Hospitals are getting physician burnout and engagement all wrong — Here's why

Physician burnout poses a threat to clinicians' well-being, patient care and the hospital bottom line — and it's on the rise. Healthcare administrators are paying increasing attention to what many have deemed an epidemic of physician burnout, going so far as to enlist consultants to assess and prescribe necessary interventions. Unfortunately, many of these efforts fail to accurately diagnose — and subsequently, help heal — burnout.

Failing to properly measure and remedy physician burnout enables the condition to fester and grow. According to Medscape, the overall burnout rate across all physician specialties in 2013 was 40 percent. That figure has risen sharply since then. In 2017, Medscape's annual physician lifestyle survey found 51 percent of physicians reported experiencing frequent or constant feelings of burnout.

In addition to the direct mental health effects of burnout, such as depression and compassion fatigue, it is also associated with increased medical error rates, heightened malpractice risk and physician turnover, which drive up costs and can be calamitous for patients. Burnout is also associated with physical symptoms in those who experience it, such as headaches, gastrointestinal disorders, muscle tension, hypertension and sleep disturbances; as well as negative job responses, including job dissatisfaction, reduced commitment to the organization, absenteeism and increased turnover.

Emerging research suggests burnout might be better classified as a chronic condition because only about one-third of afflicted physicians ever fully recover from severe burnout, and it typically takes five to 10 years to do so, according to a 2015 article published in the Journal of Hospital Administration. Thus, the urgent need to identify and address factors that contribute to burnout cannot be overstated.

However, many well-intentioned health system administrators and physician leaders have failed to accurately measure and confront the rising epidemic. The reason stems from the way some surveys define and measure burnout.    

Burnout, defined 

The prevalence of burnout has made the term ubiquitous — so much so that "burnout" is often used inappropriately and its true meaning is obscured. High stress alone doesn't equate to burnout, for example, nor does physical exhaustion, though both of these are contributing factors.

Social psychologists Christina Maslach, PhD, and Michael Leiter, PhD, professors of psychology at UC Berkeley and Wolfville, Canada-based Acadia University, respectively, are considered the pioneers of organizational burnout research. They define people's relationships with their work as a "continuum between the negative experience of burnout and the positive experience of engagement," according to their jointly authored article, "Early Predictors of Job Burnout and Engagement."

In effect, burnout and engagement are opposites. There are three interrelated dimensions of the burnout-engagement continuum, according to Drs. Maslach and Leiter: exhaustion-energy, cynicism-involvement and inefficacy-efficacy.

The exhaustion factor represents the basic overexertion component of burnout: "It refers to feelings of being overextended and depleted of one's emotional and physical resources," the authors state.

Cynicism, also referred to as depersonalization, is the "interpersonal context dimension of burnout and refers to a negative, callous or excessively detached response to various aspects of the job." Finally, inefficacy, or the feeling of diminished accomplishment, refers to the self-evaluation dimension of burnout and includes feelings of incompetence and lack of productivity in one's work.

On the opposite end of the continuum, the positive components of each dimension of burnout together produce engagement, which Drs. Maslach and Leiter define as "an energetic state of involvement with personally fulfilling activities that enhance one's sense of professional efficacy."

Exhaustion is the most widely researched and reported component of burnout and is likely the one most people think when they hear the term. However, exhaustion alone fails to address various critical aspects of the relationships people have with their jobs, according to Drs. Maslach and Leiter. They state: "Exhaustion is not something that is simply experienced — rather, it prompts actions to distance oneself emotionally and cognitively from one's work, presumably as a way to cope with work overload."

It's important to note one need not experience all three components of burnout to be at risk for the condition: "It is reasonable to assume that the appearance of high scores on one dimension of burnout, but not the others, could be an early warning sign of impending problems," Drs. Maslach and Leiter write. In particular, exhaustion and cynicism are the two primary measures of burnout because they tend to both be present in those who are burned out and tend to fade away in those who are engaged. According to Drs. Maslach and Leiter, exhaustion and cynicism often mutually reinforce each other, with a sense of inefficacy arising as a result.

Measuring burnout: Why some assessments fail

The practical significance of understanding the burnout-engagement continuum, according to Drs. Maslach and Leiter, is that engagement is the main objective of any burnout intervention. But before hospital leaders can develop and implement an intervention, they must first accurately assess the problem.

This is where many organizations — including consultancies — get tripped up. With the understanding that burnout and engagement operate on a continuum, some leaders reason that they can use engagement surveys to deduce burnout levels.

For many years, this was the case at Roanoke, Va.-based Carilion Clinic. The nonprofit health system, which employs 685 physicians across 240 practice sites, has administered a variety of engagement evaluations over the last several years, including proprietary surveys from healthcare and workplace consulting firms. The results of these surveys indicated Carilion's physicians were highly engaged, but the results of the recently administered Maslach Burnout Inventory — which is recognized as the leading measure of burnout — revealed 59 percent were burned out. A burnout rate of more than half raised serious concerns among the health system's leaders, as well as confusion.

"Imagine our surprise when our physician scores on the [Great Place to Work] survey were very high — almost in the category to qualify as a Great Place to Work," Patrice Weiss, MD, CMO at Carilion Clinic, wrote in an email. "The [physician burnout] data were amazing. So of course we are trying to reconcile these seemingly contradictory results."

Actually, the discrepancy is not indicative of a contradiction; rather, it illuminates an issue with the way some engagement surveys are used. Mainly, the engagement surveys Carilion administered do not measure engagement as defined by Drs. Maslach and Leiter — the intersection of energy, involvement and efficacy — which represents the functional opposite of burnout. If they had, it might be possible to accurately estimate general burnout levels based on their results. Instead, the surveys that were used measure satisfaction with the specific organization as a work environment and physicians' commitment to its mission.

"When you look at how engagement is being used in all of the employee engagement surveys, they are talking about something completely different" than how Dr. Maslach defines it, says Mark Greenawald, MD, vice chair for academic affairs of the Carilion Clinic Department of Family and Community Medicine and chair of the Carilion Professional Well-Being Committee. "They are using that same word, 'engagement,' but what they're talking about is engagement with the mission of the organization. They're asking — on a more superficial level — 'Do you like what you do?' and 'Are you satisfied at work?' and 'Would you recommend this job to your friends as a great place to work?'"

Even though they are called "engagement surveys," these questions measure one's level of commitment to the organization and satisfaction with the work environment, which do not cumulatively produce engagement. Respondents that are actually burned out might respond positively to questions such as these, which would lead to high scores and, as a result, conceal true burnout levels.

How to select surveys that accurately measure engagement and burnout

Engagement surveys that are not psychometrically validated — meaning they are not developed based on the definition of engagement that was established by Drs. Maslach and Leiter and verified by research — cannot be used as a de facto measure of burnout, according to Monique Valcour, PhD, an executive coach, keynote speaker, management professor and contributor to the Harvard Business Review.

"What people do in companies to measure [burnout and engagement] often diverges pretty far from the definitions that have been established in research," says Dr. Valcour.

"We see this a lot with engagement. Companies put together their own surveys and create their own questions."

This is not to say that different types of employee engagement surveys don't yield valuable insight. However, it is important to understand exactly what each survey actually measures.

"It depends what the organization's purpose is," says Dr. Valcour. "Most organizations are interested in promoting a work environment that helps to motivate their employees and to facilitate everyone's performance and well-being."

If health system leaders aim to know how satisfied their physicians are with the organization and their particular work environment, then surveys that measure job satisfaction, commitment and alignment with the organization will be useful.

If a hospital's objective is to accurately diagnose the rate of physician burnout so they can intervene appropriately, their best bet is to administer both engagement and burnout surveys, and not rely on the results of engagement surveys alone to suggest the rate of burnout.  

According to Dr. Greenawald, hospital administrators tend to favor administering engagement surveys over burnout surveys because the results are less explicitly negative; mediocre engagement scores don't seem as bad as high burnout scores. However, if health system leaders truly want to help solve the problem, both engagement and burnout surveys should be used.

When it comes to selecting surveys, Dr. Valcour suggests administrators "choose one that is psychometrically validated and be a discerning consumer of surveys. If you are using a consultancy firm, ask them specifically how they developed the measure and if it is validated," she says. "Lots of consultants who are putting together these measures typically don't have the expertise to do so. The results you get back may not be measuring what you think."

She suggests using the Maslach Burnout Inventory. Developed by Drs. Maslach, Leiter and other colleagues, the MBI is validated by 25 years' worth of research and is recognized as the leading measure of burnout. It surveys respondents on the three burnout components — exhaustion, cynicism and inefficacy — to provide a comprehensive and accurate burnout assessment.

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