Doing something about physician burnout.

Burnout aff ects more than half of practising physicians and is on the rise. When burnout was seen as a crisis of wellbeing—aff ecting physicians’ personal lives and work satisfaction—it garnered little public sympathy and could be dismissed as the whining of a privileged class. Now that evidence suggests that burnout negatively aff ects physicians’ eff ectiveness and availability to patients, as well as patient safety, physicians, healthcare organisations, and the public are justifi ably worried about quality of patient care and the health of healthcare institutions. According to psychologist Christina Maslach, burnout is when physicians feel emotionally exhausted, depersonalised (ie, cynical and detached), and ineff ective; when they feel “an erosion in values, dignity, spirit, and will”. Burnout is not an expected reaction to hard work—deeply satisfying work can involve tremendous personal sacrifi ce. It is not the same as depression, yet severe burnout can evolve into it. Initially, burnout might coexist with empathy, satisfaction, and caring, but unrelieved work stress for months diminishes the ability to call forth and sustain those attributes. Although burnout is not new, recent increases are probably due to interactions between individual and organisational factors, which contribute to a high burden of responsibility, low perceived control, discordance between individual and organisational values, unsupportive work environ ments, isolation, and loss of meaning. Burnout is not an acute self-limited illness and it has an uncertain prognosis. In The Lancet, Colin West and colleagues report a comprehensive meta-analysis that raises fundamental questions about what clinicians and health-care organisations should be doing about burnout now. They reviewed 2617 articles, of which 15 randomised trials and 37 cohort studies were of suffi cient quality; all but three were done in high-income countries. Interventions reduced overall burnout from 54% to 44%, high emotional exhaustion from 38% to 24%, and high depersonalisation from 38% to 34% among participating physicians. West and colleagues note that individual (eg, mindfulness, discussion, and stress management) and organisational (eg, work environment) interventions produced similarly large improvements in burnout; while diverse, all of these programmes share the initial step of enhancement of awareness. For example, mindfulness training can help individuals be aware of burnout in its early phases— noting changes in the body (eg, headaches or muscle tension), emotions (eg, irritability or sarcasm), or thoughts (blaming self or others)—before it becomes unmanageable, name it, and accept that it is present. Equally important is physicians’ awareness of their ability to mitigate burnout: resilience, perspective taking, and cognitive reappraisal. Just as individuals can be mindful of their level of burnout and wellbeing, health-care organisations can monitor these levels as quality indicators and disseminate fi ndings to raise collective awareness and resolve. Treatment of burnout solely as a disease or failure of individual practitioners is unlikely to be eff ective. Rather, the individual and system drivers of burnout also need to be addressed. Physicians tend to name external causes, such as productivity pressures and loss of control, yet they should pay equal attention to psychological factors. Just as resilience has a neurocognitive fi ngerprint, so might burnout. Cognitive rigidity, diffi culty with ambiguity, setting of boundaries, and forgiving oneself seem to be risk factors that can be addressed, helping physicians manifest adaptive qualities. To promote community and shared vision, meaningful discussions among colleagues and community building can help. Addressing burnout on an individual level will not be enough in the current health-care environment. Leaders