Brief history of burnout
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5268 (Published 27 December 2018) Cite this as: BMJ 2018;363:k5268
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
During my working life, it certainly was not a recognised malady in the medical profession. Nor, if I may say so, in the nursing profession. “Intensive therapy units“ came into existence in Scotland first and then in England. In the early 1960s.
The anaesthetic consultants quite often did the crossword after giving the patient a spinal anaesthetic. And when the anaesthetic machines such as the Cape Wain came in to use, the life in the theatre became easier still for the anaesthic consultant. Put the patient under, then switch him to the machine, the nurse keeps an eye and the consultant goes to the theatre sister’s room, has coffee.....
I recognise that today the life in the anaesthetic and surgical specialities is just a bit more complicated.
But, there is no need to burn yourselves out. When you have had enough - switch specialities. Or, become the Chief Executive.
Once someone said, “ Either kick or be kicked”. That was at the beginning of the era when doctors started to be ”deprofessionalised” and turned into factory hands valued according to “productivity”, “throughput”, when (now) bean counting became what treating human beings was.
Competing interests: No competing interests
Burnout may be associated with self-reported medical errors, poorer quality of care and increased threats to patient safety, but not when these outcomes are objectively assessed (1). This is not surprising, for a doctor who describes diminished work efficacy is likely to think that this must result in adverse outcomes. One study that relates burnout to a hard outcome – mortality – is that by Welp and colleagues (2), who studied doctors and nurses working in intensive care units (ICUs). This too is not surprising, given the critical nature of decision-making and action in ICUs, but it also raises the questions: is burnout the same for different disciplines and patient populations, and are subgroup studies needed?
The somewhat malleable concept of burnout needs clarification, including its overlap with depression (3). Most researchers seem to attribute most of burnout to the work environment, but some relate burnout to medical training that normalises over-commitment (4).
There are reviews that suggest that some interventions against burnout may be worth investigating further, but we should be careful about the weight we give to their findings. West and colleagues note that trials of organisational interventions are few in number, that cohort studies have substantial risk of bias and that few studies have assessed long-term outcomes (5).
The research agenda for burnout is becoming clearer, but there is a risk that interventions (often aimed at individuals) will be promoted that are based on claims about patient safety that go beyond the evidence (1). We agree with Lawson that researchers, journals and medical leaders should not at the present time infer that burnout is associated with, let alone be a cause of, medical errors or preventable adverse events (1).
Steve Iliffe, Emeritus Professor of Primary Care for older people, University College London
Professor Jill Manthorpe, Director of the Health & Social Care Workforce Research Unit, King’s College London
(1) Lawson ND Burnout is not associated with increased medical errors Mayo Clin Proc 2018; 93 (11):1683
(2) Welp A, Meier LL, Manser T Emotional exhaustion and workload predict clinician-rated and objective patient safety Frontiers in Psychology 2015; 5 (1573): 1-13
(3) Bianchi R, Schonfeld IS, Laurent E Physician burnout is better conceptualised as depression Lancet 2018; 388: 1397-1398
(4) Fortenberry K, Knox J, van Hala S What do residents want for burnout prevention?...Time Academic Med 2018;93(3) 343-344
(5) West CP, Dyrbye LN, Erwin PJ, Shanafelt TD Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis Lancet 2016; 388 (10057): 2272-2281
Competing interests: No competing interests
I found this article interesting as it raised the idea of increasing complexity as a contributing factor to physician burnout. In complex systems there are more and more interactions which can subtly influence outcome.
If you consider the number of professionals a patient meets on admission to hospital, all of whom interact with one another sometimes directly, sometimes indirectly, the system, service, patient, technology and machinery group together to form a tangled web. Likewise an individual professional in this system interacts with their work stream, technology, equipment and many other professionals, along hierarchies of responsibility and frequently with goal conflicts - it is easy to see how this could add to the mental exhaustion associated with burnout.
Human factors recognise that the workplace should be designed and organised to minimise the likelihood of error. Systems thinking considers all of the dynamic interactions between people, task, technology and working conditions - the factors that often escape analysis. It then identifies the unsafe interactions and ways to alter or remove them. As systems thinking relies on more than actions by individuals it provides an opportunity for long term learning and lasting change. https://www.youtube.com/watch?v=5oYV3Dqe0A8 Systems thinking is the type of analysis that enables us to design and organise our workplace to minimise error. It addresses complexity and may help to address the risk of burnout.
I have been privileged to visit the Air Traffic Control tower at Manchester Airport. It is quiet, peaceful (not the awkward silence of a library), the temperature is comfortable, the lighting is hardly noticeable, screens are clear, the control room is small but not crowded, the views are astounding, desks and seats are at an appropriate height. All who enter instinctively lower their voice; wait to be spoken to, we are the visitors, it is the controllers' environment, but it is not intimidating, it does not diminish those who visit – it was incredibly calm.
To conclude, I think that Rajvinder Samra has a point; interventions to optimise performance should consider complexity at the individual, team and organisational level
Competing interests: No competing interests
Thank you for your thoughtful response on this topic and to my editorial, Professors Iliffe and Manthorpe. I note your points that we do not know what burnout is, as long as studies are operationalising it differently, and that the effect of burnout on patient care is not clear.
In relation to the first point, a review led by Professor Colin West (1) indicates that physician burnout demonstrates associations with self-reported medical errors, perceived quality of care, and patient safety metrics. For example, mortality (using standardised mortality ratios) can be predicted by emotional exhaustion (2) which is a key component of burnout according to Maslach et al. (3). In terms of physician health, the review (1) identifies associations between burnout and physician depression, alcohol abuse, suicidal ideation and motor vehicle accidents. There is no evidence of causality and such results merit further investigation but do suggest that burnout is relevant to both patient and physician health.
Regarding the solutions to burnout and their effectiveness, again I would draw attention to a further review led by Professor West which is very informative about the effectiveness of different types of solutions to physician burnout (4). This review demonstrates that burnout interventions do show reductions in overall burnout scores and scores on two of the main components of burnout (emotional exhaustion and depersonalisation) when examining changes in an intervention group with a control or comparison group. I do agree that we need to ensure that studies focused on burnout should operationalise it in a way that uses established measures to allow for robust results and replicability. There are established tools for measuring general work/professional burnout such as the Maslach Burnout Inventory (3). West et al.'s review on interventions to reduce physician burnout (4) included only studies which had used a suitable and established burnout inventory.
References:
1. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med 2018;283: 516–529.
2. Welp A, Meier LL, Manser T. Emotional exhaustion and workload predict clinician-rated and objective patient safety. Frontiers in Psychology. 2015;5:1573.
3. Maslach C, Jackson SE, Leiter MP. (2017). Maslach Burnout Inventory Manual, 4th Edition. Menlo Park, CA: Mind Garden.
4. West, CP, Dyrbye, LN, Erwin, P J, & Shanafelt, TD. (2016). Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. The Lancet, 388(10057), 2272-2281.
Competing interests: No competing interests
Rajvinder Samra makes good points in his short history of burnout (1), but we should be cautious about adopting solutions to this problem. Patient care provided by practitioners with burnout does not appear impaired to their patients (2). This is an important point that should make practitioners and health service managers pause for thought. Those experiencing burnout symptoms are unlikely to enjoy them, but they do not seem disabling in a practical, clinical sense, at least in the short term.
Schwenk & Gold describe burnout as “a serious symptom, but of what?”(3) After nearly fifty years of study of it there are many proposed solutions to burnout but little evidence of their effectiveness. Studies of burnout do not agree on its precise definition and are of variable methodological quality, so it is difficult to see whether burnout is related to the job, the practitioners’ aptitudes, their personal characteristics or combinations of these characteristics. Those most at risk of burnout in medicine are (perhaps predictably) younger women working longer hours and experiencing work-home conflicts (4) , and they rather than their patients experience adverse health outcomes (5). Perhaps responses to burnout should go beyond the NHS environment.
Steve Iliffe, Emeritus Professor of Primary Care for older people, University College London
Professor Jill Manthorpe, Director of the Health & Social Care Workforce Research Unit, King’s College London
1. Samra, Rajvinder (2018). Brief history of burnout. BMJ, 363, article no. k5268
2. Maslach C & Leitner MP It’s time to take action on burnout Burnout Research 2015;2:iv-v
3. Schwenk TL & Gold KJ Physician burnout – A serious symptom, but of what? JAMA 2018; 320(11):1109-10
4. Amoafu E, Hanbali N, Patel A, Singh P What are the significant factors associated with burnout in doctors? Occupational Medicine 2015;65:117-121
5. Ahola K, Toppinen-Tanner S, Seppänen J Interventions to alleviate burnout symptoms and to support return to work among employees with burnout: Systematic review and meta-analysis. Burnout Research 2017;4: 1–11
Competing interests: No competing interests
The title holds the promise of touching on the history of 'burnout' in aviation. But the author missed the point.
The concept arose during WWI, and survived till WWII. In the full form, it was believed that young pilots burn out their 'volume' of the ability to fly and struggle effectively. In the middle of the 20th century in aviation medicine the concept was not in use because it is not necessary and not productive to bundle the different symptoms of tiredness, anxiety and disillusionment.
This part of the history of aerospace medicine is not totally lost: it is reflected in the handbooks of aerospace medicine of the 1970s and in some texts of the 21st century (1).
I hope that the buzz around this fuzzy concept will go away soon.
References
1. https://www.tandfonline.com/doi/full/10.1080/1470243042000344803
Competing interests: No competing interests
'' Burnout '' is not " Burnt out "
================== =======
In the current lexicon , '' burnout '' denotes a condition experienced by humans
following stresses of every day life. No definitive characteristic features as an
entity are assigned to it. There are no specific symptoms or signs. It reverses
without any formal intervention.
Even our neanderthal forefathers would have experienced '' burnouts " in their
life-time amidst hunting and nut gathering and regained their usual posture with
no external intervention.
,
To name this short -lived , mild existential aberration , " burnout " is an inappropriate exaggeration.
Competing interests: No competing interests
Re: Brief history of burnout
We read Rajvinder Samra’s editorial on the history of “burnout” with great interest. This is an increasing problem in healthcare as individuals become chronically exposed to a stressful working environment, coupled with high expectations and low resources. We feel that in the current climate, “burnout” is best defined by Christina Maslach’s description of a syndrome of “emotional exhaustion, reduced personal accomplishment and depersonalisation” (1), although other comparable tools such The Oldenburg Burnout Inventory (2) have been used to measure exhaustion and work engagement in various fields including healthcare.
As we now start to recognise the prevalence, contributory factors and effects of burnout amongst doctors, healthcare organisations, patient support groups as well as the General Medical Council (3) have become concerned that this may negatively impact physician effectiveness and patient safety. Dr Clare Gerada, current Medical Director of the Practitioner Health Programme (and a Past President of the Royal College of General Practitioners), recently underlined the fact that general practitioners (GPs) now have the lowest levels of job satisfaction and highest levels of stress since 1998, with an increasing number intending to leave direct patient care within the next five years (4). Some Royal Colleges such as the Royal College of Obstetricians and Gynaecologists, have established a “Supporting Our Doctors Task Group” in order to prevent, minimise and manage workplace stress experienced by trainees and consultants alike.
A Commentary in the January 2019 issue of Obstetrician and Gynaecologist (5) highlighted the fact that although there are individual focused and organisational based interventions designed to support physician “burnout” (such as stress management, work processes improvements and shortened work shifts), pooled data from the meta-analysis of 15 randomised trials of such strategies show that overall improvement following interventions were modest (around 10%). Burnout, therefore, is a condition that is best avoided than treated, particularly when it is clear that this is not an acute self-limiting illness and has an uncertain prognosis.
Senior medical students also face challenging learning environments, including competitive academic culture, poorly organised clinical rotations, administrative failures and changing living conditions, which are key factors linked to stress and burnout (6). Consequently, medical student burnout has reached epidemic levels (7) and could potentially contribute to the 11.1% attrition rate noted in a meta-analysis (8). Although there is little United Kingdom-specific data on the impact of medical student burnout, studies from the United States associate burnout with declining career interest and depressive symptoms (9). Students attribute causes of burnout to a combination of failures of administration, pressure related to assessments and apprehensions about being unassisted with regards to future career planning (10). The tendency of medical schools to prioritise technical and professional competency at the expense of personal development also pose a significant barrier to student well-being (11). Hence educational institutions play a critical role in developing a cohesive approach to tackling medical student burnout, ranging from promoting personal resilience, to creating collaborative learning environments and to providing support pathways.
Samra’s editorial aptly conceptualises what we can learn from aviation settings, whether it be managing work complexity or changes in professional culture. For many medical students and doctors, medicine is a calling; thus hard work and tremendous personal sacrifice is not new. Minimising the potential for burnout for both students and doctors needs increased awareness and acknowledgement of the problem, with systemic changes that encourage a collaborative and supportive relationship between clinicians, National Health Service management and medical schools.
References:
1. Maslach C, Schaufeli WB & Leiter MP. Job burnout. Annual Review of Psychology 2001; 52, 397-422.
2. Demerouti E, Mostert K & Bakker AB. Burnout and work engagement: a thorough investigation of the independency of both constructs. J Occup Health Psychol 2010;15(3): 209-22. doi: 10.1037/a0019408.
3. GMC | Managing your health https://www.gmc-uk.org/concerns/11544.as
4. Gerada C. 2017. https://blogs.bmj.com/bmj/2017/12/05/clare-gerada-why-has-medicine-becom...
5. Cresswell K, Graham R, Wright A, Garelick A, Yoong W. Managing Burnout in Obstetrics and Gynaecology (Commentary). The Obstetrician and Gynaecologist 2019; 21: 7-9
6. Dyrbye LN, Thomas MR, Harper W, et al. The learning environment and medical student burnout: a multicentre study. Med Educ. 2009; 43: 274–282.
7. Frajerman A, Morvan Y, Krebs M, Gorwood P, Chaumette B. Burnout in medical students before residency: A systematic review and meta-analysis. Eur Psychiatry. 2019; 55: 36-42
8. O’Neill LD, Wallstedt B, Eika B, Hartvigsen J. Factors associated with dropout in medical education: a literature review. Med Educ. 2011;45: 440-454.
9. Grace M. Depressive symptoms, burnout, and declining medical career interest among undergraduate pre-medical students. Inter J Med Educ. 2018; 9: 302-308
10. Hill, M., Goicochea, S. and Merlo, L. (2018). In their own words: stressors facing medical students in the millennial generation. Medical Education Online, 23(1), p.1530558.
11. Montgomery A. The inevitability of physician burnout: Implications for interventions. Burnout Research. 2014; 1(1): 50-56.
Authors:
Yip S*, Nauta M**, Yoong W+
*5th Year Medical Student, UCL School of Medicine, London
**General Practitioner, Camden Health Improvement Practice, London
+Consultant Obstetrician and Urogynaecologist, North Middlesex University Hospital, London
Corresponding author:
Mr Wai Yoong, Consultant Obstetrician and Urogynaecologist, North Middlesex University Hospital, London
Email: waiyoong@nhs.net
Competing interests: No competing interests