Study finds internist burnout even before the pandemic

Even among internists involved in promoting physician well-being, burnout is prevalent.

A recent survey assessed well-being among 1,305 internists (a mix of outpatient and inpatient physicians) and internal medicine trainees who participated in ACP's Well-being Champion program. Overall, 52.1% reported symptoms of burnout. An even higher percentage (71.9%) reported career satisfaction, however.

Compared with men, women had 56% higher odds of burnout. In addition, women had 61% lower odds of a joyous workplace, 39% lower odds of supportive work environments, and 61% lower odds of a manageable work pace and manageable stress from electronic medical records (EMRs), according to results published online in October 2020 by JAMA Network Open.

“I think ACP was always aware of the challenges of burnout; that's why our group built these Well-being Champions. But seeing these numbers helps us see our members are suffering and they're struggling,” said senior author Kerri Palamara, MD, MACP, physician lead for ACP's coaching services and director of the Center for Physician Well-Being at Massachusetts General Hospital in Boston.

She and coauthors Mark Linzer, MD, MACP, and Susan Thompson Hingle, MD, MACP, recently spoke with ACP Internist about the study results. Dr. Linzer is the M. Thomas Stillman Endowed Chair and Vice Chief for Education, Mentorship, and Scholarship in the department of medicine at Hennepin Healthcare and professor of medicine at the University of Minnesota in Minneapolis. Dr. Hingle is Chair of ACP's Physician Well-being and Professional Fulfillment Committee and professor of medicine at Southern Illinois University School of Medicine in Springfield.

Q: What led you to study burnout among ACP members?

A: Dr. Hingle: This was part of a bigger ACP initiative looking at well-being in internists. It was sparked by a resolution from the ACP Council of Early Career Physicians asking the ACP to tackle this important topic.

Dr. Linzer: We began a project to develop a network of Well-being Champions among ACP leaders in 2015. In 2018 and 2019, we expanded the program to Chapter-based champions throughout the 150,000 ACP members worldwide (now 163,000 members), with one or two champions per Chapter. Given the epidemic of clinician burnout, affecting 45% to 55% of physicians nationally, the idea was to address work life and wellness and provide the conceptual basis and evidence-based interventions for reducing burnout and turnover among internists, with the ultimate goal of improving sustainability and attractiveness of the profession of internal medicine.

Q: What was your reaction to the results?

A: Dr. Linzer: The results were fairly concordant with others, though the rate of burnout (52% using our single-item burnout measure) was higher than we typically find. Values alignment with leaders, a good protector against burnout and a good predictor of favorable patient outcomes, was somewhat low, only seen in 62% of respondents. We typically aim for 80%. EMR-related stress was fairly high, with 52% describing high time pressure for documentation. In the summary measures, a supportive work environment was seen in 35%—a good place to start for the profession, although we hope that continued work by the champion network can improve this. The EMR stress and work pace scale was only favorable in 9%, so that is another place for focusing our efforts for internal medicine.

Dr. Palamara: When you see the burnout number … it's validating for some, and I think it also helps to articulate the urgency and importance of it. This isn't that people can't manage stress well; this is that the system has flaws, and clinicians are not supported in the best ways that they can [be] to do the work that they set out to do. To me, this data is just telling the story of those docs who are being asked to do more with less.

Q: Why do you think female clinicians had higher odds of burnout?

A: Dr. Linzer: The findings for women MDs resonate with findings we published 20 years ago in the Journal of General Internal Medicine. In that study, odds of burnout were 60% higher in women clinicians; in this study, it was 56% higher odds. We are thus hoping the findings will allow [ACP] to move as an organization to address work lives for women clinicians and trainees. Some of the findings which might guide us include: more frequent stress in women (62% vs. 50%, with the odds ratio indicating that the odds of experiencing high stress are 63% higher in women), less frequent values alignment with leaders (20% lower odds in women), less control of the work environment (20% lower odds of work control in women, with work control being a protective factor against stress), [and] more time on EMR at home (22% greater odds of this for women). When we studied gender differences in burnout in the Netherlands in 2000, we found no gender differences. The main factors leading to gender differences in the U.S. were work hours (75% of Dutch women MDs worked part-time vs. 20% of U.S. women) and work control (very different between U.S. men and women MDs, but not that different between genders in the Dutch physicians).

We published a paper in the Journal of General Internal Medicine two years ago called “Gendered Expectations” showing that women MDs have more expectations placed upon them for listening and thus have a need to spend more time with patients and with others. This time pressure contributes to stress and burnout.

Dr. Hingle: Additionally, gender bias and gender-based harassment contribute. Women get paid less than men, too, which contributes to a sense that our work is less valued.

Dr. Linzer: Thus, women have a faster pace of work, less values alignment with leaders, and also less trust in their organization.

Q: How can these gender disparities be addressed?

A: Dr. Linzer: There are many things we can begin to do to address this, including shorter time increments for patients ([e.g.,] 20, 30, and 40 minutes [rather than only 20- and 40-minute options]) so patients can have sufficient time to discuss issues with women MDs. Also, adjusting panel size expectations by gender of patient (more female patients and more complex psychosocial patients choose to be in panels of women MDs), allowing more part-time options for women clinicians, emphasizing work-life balance in practices and departments, improving clinician control of schedule, hiring float MDs to cover for predictable life events (including illness leave and parental leave), encouraging flexible work hours, especially around child care needs, and providing training to identify and protect against gender-based discrimination.

Q: How do you explain the finding of high levels of burnout yet high levels of career satisfaction?

A: Dr. Hingle: Taking care of people is a noble endeavor. Forming meaningful relationships with people is highly satisfying.

Dr. Linzer: Most physicians like their role and job as a doctor; thus, satisfaction can be high, even when burnout is high. In short, people like being doctors, but the work environment can still be taxing, and if we are not able to improve it, they may leave their jobs to seek a more sustainable role elsewhere, or leave the profession altogether.

Dr. Palamara: This really highlights that well-being and burnout are not necessarily opposite ends of the spectrum and that you can have both. … I can love what I do, but not love the way I'm being asked to do it.

Q: What are the next steps in studying this issue?

A: Dr. Palamara: Everybody keeps saying, “Oh, I can't wait for things to go back to normal” [after the pandemic, but] if normal was OK, we wouldn't have a study to publish. So it's really helpful to understand what our old normal was. Something had to give before we had this gigantic additional stressor of COVID. If we did a burnout survey in the same people today, I don't think we could understand burnout in the same way that we did before right now because the drivers are just so radically different. You don't hear people complaining about [the EMR] right now; you hear people complaining about uncertainty and juggling life and having the autonomy to determine your own schedule, know your schedule in advance, to be able to work from home if that's what you need to do for your family, the ability to be tested if you're sick and/or worried if you're exposed.

The Well-being Champions are measuring well-being on a Chapter level to try to get aware of things now so that as they track things over time, they can have a sense for how we're doing, how we're responding, but also: What do you need right now? What are the stressors? … Perhaps there are things that have improved, such as the work environment. I think a lot of people feel very supported. There are also people who don't. But it does make you wonder how things have moved.

Q: Do you have advice for how internists can reduce burnout risk?

A: Dr. Linzer: We usually advise initiating an infrastructure, such as a wellness committee and an annual wellness survey, to provide data that can then be addressed issue by issue. High-impact issues include work control, chaotic workplaces, time pressure, and organizational culture (such as values alignment with leaders or trust in the organization). Addressing these issues, then measuring clinician reactions to their work environments again and continuing to drive burnout down to manageable levels, is the path that we recommend. Our piece in the Journal of General Internal Medicine in 2016 reporting on a national work-life survey for hospitalists and general internists may provide useful background information on this process.

Dr. Palamara: I often say to people, “If the president of the organization walked in right now, what would you say to them? If you could say anything without consequence, what would you say? If you could pick two things to complain about, with a solution, what would those be?” Dr. Linzer and I created coaching questions that can follow completing the Mini Z [burnout survey] to help people say, “OK, here's where I'm at with my burnout. Here are my stressors. Here's where the chaos is in my day. Now, what am I going to do with that?” One other thing, as far as advice, particularly right now, is that well-being means something different for different people, particularly well-being in the workplace. [Physicians should be] stopping and considering: What does well-being mean for you today? Because it will be something that changes over time, and it's certainly something that's different now than it used to be. And if we don't actually identify the vision of what it is, it will be hard to know when we've ever achieved it.