Abstract
This survey study uses the Maslach Burnout Inventory to measure physician burnout and associated outcomes in a large academic medical center.
Physician burnout is increasingly recognized as a systemic health care problem.1 Prior research has identified the adverse impact on physician health and patient care.2 Recently, studies have begun to examine the impact on health care delivery.3 We assessed the correlates and outcomes of physician burnout in a single health system.
Methods
Data for this study come from the Cleveland Clinic Health System, a large nonprofit academic health system. Physicians completed the Maslach Burnout Inventory prior to a mandatory communication skills course between August 1, 2013, and May 1, 2014. The Maslach Burnout Inventory measured burnout in 3 domains: emotional exhaustion, depersonalization, and personal accomplishment, as well as burnout overall (defined as emotional exhaustion ≥27 and/or depersonalization ≥10).4 Outcomes included leaving the organization, productivity, receipt of ombudsman complaints, and patient satisfaction with physician communication in inpatient, primary care, and specialty care.
Employment-related data were provided by the Office of Professional Staff Affairs. Patient satisfaction was assessed via Consumer Assessment of Healthcare Providers and Systems surveys tied to the discharge or outpatient physician seen.5,6 Data were entered into a registry approved by the Cleveland Clinic Institutional Review Board. All participants had the option to exclude their data from the registry. The study, which used existing data, was deemed exempt from institutional review board approval.
We assessed correlates of burnout overall and for the emotional exhaustion and depersonalization subscales using multivariable logistic regression models. We assessed outcomes of burnout using multivariable logistic models for ombudsman complaints and leaving the organization, and linear models for productivity and patient satisfaction. Models used backward variable selection, and adjusted for physician sex, race, age, years in practice, marital status, dependents younger than 18 years, full time equivalent, percent clinical full time equivalent, specialty, practice setting, and vacation and meeting days used per year.
Results
The sample included 1145 physicians (response rate, 75% [1145 of 1528]). Physician characteristics and correlates of burnout appear in Table 1. Thirty-five percent (n = 399) of physicians met criteria for overall burnout.
Table 1. Sample Characteristics of 1145 Physicians, Key Outcomes, and Correlations With Burnout.
| Characteristic | All (N = 1145) | With Overall Burnout (n = 399) | P Valuea |
|---|---|---|---|
| Race, No. (%) | |||
| White | 842 (79) | 339 (37) | <.001 |
| Nonwhite | 204 (21) | 59 (25) | |
| Age, mean (IQR), y | 50 (41-57) | 49 (41-56) | .16 |
| Sex, No. (%) | |||
| Male | 776 (68) | 274 (35) | .63 |
| Female | 369 (32) | 125 (34) | |
| Dependents younger than 18 y in household, No. (%) | |||
| No | 589 (51) | 205 (35) | .98 |
| Yes | 556 (49) | 194 (35) | |
| Married, No. (%) | |||
| No | 209 (19) | 74 (35) | .87 |
| Yes | 908 (81) | 316 (35) | |
| Practice setting, No. (%) | |||
| Any outpatient | 961 (86) | 331 (34) | .85 |
| Exclusively inpatient | 159 (14) | 56 (35) | |
| Work schedule, No. (%) | |||
| Full time | 977 (93) | 25 (33) | .84 |
| Part time | 75 (7) | 337 (34) | |
| Practice years, No. (%) | |||
| <10 | 424 (37) | 153 (36) | .39 |
| 10-20 | 344 (30) | 125 (36) | |
| >20 | 377 (33) | 121 (32) | |
| Clinical FTE, mean (IQR), % | 68 (40-100) | 72 (50-100) | .007 |
| Meeting days used, mean (IQR) | 6.5 (2-10) | 6.2 (1-10) | .26 |
| Vacation days used, mean (IQR) | 16.5 (12-22) | 16.8 (12-23) | .44 |
| Specialty, No. (%) | |||
| Anesthesiology | 141 (13) | 47 (33) | .49 |
| Emergency medicine | 29 (3) | 11 (38) | |
| Internal medicine/family medicine | 403 (38) | 142 (35) | |
| Neurology | 44 (4) | 14 (32) | |
| Obstetrics and gynecology | 40 (4) | 12 (30) | |
| Oncology | 34 (3) | 5 (15) | |
| Ophthalmology | 30 (3) | 10 (33) | |
| Pathology | 2 (0.5) | 0 | |
| Pediatrics | 73 (7) | 23 (31) | |
| Psychiatry/psychology | 25 (2) | 8 (32) | |
| Radiology | 92 (9) | 34 (37) | |
| Surgery | 139 (13) | 56 (40) | |
| Left the organization, No. (%) | |||
| No | 975 (89) | 332 (34) | .03 |
| Yes | 123 (11) | 54 (44) | |
| Receipt of ombudsman complaints, No. (%) | 769 (67) | 264 (34) | |
| No | 376 (33) | 135 (36) | .60 |
| Yes | |||
| Productivity percentile, mean (IQR) | 48 (21-77) | 48 (23-73) | .90 |
| Change in productivity percentile, mean (IQR) | −0.65 (−8 to 8) | −0.39 (−10 to 8) | .80 |
| Patients satisfied, mean (IQR), % | |||
| With primary care physician | 90 (91-98) | 89 (91-98) | .81 |
| With outpatient specialty physician | 90 (92-99) | 90 (91-98) | .60 |
| With inpatient physician | 93 (90-97) | 94 (91-97) | .13 |
Abbreviation: IQR, interquartile range.
P values for bivariate comparisons between sample characteristics and overall burnout generated using χ2 tests for categorical variables and analysis of variance for continuous variables.
Table 2 presents the adjusted models for correlates of burnout. Emotional exhaustion was associated with greater odds of leaving the organization (odds ratio, 2.19; 95% CI, 1.14-4.18) and higher patient satisfaction with primary care physician communication (β = 11.5; 95% CI, 2.31-20.8), but overall burnout and depersonalization were not. Depersonalization was associated with greater odds of ombudsman complaints (odds ratio, 1.72; 95% CI, 1.02-2.89), but overall burnout and emotional exhaustion were not. There was no significant association between burnout and productivity or patient satisfaction with inpatient or specialty care.
Table 2. Correlates and Outcomes of Burnout, Multivariable Regression Models Using Backward Variable Selection.
| Parameter | Value |
|---|---|
| Correlates of Burnout | |
| Overall Burnout, OR (95% CI) | |
| Nonwhite (vs white) | 0.54 (0.36-0.82) |
| Clinical FTE, % | 2.88 (1.58-5.28) |
| Age | 0.98 (0.97-0.99) |
| Emotional Exhaustion subscale, OR (95% CI) | |
| Nonwhite (vs white) | 0.46 (0.28-0.73) |
| Clinical FTE, % | 3.05 (1.56-5.97) |
| >20 y in practice (vs <10 y) | 0.64 (0.44-0.92) |
| Depersonalization subscale, OR (95% CI) | |
| Male sex (vs female sex) | 1.71 (1.16-2.53) |
| Age | 0.97 (0.95-0.99) |
| Outcomes of Burnout | |
| Emotional Exhaustion subscale | |
| Leaving the organization, OR (95% CI) | 2.19 (1.14-4.18) |
| Satisfaction with primary care physician communication, β (95% CI) | 11.5 (2.32-20.8) |
| Depersonalization subscale | |
| Ombudsman complaints, OR (95% CI) | 1.72 (1.02-2.89) |
Abbreviations: FTE, full time equivalent; OR, odds ratio.
Discussion
In this study of physicians in a single health system, one-third met criteria for burnout and health care delivery was affected. Depersonalization was associated with ombudsman complaints, suggesting that patients may be more affected by depersonalization than emotional exhaustion. Emotional exhaustion was associated with higher primary care physician communication scores but also with leaving the organization. A positive association between emotional exhaustion and patient satisfaction is not surprising. Physicians who give more to patients during clinical encounters may find themselves emotionally depleted. Consequently, low patient satisfaction scores are unlikely to identify physicians in need of burnout interventions. Our study was limited by its retrospective cross-sectional cohort design, which prevented inferences of causality.
Our findings have important implications for physician retention and health care delivery that have resulted in enterprise-wide mobilization and coordination of efforts to improve physician well-being. Following our survey, leadership recognized burnout as a pressing issue and responded by organizing departmental town halls to identify specific needs. They then established a Staff Experience team including 6 physicians, to implement outreach, clinical enhancements, professionalism, and well-being and professional growth programming that comprehensively supports physicians, explores practice efficiencies, and builds community in a way that reflects our group practice culture. Given similarities between Cleveland Clinic and other major health systems, routine assessment of burnout by health care organizations is warranted to identify the need for additional individual and organizational support.1
References
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