Doctors rate high on the burnout scale

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PhysicianWEBOf all professionals in the US, doctors experience some of the highest rates of burnout, with ore than half of them feeling this way, Mayo Clinic research shows.

According to a Time report, if that sounds like a bad thing for people whose job it is to heal others, it is. Studies have linked burnout to a rise in unprofessional behavior, a drop in patient satisfaction and a greater chance that a doctor will make a major medical error.

There’s no one cause for doctor burnout, but a new study has found a major one: the increasingly electronic nature of medicine. The digital parts of doctoring, like maintaining electronic health records, were linked to physician burnout.

The report says like many of us, doctors are spending more and more time in front of their screens. Health records are now maintained electronically and doctors submit medication orders to pharmacies by computer – both strategies meant to streamline doctors’ visits, reduce errors and improve patient care.

But digitisation affects doctors too – and not, it seems, for the better. Researchers at the Mayo Clinic looked at several months of 2014 survey data from 6,560 US physicians measuring features of work life, including burnout and electronic use. Even after controlling for factors like age, sex, specialty and the number of hours doctors work per week, the researchers found a strong link between burnout and time spent doing digital work. Of the many physicians who used electronic health records, 44% were dissatisfied with them and nearly 63% of doctors believed that EHRs made their jobs less efficient. Nearly half of doctors said that they spent an unreasonable amount of time on clerical tasks related to patient care.

Older doctors hated the electronic aspects of their jobs more than young physicians, possibly because they had to adjust to new technology that comes more easily to younger professionals. But the dissatisfaction with electronic busy work cut across generations. When specialty was considered, urologists, family medicine doctors, ear, nose and throat doctors and neurologists were the least satisfied with clerical work.

The report says just as disturbing, doctors were split on whether or not electronic health records actually improved patient care; 41% believed that they did not.

The report says doctors may loathe the electronic parts of their jobs because of more information overload, interruptions and distractions. But there might be a deeper reason doctors hate digital busy work: it eats up time they would otherwise spend with their patients, which is where a large number of physicians derive professional pleasure. “The introduction of computers into the examination room has the potential to shift physicians’ focus away from the patient and the human interaction,” the study authors write, “which is a source of meaning for physicians.”

Objective: To evaluate associations between the electronic environment, clerical burden, and burnout in US physicians.
Participants and Methods: Physicians across all specialties in the United States were surveyed between August and October 2014. Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics.
Results: Of 6375 responding physicians in active practice, 5389 (84.5%) reported that they used EHRs. Of 5892 physicians who indicated that CPOE was relevant to their specialty, 4858 (82.5%) reported using CPOE. Physicians who used EHRs and CPOE had lower satisfaction with the amount of time spent on clerical tasks and higher rates of burnout on univariate analysis. On multivariable analysis, physicians who used EHRs (odds ratio [OR]=0.67; 95% CI, 0.57-0.79; P<.001) or CPOE (OR=0.72; 95% CI, 0.62-0.84; P<.001) were less likely to be satisfied with the amount of time spent on clerical tasks after adjusting for age, sex, specialty, practice setting, and hours worked per week. Use of CPOE was also associated with a higher risk of burnout after adjusting for these same factors (OR=1.29; 95% CI, 1.12-1.48; P<.001). Use of EHRs was not associated with burnout in adjusted models controlling for CPOE and other factors.
Conclusion: In this large national study, physicians’ satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.

Tait D Shanafelt, Lotte N. Dyrbye, Christine Sinsky, Omar Hasan, Daniel Satele,
Jeff Sloan, Colin P West


Suicide among medical students and doctors has been a largely unacknowledged phenomenon for decades, obscured by secrecy and shame. Now, says a Stat News report, it’s beginning to emerge from the shadows.

More than 62,000 people – many of them medical professionals and their families- have signed a petition calling on medical associations to track physician suicides, provide confidential counselling, and require doctor training programs to address a “culture of abuse” too often characterised by bullying, harassment, and humiliation.

And, the report says, those groups are responding. The Association of American Medical Colleges recently convened a meeting to address an escalating crisis of depression, burnout, and suicide among physicians. Among the ideas under consideration: encouraging medical students to join clubs so they feel less isolated; ensuring that counselling is more accessible and private; and more actively tracking the mental health of students and doctors.

“This is something that the profession as a whole needs to come together around and deal with as a shared concern,” said Dr Darrell Kirch, president of the AAMC. The report says he knows the pain firsthand: He lost two students to suicide during his tenure as dean at medical schools in Pennsylvania and Georgia.

The Accreditation Council for Graduate Medical Education, which oversees the doctor training programmes known as residencies, is also focusing on the issue. Officials are studying residents’ deaths to determine which might have been preventable, and how to respond. The group sets standards for residencies and is looking at how to strengthen them to protect young doctors’ mental health. Hospitals, too, are racing to launch support groups, peer counseling, and sessions to teach doctors to manage stress by meditating or keeping journals.

The report says the starkest sign of the crisis gripping medicine is the number of physicians who commit suicide every year – 300 to 400, about the size of three average medical school classes. Male doctors are 1.4 times more likely to kill themselves than men in the general population; female physicians, 2.3 times more likely.

The report says grim tally is probably an under-count, since many suicides aren’t listed as such on death certificates. And it doesn’t include suicides among medical students, which aren’t tracked systematically in the US.

In one study of six medical schools, by researchers at University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii, nearly 1 in 4 students reported clinically significant symptoms of depression. Almost 7 percent said they had thought of ending their lives in the last two weeks.

In another, more recent study, from researchers at Brigham and Women’s Hospital, Harvard Medical School, Yale School of Medicine, Yale University, University of Cambridge, Baylor College of Medicine, Texas Medical Centre, Medical University of South Carolina, and the University of Michigan, 29% of residents suffered from significant symptoms of depression. And those symptoms escalated within a year of starting training – a sign that residency programmes themselves were contributing to the problem.

The stress starts in medical school, where students face pressure to master an overwhelming amount of material. Competition with peers can be brutal. Sleep deprivation is common. And students can face withering criticism from faculty who have little tolerance for ignorance, signs of weakness, or emotional displays.
Once they’re practicing, physicians face additional stresses: an immersion in human suffering; long work hours; high expectations; and a dread of making mistakes.

They’re often profoundly uncomfortable with acknowledging vulnerability. And they must adapt to a rapidly changing health care environment. Medical education and training are “a profoundly dehumanising experience and it’s drilled into you: Do not show your heart or tears to anyone, ever again,” said Dr Pamela Wible, a family doctor in Eugene, Oregan, who has grappled with profound depression, written a book about physician suicide, and given a popular TEDMed talk on the topic. By necessity, Wible said, doctors become “masters of disguise,” expert at concealing their emotions.

The report says an upcoming documentary about physician suicide, “Do No Harm,” is the first feature-length examination of the issue. Robyn Symon, the director, came to the topic after two young doctors in New York City jumped to their deaths in 2014. She said she hoped the film will “break the code of silence around suicide that exists in the medical profession.”

Abstract 1
Background: This multisite, anonymous study assessed depressive symptoms and suicidal ideation in medical trainees (medical students and residents).
Method: In 2003-2004, the authors surveyed medical trainees at six sites. Surveys included content from the Center for Epidemiologic Studies-Depression scale (CES-D) and the Primary Care Evaluation of Mental Disorders (PRIME-MD) (measures for depression), as well as demographic content. Rates of reported major and minor depression and of suicidal ideation were calculated. Responses were compared by level of training, gender, and ethnicity.
Results: More than 2,000 medical students and residents responded, for an overall response rate of 89%. Based on categorical levels from the CES-D, 12% had probable major depression and 9.2% had probable mild/moderate depression. There were significant differences in depression by trainee level, with a higher rate among medical students; and gender, with higher rates among women (chi2 = 10.42, df = 2, and P = .005 and chi2 = 22.1, df = 2, and P < .001, respectively). Nearly 6% reported suicidal ideation, with differences by trainee level, with a higher rate among medical students; and ethnicity, with the highest rate among black/African American respondents and the lowest among Caucasian respondents (chi2 = 5.19, df = 1, and P = .023 and chi2 = 10.42, df = 3, and P = .015, respectively).
Conclusions: Depression remains a significant issue for medical trainees. This study highlights the importance of ongoing mental health assessment, treatment, and education for medical trainees.

Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, Kent A, Kunkel M, Schechter J, Tate J.

Abstract 2
Importance: Physicians in training are at high risk for depression. However, the estimated prevalence of this disorder varies substantially between studies.
Objective: To provide a summary estimate of depression or depressive symptom prevalence among resident physicians.
Data Sources and Study Selection: Systematic search of EMBASE, ERIC, MEDLINE, and PsycINFO for studies with information on the prevalence of depression or depressive symptoms among resident physicians published between January 1963 and September 2015. Studies were eligible for inclusion if they were published in the peer-reviewed literature and used a validated method to assess for depression or depressive symptoms.
Data Extraction and Synthesis: Information on study characteristics and depression or depressive symptom prevalence was extracted independently by 2 trained investigators. Estimates were pooled using random-effects meta-analysis. Differences by study-level characteristics were estimated using meta-regression.
Main Outcomes and Measures: Point or period prevalence of depression or depressive symptoms as assessed by structured interview or validated questionnaire.
Results: Data were extracted from 31 cross-sectional studies (9447 individuals) and 23 longitudinal studies (8113 individuals). Three studies used clinical interviews and 51 used self-report instruments. The overall pooled prevalence of depression or depressive symptoms was 28.8% (4969/17 560 individuals, 95% CI, 25.3%-32.5%), with high between-study heterogeneity (Q = 1247, τ2 = 0.39, I2 = 95.8%, P < .001). Prevalence estimates ranged from 20.9% for the 9-item Patient Health Questionnaire with a cutoff of 10 or more (741/3577 individuals, 95% CI, 17.5%-24.7%, Q = 14.4, τ2 = 0.04, I2 = 79.2%) to 43.2% for the 2-item PRIME-MD (1349/2891 individuals, 95% CI, 37.6%-49.0%, Q = 45.6, τ2 = 0.09, I2 = 84.6%). There was an increased prevalence with increasing calendar year (slope = 0.5% increase per year, adjusted for assessment modality; 95% CI, 0.03%-0.9%, P = .04). In a secondary analysis of 7 longitudinal studies, the median absolute increase in depressive symptoms with the onset of residency training was 15.8% (range, 0.3%-26.3%; relative risk, 4.5). No statistically significant differences were observed between cross-sectional vs longitudinal studies, studies of only interns vs only upper-level residents, or studies of nonsurgical vs both nonsurgical and surgical residents.
Conclusions and Relevance: In this systematic review, the summary estimate of the prevalence of depression or depressive symptoms among resident physicians was 28.8%, ranging from 20.9% to 43.2% depending on the instrument used, and increased with calendar year. Further research is needed to identify effective strategies for preventing and treating depression among physicians in training.

Douglas A Mata; Marco A Ramos; Narinder Bansal; Rida Khan; Constance Guille; Emanuele Di Angelantonio; Srijan Sen

Full Time report
Mayo Clinic Proceedings abstract
Stat News report
Academic Medicine abstract
JAMA abstract

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