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Defining Physician Burnout, and Differentiating Between Burnout and Depression—II

      To the Editor:
      Shanafelt and Noseworthy
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      in a recent study are to be commended for continuing to raise awareness of physician job stress, but their reliance on fractions of questions from what they indicate to be “potentially standardized instruments” to categorize burnout is unfortunate. Among these, the popular Maslach Burnout Inventory (MBI)
      • Maslach C.
      • Jackson S.E.
      • Leiter M.P.
      Maslach Burnout Inventory Manual.
      is a proprietary test, and its use in the table titled “Candidate Dimensions of Well-being for Organizations to Access” is flawed. Not only are the ‘cutoff’ scores proposed by the developers of the MBI wholly arbitrary and devoid of any clinical referent,
      • Maslach C.
      • Jackson S.E.
      • Leiter M.P.
      Maslach Burnout Inventory Manual.
      the inventory's user manual also warns that “neither the coding nor the original numerical scores should be used for diagnostic purposes.”
      • Maslach C.
      • Jackson S.E.
      • Leiter M.P.
      Maslach Burnout Inventory Manual.
      Nonetheless, several authors have attempted to take the complexity of physician burnout syndrome down to even single-item measures validated against the MBI
      • Rohland B.M.
      • Kruse G.R.
      • Rohrer J.E.
      Validation of a single-item measure of burnout against the Maslach Burnout Inventory among physicians.
      and/or to comment on qualitative differences that describe a “sense of calling”
      • Jager A.J.
      • Tutty M.A.
      • Kao A.C.
      Association between physician burnout and identification with medicine as a calling.
      in making physician assessments.
      Because no diagnostic criteria for burnout have been developed,
      • Weber A.
      • Jaekel-Reinhard A.
      Burnout syndrome: a disease of modern societies?.
      the methods for identifying cases of burnout have proliferated, resulting in dramatic variations in prevalence estimates, as this article epitomizes in the comparison of burnout rates between 2013 and 2015, reported as the Mayo Clinic experience.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      Because the likelihood for misattribution error is present at baseline, this alone may invalidate the authors' conclusions regarding the impact of their detailed 9-strategy intervention. Namely, they report that “the absolute burnout rate among Mayo physicians decreased by 7% over 2 years, despite an 11% increase in the absolute burnout rate noted in a national comparison using the same metrics.”
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      But again, stated differently, using MBI diagnostically to assess the prevalence of burnout and changes over time leads to findings that are hard to maneuver in medical decision making.
      Another concern arises when demographic characteristics of the Mayo physicians' surveyed is considered. Factors such as physician turnover between survey intervals could introduce differences, or quite possibly the retained physicians may have learned to answer more positively in the survey—perhaps to avoid work group scrutiny, stigma associated with being labeled as “burnt out,” or termination of their group affiliation—hence, short-term improvements especially without careful characterization have limited utility. Moreover, whether “deliberate, sustained, and comprehensive efforts by the organization to reduce burnout and promote engagement can make a difference”
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      as the authors conclude, I think is open to question and may overstate the result given the time horizon is so short.
      Consequently, I am skeptical of the utility that derives from reflecting burnout repercussions as separate hemispheric domains of person or profession. Shanafelt and Noseworthy
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      imply this idea with a 50:50 shading scheme used in Figure 1 of their article. How does responsibility for repercussions of burnout adjust the interactions between clinicians and their supervisory leaders? An even split, as portrayed, ignores the current paradigm shift from blaming an individual physician to blaming the employment environment as the main driver of job stress and the predictable consequences of overwork. This graphic is misleading, and there may be other reasons the institutional leadership and other at-will employers may wish to display a sense of limited liability for burnout. Indeed, there is widespread agreement among clinicians that burnout exists, and the dysfunction of it can be solved.
      Finally, despite the authors' self-interested reporting style, and disclosure of potential competing interests, it is clear to me that they personally have an obligation as lead researchers at a vanguard institution to spearhead efforts to determine the binding diagnostic criteria for burnout, and once validated, should move onto examining burnout's prevalence. The need for sound diagnostic criteria cannot be overstated, and clarifying burnout's nosological status (eg, with respect to depression and posttraumatic stress disorder) is a prerequisite to a rigorous assessment of burnout's prevalence. Only then can we go forward confidently with medical intervention and prevention strategies for burnout that truly make a difference. With more than 400 physicians (women > men) committing suicide annually, time is of the essence.
      • Sinha P.
      Why do doctors commit suicide?.

      References

        • Shanafelt T.D.
        • Noseworthy J.H.
        Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
        Mayo Clin Proc. 2017; 92: 129-146
        • Maslach C.
        • Jackson S.E.
        • Leiter M.P.
        Maslach Burnout Inventory Manual.
        3rd ed. Consulting Psychologists Press, Pall Alto, CA1996
        • Rohland B.M.
        • Kruse G.R.
        • Rohrer J.E.
        Validation of a single-item measure of burnout against the Maslach Burnout Inventory among physicians.
        Stress Health. 2004; 20: 75-79
        • Jager A.J.
        • Tutty M.A.
        • Kao A.C.
        Association between physician burnout and identification with medicine as a calling.
        Mayo Clin Proc. 2017; 92: 415-422
        • Weber A.
        • Jaekel-Reinhard A.
        Burnout syndrome: a disease of modern societies?.
        Occup Med (Lond). 2000; 50: 512-517
        • Sinha P.
        Why do doctors commit suicide?.
        New York Times. September 4, 2014; (Accessed May 30, 2017)

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