Does academic practice protect emergency physicians against burnout?

Abstract

Burnout is a complex syndrome thought to result from long‐term exposure to career‐related stressors. Physicians are at higher risk for burnout than the general United States (US) working population, and emergency medicine has some of the highest burnout rates of any medical specialty. Burnout impacts physicians’ quality of life, but it can also increase medical errors and negatively affect patient safety. Several studies have reported lower burnout rates and higher job satisfaction in academic medicine as compared with private practice. However, researchers have only begun to explore the factors that underlie this protective effect. This paper aims to review existing literature to identify specific aspects of academic practice in emergency medicine that may be associated with lower physician burnout rates and greater career satisfaction. Broadly, it appears that spending time in the area of emergency medicine one finds most meaningful has been associated with reduced physician burnout. Certain non‐clinical academic work, including involvement in research, leadership, teaching, and mentorship, have been identified as specific activities that may protect against burnout and contribute to higher job satisfaction. Given the epidemic of physician burnout, hospitals and practice groups have a responsibility to address burnout, both by prevention and by early recognition and support. We discuss methods by which organizations can actively foster physician well‐being and provide examples of 2 leading academic institutions that have developed comprehensive programs to promote physician wellness and prevent burnout.

1. INTRODUCTION

Burnout generally is a complex syndrome thought to result from long‐term exposure to career‐related stressors. Widely accepted definitions of burnout include 3 key elements: depersonalization, emotional exhaustion, and a reduced sense of personal accomplishment. ¹ Physician burnout arises from a complex interplay of factors at the level of the individual physician, the practice environment, and the health care system as a whole. The effects of burnout on personal and professional life are manifold: burnout has been associated with reduced sense of empathy and altruism, decreased job satisfaction, increased rates of medical errors, and higher rates of depression, substance abuse, marital difficulties, physician turnover, and suicidal ideation. ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷

One study reported a 55% burnout rate among emergency physicians versus a 44% burnout rate for physicians in general, both of which far exceeded the 28% burnout rate of the general US working population. ¹⁸ As more is understood about the etiology of physician burnout, researchers have also sought to identify protective factors. One such protective factor appears to be work in academic medicine. Although direct evidence comparing academic practice versus private practice in emergency medicine is limited, there are a number of studies researching correlations between burnout rate and practice setting in other specialties that may be applicable to emergency medicine. ⁴ , ⁵ , ¹³ , ¹⁸ , ¹⁹ , ²⁰ This paper aims to review existing literature to identify aspects of academic practice that are associated with lower burnout rates and greater career satisfaction among emergency physicians and methods by which health care organizations can foster physician well‐being.

2. RESEARCH ON ACADEMIC PRACTICE VERSUS PRIVATE PRACTICE

Although career satisfaction may not be a perfect surrogate for burnout, the concepts are certainly closely related. A study of ∼1400 female emergency physicians revealed that simply practicing in an academic setting was an independent predictor of higher career satisfaction. ²¹ Similarly, studies that included all genders across various specialties found higher career satisfaction for physicians practicing in academic medicine. ⁴ , ¹⁴ Sinsky et al reported that physicians practicing in an academic setting are less likely than physicians in private practice to “intend to leave medicine altogether to pursue a different career within the next 2 years.” ¹⁴ Multiple studies have specifically reported lower burnout rates in academic medicine as compared with private practice. ⁴ , ⁵ , ¹³ , ¹⁸ , ¹⁹ , ²⁰

3. RESEARCH ON SPECIFIC CAREER ASPECTS THAT ARE ASSOCIATED WITH LOWER BURNOUT AND HIGHER CAREER SATISFACTION

Although there is growing evidence that academic physicians are less likely to experience burnout compared with physicians in private practice, it is not entirely clear which specific qualities of an academic career may be protective against burnout. Several studies have considered this question. One group examined career fit and burnout among academic faculty and found that physicians who spend at least 20% of their professional time focused on the work they find most meaningful are at lower risk for burnout; however, spending >20% of time on meaningful work did not lead to further decreases in burnout, implying that a ceiling effect exists. ²² Application of these results is complicated by different physicians finding meaning in varied areas of medical practice. In this study, for example, 68% reported that patient care was the most meaningful aspect of their work, whereas 19% ranked research as the most meaningful, followed by 9% for education, and 3% for administration. ²²

Although clinical work is widely described by physicians as meaningful, and meaningful work protects against burnout, there is also literature to suggest that maintaining a balance with non‐clinical activities is important. One study of 268 Canadian emergency physicians revealed that a successful research publication in the last 2 years was associated with lower emotional exhaustion. Interestingly, in this study, emergency physicians devoting a higher proportion of work hours to non‐clinical duties showed consistent improvement in personal accomplishment scores. ⁷

In a longitudinal study, the American Board of Emergency Medicine (ABEM) found that physicians involved in either clinical teaching or professional leadership roles were twice as likely as those without such involvement to report high career satisfaction. ²³ Several studies have also associated mentorship with improved career satisfaction. ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ Mentorship has also been associated with increased career advancement and physician retention, increased productivity, and lower burnout. ²⁷ , ²⁸ , ²⁹ The effects of mentorship on burnout are both direct and indirect: mentorship may lead to decreased burnout through enhanced career advancement and career satisfaction, in addition to the direct gratification of the personal relationship.

Research, leadership, and teaching/mentorship are all part of a well‐rounded academic practice, and, as discussed, each has been independently identified as an activity that may protect against burnout. It appears that time spent away from clinical activities, whether in teaching or continuing professional development, may reduce physician burnout. ² Conversely, then, shifting the balance of clinical service and education by increasing patient care workload and decreasing time for education may negatively impact physician wellness and increase the risk of burnout. ¹⁸ , ³⁰ , ³¹

Physicians in the ABEM longitudinal study who were unable to attend educational conferences or lacked sufficient time for personal life reported lower career satisfaction and higher levels of burnout. ²³ Similarly, physicians reported that they perceived administrative duties such as clinical documentation and medication reconciliation as burdensome and; in turn, physicians who spent more of their time engaged in these tasks reported more burnout and lower career satisfaction. ³² Another study evaluating the relationship between clerical burden and physician burnout found significant lower burnout in academic physicians versus physicians in private practice. ²⁰ Table 1 provides a summary of job factors that are associated with lower burnout and Table 2 provides a summary of factors which are associated with increased burnout.

TABLE 1.

Factors associated with lower burnout

Focusing 20% of the professional time on work found meaningful by the individual 22
Achieving balance with non‐clinical activities 7 , 14 , 19 , 23 , 32
Attending CME conferences 2 , 23
Teaching role 22 , 23
Professional leadership roles 7 , 23
Sufficient time for personal life 4 , 14 , 21 , 39
Mentorship 27 , 29
Department leadership that fosters a sense of partnership and physician engagement 42

TABLE 2.

Factors associated with increased burnout

Excessive workloads: long hours or high intensity 10 , 14 , 18 , 54

Administrative duties such as clinical documentation/medication reconciliation 20 , 32

Spending less than 20% of professional time on work found most meaningful by the individual 22

Poor work–life integration/work–home conflict 4 , 5 , 18

Private practice setting 4 , 5 , 13 , 18 , 19 , 20

When addressing physician wellness, one should also consider the impact of sex on burnout and job satisfaction. Many studies report a higher risk of burnout in female physicians than male physicians. ⁴ , ¹⁸ , ³³ , ³⁴ A 2014 study of emergency physicians revealed those mid‐career females are much more likely to consider leaving the specialty than mid‐career males. ³³ A study of female emergency physicians reported that practice in an academic setting, the amount of recognition at work, opportunities for career advancement, schedule flexibility, supportive colleagues, and compensation fairness were associated with higher career satisfaction. ²¹ A study of surgeons revealed that the causes of burnout in male and female physicians were similar; however, work–home conflicts occurred more frequently in female physicians. ⁴ Some other factors that have been associated with higher female burnout include: self‐reported sex discrimination, ³⁵ sexual harassment, ³⁶ and imposter syndrome. ³⁷ , ³⁸

4. SYSTEMS‐BASED APPROACH TO PROMOTING WELLNESS AND PREVENTING BURNOUT

Traditionally, physician burnout has been viewed as a personal failing of the individual physician. However, addressing physician burnout should be viewed as the “shared responsibility” of both physicians and health care organizations. ³⁹ As such, strategies for combating physician burnout and promoting wellness should incorporate interventions that target both individual and systemic factors. ³⁹ , ⁴⁰ One such departmental solution may be the implementation of scribes, which could improve emergency physician satisfaction by reducing the time devoted to clinical documentation. ⁴¹ Other institutional characteristics that have been broadly associated with reduced physician burnout include pathways for decisionmaking by consensus or committee and department leadership that fosters a sense of partnership and physician engagement. ⁴² Several authors have proposed that to prove a real commitment to the epidemic of physician burnout, organizations must track and report measures of physician burnout, engagement, and well‐being, in much the same way they track traditional performance metrics such as patient satisfaction, patient volume, or cost. ³⁹ , ⁴⁰

5. ORGANIZATIONAL WELL‐BEING PROGRAMS

The Mayo Clinic and Stanford Medical Center have established well‐being programs that can serve as examples for other health systems. The Mayo Clinic Program on Physician Well‐Being was founded in 2007 to develop evidence‐based operational strategies to address physician wellness. As opposed to addressing the needs of physicians who are already in distress, the program was developed to proactively identify factors that influence physician well‐being, satisfaction and productivity, to create targeted institutional approaches that prevent burnout in the first place. This group developed the Listen‐Act‐Develop model to understand specific contributors to burnout, empower physicians to implement solutions, and develop leaders in a continuous improvement process. ³⁹ , ⁴³ This model resulted in a reduction in burnout and increased in engagement and overall satisfaction. ⁴³

Stanford has worked to promote wellness and prevent burnout at both the departmental and institutional level. The emergency department has developed an innovative return‐to‐work policy for new parents. It has also provided faculty access to a professional development program focused on wellness, mindfulness, and finding meaning at work. Additionally, Stanford Emergency Medicine has developed coaching and mentorship programs for faculty. The department's wellness initiatives are complemented by a physician wellness fellowship. Institutional initiatives include a committee for professional satisfaction and support, a faculty and staff help center, and a robust peer‐support network. ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹

6. DISCUSSION

Physician burnout is highly prevalent, regardless of specialty, but emergency physicians are particularly at risk. Physicians in an academic practice may have a lower risk of burnout and emotional exhaustion. Diversification in an academic practice, 20% of a physician's time, appears to have some protective effect on burnout. ²² Dedicating time to non‐clinical work, including teaching, leadership, and research seems to have a protective effect on reducing physician burnout. However, time spent on non‐clinical activities must be balanced by a reduction of clinical hours, or the increased total workload may negate the benefits of diversified activities.

Researchers have begun to identify which aspects of an academic career protect against burnout, and some of these aspects may be translatable to private practice as well. Although balancing clinical and non‐clinical activities appears to be important, uncertainty remains about how best to achieve this balance at the individual and institutional level. Individual academicians can and should seek positions that maximize the work they find meaningful. Departmental leaders must also seek out this “most meaningful” information from faculty and should hire individuals whose career goals align with job expectations.

Another potential contributor to burnout is student debt. ⁵² A 2016 study reported a median student loan debt of emergency medicine residents was over $200,000 and this affected future career plans. ⁵³ With a high student debt, emergency physicians may be tempted to work more hours or seek higher paying private practice positions. Further research is needed to determine the amount of emergency physician burnout attributable to student debt and the level of impact of student debt on practice location.

Further research is also needed comparing burnout and job satisfaction between private practice and academic emergency physicians. Much of the research that has been done comparing physicians in academic versus private practice has been done in multispecialty studies; these results may not always be generalizable to emergency physicians. Additionally, although overall lower rates of burnout are seen in academics, burnout remains a problem in all arenas of emergency medicine practice. There are likely to be unique factors that lead certain academic jobs to engender higher burnout than others. Future studies can be designed to elucidate these elements, such as examining the effect of decreased support of protected time for academic faculty. Additional research should also focus on the burnout impact of other practice variations between academic and non‐academic jobs, such as the degree of career advancement opportunities, availability of mentorship, professional development activities, and salary structure. Further research is also needed on the association of demographic factors with emergency physician burnout.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

Norvell JG, Baker AM, Carlberg DJ, et al. Does academic practice protect emergency physicians against burnout? JACEP Open. 2021;2:e12329 10.1002/emp2.12329