One of the topics that is in the forefront of my mind these days and has been a frequent topic of conversation on this forum is that of physician burnout. A recent Medscape survey reported that over 50% of physicians are experiencing symptoms of burnout. We have just emerged from a major, global pandemic that has ravished the emotional wellbeing of our healthcare workforce. And as we look forward to the retirement of the baby-boomer generation (and baby-boomer physicians) with an expected increase in the demand for health services coupled with a rise in the number of people in the healthcare industry who have lost sight of the spark that attracted them to profession, we are in for a rough period of time ahead. Continuing to plow forward with an attitude of business as usual is not going to work.
But the parallel question about burnout that I have also been chewing on is one of resilience. We are all familiar with the inter-generational turn of phrase that in times gone by, previous generations had to walk up hill both ways barefoot in the snow. There is buried somewhere in that pejorative that younger generations have it easy and are less resilient that their older counterparts. While I mostly blow this off as bloviated chest thumping, I do have to ask myself, is there an element of truth to this statement?
In a recent meeting at work with the CEO, I posed a question about burnout and the administration’s views on the topic. While I firmly believe that much attention needs to be drawn to this topic, I still had to wonder if my desire for more time off, fewer patients per hour and more pay is motivated by laziness or a sincere and data driven believe that these factors are truly in the best interest of the institution, its patients and its providers. Stated simply, was I just being a pansy? Or do I need to take a big dose of "suck it up" and become more resilient?
I recently read an article published in JAMA in 2020 about this very topic of resilience and burnout. This study compared US physicians to an age matched cohort of individuals in the general US working population. They compared resilience scores between the 2 cohorts as well as compared physician resilience scores to physician burnout scores. Additionally, they assessed these various scores across physician specialties.
In the study, they defined resilience as "A collection of personal qualities that enable a person to adapt well and even thrive in the face of adversity and stress." This was measured by the 2-point Connor Davidson Resilience Scale - a validated scale used in other studies. Burnout is a syndrome consisting of emotional exhaustion, depersonalization, and loss of a sense of meaning. The first 2 elements were evaluated in this study and were measured using the Maslach Burnout Inventory.
When the respondent surveys were analyzed, the researchers found that overall, physicians had higher resilience scores than the general population. On a scale from 0-8, physicians scored 6.49 while the general population scored 6.25. On secondary analysis, the researchers ranked specialties according to their resilience scores. They found that the top scoring specialties were Neurosurgery, Preventative/Occupational Medicine, and Emergency Medicine. The lowest scoring specialties were Pediatrics, OB/GYN, and Neurology. However, all specialties scored greater than the general US population. Additionally, on secondary analysis, the researchers found that the resilience scores were generally inversely proportional to burnout scores. That is, more resilient physicians were less burnt out.
The researchers concluded that physicians are generally a very resilient bunch. But since burnout and resilience are inversely related, strategies to improve resilience should be employed at both the individual and system level.
So how do I interpret this paper?
1. I am encouraged by the conclusions. As physicians, I think we should take some degree of pride in the fact that we are a resilient group. We have worked hard and overcome many great challenges to get to where we are. And to top it off, we take care of some of the most difficult things. As I think over my own practice, this is definitely the case. I have cared for people who have experienced profound tragedy. Not everyone can step out of a trauma room that is covered in blood and littered with wrappings of sterilized medical utensils only to walk across the department and console the family that just lost their loved one. That takes resilience!
2. The paper reports that resilience and burnout are inversely proportional and seems to imply that a lower level of resilience results in greater degrees of burnout. I wonder if the authors have it backwards. Is the lack of resilience resulting in burnout, or is the burnout degrading one's resilience? Much like a muscle fatigues the more it gets used, I can imagine that our resilience gets fatigued the more it is required. More research needed there.
3. While this study was published in 2020, the data was collected in 2017. Something major happened in the intervening time. Let’s call it a major, global pandemic. I would be curious to see the results if the study gets redone post-COVID.
4. Finally, I have to take a victory lap for my specialty - Emergency Medicine. We peg both scales. We are the outliers that break the paradigm. We are both highly resilient and highly burnout. Leave it to us to break the mold... but that's just what we have been doing for the last 40 years!
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