Physician burnout or joy: Rediscovering the rewards of a life in medicine.

“May I always act so as to preserve the finest traditions of my calling and may I long experience theof healing those who seek my help.”—excerpted from the Hippocratic Oath

This key passage from the Hippocratic Oath has been sworn to by many of us at the starting gate, as young and enthusiastic medical school graduates, eager to embark on the intriguing and kinetic trajectory of medicine. Yet in today's high-stress world, the avowed “joy of healing” may at times become overshadowed by the quotidian burdens of modern-day medicine.

Despite the early years of enthusiasm and idealism among physicians as healers and caregivers, a burgeoning body of data has emerged suggesting pandemic burnout among physicians in multiple specialties (Shanafelt et al., 2012, Shanafelt et al., 2019). The syndrome of burnout undoubtedly affects the ability of physicians to practice medicine with ongoing compassion, empathy, respect, quality of care, and understanding.

A closer look at physician burnout

The syndrome of burnout encompasses a spectrum of emotions, including feelings of ineffectiveness, emotional exhaustion, loss of meaning at work, depersonalization, loss of motivation, self-doubt, helplessness, and reduced personal accomplishment. Recent reports suggest that major causes of physician burnout include electronic medical records and comprehensive records documentation, excessive clerical burden, excessive workload, too many hours at work, loss of autonomy and control, loss of support from colleagues, loss of work–life balance, and loss of self-accomplishment (Dorrell et al., 2019 Jul, Patel et al., 2018, Shanafelt et al., 2012) (Table 1).

Table 1

Signs and causes of burnout.

Signs/symptoms	Causes
Loss of meaning at work	Electronic medical records
Emotional exhaustion	Comprehensive records documentation
Self-doubt	Excessive clerical burden/too many hours
Loss of motivation	Excessive workload
Reduced personal accomplishment	Loss of personal accomplishment
Feeling helpless	Loss of support from colleagues
Feeling of ineffectiveness	Loss of work–life balance
Depersonalization	Loss of autonomy and control

The numbers help tell the burnout story

Physicians who spend <20% of their time on the activity that they find most meaningful have been reported to be three times more likely to experience burnout versus those who spend at least 20% of their time on a favorite work effort (Shanafelt et al., 2019). Unfortunately, practicing physicians have witnessed their specialties being undermined by the monetary goals of behemoth health systems, which regard them as commodities, and their exemplary skillsets have been profoundly marginalized.

Physicians have the highest suicide rate of any profession. It has been reported to be twice that of the general population of 12.3 per 100,000 (Anderson, 2018). Female physicians attempt suicide less often than women in the general population, but their completion rate equals that of male physicians and is estimated at 2.5 to 4 times that of the general population (Dobson, 2007, Frank and Dingle, 1999, Lim, 2003, Schernhammer and Colditz, 2004). Risk factors for suicide include depression, substance or alcohol abuse, as well as knowledge of and access to lethal means. It has been suggested that programs that address wellness and burnout may reduce suicide rates in physicians (Anderson, 2018).

The consequences of burnout are myriad, including attrition and loss of physician workforce, increased physician turnover, decreased quality of life and self-care, increased health care costs, medical errors, increased medical malpractice, lower quality of patient care, less patient access, and lower patient satisfaction.

Recent studies, however, document key difficulties in accurately measuring physician burnout. Rotenstein et al. (2018) assessed the prevalence of burnout in a systematic review of 182 studies involving 109,628 individuals in 45 countries. The authors reported substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods, and study quality. The researchers emphasized the importance of developing a consensus definition for burnout and standardizing measurement tools to assess the effects of chronic occupational stress on physicians.

In 2011, Shanafelt et al. assessed burnout and satisfaction with work–life balance among U.S. physicians relative to that among the general U.S. population using the Maslach Burnout Inventory Scale. The researchers surveyed 7288 physicians from medical and surgical specialties nationwide. Physicians had a higher frequency of burnout symptoms (37.9% vs 27.8%) and dissatisfaction with work–life balance (40.2% vs 23.2%) compared with a probability-based sample. Substantial differences in burnout were observed by specialty, with the highest rates noted among physicians at the front line of care. Such specialties included family medicine, internal medicine, and emergency medicine. Physicians practicing dermatology were at one of the lowest risks for burnout.

A follow-up study by the authors in 2014 evaluated burnout and work–life balance relative to the reported data from 2011. Of the 6880 physicians who completed the survey, there was a statistically significant increase in burnout compared with 2011, with 54% of physicians reporting at least one symptom of burnout compared with 45.5% in 2011. Interestingly, dermatology had the highest increase in burnout, moving to the top 10 group and ranking ninth highest among medical specialties compared with 23rd of 24 in 2011(Shanafelt et al., 2012).

A recent survey explored burnout among U.S. resident physicians in a cohort of 4732 U.S. residents. Subjects completed a baseline questionnaire during the first year of medical school and follow-up questionnaires during the fourth year of medical school and second year of residency. Symptoms of burnout were reported in 45.2% of residents and career choice regrets in 14%. Characteristics that were connected with a higher risk of burnout included female sex and higher reported levels of anxiety during medical school. Additionally, a higher reported level of empathy during medical school was associated with a lower reported risk of burnout (Dyrbye et al., 2018).

Dorrell et al. (2019) assessed the most common causes of burnout among practicing academic dermatologists in the United States. Of 518 e-mail reports, 91 attending dermatologists completed the survey. Common causes of burnout in this group included excessive documentation and time spent on electronic medical records (22%), lack of protected time for pursuing academic interests such as teaching and research (17%), and increased administrative demands for productivity. This study suggested that institutions valued finances over proper patient care and academic pursuits (Dorrell et al., 2019).

Currently, women now represent 50% of residency training positions and 45% of practicing dermatologists. Despite cultural shifts, female physicians still spend more time parenting children and orchestrating household demands compared with male physicians (Wietsma, 2014). Women juggle the demands of family and household with career growth and advancement. Multiple U.S. studies have reported a higher frequency of burnout among female physicians, who have been found to have 20% to 60% increased odds of burnout. Suggested causes include work–life balance, home–work conflicts, sexism, and discrimination (Dyrbye et al., 2011, Dyrbye et al., 2014, Fnais et al., 2014).

Raffi et al. (2019) assessed work–life balance among 127 female dermatologists surveyed from the Women’s Dermatologic Society. Eighty-five percent of surveyed women were married and 75% had ≥1 children, suggesting that the surveyed women pursued a career and family development. Interestingly, 40% claimed to have only 1 to 3 hours per week of personal downtime suggesting a profound lack of work–life balance (Raffi et al., 2019).

A recent survey reported that burnout and satisfaction with work–life balance improved between 2014 and 2017 compared with 2011 and 2014, with burnout nearing the 2011 level. A 2018 Medscape National Physician Burnout and Depression report identified burnout in 32% of dermatologists compared with 46% in 2017 (Medscape, 2018). However, physicians remained at risk compared with professionals in other fields (Shanafelt et al., 2019). Multiple strategies have been proposed to address burnout at both organizational and personal levels (Table 2).

Table 2

Strategies to reduce or prevent physician burnout.

Reduction in daily hours

Optimization of electronic medical records systems

Respect and optimization of work–life balance and schedule

Physician engagement for leadership training/advocacy and mentoring

Part-time work schedules

Engagement in self-care

Stress management, efficiency, and life skills training

Delegation of nonessential tasks

Finding and defining your passion

Mindfulness exercises and training

Rotenstein et al., 2018.

Given the aforementioned statistics, how can we restore personal and professional joy and humanity to the practice of dermatology and medicine?

The antidote to burnout: Recapturing joy in medicine

Multiple studies have begun to address recapturing joy in medicine. Efforts to recapture or maintain joy incorporate support for physician wellness, self-care, professional satisfaction, and a healthy work environment. Maintaining and/or restoring joy in the practice of medicine is key for optimal health outcomes (Wohlever, 2019, West et al., 2018).

Joy is about who you are as a physician, why you are a physician, and how you are as a physician. Joy is an internal barometer of well-being and wellness. However, we must make the distinction between joy and happiness. David Brooks, esteemed New York Times writer and columnist, recently shared his perspectives on the differences between joy and happiness: “Happiness involves a victory for self. Joy involves the transcendence of self. Happiness comes from accomplishments. True joy is the present that life gives you as you give away your gifts” (Brooks, 2019).

Sinsky et al. (2013) conducted a site visit analysis of 23 highly functional primary care practices to address effective and efficient models that promote joy in the practice of medicine. The authors’ findings suggested that a shift from a physician-centric model of work distribution and responsibility to a shared-care model including higher levels of clinical support staff for physicians would enhance joy in the workplace. Such changes would ultimately lower health care costs while optimizing quality care for patients (Sinsky et al., 2013).

Bohman et al. (2017) suggested that the facilitators of both burnout and high professional fulfillment involve three major domains: the culture of wellness, efficiency of practice, and personal resilience. Each domain reciprocally influences the others. Hence, a balanced approach is necessary to build a stable platform that drives sustained improvements in well-being and optimal performance of health care systems (Bohman et al., 2017). In reality, these are essential pillars necessary to sustain joy in the practice of medicine.

A personal tale of burnout and joy

After years of a full-time career in academia and research, I made the decision to enter the private domain by establishing a pigmentation institute for research and patient care. The stark reality is that I work so much harder today than I did in full-time academia. After the transition, I experienced periods of emotional exhaustion, helplessness, and self-doubt. I also questioned the impact of my work on my local community. These emotions forced me to ask why I do this. Why does it matter? What will my legacy be? My answers to these questions were grounded in my passion for the trajectory of medicine: the trajectory that encompassed my love for healing, science, research, and making an impact among underserved populations.

I wear multiple, complex capes on a daily basis. I am a caregiver, researcher, educator, leader, mentor, administrator, and entrepreneur. Additionally, I am the founder and president of a nonprofit organization for foster and at-risk youth serving an urban Los Angeles population. I have practiced dermatology for >30 years and have navigated, negotiated, and defied the shroud of burnout. During these bleak periods, I chose to relinquish the chains of burnout and find the freedom of joy. Despite a heavy workload and flawed work–life balance, I remain joyful and balanced. I actively champion joy no matter what. It is not always easy or readily possible to do this, but my GPS is set to “finding joy” in whatever path I am on.

I manage to control my destiny as a solo practitioner while masterminding my successes, mitigating my failures, and having the resilience to stand strong after defeat. After >30 years of practice, I remain as excited when my patient says “Oh, Dr. Grimes, I am so much better, thank you!” as I was 30 years ago. My patients are an endless source of joy!

I listen to my patients’ stories of joy, success, heartache, pain and loss. I know their families. Sharing such stories is part of their healing process. I have witnessed and followed the growth of many patients from childhood to adulthood. I treat them with unwavering compassion, empathy, dignity, and respect, and I have learned from them as much—if not more—than they have learned from me. Their resilience through hardship and illness reinforces my passion for change and making a difference. I feel a profound and unwavering joy in knowing that I have changed lives.

Despite my heavy workload, I never lose sight of the pressing need to connect at some level with each individual and provide the best possible care based on evidence- and experience-based medicine.

Joy lurks in the most obscure places. We can create joy and we can choose joy. We must seek and find joy in our daily practices and lives.

Renewing our oath

Burnout can destroy us. Joy saves and heals us. Let us be joy's champion, every day. Let us renew the joy clause in our Oath:

May I always act so as to preserve the finest traditions of my calling and may I long experience theof healing those who seek my help.

Conflict of Interest

None.

Funding

None.

Study Approval

NA.