Assessment of Adverse Childhood Experiences, Adverse Professional Experiences, Depression, and Burnout in US Physicians.

OBJECTIVE: To assess associations of adverse childhood experiences (ACEs) and adverse occupational experiences (AOEs) with depression and burnout in US physicians. PARTICIPANTS AND METHODS: We performed a secondary analysis of data from a representative sample survey of US physicians conducted between November 20, 2020, and March 23, 2021, and from a probability-based sample of other US workers. The ACEs, AOEs, burnout, and depression were assessed using previously published measures. RESULTS: Analyses included data from 1125 of the 3671 physicians (30.6%) who received a mailed survey and 6235 of 90,000 physicians (6.9%) who received an electronic survey. The proportion of physicians age 29-65 who had lived with a family member with substance misuse during childhood (673 of 5039[13.4%]) was marginally lower (P <.001) than that of workers in other professions (448 of 2505 [17.9%]). The proportion of physicians age 29-65 who experienced childhood emotional abuse (823 of 5038 [16.3%]) was similar to that of workers in other professions (406 of 2508 [16.2%]). The average physician depression T-score was 49.60 (raw score ± SD, 6.48±3.15), similar to the normed US average. The AOEs were associated with mild to severe depression, including making a recent significant medical error (odds ratio [OR], 1.64; 95% CI, 1.33 to 2.02, P<.001), being named in a malpractice suit (OR, 1.30; 95% CI, 1.07 to 1.59, P=.008), and experiencing one or more coronavirus disease 2019-related AOEs (OR, 1.76; 95% CI, 1.56 to 1.99, P<.001). Having one or more ACEs was associated with mild to severe depression (OR, 1.58; 95% CI, 1.38 to 1.79, P<.001). The ACEs, coronavirus disease 2019-related AOEs, and medical errors were also associated with burnout. CONCLUSION: Assessing ACEs and AOEs and implementing selective primary prevention interventions may improve population health efforts to mitigate depression and burnout in physicians.

Career Plans of US Physicians After the First 2 Years of the COVID-19 Pandemic.

OBJECTIVE: To assess the career plans of US physicians at the end of 2021 relative to 2011 and 2014. METHODS: Physicians in the United States were surveyed from December 9, 2021, to January 24, 2022, using methods similar to prior studies in 2011 and 2014. Responding physicians in active practice (n=1884) were included in the analysis. At all time-points, physicians indicated the likelihood they would (1) reduce clinical work hours in the next 12 months and (2) leave their current practice within 24 months. RESULTS: In 2021, 542 of 1344 (40.3%) indicated that it was "likely" or "definite" they would reduce clinical work hours in the next 12 months compared with 1120 of 6950 (16.1%) and 1275 of 6452 (19.8%) in 2011 and 2014. In 2021, 466 of 1817 (25.6%) indicated it was "likely" or "definite" they would leave their current practice in the next 24 months compared with 1284 of 6975 (18.4%) and 1726 of 6496 (26.6%) in 2011 and 2014. On multivariable analysis pooling responders from 2011, 2014, and 2021, physicians who responded in 2021 had higher odds of reporting intent to reduce clinical work hours compared with those who responded in 2014 (OR, 3.12; 95% CI, 2.73 to 3.57), whereas those responding in 2011 had lower odds relative to 2014 (OR, 0.81; 95% CI, 0.74 to 0.89). CONCLUSION: Roughly two of every five US physicians intend to reduce their clinical work hours in the next year, more than double previous rates. These findings have potentially profound implications for the adequacy of a US physician workforce already facing substantial shortages.

Politicization of Medical Care, Burnout, and Professionally Conflicting Emotions Among Physicians During COVID-19.

OBJECTIVE: To evaluate the association of politicization of medical care with burnout, professional fulfillment, and professionally conflicting emotions (eg, less empathy, compassion; more anger, frustration, resentment). PARTICIPANTS AND METHODS: Physicians in select specialties were surveyed between December 2021 and January 2022 using methods similar to our prior studies, with additional assessment of politicization of medical care; moral distress; and having had to compromise professional integrity, workload, and professionally conflicting emotions. RESULTS: In a sample of 2780 physicians in emergency medicine, critical care, noncritical care hospital medicine, and ambulatory care, stress related to politicization of medical care was reported by 91.8% of physicians. On multivariable analysis, compromised integrity (odds ratio [OR], 3.64; 95% CI, 2.31 to 5.98), moral distress (OR, 2.82; 95% CI, 2.16 to 3.68), and feeling more exhausted taking care of patients with coronavirus disease 2019 (COVID-19) (OR, 3.46; 95% CI, 2.63 to 4.54) were associated with burnout. Compromised integrity, moral distress, and feeling more exhausted taking care of patients with COVID-19 were also statistically significantly associated with lower odds of professional fulfillment and professionally conflicting emotions. Stress related to conversations about non-approved COVID-19 therapies (OR, 1.74; 95% CI, 1.08 to 2.89), patient resistance to mask wearing (OR, 1.84; 95% CI, 1.35 to 2.55), and working more hours due to COVID (OR, 0.66; 95% CI, 0.49 to 0.89) were associated with professionally conflicting emotions. CONCLUSION: Most physicians experienced intrusion of politics into medical care during the pandemic. These experiences are associated with professionally conflicting emotions, including less compassion and empathy, greater frustration, and resentment. COVID-19-related moral distress and compromised integrity were also associated with less professional fulfillment and greater occupational burnout.

At-Risk Work Hours Among U.S. Physicians and Other U.S. Workers.

INTRODUCTION: Systematic reviews by the WHO have shown an increased risk of morbidity and mortality related to ischemic heart disease and stroke among individuals working an average of ≥55 hours/week. METHODS: A cross-sectional survey of U.S. physicians and a probability-based sample of the general U.S. working population (n=2,508) was conducted between November 20, 2020, and February 16, 2021 (data analyzed in 2022). Among 3,617 physicians who received a mailed survey, 1,162 (31.7%) responded; among 90,000 physicians who received an electronic survey, 6,348 (7.1%) responded. Mean weekly work hours were assessed. RESULTS: The mean reported weekly work hours for physicians and U.S. workers in other fields were 50.8 hours and 40.7 hours, respectively (p<0.001). Less than 10% of U.S. workers in other fields (9.2%) reported working ≥55 hours/week compared with 40.7% of physicians. Although work hours decreased among physicians working less than full time, the decrease in work hours was smaller than the reported reduction in professional work effort. Specifically, for physicians who worked between half-time and full-time (i.e., full-time equivalent=50%-99%), work hours decreased by approximately 14% for each 20% reduction in full-time equivalent. On multivariable analysis of physicians and workers in other fields adjusting for age, gender, relationship status, and level of education, individuals with a professional/doctorate degree other than an MD/DO (OR=3.74; 95% CI=2.28, 6.09) and physicians (OR=8.62; 95% CI=6.44, 11.80) were more likely to work ≥55 hours/week. CONCLUSIONS: A substantial proportion of physicians have work hours previously shown to be associated with adverse personal health outcomes.

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic.

OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) in US physicians at the end of 2021, roughly 21 months into the COVID-19 pandemic, with comparison to 2020, 2017, 2014, and 2011. METHODS: Between December 9, 2021, and January 24, 2022, we surveyed US physicians using methods similar to those of our prior studies. Burnout, WLI, depression, and professional fulfillment were assessed with standard instruments. RESULTS: There were 2440 physicians who participated in the 2021 survey. Mean emotional exhaustion and depersonalization scores were higher in 2021 than those observed in 2020, 2017, 2014, and 2011 (all P<.001). Mean emotional exhaustion scores increased 38.6% (2020 mean, 21.0; 2021 mean, 29.1; P<.001), whereas mean depersonalization scores increased 60.7% (2020 mean, 6.1; 2021 mean, 9.8; P<.001). Overall, 62.8% of physicians had at least 1 manifestation of burnout in 2021 compared with 38.2% in 2020, 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Although these trends were consistent across nearly all specialties, substantial variability by specialty was observed. Satisfaction with WLI declined from 46.1% in 2020 to 30.2% in 2021 (P<.001). Mean scores for depression increased 6.1% (2020 mean, 49.54; 2021 mean, 52.59; P<.001). CONCLUSION: A dramatic increase in burnout and decrease in satisfaction with WLI occurred in US physicians between 2020 and 2021. Differences in mean depression scores were modest, suggesting that the increase in physician distress was overwhelmingly work related. Given the association of physician burnout with quality of care, turnover, and reductions in work effort, these findings have profound implications for the US health care system.

Imposter Phenomenon in US Physicians Relative to the US Working Population.

OBJECTIVE: To determine the prevalence of imposter phenomenon (IP) experiences among physicians and evaluate their relationship to personal and professional characteristics, professional fulfillment, burnout, and suicidal ideation. PARTICIPANTS AND METHODS: Between November 20, 2020, and February 16, 2021, we surveyed US physicians and a probability-based sample of the US working population. Imposter phenomenon was measured using a 4-item version of the Clance Imposter Phenomenon Scale. Burnout and professional fulfillment were measured using standardized instruments. RESULTS: Among the 3237 physician responders invited to complete the subsurvey including the IP scale, 3116 completed the IP questions. Between 4% (133) and 10% (308) of the 3116 physicians endorsed each of the 4 IP items as a "very true" characterization of their experience. Relative to those with a low IP score, the odds ratio for burnout among those with moderate, frequent, and intense IP was 1.28 (95% CI, 1.04 to 1.58), 1.79 (95% CI, 1.38 to 2.32), and 2.13 (95% CI, 1.43 to 3.19), respectively. A similar association between IP and suicidal ideation was observed. On multivariable analysis, physicians endorsed greater intensity of IP than workers in other fields in response to the item, "I am disappointed at times in my present accomplishments and think I should have accomplished more." CONCLUSION: Imposter phenomenon experiences are common among US physicians, and physicians have more frequent experiences of disappointment in accomplishments than workers in other fields. Imposter phenomenon experiences are associated with increased burnout and suicidal ideation and lower professional fulfillment. Systematic efforts to address the professional norms and perfectionistic attitudes that contribute to this phenomenon are necessary.

Physicians' Experiences With Mistreatment and Discrimination by Patients, Families, and Visitors and Association With Burnout.

Importance: Burnout is common among physicians and is associated with suboptimal patient outcomes. Little is known about how experiences with patients, families, and visitors differ by physician characteristics or contribute to the risk of burnout. Objective: To examine the occurrence of mistreatment and discrimination by patients, families, and visitors by physician characteristics and the association between such interactions and experiencing burnout. Design, Setting, and Participants: This cross-sectional survey was conducted from November 20, 2020, to March 23, 2021, among US physicians. Exposures: Mistreatment and discrimination were measured using items adapted from the Association of American Medical College's Graduation Questionnaire with an additional item querying respondents about refusal of care because of the physicians' personal attributes; higher score indicated greater exposure to mistreatment and discrimination. Main Outcomes and Measures: Burnout as measured by the Maslach Burnout Inventory. Results: Of 6512 responding physicians, 2450 (39.4%) were female, and 369 (7.2%) were Hispanic; 681 (13.3%) were non-Hispanic Asian, Native Hawaiian, or Pacific Islander; and 3633 (70.5%) were non-Hispanic White individuals. Being subjected to racially or ethnically offensive remarks (1849 [29.4%]), offensive sexist remarks (1810 [28.7%]), or unwanted sexual advances (1291 [20.5%]) by patients, families, or visitors at least once in the previous year were common experiences. Approximately 1 in 5 physicians (1359 [21.6%]) had experienced a patient or their family refusing to allow them to provide care because of the physician's personal attributes at least once in the previous year. On multivariable analyses, female physicians (OR, 2.33; 95% CI, 2.02-2.69) and ethnic and racial minority physicians (eg, Black or African American: OR, 1.59; 95% CI, 1.13-2.23) were more likely to report mistreatment or discrimination in the previous year. Experience of mistreatment or discrimination was independently associated with higher odds of burnout (vs score of 0 [no mistreatment], score of 1: OR, 1.27; 95% CI, 1.04-1.55; score of 2: OR, 1.70; 95% CI, 1.38-2.08; score of 3: OR, 2.20; 95% CI, 1.89-2.57). There was no difference in the odds of burnout by gender after controlling for experiencing mistreatment and discrimination score and other demographic factors, specialty, practice setting, work hours, and frequency of overnight call. Conclusions and Relevance: In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct.

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2020.

OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life integration (WLI) among physicians and US workers in 2020 relative to 2011, 2014, and 2017. METHODS: Between November 20, 2020, and March 23, 2021, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our prior studies. Burnout and WLI were measured using standard tools. Information about specific work-related COVID-19 experiences was collected. RESULTS: There were 7510 physicians who participated in the survey. Nonresponder analysis suggested that participants were representative of US physicians. Mean emotional exhaustion and depersonalization scores were lower in 2020 than in 2017, 2014, and 2011 (all P<.001). However, emotional exhaustion and depersonalization scores did not improve in specialties most heavily affected by COVID-19. Overall, 38.2% of physicians reported 1 or more symptoms of burnout in 2020 compared with 43.9% in 2017, 54.4% in 2014, and 45.5% in 2011 (all P<.001). Providing care without adequate personal protective equipment (odds ratio [OR], 1.53; 95% CI, 1.35 to 1.72) and having suffered disruptive economic consequences due to COVID-19 (OR, 1.49; 95% CI, 1.32 to 1.69) were independently associated with risk of burnout. On multivariable analysis, physicians were at increased risk for burnout (OR, 1.41; 95% CI, 1.25 to 1.58) and were less likely to be satisfied with WLI (OR, 0.71; 95% CI, 0.64 to 0.79) than other working US adults. CONCLUSION: Burnout and satisfaction with WLI among US physicians improved between 2017 and 2020. The impact of the COVID-19 pandemic on physicians varies on the basis of professional characteristics and experiences. Physicians remain at increased risk for burnout relative to workers in other fields.

Suicidal Ideation and Attitudes Regarding Help Seeking in US Physicians Relative to the US Working Population.

OBJECTIVE: To evaluate the prevalence of suicidal ideation (SI) and attitudes regarding help seeking among US physicians relative to the general US working population. PARTICIPANTS AND METHODS: A secondary analysis of a cross-sectional survey of US physicians and a probability-based sample of the US working population was conducted between October 12, 2017, and March 15, 2018. Among 30,456 invited physicians, 5197 (17.1%) completed the primary survey. Suicidal ideation in the last year, attitudes regarding help seeking, symptoms of depression, and burnout were assessed by standardized questions. RESULTS: Among the 4833 physicians who responded regarding SI, 316 (6.5%) reported having suicidal thoughts in the last 12 months. Most physicians (3527 [72.9%]) reported that they would seek professional help if they had a serious emotional problem. Physicians with SI were less likely to report that they would seek help (203/316 [64.2%]) than physicians without SI (3318/4517 [73.5%]; P=.001). On multivariable analysis, symptoms of depression (odds ratio [OR], 4.42; 95% CI, 1.89 to 11.52), emotional exhaustion (OR, 1.07 each 1-point increase; 95% CI, 1.03 to 1.11), and self-valuation (OR, 0.84 each 1-point increase; 95% CI, 0.70 to 0.99) were associated with SI. Among individuals aged 29 to 65 years, physicians were more likely than workers in other fields to report SI (7.1% vs 4.3%; P<.001), a finding that persisted on multivariable analysis. CONCLUSION: In this national study conducted before the COVID-19 pandemic, 1 in 15 US physicians had thoughts of taking their own life in the last year, which exceeded the prevalence of SI among US workers in other fields.

Self-Valuation Challenges in the Culture and Practice of Medicine and Physician Well-being.

OBJECTIVE: To compare physicians with workers in other fields on measures of self-valuation (SV) and determine the effect of adjusting for SV on the relationship between being a physician and risk for burnout. PATIENTS AND METHODS: A random sample of physicians from the American Medical Association Physician Masterfile and a probability sample from the general US population were used. Data were collected for this cross-sectional study between October 12, 2017 and March 15, 2018. Burnout was indicated by a score of 27 or higher on Emotional Exhaustion or 10 or higher on Depersonalization, using the Maslach Burnout Inventory. Self-valuation was measured with Self-valuation Scale items. RESULTS: Physicians (248/832=29.8%) more than workers in other fields (1036/5182=20.0%) "often" or "always" felt more self-condemnation than self-encouragement to learn from the experience when they made a mistake. Physicians (435/832=52.3%) more than workers in other fields (771/5182=14.9%) "often" or "always" put off taking care of their own health due to time pressure. Physicians had greater odds of burnout before (odds ratio [OR], 1.51; 95% CI, 1.30 to 1.76) but not after adjusting for SV responses (OR, 0.93; 95% CI, 0.78 to 1.11). After adjustment for SV, work hours, sex, and age, physicians had lower odds of burnout than workers in other fields (OR, 0.82; 95% CI, 0.68 to 0.99). CONCLUSION: Self-valuation is lower in physicians compared with workers in other fields and adjusting for SV eliminated the association between being a physician and higher risk for burnout. Experimental design research is needed to determine whether the association of SV with burnout is causal and the degree to which SV is malleable to intervention at individual, organization, and professional culture levels.

Physician Task Load and the Risk of Burnout Among US Physicians in a National Survey.

BACKGROUND: Cognitive task load can affect providers' ability to perform their job well and may contribute to burnout. METHODS: The researchers evaluated whether task load, measured by the National Aeronautics and Space Administration (NASA) Task Load Index (TLX), correlated with burnout scores in a large national study of US physicians between October 2017 and March 2018 with a 17.1% response rate. Burnout was measured using the Emotional Exhaustion and Depersonalization scales of the Maslach Burnout Inventory, and a high score on either score was considered a manifestation of professional burnout. The NASA-TLX was chosen to evaluate physician task load (PTL) due to its robust validation and use across many industries, including health care, over the past 30 years. The domains included in the PTL were mental, physical, and temporal demands, and perception of effort. RESULTS: Mean score in task load dimension varied by specialty. In aggregate, high emotional exhaustion, depersonalization, and one symptom of burnout was seen in 38.8%, 27.4%, and 44.0% of participants, respectively. The mean PTL score was 260.9/400 (standard deviation = 71.4). The specialties with the highest PTL score were emergency medicine, urology, anesthesiology, general surgery subspecialties, radiology, and internal medicine subspecialties. A dose response relationship between PTL and burnout was observed. For every 40-point (10%) decrease in PTL there was 33% lower odds of experiencing burnout (odds ratio = 0.67, 95% confidence interval = 0.65-0.70, p < 0.0001). CONCLUSION: The relationship between PTL and burnout may suggest areas of particular focus to improve the practice environment and reduce physician burnout.

Burnout, Depression, Career Satisfaction, and Work-Life Integration by Physician Race/Ethnicity.

Importance: Previous research suggests that the prevalence of occupational burnout varies by demographic characteristics, such as sex and age, but the association between physician race/ethnicity and occupational burnout is less well understood. Objective: To investigate possible differences in occupational burnout, depressive symptoms, career satisfaction, and work-life integration by race/ethnicity in a sample of US physicians. Design, Setting, and Participants: In this cross-sectional study, data for this secondary analysis of 4424 physicians were originally collected from a cross-sectional survey of US physicians between October 12, 2017, and March 15, 2018. The dates of analysis were March 8, 2019, to May 21, 2020. Multivariable logistic regression, including statistical adjustment for physician demographic and clinical practice characteristics, was performed to examine the association between physician race/ethnicity and occupational burnout, depressive symptoms, career satisfaction, and work-life integration. Exposures: Physician demographic and clinical practice characteristics included race/ethnicity, sex, age, clinical specialty, hours worked per week, primary practice setting, and relationship status. Main Outcomes and Measures: Physicians with a high score on the emotional exhaustion or depersonalization subscale of the Maslach Burnout Inventory were classified as having burnout. Depressive symptoms were measured using the Primary Care Evaluation of Mental Disorders instrument. Physicians who marked "strongly agree" or "agree" in response to the survey items "I would choose to become a physician again" and "My work schedule leaves me enough time for my personal/family life" were considered to be satisfied with their career and work-life integration, respectively. Results: Data were available for 4424 physicians (mean [SD] age, 52.46 [12.03] years; 61.5% [2722 of 4424] male). Most physicians (78.7% [3480 of 4424]) were non-Hispanic White. Non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic Black physicians comprised 12.3% (542 of 4424), 6.3% (278 of 4424), and 2.8% (124 of 4424) of the sample, respectively. Burnout was observed in 44.7% (1540 of 3447) of non-Hispanic White physicians, 41.7% (225 of 540) of non-Hispanic Asian physicians, 38.5% (47 of 122) of non-Hispanic Black physicians, and 37.4% (104 of 278) of Hispanic/Latinx physicians. The adjusted odds of burnout were lower in non-Hispanic Asian physicians (odds ratio [OR], 0.77; 95% CI, 0.61-0.96), Hispanic/Latinx physicians (OR, 0.63; 95% CI, 0.47-0.86), and non-Hispanic Black physicians (OR, 0.49; 95% CI, 0.30-0.79) compared with non-Hispanic White physicians. Non-Hispanic Black physicians were more likely to report satisfaction with work-life integration compared with non-Hispanic White physicians (OR, 1.69; 95% CI, 1.05-2.73). No differences in depressive symptoms or career satisfaction were observed by race/ethnicity. Conclusions and Relevance: Physicians in minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic White physicians. Future research is necessary to confirm these results, investigate factors contributing to increased rates of burnout among non-Hispanic White physicians, and assess factors underlying the observed patterns in measures of physician wellness by race/ethnicity.

Resilience and Burnout Among Physicians and the General US Working Population.

Importance: The prevalence of physician burnout is well documented, and resilience training has been proposed as an option to support physician well-being. However, the resilience of physicians compared with that of the US working population is not established, and the association between resilience and physician burnout is not well understood. Objectives: To evaluate resilience among physicians and US workers, and to determine the association between resilience and burnout among US physicians. Design, Setting, and Participants: A cross-sectional national survey study of 5445 US physicians and a probability-based sample of 5198 individuals in the US working population was conducted between October 12, 2017, and March 15, 2018. Main Outcomes and Measures: Resilience was measured using the 2-item Connor-Davidson Resilience Scale (total scores range from 0-8; higher scores indicate greater resilience); burnout was measured using the full Maslach Burnout Inventory with overall burnout indicated by a score of at least 27 on the 0 to 54 emotional exhaustion subscale and/or at least 10 on the depersonalization subscale (higher scores indicate greater burnout). Results: Of 30 456 physicians who received an invitation to participate, 5445 (17.9%) completed surveys (2995 men [62.1%]; median [IQR] age of 53 [42-62] years). In multivariable analysis, mean (SD) resilience scores were higher among physicians than the general employed population (6.49 [1.30] vs 6.25 [1.37]; adjusted mean difference, 0.25 points; 95% CI, 0.19-0.32; P < .001). Among physicians, resilience was associated with burnout. Physicians without overall burnout had higher mean (SD) resilience scores than physicians with burnout (6.82 [1.15] vs 6.13 [1.36]; adjusted mean difference, 0.68 points, 95% CI, 0.61-0.76; P < .001). Each 1-point increase in resilience score was associated with 36% lower odds of overall burnout (odds ratio, 0.64; 95% CI, 0.60-0.67; P < .001). However, 392 of 1350 physicians (29%) with the highest possible resilience score had burnout. Conclusions and Relevance: The findings of this national survey study suggest that physicians exhibited higher levels of resilience than the general working population in the US. Resilience was inversely associated with burnout symptoms, but burnout rates were substantial even among the most resilient physicians. Additional solutions, including efforts to address system issues in the clinical care environment, are needed to reduce burnout and promote physician well-being.

Disparities in Burnout and Satisfaction With Work-Life Integration in U.S. Physicians by Gender and Practice Setting.

PURPOSE: To explore the interaction between practice setting (academic practice [AP], private practice [PP]) and gender in relation to physician burnout and satisfaction with work-life integration (WLI). METHOD: In 2017, the authors administered a cross-sectional survey of U.S. physicians and characterized rates of burnout and satisfaction with WLI using previously validated and/or standardized tools. They conducted multivariable logistic regression to determine the interaction between the included variables. RESULTS: Of the 3,603 participants in the final analysis, female physicians reported a higher prevalence of burnout than male physicians in both AP (50.7% vs 38.2%, P < .0001) and PP (48.1% vs 40.7%, P = .001). However, the multivariable analysis found no statistically significant gender-based differences in burnout (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.76-1.17, P = .60). Women and men in AP were less likely to report burnout than men in PP (OR 0.70, 95% CI 0.52-0.94, P = .01 and OR 0.69, 95% CI 0.53-0.90, P < .01, respectively); women in PP did not report different burnout rates from men in PP (OR 0.89, 95% CI 0.68-1.16, P = .38). Women in both AP and PP were less likely to be satisfied with WLI than men in PP (OR 0.62, 95% CI 0.47-0.83, P < .01 and OR 0.75, 95% CI 0.58-0.97, P = .03, respectively); men in AP did not report different satisfaction with WLI than men in PP (OR 1.05, 95% CI 0.82-1.33, P = .71). CONCLUSIONS: Gender differences in rates of burnout are related to practice setting and other differences in physicians' personal and professional lives. These results highlight the complex relationships among gender, practice setting, and other personal and professional factors in their influence on burnout and satisfaction with WLI.

Relationship Between Burnout, Professional Behaviors, and Cost-Conscious Attitudes Among US Physicians.

BACKGROUND: Despite the importance of professionalism, little is known about how burnout relates to professionalism among practicing physicians. OBJECTIVE: To evaluate the relationship between burnout and professional behaviors and cost-conscious attitudes. DESIGN AND PARTICIPANTS: Cross-sectional study in a national sample of physicians of whom a fourth received a sub-survey with items exploring professional behaviors and cost-conscious attitudes. Responders who were not in practice or in select specialties were excluded. MEASURES: Maslach Burnout Inventory and items on professional behaviors and cost-conscious attitudes. KEY RESULTS: Among those who received the sub-survey 1008/1224 (82.3%) responded, and 801 were eligible for inclusion. Up to one third of participants reported engaging in unprofessional behaviors related to administrative aspects of patient care in the last year, such as documenting something they did not do to close an encounter in the medical record (243/759, 32.0%). Fewer physicians reported other dishonest behavior (e.g., claiming unearned continuing medical education credit; 40/815, 4.9%). Most physicians endorsed cost-conscious attitudes with over 75% (618/821) agreeing physicians have a responsibility to try to control health-care costs and 62.9% (512/814) agreeing that cost to society is important in their care decisions regarding use of an intervention. On multivariable analysis adjusting for personal and professional characteristics, burnout was independently associated with reporting 1 or more unprofessional behaviors (OR 2.01, 95%CI 1.47-2.73, p < 0.0001) and having less favorable cost-conscious attitudes (difference on 6-24 scale - 0.90, 95%CI - 1.44 to - 0.35, p = 0.001). CONCLUSIONS: Professional burnout is associated with self-reported unprofessional behaviors and less favorable cost-conscious attitudes among physicians.

The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians.

OBJECTIVE: To describe and benchmark physician-perceived electronic health record (EHR) usability as defined by a standardized metric of technology usability and evaluate the association with professional burnout among physicians. PARTICIPANTS AND METHODS: This cross-sectional survey of US physicians from all specialty disciplines was conducted between October 12, 2017, and March 15, 2018, using the American Medical Association Physician Masterfile. Among the 30,456 invited physicians, 5197 (17.1%) completed surveys. A random 25% (n=1250) of respondents in the primary survey received a subsurvey evaluating EHR usability, and 870 (69.6%) completed it. EHR usability was assessed using the System Usability Scale (SUS; range 0-100). SUS scores were normalized to percentile rankings across more than 1300 previous studies from other industries. Burnout was measured using the Maslach Burnout Inventory. RESULTS: Mean ± SD SUS score was 45.9±21.9. A score of 45.9 is in the bottom 9% of scores across previous studies and categorized in the "not acceptable" range or with a grade of F. On multivariate analysis adjusting for age, sex, medical specialty, practice setting, hours worked, and number of nights on call weekly, physician-rated EHR usability was independently associated with the odds of burnout with each 1 point more favorable SUS score associated with a 3% lower odds of burnout (odds ratio, 0.97; 95% CI, 0.97-0.98; P<.001). CONCLUSION: The usability of current EHR systems received a grade of F by physician users when evaluated using a standardized metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed.

The complex case of EHRs: examining the factors impacting the EHR user experience.

Physicians can spend more time completing administrative tasks in their electronic health record (EHR) than engaging in direct face time with patients. Increasing rates of burnout associated with EHR use necessitate improvements in how EHRs are developed and used. Although EHR design often bears the brunt of the blame for frustrations expressed by physicians, the EHR user experience is influenced by a variety of factors, including decisions made by entities other than the developers and end users, such as regulators, policymakers, and administrators. Identifying these key influences can help create a deeper understanding of the challenges in developing a better EHR user experience. There are multiple opportunities for regulators, policymakers, EHR developers, payers, health system leadership, and users each to make changes to collectively improve the use and efficacy of EHRs.

Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017.

OBJECTIVE: To evaluate the prevalence of burnout and satisfaction with work-life integration among physicians and other US workers in 2017 compared with 2011 and 2014. PARTICIPANTS AND METHODS: Between October 12, 2017, and March 15, 2018, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our 2011 and 2014 studies. A secondary survey with intensive follow-up was conducted in a sample of nonresponders to evaluate response bias. Burnout and work-life integration were measured using standard tools. RESULTS: Of 30,456 physicians who received an invitation to participate, 5197 (17.1%) completed surveys. Among the 476 physicians in the secondary survey of nonresponders, 248 (52.1%) responded. A comparison of responders in the 2 surveys revealed no significant differences in burnout scores (P=.66), suggesting that participants were representative of US physicians. When assessed using the Maslach Burnout Inventory, 43.9% (2147 of 4893) of the physicians who completed the MBI reported at least one symptom of burnout in 2017 compared with 54.4% (3680 of 6767) in 2014 (P<.001) and 45.5% (3310 of 7227) in 2011 (P=.04). Satisfaction with work-life integration was more favorable in 2017 (42.7% [2056 of 4809]) than in 2014 (40.9% [2718 of 6651]; P<.001) but less favorable than in 2011 (48.5% [3512 of 7244]; P<.001). On multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians were at increased risk for burnout (odds ratio, 1.39; 95% CI, 1.26-1.54; P<.001) and were less likely to be satisfied with work-life integration (odds ratio, 0.77; 95% CI, 0.70-0.85; P<.001) than other working US adults. CONCLUSION: Burnout and satisfaction with work-life integration among US physicians improved between 2014 and 2017, with burnout currently near 2011 levels. Physicians remain at increased risk for burnout relative to workers in other fields.

Effect of Organization-Directed Workplace Interventions on Physician Burnout: A Systematic Review.

To assess the impact of organization-directed workplace interventions on physician burnout, including stress or job satisfaction in all settings, we conducted a systematic review of the literature published from January 1, 2007, to October 3, 2018, from multiple databases. Manual searches of grey literature and bibliographies were also performed. Of the 633 identified citations, 50 met inclusion criteria. Four unique categories of organization-directed workplace interventions were identified. Teamwork involved initiatives to incorporate scribes or medical assistants into electronic health record (EHR) processes, expand team responsibilities, and improve communication among physicians. Time studies evaluated the impact of schedule adjustments, duty hour restrictions, and time-banking initiatives. Transitions referred to workflow changes such as process improvement initiatives or policy changes within the organization. Technology related to the implementation or improvement of EHRs. Of the 50 included studies, 35 (70.0%) reported interventions that successfully improved the 3 measures of physician burnout, job satisfaction, and/or stress. The largest benefits resulted from interventions that improved processes, promoted team-based care, and incorporated the use of scribes/medical assistants to complete EHR documentation and tasks. Implementation of EHR interventions to improve clinical workflows worsened burnout, but EHR improvements had positive effects. Time interventions had mixed effects on burnout. The results of our study suggest that organization-directed workplace interventions that improve processes, optimize EHRs, reduce clerical burden by the use of scribes, and implement team-based care can lessen physician burnout. Benefits of process changes can enhance physician resiliency, augment care provided by the team, and optimize the coordination and communication of patient care and health information.