It has been nearly two full years since the coronavirus pandemic began and our doctors are burned out. It’s to the point now that many physicians are considering leaving medicine altogether. But is COVID solely to blame for this burnout epidemic, or is there more to the story?
What is Burnout and Why Should You Care?
Burnout can be defined as a state of emotional, mental, and physical stress caused by prolonged or repeated workplace stress. It is characterized by feelings of exhaustion, low productivity, and cynicism towards work.
According to recent polls, nearly half of all physicians in the United States report feeling burned out, and about one in five have considered leaving medicine altogether. What is perhaps most alarming about these numbers is that they come at a time when our healthcare system is already strained and we’re experiencing physician shortages across a wide range of specialties.
The AAMC predicts that if we don’t take steps to lessen this gap, we will face a shortage of up to 124,000 physicians by the year 2034. Thus far, the focus has largely been on increasing the number of medical school and residency positions; however, if we don’t figure out how to keep our physicians practicing, all this work could be for nothing.
Burnout is a common precursor to depression and suicide and physicians already have some of the highest suicide rates out of any profession. According to one survey, as high as 13% of physicians have had suicidal thoughts with 1% of physicians reporting that they have attempted taking their own life. These are incredibly worrisome statistics when you consider that anyone who has attempted suicide is at a greater risk of completing the act sometime in the future.
It’s not just the well-being of our physicians at risk either. If burnout affects half of our physicians, it’s also indirectly affecting half of our patients. Physicians who are burned out or depressed are more likely to make medical errors which adversely affects patient safety. It is estimated that medical errors are responsible for more than 250,000 deaths each year making it the third leading cause of death in the United States behind heart disease and cancer.
Burnout can also place a significant strain on a physician’s relationships. Doctors who are burned out may exhibit increased isolation, greater irritability, more time away from home, less communication, less physical intimacy with their partner and more emotional separation. The added strain on these relationships can then become it’s own source of stress further increasing the risk of depression and suicidal ideation amongst physicians.
How Has COVID Affected Physician Burnout?
So now that we know what burnout is and why it’s a problem, is COVID-19 to blame for the burnout epidemic?
According to Medscape’s 2021 Physician Burnout & Suicide Report, of the 42% of physicians who reported feeling burned out, only 21% reported that it started after the pandemic. This means that the vast majority of physicians were already experiencing burnout long before COVID-19.
This isn’t to say that coronavirus hasn’t made things much more difficult for many doctors, but rather to point out that physician burnout has been a problem for years.
The pandemic has been incredibly stressful for physicians and healthcare workers. At the beginning of the pandemic, there was a lot of uncertainty surrounding the virus. Doctors were putting themselves at risk trying to treat a virus that we knew little about. Where most other industries experienced decreased workloads and work hours during the pandemic, many doctors and healthcare workers had to work harder and longer hours taking care of COVID patients.
Physicians are not immune to the virus either. Many got sick themselves or had family, friends, and colleagues who got sick. Higher viral loads also lead to more severe illness, which is scary when you’re taking care of a lot of COVID patients.
Not only is this incredibly stressful for physicians, but when members of the healthcare team are sick, there are fewer people to take care of patients. As a result, the responsibility falls on the rest of the healthcare team which leads to even longer and more difficult hours.
The pandemic has also been especially difficult for smaller, private practices. At the beginning of the pandemic, the lack of personal protective equipment amongst small practices was a big issue. Whereas large healthcare systems had established PPE suppliers, many small businesses had to fend for themselves to find masks and gloves. Due to the limited supply of these items at the beginning of the pandemic, cost became a significant financial issue for some practices.
Many private practices also experienced a significant decrease in patient volume during the pandemic. There were many patients that canceled their appointments due to fear of contracting COVID. Although some practices were able to supplement their numbers through telemedicine appointments, for many the volume still wasn’t enough to make ends meet. There have been many private practices that had to close their doors during the pandemic – some of them for good.
The freeze on elective procedures during the pandemic was another source of stress for many physicians. Many specialties that rely on these procedures experienced significant decreases in their income.
But regardless of how each specialty was affected specifically, it is evident that some specialties were hit harder than others. The top 5 specialties with the highest burnout rate in 2020 were urology, neurology, nephrology, endocrinology, and family medicine. In 2021, these changed to critical care, rheumatology, infectious disease, urology, and pulmonary medicine with family medicine, internal medicine, and emergency medicine following close behind.
From 2020 to 2021, we can see a shift towards front-line specialties like critical care, infectious disease, and pulmonology feeling more burned out.
But despite these trends, most physicians still reported that their burnout began before the coronavirus pandemic. So, if COVID isn’t to blame, what’s really causing our physicians to feel so burned out?
What Are the Leading Causes of Burnout?
According to Medscape, the top 5 reasons for physician burnout in 2021 were: too many bureaucratic tasks, too many hours at work, lack of respect from administrators and colleagues, insufficient compensation and reimbursement, and lack of autonomy.
Causes of burnout related to the pandemic such as stress related to social distancing, treating COVID-19 patients, and government regulations were still within the top ten but were much lower down on the list.
What is interesting though, is that the top 5 reasons for burnout have remained largely unchanged since 2016 – long before the pandemic began.
Physicians have been working long and difficult hours for years. They’ve spent several hours each day filling out charts and paperwork to meet hospital and insurance company requirements. In some specialties like primary care, as much as two-thirds of their day is spent charting.
These reasons don’t exist in isolation either. As one physician summed it up: “it’s all of these causes; its death by 1000 cuts.”
What Can We Do About Burnout?
To address the burnout pandemic, we need to look at solutions both on an individual and a systemic level.
At an individual level, there are a few actionable pieces of advice.
The most consistent finding throughout the scientific literature is that social support reduces burnout. If you believe you are burned out, depressed, or suicidal, the first thing you should do is seek professional help. The second is to seek support from your friends, family, and colleagues.
Sleep duration has also been inversely correlated with rates of burnout, meaning the more you sleep, the less likely you are to be burned out. To learn more about how to improve your sleep, check out my article covering Surgeon Sleep Secrets.
Exercise is another popular way to cope with burnout with approximately 45% of physicians reporting this as their preferred method. Exercise has been correlated with improved well-being and decreased psychological distress, stress, and emotional exhaustion.
That being said, burnout is ultimately more of a systemic issue than a personal one. While we must take responsibility to mitigate it in our own lives, the fact that burnout amongst physicians has been consistently rising for decades points to a systemic cause.
An increasing number of healthcare systems are promoting wellness programs to address the issue of burnout. Although well-intentioned, these programs push the narrative that burnout is the physician’s problem – a failure to properly engage in self-care, sleep, exercise, and mitigate stress. Ironically, requiring physicians to attend one-hour wellness lectures also tends to reduce their time and ability to engage in more meaningful self-care behaviors.
These solutions, although helpful, only address the symptoms of burnout, not the root causes. In 2021, administrative burdens, too many hours at work, and a lack of respect from administrators and colleagues were the leading causes of physician burnout. No amount of self-care, sleep, or exercise is going to provide a sustainable solution to those.
We need health care policymakers, regulators, and standard-setting bodies to work with physicians to help identify and eliminate areas that contribute little to no value to patient care. This would decrease administrative burden and let doctors spend more time being doctors and less time being typists or clerks. Instead of focusing on documenting every minute detail to fulfill a billing code, we need to put the focus back on the patient.
Another common source of burnout amongst physicians is insufficient compensation; therefore, the obvious solution would be to pay doctors more. Although there are many people that will argue physicians are already paid too much, what they often fail to consider is the cost of becoming a doctor.
After high school, becoming a physician takes a minimum of 11 years – four years of college, four years of medical school, and at least three years of residency – and many students take longer.
Getting into medical school is becoming increasingly difficult, so many students take gap years or spend extra time during college to bolster their applications. In addition, depending on what specialty you choose to pursue, residency and fellowship can last anywhere from 3 years at the shorter end of the spectrum to upwards of 8 years.
The cost of medical education has also increased significantly over the years. The average medical student graduates with over $200,000 in debt which accrues interest during the many years spent in training. By the time physicians complete residency training and start earning an attending physician’s salary, their debt has already had several years to grow and compound.
To address the burnout epidemic, we also need to de-stigmatize mental health diagnoses amongst physicians. Despite having some of the highest rates of depression and suicide out of any profession, many physicians never reach out for help – even when they know they need it.
Many state medical license applications ask questions regarding mental health history and its effect on a physician’s competency, even though this goes against the Americans with Disabilities Act. As such, many physicians never seek professional help for fear that it will negatively impact their ability to gain licensure.
Within the past few years, the Federation of State Medical Boards has come out with new recommendations to help address this issue and omit such questions from licensing applications. Numerous states have adopted some of these recommendations; however, very few have adopted them fully. This is a step in the right direction, but we still have a lot of work to do before our physicians can feel safe seeking help.
Although the coronavirus pandemic has surely added to the issue of physician burnout, we can’t use it as a scapegoat and blame it entirely. This is an issue that has been decades in the making and many physicians are starting to reach their breaking point. We need to take a good hard look at the root causes of physician burnout and start making strides to improve them. Only then will we be able to make meaningful progress towards happier and healthier physicians.