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Potential Impact of Burnout on the US Physician Workforce

      To the Editor:
      The US Department of Health and Human Services projects a shortfall of 45,000 to 90,000 physicians by 2025.

      Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Association of American Medical Colleges website. https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC-_-ScientificAffairs-_-PDF-_-ihsreport. Published March 2015. Accessed April 15, 2015.

      US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. Bureau of Health Professions, Health Resources and Services Administration website. http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Published December 2008. Accessed April 15, 2015.

      The magnitude of this shortage may be more acute in specialties such as the primary care disciplines and general surgery.

      Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Association of American Medical Colleges website. https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC-_-ScientificAffairs-_-PDF-_-ihsreport. Published March 2015. Accessed April 15, 2015.

      One underrecognized factor that may influence the supply of physicians is professional burnout. Based on a prospective, longitudinal analysis of burnout and payroll records, we recently reported that higher emotional exhaustion (EE) (a dimension of burnout) is associated with an increased likelihood that physicians will reduce their professional work effort.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      Specifically, each 1-point increase in EE (on a scale of 0-6) was associated with a 43% higher likelihood (odds ratio, 1.43; 95% CI, 1.23-1.67; P<.001) of a reduction in professional effort over the next 24 months after adjusting for age, sex, and specialty.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      Notably, the prevalence of burnout appears to be increasing among US physicians nationally, with the average EE score on this same scale increasing from 3.42 in 2011 to 3.83 in 2014.
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      The potential repercussions of this increase in burnout for the US physician workforce, and whether reducing professional work effort is an effective approach to reduce burnout, are unknown.
      We used published data on changes in EE among US physicians
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      along with the data on the relationship between EE and reductions in professional work effort
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      to estimate the potential effect of increased burnout on the physician workforce at the national level. On the basis of these data, the 0.41-point increase in EE in US physicians between 2011 and 2014
      • Shanafelt T.D.
      • Hasan O.
      • Dyrbye L.N.
      • et al.
      Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
      would be expected to increase the absolute percentage of physicians reducing their professional work effort from 4.0% to 4.7% after adjusting for age, sex, and specialty. With approximately 835,000 physicians in the United States, this would translate into approximately 5929 additional physicians reducing their professional effort due to burnout between 2011 and 2014. Based on the average reduction in professional work effort in our previous publication (18% absolute reduction; SD, 9%; median, 20%),
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      this would equate to a net loss of approximately 1067 physicians (ie, approximately 1.2% of the US physician workforce).
      Mayo Clinic surveys its physicians every 12 to 24 months, and we now have follow-up data that allow us to analyze changes in burnout scores among physicians who did or did not reduce their professional work effort.
      • Shanafelt T.D.
      • Mungo M.
      • Schmitgen J.
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      Among the 2231 Mayo Clinic physicians who completed surveys in 2013, 1459 (65.4%) completed surveys in 2015. Mean EE and depersonalization scores improved for physicians who reduced professional work effort relative to those who did not (Table). The EE scores improved in 20 of the 40 physicians who reduced their professional work effort 20 (50%) and worsened in 5 (13%). Among the 1410 physicians who did not reduce professional work effort, EE scores improved in 508 (36%) and worsened in 412 (29%). Similar results were observed for the depersonalization domain of burnout. These results indicate that reducing work hours is an effective individual strategy to reduce burnout for many physicians.
      TableChanges in Burnout Between 2013 and 2015 Based on Whether Physicians Reduced Professional Work Effort
      Burnout variableReduced professional work effort in 12 mo following 2013 survey (n=40)Did not reduce professional effort (n=1410)P value
      Change in emotional exhaustion score
      Change in emotional exhaustion between 2013 and 2015 surveys (Likert scale, score range 0-65).
       Mean change
      Positive values indicate a worsening in score (higher burnout), and negative values indicate an improvement in score (lower burnout).
      −0.63−.09.02
      Change in depersonalization between 2011 and 2013 surveys (Likert scale, score range 0-65).
       Median change
      Positive values indicate a worsening in score (higher burnout), and negative values indicate an improvement in score (lower burnout).
      −10.02
      Analysis of variance.
       ≥3-Point improvement3 (8%)69 (5%).02
      Change in depersonalization between 2011 and 2013 surveys (Likert scale, score range 0-65).
       2-Point improvement6 (15%)140 (10%)
       1-Point improvement11 (28%)299 (21%)
       No change15 (38%)490 (35%)
       1-Point worsening3 (8%)235 (17%)
       2-Point worsening2 (5%)109 (8%)
       ≥3-Point worsening0 (0%)68 (5%)
      Change in depersonalization score
      Mann-Whitney test.
       Mean change
      Positive values indicate a worsening in score (higher burnout), and negative values indicate an improvement in score (lower burnout).
      −0.53+0.02.02
      Change in depersonalization between 2011 and 2013 surveys (Likert scale, score range 0-65).
       Median change
      Positive values indicate a worsening in score (higher burnout), and negative values indicate an improvement in score (lower burnout).
      00.08
      Analysis of variance.
       ≥3-Point improvement4 (10%)65 (5%).02
      Change in depersonalization between 2011 and 2013 surveys (Likert scale, score range 0-65).
       2-Point improvement5 (13%)87 (6%)
       1-Point improvement6 (15%)209 (15%)
       No change16 (40%)683 (48%)
       1-Point worsening8 (20%)211 (15%)
       2-Point worsening1 (3%)82 (6%)
       ≥3-Point worsening0 (0%)73 (5%)
      a Change in emotional exhaustion between 2013 and 2015 surveys (Likert scale, score range 0-6
      • West C.P.
      • Dyrbye L.N.
      • Sloan J.A.
      • Shanafelt T.D.
      Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.
      ).
      b Positive values indicate a worsening in score (higher burnout), and negative values indicate an improvement in score (lower burnout).
      c Change in depersonalization between 2011 and 2013 surveys (Likert scale, score range 0-6
      • West C.P.
      • Dyrbye L.N.
      • Sloan J.A.
      • Shanafelt T.D.
      Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.
      ).
      d Analysis of variance.
      e Mann-Whitney test.
      In summary, the increase in burnout observed in US physicians between 2011 and 2014 likely translated into approximately a 1% reduction in the professional effort of the US physician workforce. This loss is roughly equivalent to eliminating the graduating class of 7 US medical schools.
      • Association of American Medical Colleges
      Medical School Enrollment Plans Through 2013: Analysis of the 2008 AAMC Survey.
      This estimate does not include other potential impacts of burnout on the physician workforce such as early retirement or physicians leaving the profession to pursue nonmedical careers. Reducing professional work effort does appear to be an effective strategy for individual physicians to reduce burnout. Although this approach may help individual physicians, at the societal level it has the potential to exacerbate the pending physician workforce shortage. To preserve adequate access to care, there is a societal imperative to provide physicians a better option than burning out, working part-time, or leaving the profession.

      References

      1. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Association of American Medical Colleges website. https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC-_-ScientificAffairs-_-PDF-_-ihsreport. Published March 2015. Accessed April 15, 2015.

      2. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. Bureau of Health Professions, Health Resources and Services Administration website. http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Published December 2008. Accessed April 15, 2015.

        • Shanafelt T.D.
        • Mungo M.
        • Schmitgen J.
        • et al.
        Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
        Mayo Clin Proc. 2016; 91: 422-431
        • Shanafelt T.D.
        • Hasan O.
        • Dyrbye L.N.
        • et al.
        Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.
        Mayo Clin Proc. 2015; 90 ([published correction appears in Mayo Clin Proc. 2016;91(2):276]): 1600-1613
        • West C.P.
        • Dyrbye L.N.
        • Sloan J.A.
        • Shanafelt T.D.
        Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals.
        J Gen Intern Med. 2009; 24: 1318-1321
        • Association of American Medical Colleges
        Medical School Enrollment Plans Through 2013: Analysis of the 2008 AAMC Survey.
        Association of American Medical Colleges, Washington, DC2009