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

Open AccessPublished:February 22, 2019DOI:https://doi.org/10.1016/j.mayocp.2018.10.023

      Abstract

      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.

      Abbreviations and Acronyms:

      AMA (American Medical Association), EHR (electronic health records), MBI (Maslach Burnout Inventory), OR (odds ratio), WLI (work-life integration)
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      Health care regulations and policies, including the Affordable Care Act, Meaningful Use, and the Medicare Access and CHIP Reauthorization Act of 2015 have transformed the day-to-day work of US physicians. Widespread penetration of electronic health records (EHRs) has increased administrative burden and led to decreased physician face time with patients.
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      In 2011, we began surveying US physicians and workers in other fields every 3 years to chronicle the changing rates of burnout and satisfaction with work-life integration (WLI) among physicians relative to the general working population. In 2011, 45% of US physicians had at least one manifestation of professional burnout (emotional exhaustion or depersonalization), and problems with burnout and WLI were more common in physicians than in workers in other fields even after adjusting for level of education, hours worked, and other factors.
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      These gaps between physicians and workers in other fields widened by 2014 as physician burnout and problems with WLI increased.
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      To Care Is Human - collectively confronting the clinician-burnout crisis.
      The American Medical Association (AMA) began working to mitigate physician burnout and promote professional satisfaction in 2012, commissioned a RAND report in 2013, convened numerous meetings of experts, chief executive officers, chief medical officers, and other diverse stakeholders (regulators, payers, EHR vendors), and created online resources and modules.
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      In early 2017, the National Academy of Medicine launched a large-scale, national, multidisciplinary effort engaging payers, regulators, professional societies, health care organizations, EHR vendors, and others to galvanize efforts to address system issues contributing to the problem.
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      Action collaborative on clinicial well-being and resilience. National Academy of Medicine website.
      Recognizing that system-level factors are the primary driver of burnout, a number of large health care organizations have begun to make changes to improve the work environment. Although encouraging results have stemmed from these interventions,
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      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
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      • et al.
      A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study.
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      organizational efforts remain sporadic and inconsistent. Because many of these efforts are still at a nascent stage, their national impact is unknown. Here, we report the results of the 2017 national survey evaluating changes in burnout and satisfaction with WLI among physicians and other US workers compared with 2011 and 2014.

      Participants and Methods

      The 2017 survey employed methods similar to the 2011 and 2014 studies.
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      • 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.
      At all 3 time points, we assessed a range of personal and professional characteristics, as well as several dimensions of well-being.

       Study Participants

       Physician Sample

      A sample of physicians from all specialty disciplines was assembled using the AMA Physician Masterfile. The Masterfile is a nearly complete record of all US physicians independent of AMA membership. Similar to 2011 and 2014, we oversampled physicians in fields other than family medicine, general pediatrics, general internal medicine, and obstetrics/gynecology to ensure an adequate sample of physicians from each specialty. Canvassing e-mails stating the purpose of the study (ie, to better understand the factors that contribute to satisfaction among US physicians), along with an invitation to participate and a link to the survey, were sent to 83,291 physicians on October 12, 2017, with 4 reminder requests sent over the ensuing 6 weeks. A total of 27,071 physicians opened at least 1 invitation e-mail. After completion of the electronic survey, a random sample of 5000 physicians who did not respond to the electronic survey (1426 of whom had opened an e-mail invitation and 3574 had not) were mailed a paper version of the survey on December 6, 2017. Of the 5000 mailed surveys, 269 were returned as undeliverable (80 sent to physicians who had opened an e-mail invitation and 189 who had not). Completed surveys returned by March 15, 2018, were included in the analysis. The 30,456 physicians who opened at least 1 invitation e-mail and/or received a paper mailing of the survey were considered to have received an invitation to participate in the study, while the others were classified as “unable to contact.”
      American Association for Public Opinion Research
      Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 2016.
      Participation was voluntary, and all responses were anonymous.
      To estimate response bias, we also conducted a secondary survey with intensive follow-up in a random sample of 500 physicians who did not respond to the electronic survey.
      • Cimiotti J.P.
      • Aiken L.H.
      • Sloane D.M.
      • Wu E.S.
      Nurse staffing, burnout, and health care-associated infection.
      These individuals were mailed a paper copy of the survey with a $20 incentive to participate. Individuals in the secondary survey who did not respond to the first mailing were sent a second mailing 3 weeks later (without additional compensation). Twenty-four mailed surveys were returned as undeliverable, yielding a final sample of 476. Those who did not respond to the second mailing within 3 weeks were mailed a brief postcard survey requesting basic demographic characteristics and measures of well-being.

       Population Sample

      For comparison to physicians, we surveyed a probability-based sample of individuals from the general US population from October 13 through October 21, 2017. Consistent with the approach used in 2014, the 2017 population survey oversampled individuals aged 35 to 65 years to better match the age range of practicing US physicians. The population survey was conducted using the KnowledgePanel, a probability-based panel designed to be representative of the US population (http://www.knowledgenetworks.com/knpanel/index.html and http://www.knowledgenetworks.com/ganp/reviewer-info.html). Based on the intent to compare workers in other fields to physicians, only employed individuals were surveyed. The Stanford University and Mayo Clinic institutional review boards reviewed and approved the study.

       Study Measures

      Both the physician and population controls provided information on demographic characteristics (age, sex, relationship status), hours worked per week, symptoms of burnout, symptoms of depression, suicidal ideation, and satisfaction with WLI. Physician professional characteristics were ascertained by asking physicians about their practice.

       Burnout

      Burnout among physicians was measured using the emotional exhaustion and depersonalization scales of the Maslach Burnout Inventory (MBI), a validated questionnaire considered the criterion standard tool for measuring burnout.
      • Maslach C.
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      • Leiter M.
      Maslach Burnout Inventory Manual.
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      • Rudisill J.R.
      Validity of the Maslach Burnout Inventory for family practice physicians.
      • Lee R.T.
      • Ashforth B.E.
      A meta-analytic examination of the correlates of the three dimensions of job burnout.
      • Leiter M.P.
      • Durup J.
      The discriminant validity of burnout and depression: a confirmatory factor analytic study.
      Consistent with convention,
      • Shanafelt T.D.
      • Bradley K.A.
      • Wipf J.E.
      • Back A.L.
      Burnout and self-reported patient care in an internal medicine residency program.
      • Thomas N.K.
      Resident burnout.
      • Rosen I.M.
      • Gimotty P.A.
      • Shea J.A.
      • Bellini L.M.
      Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns.
      we considered physicians with a high score on the depersonalization and/or emotional exhaustion subscale of the MBI as having at least one manifestation of professional burnout.
      • Maslach C.
      • Jackson S.E.
      • Leiter M.
      Maslach Burnout Inventory Manual.
      Although the MBI is the criterion standard for the assessment of burnout,
      • Maslach C.
      • Jackson S.E.
      • Leiter M.
      Maslach Burnout Inventory Manual.
      its length and expense limit feasibility for use in long surveys addressing multiple content areas or in large population samples. Thus, to allow comparison of burnout between physicians and population controls, we measured burnout in both groups using 2 single-item measures adapted from the full MBI. These 2 items correlated strongly with the emotional exhaustion and depersonalization domains of burnout measured by the full MBI in a sample of more than 10,000 individuals,
      • 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.
      • West C.P.
      • Dyrbye L.N.
      • Satele D.V.
      • Sloan J.A.
      • Shanafelt T.D.
      Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment.
      with an area under the receiver operating characteristic curve of 0.94 and 0.93 for emotional exhaustion and depersonalization, respectively, for these single items relative to the full MBI.

       Symptoms of Depression

      Symptoms of depression among physicians were assessed using the 2-item Primary Care Evaluation of Mental Disorders,
      • Spitzer R.L.
      • Williams J.B.
      • Kroenke K.
      • et al.
      Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study.
      a standardized and validated assessment tool for depression screening that performs as well as lengthier instruments.
      • Whooley M.A.
      • Avins A.L.
      • Miranda J.
      • Browner W.S.
      Case-finding instruments for depression: two questions are as good as many.
      This tool has a high sensitivity but lower specificity such that approximately 1 of every 4 individuals screening positive would meet criteria for major depression if they were to undergo full psychiatric assessment.

       Satisfaction With WLI

      Satisfaction with WLI was assessed by the item, “My work schedule leaves me enough time for my personal/family life” (response options: strongly agree, agree, neutral, disagree, strongly disagree).
      • Shanafelt T.D.
      • Boone S.
      • Tan L.
      • et al.
      Burnout and satisfaction with work-life balance among US physicians relative to the general US population.
      Individuals who indicated “strongly agree” or “agree” were considered to be satisfied with their WLI, whereas those who indicated “disagree” or “strongly disagree” were considered to be dissatisfied with their WLI.

       Statistical Analyses

      Standard descriptive summary statistics were used to characterize the physician and comparison samples. Associations between variables were evaluated using the Kruskal-Wallis test (continuous variables) or χ2 test (categorical variables), as appropriate. All tests were 2-sided with type I error rates of .05. We used multivariate logistic regression to analyze differences in burnout and WLI in 2017. For other multivariate analyses, we pooled physicians who responded in 2011, 2014, and 2017 and evaluated the risk of burnout or symptoms of depression by participation year after adjusting for age, sex, and practice setting. Finally, a pooled multivariate logistic regression analysis of physicians and workers in other fields was performed to identify demographic and professional characteristics associated with the dependent outcomes. For all comparisons with population comparators, physician data were restricted to responders who were between the ages of 29 and 65 years and not retired to match the population sample. We compared demographic and professional characteristics of physicians responding in 2017 to those of physicians who responded in 2011 and 2014 using χ2 or Kruskal-Wallis tests as appropriate. These data were not paired and were treated as independent samples. Comparisons in the proportions of burnout and satisfaction with WLI between physicians and the general population across 2011, 2014, and 2017 were performed using Breslow-Day tests. All analyses were completed using SAS statistical software, version 9 (SAS Institute).

      Results

       Well-being of US Physicians

      Of the 30,456 physicians who received an invitation to participate either electronically and/or by mail, 5197 (17.1%) completed a survey. To evaluate whether participants were representative of all physicians in the sample, we also conducted a secondary survey with intensive follow-up in a random sample of 476 individuals who did not respond to the electronic survey. With compensation and extensive follow-up, 248 (52.1%) responded. Although the proportion of women participating in the electronic survey was higher than in the secondary survey (39.0% [1583 of 4063] vs 30.4% [75 of 247]; P=.02), we found no statistically significant differences in age (P=.83), years in practice (P=.41), burnout prevalence (full MBI 44.4% [1865 of 4198] vs 42.9% [97 of 226], P=.66), or satisfaction with WLI (41.8% [1694 of 4052] vs 47.4% [117 of 247], P=.09) (Supplemental Table 1, available online at http://www.mayoclinicproceedings.org). These findings support the absence of response bias in the electronic survey respondents with respect to burnout and satisfaction with WLI, suggesting that participants were generally representative of US physicians in these domains. Given the consistency with respect to the experience of burnout and WLI, all responders were subsequently pooled for further analysis.
      The demographic characteristics of participants relative to all 890,083 practicing US physicians were generally similar, although participants were slightly older (Table 1). A greater proportion of participants were in specialties other than primary care, consistent with the sampling approach (see “Physician Sample”). The 2017 participants were similar to the 2011 and 2014 participants except for being slightly younger and more largely represented by women, consistent with the increased proportion of women among US physicians in the Masterfile overall (2011, 30.7%; 2014, 33.2%; 2018, 35.0%).
      Table 1Demographic Characteristics of Responding Physicians Compared With All US Physicians
      IQR = interquartile range; — = not available.
      ,
      Data are presented as No. (percentage) unless indicated otherwise. Percentages may not total 100 because of rounding.
      Characteristic2017 Responders (N=5445)All US physicians, 2017 (N=890,083)
      As of October 18, 2017.
      2014 Responders (N=6880)2011 Responders (N=7288)
      Sex
       Male2995 (62.1)577,339 (64.9)4497 (67.5)5241 (71.9)
       Female1818 (37.7)311,776 (35.1)2162 (32.5)2046 (28.1)
       Other13 (0.3)NANANA
       Missing6199682211
      Age (y)
       Median53525655
       <35305 (6.4)80,780 (9.1)332 (5.0)321 (4.5)
       35-441120 (23.5)224,341 (25.2)1223 (18.4)1299 (18.0)
       45-541103 (23.1)227,421 (25.6)1416 (21.3)1845 (25.6)
       55-641371 (28.7)221,199 (24.9)2193 (33.0)2586 (35.9)
       ≥65874 (18.3)135,596 (15.2)1491 (22.4)1162 (16.1)
       Missing67274622575
      Primary care
      Physicians in subspecialty areas were intentionally oversampled to provide an adequate number of responses from physicians from each specialty to allow comparison across specialties. Primary care specialties include internal medicine-general, general practice, family medicine, obstetrics/gynecology, and pediatrics-general.
       Yes1281 (23.8)349,597 (39.3)1596 (23.3)1907 (26.4)
       No4103 (76.2)540,486 (60.7)5249 (76.7)5326 (73.6)
      Specialty
       Anesthesiology254 (4.7)236 (3.5)309 (4.3)
       Dermatology136 (2.5)164 (2.4)174 (2.4)
       Emergency medicine304 (5.7)355 (5.2)333 (4.6)
       Family medicine415 (7.7)540 (7.9)752 (10.4)
       General surgery160 (3.0)259 (3.8)276 (3.8)
       General surgery subspecialty
      For further subspecialty breakdown see Supplementary Material.
      398 (7.4)381 (5.6)374 (5.2)
       Internal medicine-general425 (7.9)453 (6.6)578 (8.0)
       Internal medicine subspecialty
      For further subspecialty breakdown see Supplementary Material.
      652 (12.2)784 (11.5)1019 (14.1)
       Neurology195 (3.6)246 (3.6)252 (3.5)
       Neurosurgery66 (1.2)58 (0.9)82 (1.1)
       Obstetrics and gynecology195 (3.6)246 (3.6)312 (4.3)
       Ophthalmology146 (2.7)241 (3.5)199 (2.8)
       Orthopedic surgery276 (5.1)239 (3.5)269 (3.7)
       Otolaryngology45 (0.8)165 (2.4)193 (2.7)
       Other162 (3.0)255 (3.7)329 (4.6)
       Pathology147 (2.7)170 (2.5)184 (2.5)
       Pediatrics-general264 (4.9)362 (5.3)286 (4.0)
       Pediatric subspecialty
      For further subspecialty breakdown see Supplementary Material.
      225 (4.2)321 (4.7)239 (3.3)
       Physical medicine and rehabilitation131 (2.4)170 (2.5)97 (1.3)
       Preventive medicine/ occupational medicine30 (0.6)112 (1.6)76 (1.1)
       Psychiatry432 (8.1)566 (8.3)488 (6.8)
       Radiation oncology42 (0.8)64 (0.9)55 (0.8)
       Radiology225 (4.2)261 (3.8)216 (3.0)
       Urology35 (0.7)119 (1.7)136 (1.9)
       Missing856660
      Hours worked per week
       Median (IQR)50 (40-60)50 (40-60)50 (40-60)
       <40961 (18.9)1172 (17.4)985 (14.3)
       40-491053 (20.7)1340 (19.9)1459 (21.1)
       50-591245 (24.4)1667 (24.7)1852 (26.8)
       60-691084 (21.3)1526 (22.6)1659 (24.0)
       70-79386 (7.6)535 (7.9)455 (6.6)
       ≥80367 (7.2)509 (7.5)497 (7.2)
       Missing349131381
      No. of nights on call per week, median (IQR)1 (0-2)1 (0-3)1 (0-3)
      Primary practice setting
       Private practice2474 (48.0)3605 (52.6)4087 (57.7)
       Academic medical center1394 (27.1)1625 (23.7)1494 (21.1)
       Veterans hospital107 (2.1)104 (1.5)184 (2.6)
       Active military practice55 (1.1)58 (0.8)65 (0.9)
       Not in practice or retired169 (3.3)160 (2.3)89 (1.3)
       Other950 (18.5)1303 (19.0)1164 (16.4)
       Missing29625205
      a IQR = interquartile range; — = not available.
      b Data are presented as No. (percentage) unless indicated otherwise. Percentages may not total 100 because of rounding.
      c As of October 18, 2017.
      d Physicians in subspecialty areas were intentionally oversampled to provide an adequate number of responses from physicians from each specialty to allow comparison across specialties. Primary care specialties include internal medicine-general, general practice, family medicine, obstetrics/gynecology, and pediatrics-general.
      e For further subspecialty breakdown see Supplementary Material.
      Mean emotional exhaustion and depersonalization scores were lower in 2017 than in 2014 (Table 2). The mean emotional exhaustion scores in 2017 remained higher than in 2011 (P=.03), whereas the mean depersonalization scores were slightly lower (P<.001). In aggregate, 43.9% (2147 of 4893) of physicians had at least one manifestation 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). On multivariate analysis pooling responders from the 2011, 2014, and 2017 surveys and adjusted for age, sex, specialty, hours worked per week, and practice setting, physicians who responded in 2017 (odds ratio [OR], 0.606; 95% CI, 0.559-0.657) or 2011 (OR, 0.682; 95% CI, 0.634-0.733) were at lower odds of burnout compared with physicians who responded in 2014 (Supplemental Table 2, available online at http://www.mayoclinicproceedings.org).
      Table 2Physician Burnout, Depression, Career Satisfaction, and Satisfaction With Work-Life Integration in 2017 Compared With 2014 and 2011
      NA = not applicable.
      ,
      Data are presented as No. (percentage) unless indicated otherwise.
      Variable2017 (N=5445)2014 (N=6880)2011 (N=7288)P value,

      2017 vs 2014
      P value,

      2017 vs 2011
      Burnout indices
      As assessed using the full Maslach Burnout Inventory. Per the traditional scoring for health care workers, physicians with scores ≥27 on the emotional exhaustion subscale, ≥10 on the depersonalization subscale, or <33 on the personal accomplishment subscale are considered to have a high degree of burnout in that dimension.
       Emotional exhaustion
      Median22.025.021.0<.001.03
      Mean (SD)23.2 (13.2)25.5 (13.5)22.7 (13.0)<.001.03
      Low score1991 (41.0)2299 (34.1)3041 (42.2)<.001.40
      Intermediate score989 (20.3)1283 (19.0)1433 (19.9)
      High score1881 (38.7)3165 (46.9)2734 (37.9)
      Missing58413380NANA
       Depersonalization
      Mean (SD)6.8 (6.5)8.1 (6.6)7.1 (6.1)<.001<.001
      Low score2644 (54.2)2951 (44.0)3601 (50.1)<.001<.001
      Intermediate score907 (18.6)1434 (21.4)1476 (20.5)
      High score1331 (27.3)2325 (34.6)2116 (29.4)
      Missing56317095NANA
       Burned out
      High score on emotional exhaustion and/or depersonalization subscales of the Maslach Burnout Inventory (see “Participants and Methods”).
      2147/4893 (43.9)3680/6767 (54.4)3310/7227 (45.8)<.001.04
      Depression
       Screening positive for depression2022/4854 (41.7)2715/6818 (39.8)2753/7213 (38.2).05<.001
      Career satisfaction
       Would choose to become a physician again3508/5122 (68.5)4476/6676 (67.0)5081/7236 (70.2).10.04
      Work-life integration
       Work schedule leaves me enough time for my personal and/or family life
      Strongly agree602 (12.5)706 (10.6)1233 (17.0)<.001<.001
      Agree1454 (30.2)2012 (30.3)2279 (31.5)
      Neutral796 (16.6)973 (14.6)1046 (14.4)
      Disagree1272 (26.5)2004 (30.1)1775 (24.5)
      Strongly disagree685 (14.2)956 (14.4)911 (12.6)
      Missing63622944NANA
      a NA = not applicable.
      b Data are presented as No. (percentage) unless indicated otherwise.
      c As assessed using the full Maslach Burnout Inventory. Per the traditional scoring for health care workers, physicians with scores ≥27 on the emotional exhaustion subscale, ≥10 on the depersonalization subscale, or <33 on the personal accomplishment subscale are considered to have a high degree of burnout in that dimension.
      d High score on emotional exhaustion and/or depersonalization subscales of the Maslach Burnout Inventory (see “Participants and Methods”).
      A more nuanced picture emerged when comparing differences in burnout by specialty at each time point (2011, 2014, 2017), with some specialties experiencing minimal change in the proportion with burnout during the interval (eg, obstetrics and gynecology) and most hitting a peak in burnout in 2014 (Figure 1A). For some specialties, the proportion burned out in 2017 was lower than in 2011 (eg, anesthesiology, emergency medicine, orthopedic surgery) whereas for others the proportion with burnout remained higher in 2017 than in 2011 (eg, dermatology) even though it was lower than in 2014 (Supplemental Table 3, available online at http://www.mayoclinicproceedings.org). Mean emotional exhaustion and depersonalization scores for each specialty by year are shown in Supplemental Table 4 (available online at http://www.mayoclinicproceedings.org).
      Figure thumbnail gr1
      Figure 1Burnout (A) and satisfaction with work-life integration (WLI) (B) by specialty, 2017, 2014, and 2011.
      The proportion of physicians screening positive for depression showed a modest but steady increase between 2011 and 2017 (2011, 38.2% [2753 of 7213]; 2014, 39.8% [2715 of 6818]; 2017, 41.7% [2022 of 4854]; P<.001). On multivariate analysis pooling responders from the 2011, 2014, and 2017 surveys and adjusted for age, sex, specialty, hours worked per week, and practice setting, physicians who responded in 2017 (OR, 1.15; 95% CI, 1.061-1.243) or 2014 (OR, 1.090; 95% CI, 1.014-1.171) were at higher odds of screening positive for depression than physicians who responded in 2011.
      Satisfaction with WLI was also greater in 2017 than in 2014 but remained lower than 2011 levels (Table 2). Differences in satisfaction with WLI between 2011 and 2017 by specialty are shown in Figure 1B and Supplemental Table 5 (available online at http://www.mayoclinicproceedings.org).
      On multivariate analysis of the 2017 data, being a woman and working more hours per week were independently associated with higher rates of burnout and lower degrees of satisfaction with WLI (Table 3). Practicing in certain specialties was also independently associated with higher or lower rates of burnout.
      Table 3Multivariate Models Among Practicing Physicians in 2017
      OR = odds ratio; WLI = work-life integration.
      OutcomePredictorOR (95% CI)P value
      Burned out
      Both models included the following variables: age (<35 years referent category), sex (male referent), relationship status (single referent), specialty (internal medicine subspecialty referent), hours worked per week, and practice setting (private practice referent category).
      Age ≥65 y (vs age <35 y)0.435 (0.320-0.591)<.001
      Female (vs male)1.329 (1.156-1.528)<.001
      Married (vs single)0.719 (0.593-0.872)<.001
      Hours worked per week (for each additional hour)1.021 (1.017-1.026)<.001
      Specialty (vs internal medicine subspecialty)
      Emergency medicine1.875 (1.360-2.584)<.001
      General surgery subspecialty0.656 (0.491-0.877).004
      Neurosurgery0.476 (0.255-0.890).020
      Pediatric subspecialty0.539 (0.378-0.770)<.001
      Satisfied with WLI
      Both models included the following variables: age (<35 years referent category), sex (male referent), relationship status (single referent), specialty (internal medicine subspecialty referent), hours worked per week, and practice setting (private practice referent category).
      Age 35-44 y (vs age <35 y)0.630 (0.475-0.835).001
      Age 45-54 y (vs age <35 y)0.648 (0.488-0.860).003
      Age 55-64 y (vs age <35 y)0.643 (0.486-0.851).002
      Female (vs male)0.512 (0.444-0.592)<.001
      Hours worked per week (for each additional hour)0.944 (0.939-0.948)<.001
      a OR = odds ratio; WLI = work-life integration.
      b Both models included the following variables: age (<35 years referent category), sex (male referent), relationship status (single referent), specialty (internal medicine subspecialty referent), hours worked per week, and practice setting (private practice referent category).

       Comparison of Physicians to the General US Working Population

      To compare the professional experience of practicing physicians relative to working US adults, 3971 nonretired physicians aged 29 to 65 years were compared with 5198 employed general population respondents aged 29 to 65 years (Table 4). The overall prevalence of burnout on the 2-item burnout measure for the general US working population in 2017 was similar to 2011 and 2014 (2011, 28.6% [1654 of 5791]; 2014, 28.4% [1532 of 5394]; 2017, 28.1% [1452 of 5169]; comparison 2017 to 2011, P=.58; comparison 2017 to 2014, P=.72). Satisfaction with WLI for the general US working population in 2017 was similar to 2014 and remained more favorable than 2011 (2011, 55.1% [3225 of 5858]; 2014, 61.3% [3320 of 5412]; 2017, 61.0% [3159 of 5179]; comparison 2017 to 2011, P<.001; comparison 2017 to 2014:, P=.71).
      Table 4Comparison of Employed Physicians in the Sample Aged 29 to 65 Years With a Probability-Based Sample of the Employed US Population Aged 29 to 65 Years in 2017
      NA = not applicable.
      VariablePhysicians, No. (%) (N=3971)Population, No. (%) (N=5198)P value
      Sex<.001
       Male2279 (57.5)2702 (52.0)
       Female1674 (42.2)2496 (48.0)
       Other11 (0.3)0 (0.0)
       Missing70
      Age (y)
       Median50.052.0<.001
       29-34299 (7.5)500 (9.6)<.001
       35-441117 (28.1)1000 (19.2)
       45-541095 (27.6)1498 (28.8)
       55-651460 (36.8)2200 (42.3)
      Relationship status<.001
       Single498 (12.7)1436 (27.6)
       Married3233 (82.2)3429 (66.0)
       Partnered168 (4.3)229 (4.4)
       Widow/widower35 (0.9)104 (2.0)
       Missing370
      Hours worked per week
       Mean (SD)52.6 (16.1)40.3 (11.8)<.001
       Median50.040.0
       <40569 (14.6)1368 (26.3)<.001
       40-49801 (20.5)2813 (54.2)
       50-591017 (26.0)693 (13.3)
       60-69887 (22.7)234 (4.5)
       70-79323 (8.3)53 (1.0)
       ≥80309 (7.9)33 (0.6)
       Missing654
      Highest level of educationNA
       Less than high school graduateNA114 (2.2)
       High school graduateNA1156 (22.2)
       Some college, no degreeNA1025 (19.7)
       Associate degreeNA606 (11.7)
       Bachelor’s degreeNA1291 (24.8)
       Master’s degreeNA721 (13.9)
       Professional or doctorate degree (other than MD/DO)3971 (100)285 (5.5)
      OccupationNA
       Professional
      Business/financial, management, computer/mathematical, architecture/engineering, lawyer/judge, life/physical/social sciences, community/social services, teacher nonuniversity, teacher college/university, other.
      NA2217 (43.1)
       Health care
      Nurse, pharmacist, paramedic, laboratory technician, nursing aide, orderly, dental assistant.
      NA386 (7.5)
       Service
      Protective service, food preparation/service, building cleaning/maintenance, personal care/service.
      NA386 (7.5)
       Sales
      Sales representative, retails sales, other sales.
      NA331 (6.4)
       Office and administrative supportNA469 (9.1)
       Farming, forestry, fishingNA22 (0.4)
       Precision production, craft and repair
      Construction and extraction, installation/maintenance/repair, precision production (machinist, welder, backer, printer, tailor).
      NA339 (6.6)
       Transportation and material movingNA168 (3.3)
       Armed servicesNA26 (0.5)
       OtherNA803 (15.6)
       MissingNA51
      Distress
       Burnout
      As assessed using the single-item measures for emotional exhaustion (EE) and depersonalization (DP) adapted from the full Maslach Burnout Inventory (MBI). Area under the receiver operating characteristic curve for the EE and DP single items relative to that of their respective full MBI domain score in previous studies were 0.94 and 0.93, and the positive predictive values of the single-item thresholds for high levels of EE and DP were 88.2% and 89.6%, respectively.2,34,35
      Emotional exhaustion
      Individuals indicating symptoms of EE weekly or more often have median full MBI EE scores of >30 and have a >75% probability of having a high EE score as defined by the MBI (≥27).
      <.001
      Never473 (12.0)725 (14.0)
      A few times a year863 (21.9)1362 (26.3)
      Once a month or less553 (14.0)843 (16.3)
      A few times a month618 (15.7)971 (18.7)
      Once a week390 (9.9)415 (8.0)
      A few times a week585 (14.8)559 (10.8)
      Every day462 (11.7)311 (6.0)
      Missing2712
      High score1437 (36.4)1285 (24.8)<.001
      Depersonalization
      Individuals indicating symptoms of DP weekly or more often have median full MBI DP scores of >13 and have a >85% probability of having a high DP score as defined by the MBI (≥10).
      <.001
      Never1435 (36.4)2277 (44.1)
      A few times a year917 (23.3)1116 (21.6)
      Once a month or less462 (11.7)551 (10.7)
      A few times a month417 (10.6)522 (10.1)
      Once a week209 (5.3)233 (4.5)
      A few times a week299 (7.6)246 (4.8)
      Every day199 (5.1)220 (4.3)
      Missing3333
      High score707 (18.0)699 (13.5)<.001
      Burned out
      High score (≥weekly) on EE and/or DP scale.
      1566/3933 (39.8)1452/5169 (28.1)<.001
       Work-life Integration
       Work schedule leaves me enough time for my personal/family life<.001
      Strongly agree422 (10.7)1205 (23.3)
      Agree1157 (29.3)1954 (37.7)
      Neutral641 (16.2)953 (18.4)
      Disagree1103 (27.9)781 (15.1)
      Strongly disagree626 (15.9)286 (5.5)
      Missing2219
      a NA = not applicable.
      b Business/financial, management, computer/mathematical, architecture/engineering, lawyer/judge, life/physical/social sciences, community/social services, teacher nonuniversity, teacher college/university, other.
      c Nurse, pharmacist, paramedic, laboratory technician, nursing aide, orderly, dental assistant.
      d Protective service, food preparation/service, building cleaning/maintenance, personal care/service.
      e Sales representative, retails sales, other sales.
      f Construction and extraction, installation/maintenance/repair, precision production (machinist, welder, backer, printer, tailor).
      g As assessed using the single-item measures for emotional exhaustion (EE) and depersonalization (DP) adapted from the full Maslach Burnout Inventory (MBI). Area under the receiver operating characteristic curve for the EE and DP single items relative to that of their respective full MBI domain score in previous studies were 0.94 and 0.93, and the positive predictive values of the single-item thresholds for high levels of EE and DP were 88.2% and 89.6%, respectively.
      • Sinsky C.
      • Colligan L.
      • Li L.
      • et al.
      Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
      • 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.
      • West C.P.
      • Dyrbye L.N.
      • Satele D.V.
      • Sloan J.A.
      • Shanafelt T.D.
      Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment.
      h Individuals indicating symptoms of EE weekly or more often have median full MBI EE scores of >30 and have a >75% probability of having a high EE score as defined by the MBI (≥27).
      i Individuals indicating symptoms of DP weekly or more often have median full MBI DP scores of >13 and have a >85% probability of having a high DP score as defined by the MBI (≥10).
      j High score (≥weekly) on EE and/or DP scale.
      Demographic differences between the physician and general population samples in 2017 are shown in Table 4. Similar to 2011 and 2014, physicians reported working a mean of 12 hours more per week (52.6 vs 40.3 hours), with 38.9% of physicians (1519 of 3906) and 6.2% of the general population respondents (320 of 5194) working 60 hours or more per week (P<.001 for both). On the 2-item burnout measure, physicians had higher rates of emotional exhaustion (36.4% [1436 of 3944] vs 24.8% [1285 of 5186]; OR, 1.74; P<.001), depersonalization (18.0% [707 of 3938] vs 13.5% [699 of 5165]; OR, 1.33; P<.001), and overall burnout (39.8% [1566 of 3933] vs 28.1% [1452 of 5169]; OR, 1.69; P<.001) (Figure 2A). After adjusting for age, sex, relationship status, and hours worked per week, physicians remained at increased risk for burnout compared with the general US working population (OR, 1.39; 95% CI, 1.26-1.54; P<.001). Physicians had a lower rate of satisfaction with WLI than the general US working population (40.0% [1579 of 3949] vs 61.0% [3159 of 5179]; OR, 0.43; 95% CI, 0.39-0.46; P<.001) (Figure 2B). After adjusting for age, sex, relationship status, and hours worked per week, physicians remained less likely to be satisfied with WLI compared with the general population (OR, 0.77; 95% CI, 0.70-0.85; P<.001.
      Figure thumbnail gr2
      Figure 2Changes in burnout (A) and satisfaction with work-life integration (WLI) (B) in physicians and US working population.

      Discussion

      The current prevalence of burnout among US physicians appears to be lower than in 2014 and near 2011 levels. This trend is encouraging and suggests improvement is possible despite the numerous contributing factors and complexity of the problem. Although the improvement is good news, symptoms of burnout remain a pervasive problem, and its prevalence among physicians continues to be markedly higher than in the general US working population, even after adjustment for differences in hours worked, age, sex, and relationship status. Notably, the improvement in burnout among physicians has not been realized equally across all specialties, as levels remain higher than in 2011 for many disciplines.
      To what can the improvement in the prevalence of physician burnout over the past 3 years be attributed? It is possible that 2014 was a particularly challenging time because of consolidation of hospitals and medical groups, a number of new regulatory factors, increasing EHR penetration, and increased administrative burden.
      • Sinsky C.
      • Colligan L.
      • Li L.
      • et al.
      Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • Sinsky C.
      • et al.
      Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction.
      • Tai-Seale M.
      • Olson C.W.
      • Li J.
      • et al.
      Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine.
      • Arndt B.G.
      • Beasley J.W.
      • Watkinson M.D.
      • et al.
      Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations.
      The situation may be improving as physicians and organizations adapt to the new practice environment. It is also possible that the prevalence of burnout improved due to burned out physicians leaving the workforce or reducing clinical effort.
      • Sinsky C.A.
      • Dyrbye L.N.
      • West C.P.
      • Satele D.
      • Tutty M.
      • Shanafelt T.D.
      Professional satisfaction and the career plans of US physicians.
      It should be noted, however, that many large-scale efforts have been initiated at the national level to address this issue.
      • Noseworthy J.
      • Madara J.
      • Cosgrove D.
      • et al.
      Physician burnout is a public health crisis: a message to our fellow health care CEOs. Health Affairs website.
      • Dzau V.J.
      • Kirch D.G.
      • Nasca T.J.
      To Care Is Human - collectively confronting the clinician-burnout crisis.
      • Shanafelt T.D.
      • Dyrbye L.N.
      • West C.P.
      Addressing physician burnout: the way forward.
      • Thomas L.R.
      • Ripp J.A.
      • West C.P.
      Charter on physician well-being.
      • Erickson S.M.
      • Rockwern B.
      • Koltov M.
      • McLean R.M.
      Medical Practice and Quality Committee of the American College of Physicians
      Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.
      • McMahon G.T.
      The leadership case for investing in continuing professional development.
      Even though they are still in their early stages, these efforts may have already made a difference: people are talking about the problems, individuals recognize that they are not alone, and the visible leadership by influential national organizations and accrediting bodies (eg, National Academy of Medicine, AMA, Association of American Medical Colleges, Accreditation Council for Graduate Medical Education, the Joint Commission, American College of Physicians, Accreditation Council for Continuing Medical Education) engaging regulators, payers, and other organizations may provide optimism for meaningful change.
      • Dzau V.J.
      • Kirch D.G.
      • Nasca T.J.
      To Care Is Human - collectively confronting the clinician-burnout crisis.
      • Erickson S.M.
      • Rockwern B.
      • Koltov M.
      • McLean R.M.
      Medical Practice and Quality Committee of the American College of Physicians
      Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.
      • McMahon G.T.
      The leadership case for investing in continuing professional development.
      • Sinsky C.A.
      • Privitera M.R.
      Creating a "manageable cockpit" for clinicians: a shared responsibility.
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      Many organizations have also made substantive efforts to improve the efficiency of the practice environment through better team-based care, documentation assistance, and streamlined workflows.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      • Linzer M.
      • Poplau S.
      • Grossman E.
      • et al.
      A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study.
      • Swenson S.
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      • Shanafelt T.
      Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience.
      • Gidwani R.
      • Nguyen C.
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      • et al.
      Impact of scribes on physician satisfaction, patient satisfaction, and charting efficiency: a randomized controlled trial.
      • Rao S.K.
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      The impact of administrative burden on academic physicians: results of a hospital-wide physician survey.
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      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      • Martel M.L.
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      • Holm K.M.
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      Developing a medical scribe program at an academic hospital: the Hennepin County Medical Center experience.
      These and other efforts to improve physician well-being have proven to be efficacious
      • West C.P.
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      • Erwin P.J.
      • Shanafelt T.D.
      Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
      • Panagioti M.
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      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      • Linzer M.
      • Poplau S.
      • Grossman E.
      • et al.
      A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study.
      • West C.P.
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      • et al.
      Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial.
      and should be recognized as potential contributors to the favorable trend.
      Despite the modest improvement, our results indicate that burnout among US physicians remains a major problem for the health care delivery system. In our view, the effort to improve health care professional well-being is an ongoing journey, analogous to efforts to improve quality and safety.
      • Dzau V.J.
      • Kirch D.G.
      • Nasca T.J.
      To Care Is Human - collectively confronting the clinician-burnout crisis.
      • Shanafelt T.
      • Goh J.
      • Sinsky C.
      The business case for investing in physician well-being.
      A coordinated, systems-based approach at both the national and organizational levels that addresses the underlying drivers is the key to making progress.
      • Shanafelt T.D.
      • Noseworthy J.H.
      Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout.
      • Shanafelt T.
      • Trockel M.
      • Ripp J.
      • Murphy M.
      • Sandborg C.
      • Bohman B.
      Building a program on well-being: key design considerations to meet the unique needs of each organization [published online ahead of print August 21, 2018]. Acad Med.
      Evidence indicates that both individual- and organization-focused interventions are effective and indeed complementary.
      • West C.P.
      • Dyrbye L.N.
      • Erwin P.J.
      • Shanafelt T.D.
      Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.
      • Panagioti M.
      • Panagopoulou E.
      • Bower P.
      • et al.
      Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis.
      A formal program to assess, design, coordinate, and lead efforts to reduce the occupational risk for burnout and cultivate professional well-being can help accelerate progress at the organization level.
      • Shanafelt T.
      • Trockel M.
      • Ripp J.
      • Murphy M.
      • Sandborg C.
      • Bohman B.
      Building a program on well-being: key design considerations to meet the unique needs of each organization [published online ahead of print August 21, 2018]. Acad Med.
      Although the change in burnout is favorable, symptoms of depression among physicians have continued to worsen. Distress is a multidimensional construct that includes burnout, depression, stress, WLI, professional satisfaction, and fatigue as well as other domains. These dimensions of distress have both shared and distinct drivers and do not always move in the same direction.
      Our study is subject to several limitations, the potential for response bias being the most important. The majority of physicians did not open the e-mails informing them of the study and accordingly never received the invitation to participate. The participation rate among those who opened the invitation e-mail was only 17.1%. Although consistent with other national survey studies of physicians,
      • Allegra C.
      • Hall R.
      • Yothers G.
      Prevalence of burnout in the U.S. oncology community: results of a 2003 survey.
      • Kuerer H.M.
      • Eberlein T.J.
      • Pollock R.E.
      • et al.
      Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology.
      • Shanafelt T.D.
      • Balch C.M.
      • Bechamps G.J.
      • et al.
      Burnout and career satisfaction among American surgeons.
      this response is lower than typical response rates of physician surveys in general.
      • Asch D.A.
      • Jedrziewski M.K.
      • Christakis N.A.
      Response rates to mail surveys published in medical journals.
      We did, however, employ a robust double survey approach using incentives to compare participants to nonresponders.
      • Johnson T.P.
      • Wislar J.S.
      Response rates and nonresponse errors in surveys.
      The results revealed no statistically significant differences with respect to age (P=.83), years in practice (P=.41), burnout (P=.66), or satisfaction with WLI (P=.09), suggesting that the participants were representative of US physicians. Because our results are based on anonymous responses, we are unable to assess changes in burnout and WLI of individual physicians over time, and the study methodology cannot determine the direction of effect or potential causality between the variables assessed. It is also possible that social desirability bias could alter an individual’s response to items about burnout.

      Conclusion

      Burnout and satisfaction with WLI among US physicians improved between 2014 and 2017. This trend is reason for optimism and suggests that progress is both possible and under way. Despite this improvement, symptoms of burnout among physicians continue to be prevalent and markedly higher than seen in the general US working population. Given the evidence that burnout impacts patient satisfaction, access, quality of care, and costs, continued efforts to make progress are needed.

      Supplemental Online Material

      Supplemental material can be found online at http://www.mayoclinicproceedings.org. Supplemental material attached to journal articles has not been edited, and the authors take responsibility for the accuracy of all data.

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