Do we overdramatize family physician burnout?

A drama unfolding

How is burnout overdramatized? First, it is rarely presented in context. Most physicians have excellent health and more than 90% report that they are in good or excellent health.⁷ Burnout is regularly juxtaposed with depression and issues of impairment and even suicide to underscore its importance—to draw us in to a drama unfolding: “For a substantial proportion of practitioners, their work and working conditions affect them negatively, and lead to stress, fatigue, burnout, anxiety or depression, and substance abuse.”⁸ We read that burnout is a threat to health reform, a concern for the medical work force numbers, an impediment to the delivery of high-quality patient care, and a barrier to professionalism.⁹ The researchers qualify their findings, explaining that these are associations. However, these limitations are quickly lost in the overarching presentation of physician burnout. Only a few commentaries remind us that these studies “cannot tease out the nature of these interactions and cannot determine whether the relationships are causal.”¹⁰ Usually the audience is enticed into the drama and encouraged to assume a causative relationship. Such overdramatization makes for excellent headlines but contributes to the distortion of the debate.

Since Freudenberger first described the concept of burnout in the 1970s, studies have declared the need to address burnout.¹¹ Maslach et al helped to define burnout, “initially, a very slippery concept,”¹² as prolonged response to chronic emotional and interpersonal stressors on the job, defined by the 3 dimensions of exhaustion, cynicism, and inefficacy.¹² With the development of tools such as the Maslach Burnout Inventory, burnout became readily measurable—and measure we did. The resulting abundance of literature on physician burnout produced prevalence data, highlighted changes in prevalence, and enabled the reporting of interesting associations. There has been a perennial search for ways to identify “those at risk” so that “we” can “help” “them” avoid burnout. This approach clearly plays to the physician’s desire to heal, yet it enhances the potential for “othering” of “those who are at risk.” The risk of stigma is clear, as recently highlighted by Wallace.¹³ It is also reasonable to question whether physicians might find some comfort in this quantitative approach to burnout. Perhaps this focus on numbers provides the medical profession with a culturally acceptable biomedical approach with which to safely acknowledge the experience of burnout. The reality is that we are not exactly looking for a needle in a haystack. If half of us, as family physicians, have burnout, and if some physicians improve over 12 months while others develop it, then it appears that we are all at risk.

The dangers of drama

I would also contend that this comfortable focus on the high prevalence of burnout (a proxy for shouting within the medical literature) has seriously affected our investigation into understanding family physician burnout. For such a serious issue, there is simply a dearth of qualitative research exploring family physician burnout.¹⁴ One study of Canadian family physicians has elegantly provided important insights into how physicians can avoid stress and burnout.¹⁵ Such studies might not deliver “dramatic statistics” that feed into evocative headlines, but they are likely to provide the necessary information required to develop a response.

Not only has the drama affected the approach to research, but it has also distorted the focus of research. There are very few studies that focus on interventions.¹⁴ The vacuum left in the intervention space has been readily filled by expert opinion. For example, when advising on strategies to combat burnout, one commentary begins, “State law often requires institutions and health care professionals to report their concerns about physician impairment to the licensing board.”¹⁶ Suddenly burnout is equated with impairment. Common sense would suggest that such solutions are somewhat misguided if more than half of family physicians have burnout. However, without research to inform an appropriate response, overstated offerings will abound.

If we consider the few intervention studies, then we find that while counseling, Balint groups, and mindfulness offer some hope, these interventions focus on the individual.¹⁴ Previously Maslach et al have commented: [M]ost discussions of burnout interventions focus primarily on individual-centered solutions, such as removing the worker from the job, or individual strategies for the worker, in which one either strengthens one’s internal resources or changes one’s work behaviors. This is particularly paradoxical given that research has found that situational and organizational factors play a bigger role in burnout than individual ones.¹²

While it might be more comforting to focus on “those individuals over there with a problem,” the real challenge in addressing burnout is changing our occupational environment and addressing the cultural issues that emerge from our professional discourse. Because burnout is a shared experience across the health sector, there is clearly a place for interprofessional learning and support. Currently our overdramatization of these issues (which could arguably be [mis]interpreted as saying “our” burnout is more serious than “yours”) is unlikely to encourage such vital interchange.

In conclusion, family physician burnout is currently overdramatized. The consequences of being mesmerized by this unfolding drama are potentially serious. We can do better in our approach to physician health. It is time to step back and improve our performance.