to question the old paradigm of “super doc” culture and encourage initiatives that can foster medical professionals to show the same natural compassion they have towards their patients to their colleagues as well.

Disclosure

The authors report no conflicts of interest.