Although the potential for emotional exhaustion that is central to burnout has been long recognized, the topic emerged as one of professional focus in the mid-1970s. The term “burnout” was first used in the literature by a psychiatrist who described the gradual loss of motivation and commitment he observed in volunteers in a human services agency.3 At about the same time, burnout became a subject of empirical investigation. Since then it has been studied extensively and has been found to occur in a large proportion of doctors: as many as 30% to 60% of practicing physicians have been reported to have burnout when measured with validated instruments.4,5
Findings from a literature review indicate that a variety of factors may contribute to physician burnout.6 These include personal traits, such as perfectionism or obsessive worrying; the culture of medicine that promotes unbalanced lifestyles, expectations for personal invulnerability, and denial of personal needs; and recurring exposure to emotionally intense experiences, such as patient pain, suffering, and mortality.
Social exchange theory may also explain physician burnout.7 The lack of reciprocity in the physician-patient relationship, in which the relationship exists for the benefit of the patient, can create an imbalance between emotional investments and outcomes. This, in turn, can lead to fatigue and emotional drain. Work pressures have also been suggested, including excessive clinical loads, medicolegal concerns, lack of collegial support, and a perception of inadequate resources for accomplishing expected tasks. A perception of excessive career demands and inadequate resources have been identified as particularly important in predicting burnout.8
CHECKPOINTS
■ Burnout is often associated with experiencing a lack of control; finding ways to increase one’s sense of control improves resilience.
■ Setting professional and personal limits can be keys to maintaining positive attitudes.
■ Sharing feelings and responsibilities can be an important ingredient to overcoming burnout; support can be found in interpersonal relationships and in group settings.
■ Age and experience may be positive protective factors against burnout.
Not all findings about burnout are intuitive. For example, a recent comparison of burnout between family medicine and psychiatry residents that used the Maslach Burnout Inventory and Work Environment Scale found that being female, having children, and being from another culture appeared to be protective factors.9 Psychiatry residents reported less burnout than family medicine residents on the Depersonalization and Emotional Exhaustion Scales (respectively: t = 2.49, P = .014; t = 2.05, P = .042) and higher physical comfort on the Work Environment Scale (t = 22.60, P = .011). Family medicine residents reported higher peer cohesion, supervisor support, and autonomy (respectively: t = 3.41, P = .001; t = 2.38, P = .019; t = 2.27, P = .025). These data suggest possible differences in burnout experiences by specialty, but current literature is inadequate to fully define the differences.
Patient and physician outcomes
Spickard and colleagues10 noted that burnout is associated with numerous adverse outcomes. It negatively alters both the nature of the physician-patient relationship and the quality of care physicians provide. Burnout can lead to an increase in medical errors. This is obviously detrimental to patient care but also fuels a sense of incompetence that only perpetuates and exacerbates burnout. Escalating burnout has also been associated with additional problems—such as reduced physician empathy, reduced patient trust and satisfaction with care, impaired professionalism, increased risk of physician substance abuse and depression, career changes, and physician suicide.11
As a group, psychiatrists may have unique experiences that make them vulnerable to burnout. Kumar12 notes that psychiatrists, more than physicians in other specialties, use themselves as “tools” in the execution of their professional activities. This use of self is challenging and requires special diligence to remain emotionally responsive while protecting boundaries. Physician-patient relationships in psychiatry may be particularly delicate. The nature of patient problems and the stigma associated with mental health problems increase the burden of confidentiality for psychiatrists. While all physicians must confront the reality of patient death or other adverse outcomes, the increased emotional load associated with patient suicide may be especially hard on psychiatrists.
