The Association Between Burnout and Pediatrician Management of Adolescent Depression

Abstract

Objective: Given the increased demand for pediatric primary care providers to manage adolescent depression, the current study examines the association between burnout and provider comfort and perception of feasibility managing adolescent depression. Method: Data were collected from 52 pediatricians at a Midwest academic health center. Results: Higher scores on depersonalization were associated with lower provider-reported comfort managing adolescent depression. Emotional exhaustion and personal accomplishment were not associated with provider-reported comfort managing adolescent depression. None of the burnout domains were associated with the provider-reported perception of the feasibility managing adolescent depression in this setting. Limitations and recommendations for future research regarding the impact of behavioral health training on burnout are discussed. Conclusions: The interpersonal stress dimension of burnout is associated with less comfort managing depression. Adding positive systematic interventions, such as behavioral health trainings that support pediatricians in the management of behavioral health may have impact on burnout.

As providers face a rapidly expanding knowledge base and increased workloads, burnout has become an important concern within the health care field.¹ Burnout is defined as a type of job stress comprising emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment in one’s work.² Emotional exhaustion is the stress dimension of burnout that occurs when providers’ work drains their emotional and physical resources. Depersonalization is the interpersonal dimension of burnout that occurs when providers put distance between themselves and their patient. Diminished personal accomplishment is the self-evaluative component which occurs when providers lose their sense of effectiveness when they are faced with overwhelming demands and lack of resources. Compared with burnout in other specialties, pediatrician burnout rates are increasing faster than other specialties.³ Pediatricians are especially vulnerable given that many traits that are highly valued and socially expected of them (eg, compassion, altruism) are risk factors of burnout.⁴ The job demands–resources model supposes that two factors contributing to burnout include high demands and inadequate resources to keep up with demands.⁵ Consistent with this model, data indicate poor work environments, high work stress, and low access to resources and referrals for patients are associated with higher levels of pediatrician burnout.⁶ An increased demand to screen for behavioral health concerns despite having few resources to manage such concerns has made pediatricians more vulnerable to burnout. Yet, no studies have examined the association between burnout and management of behavioral health concerns among pediatric patients.

The American Academy of Pediatrics (AAP) recommends pediatricians screen and monitor depression symptoms for all patients ages 11 to 21 years.⁷ Given the limited training pediatricians receive in managing depression, adolescent depression is a particularly burdensome behavioral health concern for pediatricians.⁸ Pediatricians report that low comfort managing depression, insufficient time, and a lack of clinical training are barriers to adequately managing depression during medical visits.^9,10

Thus, in addition to describing burnout among a sample of pediatricians in an academic medical center, the current study examined the association between aspects of physician burnout and provider-reported comfort with managing depression and their perception of the feasibility of managing depression among their adolescent patients. It was hypothesized that burnout would be associated with lower provider-reported comfort managing depression and lower provider-reported feasibility managing depression.

Method

Participants and Procedure

The study was reviewed and deemed exempt by the institution’s internal review board. All pediatricians at the institution (N = 54) were invited to participate in a 90-minute behavioral health training conducted at their clinic. The purpose of the training was to support pediatrician management of adolescent depression. Participation in the training was encouraged by general pediatric leadership, but provider attendance at the training and their completion of training surveys was voluntary. Of the pediatricians across 9 primary care offices, 52 participated and were included in the following analyses. Data were collected during the first 10 minutes of the training via Qualtrics surveys. This study comprises ancillary analysis from the larger study that examined the effectiveness of the training. Descriptive statistics (eg, frequency, mean and standard deviation, and range) were used to describe burnout in this sample of pediatricians. Pearson’s bivariate correlation analyses were used to examine association between burnout dimensions, years in practice, and comfort and perception of feasibility managing adolescent depression.

Measures

Burnout was measured using the 22-item Maslach Burnout Inventory Human Services Survey for Medical Professionals (MBI-HSS-MP).¹¹ The MBI-HSS-MP is a validated measure of burnout that is composed of three subscales: Emotional Exhaustion, Depersonalization, and Personal Accomplishment.^11,12 Statements were rated on a 7-point Likert-type scale ranging from 0 (never) to 6 (every day). Higher scores on Emotional Exhaustion and Depersonalization and lower scores on Personal Accomplishment are indicative of higher burnout. Cronbach’s alpha demonstrated acceptable internal reliability among this sample (.91, .69, and .70 respectively).

Provider-reported comfort and perception of the feasibility managing adolescent depression were measured using two 5-item self-report questionnaires. These questionnaires were developed for the purpose of this training and thus reflected aspects of depression management that were covered in the training (eg, comfort and feasibility treating depression, comfort and feasibility explaining a depression handout, comfort and feasibility conducting a risk assessment, comfort and feasibility managing psychotropic medication for depression, comfort and feasibility using an automated documentation tool to document screening results and interventions used). Statements were rated on a 6-point Likert-type scale ranging from 1 (very uncomfortable) to 6 (very comfortable) and 1 (very unfeasible) to 6 (very feasible). Cronbach’s alpha (.81 and .77, respectively) indicated adequate internal reliability among this sample.

Results

The average pediatrician age was 42 years (SD = 9.68), ranging from 30 to 67 years. Years of practice was variable, ranging from 1 to 41 years (M = 12.94 years, SD = 9.64). Pediatricians reported an average Emotional Exhaustion score of 2.59 (SD = 1.18), an average Depersonalization score of 1.02 (SD = 0.82), and an average Personal Accomplishment score of 4.95 (SD = 0.71). Based on cut-off scores used in previous studies,¹³ 35% met the cutoff for significant levels of emotional exhaustion, 14% met the cutoff for significant levels of depersonalization, and 14% met the cutoff for significantly low levels of personal accomplishment. Only 1 pediatrician in this sample met the criteria across all 3 burnout domains.

Results from Pearson’s bivariate correlations showed that burnout was not significantly associated with years in practice. Higher depersonalization was associated with lower provider-reported comfort managing adolescent depression (Table 1). Neither emotional exhaustion nor personal accomplishment were associated with provider-reported comfort managing adolescent depression. Burnout was not associated with provider perceptions regarding the feasibility of managing adolescent depression.

Table 1.

Correlations Between Burnout, Provider-Reported Comfort Managing Depression, and Perceptions of Feasibility Managing Depression.

	Emotional Exhaustion	Depersonalization	Personal Accomplishment	Feasibility	Comfort
Years in practice	.16	−.23	−.17	.02	.15
Emotional Exhaustion	—	.46**	−.37**	−.16	−.24
Depersonalization		—	−.33*	−.03	−.30*
Personal Accomplishment			—	.22	.15
Feasibility				—	.62**

^*p < .05, **p < .01.

Discussion

Pediatricians indicated feelings of personal accomplishment occur a few times per week, feelings of emotional exhaustion occur a few times per month, and feelings of depersonalization occur a few times a year. These results are comparable to burnout ratings reported by pediatricians in the published literature.¹⁴ The results of this study indicated that even though depersonalization did not occur very often, more depersonalization was associated with less comfort managing depression. It appears that there may be an association between the interpersonal-stress domain of burnout (ie, depersonalization) and self-reported comfort managing depression among adolescent patients. The direction of this association remains unclear. However, one hypothesis is that a lack of comfort managing a behavioral health concern that commonly presents to pediatricians leads to an increase in interpersonal stress among providers. This hypothesis aligns with studies demonstrating that a lack of referral options to manage mental health concerns is linked to increased rates of provider burnout.⁶ Alternatively, it is possible that providers who report increased interpersonal stress, tend to have less perceived comfort treating difficult patient presentations, paralleling the finding that pediatricians who rated themselves as having elevated work stress and burnout reported reduced quality of patient care.¹⁵ Further study of the link between interpersonal stress and provider comfort is needed to better understand this association.

Limitations of the current study include small sample size contributing to low power to detect small effect sizes. Additionally, the applied nature of the sampling method (ie, lack of randomization and institutional promotion of the training) affects the internal validity of findings. Furthermore, this study used measures that are not well-validated to assess provider-reported comfort managing depression. Importantly, provider-reported comfort is not equivalent to competence or provider ability to manage depression. Despite this limitation, a lack of comfort managing depression has been reported by primary care providers as a barrier to effective patient care.^10,16 Thus behavioral health trainings that increase comfort managing depression may reduce such perceived barriers.

Because results from this study cannot provide information concerning the directionality of the association between burnout and comfort managing depression, future research should consider whether trainings aimed at improving comfort managing behavioral health can decrease the levels of interpersonal stress, specifically depersonalization. Interestingly, burnout was not associated with the providers’ perception regarding the feasibility of managing adolescent depression. Maximizing available resources for patient care may have an important role in reducing the impact of burnout on pediatricians.⁶ Adding positive systematic interventions, such as behavioral health trainings that support pediatricians in the management of behavioral health, rather than reducing negative-systematic interventions may have a much longer impact on burnout.

Conclusion

Burnout is a concern for pediatricians who are taking on more responsibility for screening and monitoring depression among their adolescent patients. Among the pediatricians from an academic medical center, burnout was not associated with provider-reported perception regarding the feasibility of managing adolescent depression in primary care, however interpersonal stress was associated with less comfort managing depression. Interpersonal stress deserves further attention, as it may impact pediatrician management of behavioral health in pediatric primary care.