Why are ob/gyns burning out?

February 22, 2016

Issues with work-life balance, reimbursement, and time are contributors.

 

Dr Cass is Vice Chair and Clinical Professor, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California. She is also a member of the Contemporary OB/GYN editorial board.

Dr Duska is Professor, Obstetrics and Gynecology, Division of Gynecologic Oncology, Fellowship Director, Gynecologic Oncology, and Associate Dean for Clinical Research, University of Virginia School of Medicine, Charlottesville.

 

A career in obstetrics and gynecology is both enormously gratifying and demanding. The combination of long and unpredictable hours, high-stakes decision-making, and associated liability issues can take a toll on ob/gyns. With the current uncertainty about how healthcare reform will modify reimbursement and healthcare delivery, ob/gyns often feel overwhelmed and are at high risk of burnout. Burnout is a critical issue for us to acknowledge and address, because we are at risk of losing providers and perhaps even our ability to continue to provide women with excellent care.

We hear a lot about burnout: on social media, on popular websites, and in the popular press. But what exactly is it and how can it be objectively assessed? Burnout is a triad defined by any of the following 3 elements: lack of enthusiasm for work, skepticism and distrust, and low sense of personal accomplishment. Objectively, burnout can be measured by the Maslach Burnout Inventory, a valid and reliable tool that assesses 3 domains: emotional exhaustion, depersonalization, and low personal accomplishment. The syndrome of burnout is present if at least 1 of these elements is significantly abnormal.1

It has been estimated that half of all medical students, residents, and attending physicians experience burnout, and that healthcare providers suffer more burnout than other American workers.2,3 Unfortunately, ob/gyns are at particularly high risk. One large study of more than 12,000 physicians compared career satisfaction among specialties, and ranked obstetrics and gynecology 30th out of 31 specialties in terms of career satisfaction leading to significant professional distress.4 Two large studies-a 2014 survey of 369 members of the Society of Gynecologic Oncologists (SGO) and a 2008 survey of 7900 members of the American College of Surgeons (ACS)-established the high prevalence of burnout in gynecologic oncologists and surgeons, affecting 32%–40% of responders, respectively.5,6

 

 

Data show that burnout in our specialty is increasing, and not surprisingly is associated with a decline in satisfaction with work-life balance.7,8 Unfortunately, the outlook for burnout among ob/gyn trainees is no better. Two different surveys of residency programs from around the country found that 50%–89% of residents had burnout and that it was significantly associated with career choice dissatisfaction and depression.9,10

Why is burnout increasing, particularly in our specialty? One important factor relates to the recent changes in healthcare delivery in the United States. More than 900 readers responded to the first annual Labor Force survey in the January 2016 issue of Contemporary OB/GYN. Sixty-two percent reported that they were less optimistic about their future. They attributed this mostly to healthcare reform, inadequate reimbursement, insufficient time with patients, and electronic medical records. The majority of responders said that both their workload and stress levels had increased in the past year. More time spent on administrative tasks, ineffective or burdensome technology, and increased patient volume were cited as the principal causes of increased work stress.

Notably, only 32% of the respondents reported being satisfied with their job situation, whereas 37% reported being somewhat dissatisfied, and 20% reported being very dissatisfied. Not surprisingly, 40% of respondents reported that they are considering a job change in the next 12 months, and another 20% had transitioned to part-time, both groups driven primarily by a desire to achieve a better work-life balance.11

Notably for the ob/gyn workforce, female gender and younger age are consistently cited as risk factors for physician burnout. A recent study of more than 7000 US physicians assessed work-home conflict in dual-career relationships and found that female physicians were 60% more likely than male physicians to report signs or symptoms of burnout.12 Female ob/gyns tend to take more time away from clinical practice to care for their families than do their male partners.13 One study found that up to 23% of female ob/gyns younger than age 40 had reduced their work hours or had taken extended periods of time off compared to just 5% of their male counterparts.14

The changing demographics of ob/gyn residencies, with women making up more than 80% of graduating classes each year, make these issues particularly relevant to our profession.

Why is it important that we as a specialty address burnout? The consequences of burnout extend beyond the individual physician, affecting patient care and eroding our profession. Burned-out physicians have higher rates of mental illness, substance abuse, and suicide. Unfortunately, studies show that physicians are not likely to ask for assistance with either depression or substance abuse problems, possibly because of fear of professional exposure.15-17 Additionally, burned-out physicians are less likely to comply with age- and sex-appropriate healthcare screening guidelines for themselves, to employ personal wellness promotion strategies, or to adhere to Centers for Disease Control and Prevention recommendations for aerobic exercise.18

 

 

Physician burnout also negatively affects patient care; it is related to suboptimal patient outcomes, as well as increases in medical errors (among attending physicians and those in training), liability claims, and inappropriate prescriptions.19-21 Patient satisfaction is also negatively affected by physician burnout. Patients of physicians with high emotional exhaustion and high depersonalization had significantly lower satisfaction scores compared with patients of physicians with low exhaustion and low depersonalization, respectively.21 Physicians suffering from burnout also have higher referral rates, which may be a surrogate marker for overuse of resources leading to unnecessary interventions for patients and increased costs.22

Finally, the ramifications of burnout for society as a whole are significant. Physician burnout is associated with decreased career satisfaction, which can lead to lower productivity and efficiency. Dissatisfied physicians are more likely to change jobs or leave medicine altogether, thus increasing cost and contributing to physician shortages. The loss of highly trained physicians through early retirement as well as the loss of productivity of dissatisfied physicians will place increasing burdens on our profession and the medical system.23 Finally, 400 physicians commit suicide annually, the equivalent of an entire medical school each year. This is a tremendous loss to society as we face potential doctor shortages in the future, as well as a loss of dollars and time invested in training.2,15

 

Possible solutions

Clearly, burnout is an important issue, worthy of investment in prevention strategies. The preponderance of data suggest that there are practical solutions. These solutions require frank discussions and a commitment of time and resources with and for our trainees and leadership. In the wake of the publication of the recent SGO survey, a wellness task force was created to promote physician wellbeing through seminars at the SGO annual meeting.5

The American College of Obstetricians and Gynecologists (ACOG) has recognized that ob/gyns have limitations and may need help navigating the waters of their highly rewarding but demanding careers. A clinical seminar on burnout will be held at the ACOG Annual Meeting in May 2016. Resources are also available on the ACOG website. We must also invest in further research into evidence-based solutions and commit to teaching our leaders (such as department chairs and national society leaders) strategies to recognize and address burnout. Left unchecked, physician burnout has the potential to compromise our careers and with it, our ability to care for our patients.

NEXT: Burnout in gynecologic oncology >>

 

 

 

References

1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422.

2.  Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general working population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600–1613.

3.  Dyrbye LN, Masie FS, Eacker A, et al. Relationship between burnout and professional conduct and attitiude among US medical students. JAMA. 2010;304(11):1173–1180.

4. Kravitz RL, Leigh JPL, Samules SJ, Schembri M, Gilbert WM. Tracking career satisfaction and perceptions of quality among US obstetricians and gynecologosts. Obstet Gynecol. 2003; 102(3):463–470.

5. Rath KS, Huffman LB, Phillips GS, Carpenter KM, Fowler JM. Burnout and associated factors among members of the Society of Gynecologic Oncology. AJOG. 2015;213(6):824.

6. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463–471.

7. American College of Obstetricians and Gynecologists. Survey finds burnout rate high among ob-gyns. http://www.acog.org/-/media/ACOG-Today/acogToday1005.pdf#page=5?la=en. October 2005. Accessed February 19, 2016.

8. Peckham C. Medscape surgery lifestyle report 2016: bias and burnout. http://www.medscape.com/features/slideshow/lifestyle/2016/general-surgery. Accessed February 19, 2016.

9. Becker JL, Milad MP, Klock SC. Burnout, depression and career satsifaction: Cross-sectional study of obsterics and gynecology residents. AJOG. 2006;195:1444–1449.

10. Govardhan LM, Pinelli V, Schnatz PF. Burnout, depression and job satsifaction in obstetrics and gynecology residents. Conn Med. 2012;76(7):389–395.

11. Your life, your work. Contemporary OB/GYN. 2016;61(1):18–26.

12. Dyrbye LN, Sotile W, Boone S, et al. A survey of U.S. physicians and their partners regarding the impact of work-home conflict. J Gen Intern Med. 2014;29(1):155–161.

13. Pearse WH, Haffner WH, Primack A. Effect of gender on the obstetric-gynecologic work force. Obstet Gynecol. 2001;97(5 Pt 1):794–797.

14. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007;109(4):949–955.

15. Shanafelt TD, Balch CM, Dyrbye LD, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146 (1):54–62.

16. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168–174.

17. Hughes PH, Brandenburg N, Baldwin DC, Jr., et al. Prevalence of substance use among US physicians. JAMA. 1992;267(17):2333–2339.

18. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: the personal health habits and wellness practices of US surgeons. Ann Surg. 2012;255(4):625–633.

19. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294–1300.

20. de Oliveira GS, Jr., Chang R, Fitzgerald PC, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg. 2013;117(1):182–193.

21. Anagnostopoulos F, Liolios E, Persefonis G, Slater J, Kafetsios K, Niakas D. Physician burnout and patient satisfaction with consultation in primary health care settings: evidence of relationships from a one-with-many design. J Clin Psychol Med Settings. 2012;19(4):401–410.

22. Kushnir T, Greenberg D, Madjar N, Hadari I, Yermiahu Y, Bachner YG. Is burnout associated with referral rates among primary care physicians in community clinics? Fam Pract. 2014;31(1):44–50.

23. Linzer M, Visser MR, Oort FJ, et al. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. 2001;111(2):170–175.