Exploring strategies to mitigate physician burnout

April 29, 2024 - The onset and continuous impacts of the COVID-19 pandemic were trying times for healthcare systems globally. Physicians and healthcare professionals were burdened with excess workloads, increased patient risks, and additional challenges, contributing to the seemingly never-ending epidemic of physician burnout.

While the challenges of the COVID-19 pandemic continue to be felt globally, one silver lining is the light it shined on the existing and amplified physician burnout epidemic and experience.

Although many professionals have been working for years to address mental health challenges across the profession, the pandemic’s impacts sparked a newfound interest in the matter.

Gail Gazelle, MD, professor at Harvard Medical School, mindfulness coach, and author of Mindful MD, sat down with LifeSciencesIntelligence to discuss physician burnout, the mental health stigma across health professions, and potential solutions. 

Physician Burnout

“We are in an epidemic of physician burnout, and that epidemic started before the pandemic hit the world,” began Gazelle, clarifying that this issue existed far before SARS-CoV-2 made its way across the globe.

Based on her commentary, the crisis of physician burnout has been ongoing for the last decade, with roughly 50% of all physicians experiencing burnout. Another source, the Mayo Clinic Proceedings, estimates that rates were even higher in the first two years of the pandemic at over 60%.

While prevalence varies across different specialties, StatPearls notes that emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties have the highest rates of burnout.

Gazelle mentioned that three symptoms characterize burnout. The first is a sense of emotional exhaustion associated with compassion fatigue. The second symptom is a sense of cynicism.

Gazelle noted that physicians may find themselves asking, “Why did I go into the practice of medicine in the first place? I can't really help people.”

The last symptom is a loss of connection, meaning, or purpose in their work. Providers may lack a sense of accomplishment or pride.

“That's what we call the clinical triad,” she noted. “Those three elements are the clinical triad of burnout, but the fourth that I see a lot is tunnel vision, where everything looks bad. We can't see the good in ourselves, our environment, and our practices. It's a tunnel vision where all the good is excluded.”

Factors That Contribute to Burnout

Gazelle explained that physicians learn nearly nothing about managing their own mental health throughout their medical training. There is no pre-emptive, structural education for physicians about managing depressive and anxious thoughts or feelings of imposter syndrome.

“There's a lot that we learn in training that is fear-based. How are you going to measure up against others? We see shaming on rounds. We see high levels of maladaptive perfectionism where it's not just striving to be good because it's important to give excellence in patient care, but fear-based thinking, fear of shattering the positive perceptions of others. In our medical school training, we learn to be very critical of ourselves and to say things to ourselves we would never say to another physician or peers.”

Other Mental Health Concerns Among Physicians

“Alongside the burnout epidemic, we see a lot of depression and anxiety in the physician workforce,” added Gazelle.

According to a report from the Association of American Medical Colleges (AAMC), depression rates among medical residents are incredibly high, with a prevalence of 29% as opposed to 8% in the non-physician population. The American Medical Association (AMA) notes that urology, emergency medicine, family medicine, obstetrics and gynecology, general internal medicine, physical medicine and rehabilitation, radiology, pediatric subspecialty, psychiatry, and dermatology have the highest rates of mild-to-severe depression symptoms — many of those specialties overlap with those who have the highest rates of burnout.

“It's well known that levels of suicide are higher in physicians, and again, the data is imperfect because a lot of times when there's a physician death, and people have a sense that it's by suicide, the medical examiner won't necessarily state that, in other words, to protect that individual,” added Gazelle.

She noted that one study in the Annals of Surgery found that roughly 10% of surgeons have experienced suicidal ideation in the past year. In addition, the AAMC notes that physicians die by suicide at twice the rate of the general population.

Mental Health Stigma Among Physicians

In addition to the ongoing concerns of physician mental health, Gazelle discussed the factors that may deter these professionals from seeking care.

Malpractice Suits

“Physicians are always worried about malpractice suits. We live in a litigious society. This is a genuine concern,” she explained. “They're very concerned that if they were ever brought before a jury and there was any question about their mental health, they would be in trouble.”

While many surgeons or physicians dealing with mental health issues may be assisted by antidepressants or other mental health medications, many refrain from seeking assistance from these medications. Gazelle implied that physicians fear their medical information may be made public if litigation or legal action is taken against them.

Privacy Issues

“Something that's not obvious to the public is the bureaucracy physicians have to go through to do what they do,” added Gazelle. “They have to take board exams. They have to fill out credentialing forms with all the insurances that they take. One question that's asked is, ‘Have you ever suffered from a mental illness?’ Nothing is private for physicians, even for their state licensure, and this has become a bit more of a public issue because there have been legislative attempts in a variety of states to lessen the questions that physicians get asked for licensure because it is so invasive.”

For example, many questions include inquisitions about previous mental health treatments at any point. Even visits in their undergraduate days may be up for question.

Steps Toward Improving Burnout

“On a systemic level, a lot needs to be done. The good news is that because of the burnout epidemic in trainees, students, and attending-level physicians, there is more concern and programs,” she noted. “There's so much more awareness now. So that's the good news. The bad news is that we're still training people in ways that keep them burned out.”

Some boxes have to be checked concerning mental health in medical education. For example, the American Coalition of Graduate Medical Education has specific requirements for residency and fellowship programs; however, the question is whether they are making an impact.

“If you're a program director, you can check the box if you give a lecture about mindfulness, but does that really solve the issue just by going to meditate? It doesn't solve the issue. It's deeper than that. So, it's complicated.”

“The AMA has a wonderful program called Steps Forward. It awards hospital systems and medical entities that have made major improvements to physician well-being.”

Steps Forward shines a light on programs successfully incorporating tools for improving physician mental health and well-being.

“It will have a profound impact,” concluded Gazelle, explaining how improving physician mental health will impact patient outcomes.