Health workforce brief

Health Workforce Brief
Patient & Peer Relationships
and Physician Burnout
Debra Street & Jeralynn S. Cossman
This is the third in a series of four Mississippi Center for Health Workforce Research Briefs on physician burnout. Data are from the Mississippi Workforce Study (2007/08 MSMD); over 1400 doctors licensed to practice in Mississippi (2006-07) responded to the 2007/08 MSMD survey. Data from physicians in active practice involving direct patient care who answered the questions on burnout (N=636) are analyzed in this brief. INTRODUCTION AND BACKGROUND
Physician burnout is a syndrome characterized by depersonalization (of patients, family, and friends), emotional exhaustion, and a reduced sense of accomplishment (Shanafelt, et al. 2002; Spickard 2002) that, if left unaddressed, can lead to decreased work effectiveness and abandoned medical careers. One recent national study estimated that around 22% of primary care physicians met at least some criteria for physician burnout (Linzer, et al., 2001). For physicians practicing in particular specialties, such as oncology, rates can be even higher (Allegra, et al.2005). Similar to the important influences of clients and peers in other professional realms (see, for example, Quinn, Anderson, and Finkelstein, 1998), the quality of patient and peer relationships are contextual factors that shape Mississippi physicians’ daily experiences of their medical roles. The depersonalization associated with burnout may reduce the perceived quality of peer and patient-provider relationships for physicians who experience burnout syndrome. Pressures generated by patient relationships or practice burdens can contribute to depersonalization (the inability to ful y empathize with patients and others) and emotional exhaustion (feeling and being overwhelmed). The depersonalization that accompanies physicians’ negative perceptions of patient relationships may place the delivery of high quality health care at risk. Conventional wisdom assumes that poorer quality relationships (peer and/or patient) may contribute to burnout. However, burned out physicians’ negative perception of relationship quality may result from their own harsh self-judgments. That may be a component of the occupational risk of setting unreasonably high standards that physicians then sometimes fail to attain (in their own judgment, although not necessarily the judgment of others), which contributes to burnout (Maslach and Leither, 1997). Feeling alienated from fellow professionals poses additional risks for burnout, providing a platform by which already stressed physicians may compare themselves unfavorably to their peers, magnifying tendencies towards a reduced sense of accomplishment—the sense that even high quality performance somehow fal s short of the mark. Negatively perceived patient and peer relationships, when unrelenting, can lead to higher levels of stress. This sets the stage for cascading risks of pressure towards depersonalization, emotional exhaustion and the reduced sense of accomplishment that together characterize physician burnout syndrome. This process of burnout may pose serious risks for a thriving Mississippi physician workforce if the syndrome is widespread.
DATA AND METHODS
A validated single measure of burnout (Rohland, Kruse and Rohrer, 2004) on the 2007/8 MSMD survey asked the “Please choose the single item that most closely represents how you feel: (1) I enjoy my work. I do not feel burned out. (2) Occasional y I am under stress, and I don’t always have as much energy as I once did. But, I don’t feel burned out. (3) I am definitely burning out and have one or more symptoms of burnout, such as physical or emotional exhaustion. (4) The symptoms of burnout that I’m experiencing won’t go away. I think about frustrations at work a lot. Or (5) I feel completely burned out and often wonder if I can go on. I am at the point where I may need to make some changes or may need to seek some sort of help.” The two highest burnout scores (symptoms won’t go away and feeling completely burned out) were combined into a single measure of persistent burnout. Respondents were then categorized by reported levels of burnout in their professional lives, ranging from (1) no burnout to (2) stressed [no burnout], (3) occasional burnout, or (4) persistent burnout. Among respondents to the MSMD 2007/08 survey, 19% of respondents reported occasional and 5% reported persistent burnout. Fifty-five percent of Mississippi’s felt stressed; only 20% experienced no burnout at all. We analyzed the association between burnout responses from the actively practicing physicians (N=633) who responded to that section of the 2007 MSMD survey alongside items measuring different aspects of physicians’ professional relationships. The first set of items measured agreement with statements used to assess the perceived quality of doctor-patient relationships: • I am overwhelmed by the needs of my patients. • My relationship with patients is more adversarial than it used to be. • Time pressures prevent me from developing good patient relationships. • I often feel like what I do for my patients is just a drop in the bucket. • I feel a strong personal connection to my patients. The second set of statements measured agreement with items designed to ascertain how Mississippi physicians with different burnout levels perceived their relationships with peers (fel ow physicians and col eagues). • My colleagues support my efforts to balance family and career responsibilities. • Many of my col eagues do not share my life experiences. • My physician colleagues are an important source of personal support. • My physician colleagues are a source of professional stimulation. • I wish there were more doctors like me in my practice. The association between burnout level and patient/peer relationship quality are depicted in Figure 1 and Figure 2, respectively. Higher average scores on the relationship items indicate higher levels of agreement with statements.
FINDINGS
Relationships with patients. Physicians Figure 1. Burnout and Patient Relationships
(occasional or persistent burnout) were much more likely to agree that patients’ medical interventions were “just a drop stressed physicians (no burnout or stressed). Items characterizing patients as developing good patient relationships.
more adversarial or perceiving a lack of time to build good patient relationships patients is just a drop in the bucket.
with physicians’ level of self-reported lowest level of burnout (no burnout or stressed) were most likely to disagree that Strongly Disagree=1 Strongly Agree=5
good patient relationships, while physicians with the highest levels of burnout (oc asional or persistent) were much more likely to agree with those statements. In contrast to these systematic differences in perceptions of patient relationships by burnout level, most Mississippi physicians who responded to the 2007/08 MSMD survey felt personal y connected to their patients, regardless of how much burnout they reported. Relationships with peers. There was little difference across burnout levels in whether, Figure 2. Burnout and Col eague Relationships
on average, physicians felt a need for “more doctors like me” in their practices (most agreed they would like more doctors like them), nor in whether they felt supported physicians with oc asional or persistent burnout were only slightly less likely than physicians experiencing no burnout at all or who were important source of personal support.
stressed to regard other physicians as (Figure 2). However, differences in other peer relationship items followed distinctive stressed or experiencing no burnout, physicians with persistent or occasional burnout were less Strongly Disagree=1 Strongly Agree=5
likely to say that peers supported their efforts to balance family and career responsibilities, shared similar life experiences, or to regard their physician col eagues as sources of professional stimulation.
IMPLICATIONS

Doctor-patient relationships have inevitable hierarchical qualities, while relationships with other physicians and
professional colleagues are more likely to be lateral peer relationships. This descriptive analysis of the MSMD 2008/08 data suggests that the hierarchical character of patient relationships may render them more vulnerable than peer relationships to the depersonalization component of physician burnout. The range of variation (from lowest levels of agreement to highest) by burnout category was greater across the patient measures than for the professional ones. Recent research has underscored ways that traditional doctor-patient relationships are evolving (Schneider, 1998), including the propensity for contemporary patients to be more demanding, informed consumers of health care than ever before (Rothman 2001). The temporal reality of rapid changes in healthcare relationships (Warren, Weitz, and Kulis 1998) suggests the need for “anti-burnout” strategies that are attentive to career stage of the physicians at risk, a potential direction for future research. Regardless of burnout level, Mississippi physicians in the study recognized that, while other doctors are not necessarily their mirror images, peers are nonetheless important sources of personal support. From this general vantage point, peer relationships differed little by burnout level. However, more specific components of peer relationships (support for work/life balance, professional stimulation, shared life experience) varied by burnout level, as physicians with persistent or occasional burnout differed substantially from their less beleaguered counterparts. Other research demonstrates that work and family imbalance are also associated with high rates of burnout (see Cossman and Street 2009). Consequently, to the extent that peers can help fel ow professionals to re-calibrate critical aspects of the personal/professional interface, that kind of support likely mitigates stress that could otherwise contribute to higher burnout risks. As for perceiving professional stimulation and shared life experiences in peer relationships, those are more common stances for the least burned out physicians (stressed, no burnout) in the study. Unmet expectations about patient or peer relationships, plus other medical practice pressures, are a recipe for physician burnout. What could be done to ameliorate the burnout risks associated with negative perceptions of peer relationship quality? A first step is better and ongoing education starting with early medical training and spanning lifelong learning about the importance of intra-professional support and patient relationship management for successful medical practices and careers. More training and professional society attention to the changing generational expectations and experiences of physicians is in order. It could help minimize some peer-related burnout risks by reinforcing respect and support both for what experienced physicians in more traditional roles bring to the table, and by understanding the changing pace of medical care and professional expectations for newly trained physicians. Future healthcare provision, even in rural areas, is evolving towards more inter and intra-professional collaboration and less solo practice. This requires further adaptations both to the doctor-patient role in a multi-professional practice environment and to finding mechanisms that identify and support physicians considered “at risk” for burnout. We cannot establish directionality for peer relationships and burnout—it may be that physicians who report higher levels of stress perceive peer relationships more negatively because they do not receive adequate work-life balance support or professional stimulation from them, or their life experiences are very different, or patient needs real y are unmanageable and overwhelming. Alternatively, physicians who experience high levels of burnout and who have the least positive patient and peer relationships may view those relationships through a negative lens because they are already burned out and, consequently, are less likely to notice or focus on more positive aspects of their professional relationships. In many ways the quality of relationships and degrees of burnout seem to be components in a virtuous (when positive) or vicious (when negative) circle. Devising interventions to interrupt the negative aspects of relationships and/or burnout cycles, or to reinforce the continuation of positive ones, seem an urgent requirement for a workforce that deals with manageable amounts of pressure and stress.
REFERENCES
Al egra CJ, Hal R, Yothers G. Prevalence of burnout in the U.S. oncology community: results of a 2003 survey. Journal of Oncology Practice. 2005; 1:140-147. Cossman, JS and D Street. 2009. Families, Communities and Physician 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 Aug; 111(2):170–175. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: 3rd edition, in Zalaquett CP, Wood RJ (eds.) Evaluating Stress: A book of resources. Scarecrow Education; 1997; 191-218. Quinn, JB, Anderson P, Finkelstein S. Managing professional intel ect: Making the most of the best. Harv Bus Rev. Rohland BM, Kruse GR, Rohrer JE. Validation of a single-item measure of burnoug against the Maslach Burnout Inventory among physicians. Stress and Health, 2004; 20(2): 75-79. Rothman DJ. The origins and consequences of patient autonomy: A 25-Year Retrospective. Health Care Analysis Schneider CE. The practice of autonomy: patients, doctors, and medical decisions. New York: Oxford University Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367. Spickard A, Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA.2002; Warren MG, Weitz R, Kulis S. Physician satisfaction in a changing health care environment: the impact of chal enges to professional autonomy, authority, and dominance. J Health Soc Behav 1998; 39(4): 56-367.
ABOUT THE AUTHORS
Jeralynn S. Cossman, Clinton Wallace Dean’s Eminent Scholar and Associate Professor of Sociology at Mississippi State University, is the Director of the Mississippi Center for Health Workforce.
Debra Street, an Associate Professor of Sociology at the State University of New York at Buffalo, is an alumna of the Robert Wood Johnson
Scholars in Health Policy Research Program and a member of the National Academy of Social Insurance. The North East Mississippi Area Health Education Center (NE MS AHEC, is hosted by the Social Science Research Center at Mississippi State University and is an affiliate of the Mississippi Area Health Education Center Program (MS AHEC) at the University of Mississippi Medical Center. The MS AHEC Program is partially funded by a grant from the Health Resources and Services Administration (HRSA). The Mississippi State Medical Association, the Mississippi Academy of Family Physicians, the American Academy of Family Physicians, and the Social Science Research Center at Mississippi State University provided resources for the Mississippi Workforce Study (2007/08 MSMD). The material in this brief reflects the authors’ perspective, but not necessarily those of affiliated organizations and funding organizations or funding agencies.

Source: http://www.nemsahec.msstate.edu/publications/policybriefs/BurnoutBrief3Final.pdf