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Physician Stress and Burnout

Open AccessPublished:September 11, 2019DOI:https://doi.org/10.1016/j.amjmed.2019.08.034

      Abstract

      Tens (or hundreds) of thousands of Americans die each year as a result of preventable medical errors. Changes in the practice and business of medicine have caused some to question whether burnout among physicians and other healthcare providers may adversely affect patient outcomes. A clear consensus supports the contention that burnout affects patients, albeit with low-quality objective data. The psychological and physical impact on physicians and other providers is quite clear, however, and the impact on the physician workforce (where large shortages are projected) is yet another cause for concern. We have all heard the airplane safety announcement remind us to “Please put on your own oxygen mask first before assisting others.” Unfortunately, like many airline passengers (very few of whom use oxygen masks correctly when they are needed), physicians often do not recognize symptoms of burnout or depression, and even less often do they seek help. We detail the causes and consequences of physician burnout and propose solutions to increase physician work satisfaction.

      Keywords

      Clinical Significance
      • Burnout affects approximately one-half of physicians in practice.
      • Burnout results in medical errors, lower quality of care, higher costs, and overall worse outcomes; the impact of burnout on the physician workforce is substantial.
      • Burnout is a system problem, not an individual disease and must be addressed with systematic solutions.
      • We will not achieve the goals of the Triple Aim unless we add a fourth goal—to address physician wellness.
      “Put on your own oxygen mask before assisting others.”— Randy Pausch, The Last Lecture

      Scope and Impact of Physician Burnout

      Research regarding physician burnout is plagued by large variability in reported prevalence rates and a lack of agreed terminology (a review of 182 studies found at least 142 unique definitions).
      • Rotenstein LS
      • Torre M
      • Ramos MA
      • et al.
      Prevalence of burnout among physicians: a systematic review.
      Most authors suggest a prevalence rate of approximately half; twice that of the general working population in the United States and with an estimated cost of roughly $5 billion per year related to reduced clinical productivity and increased physician turnover.
      • Han S
      • Shanafelt TD
      • Sinsky CA
      • et al.
      Estimating the attributable cost of physician burnout in the United States.
      Some believe the condition to manifest at some level in nearly all physicians.
      • Patel R
      • Bachu R
      • Adikey A
      • Malik M
      • Shah M
      Factors related to physician burnout and its consequences: a review.
      The burned-out physician “is angry, irritable, impatient, has increased absenteeism, decreased productivity and decreased quality of care.” Evidence of burnout was found in 42% of 15,000 US physicians who responded to a 2018 online survey. The greatest incidence of burnout (50%) was among physicians 45-54 years old, the age group in which work productivity should peak and practices should be economically stable.
      • Nicholls M
      Cardiologists and the burnout scenario.
      Repeated in 2019, the findings were similar, with an overall 44% rate of “feeling burned out,” and an alarming 14% reporting suicidal thoughts. Of those experiencing suicidal thoughts, only one-third sought treatment.

      Medscape. Medscape national physician burnout, depression & suicide report 2019. Available at: https://www.medscape.com/2019-lifestyle-burnout. Published 2019. Accessed August 17, 2019.

      Compared with doctoral-level professionals in other fields, physicians work more long hours, are less satisfied with the balance between their professional and personal lives, and experience symptoms of burnout at significantly higher rates.
      • Shanafelt TD
      • Sinsky C
      • Dyrbye LN
      • Trockel M
      • West CP
      Burnout among physicians compared with individuals with a professional or doctoral degree in a field outside of medicine.
      Burnout is associated with an increased risk of major medical errors.
      • Tawfik DS
      • Profit J
      • Morgenthaler TI
      • et al.
      Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.
      A recent meta-analysis of 47 studies involving more than 42,000 physicians found that physician burnout doubled the risk of adverse patient safety incidents and led to poorer overall quality of care and decreased patient satisfaction.
      • Panagioti M
      • Geraghty K
      • Johnson J
      • et al.
      Association between physician burnout and patient safety, professionalism, and patient satisfaction.
      Physicians reporting burnout symptoms work fewer hours and leave clinical medicine at a higher rate than do those not affected.
      • Shanafelt TD
      • Mungo M
      • Schmitgen J
      • et al.
      Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
      Burnout among primary care physicians also increases turnover, and therefore costs.
      • Willard-Grace R
      • Knox M
      • Huang B
      • Hammer H
      • Kivlahan C
      • Grumbach K
      Burnout and health care workforce turnover.
      Physician burnout and the resultant decreased productivity may exacerbate the previously predicted shortfall of 45,000 to 90,000 physicians in the United States by 2025.
      • Shanafelt TD
      • Dyrbye LN
      • West CP
      • Sinsky CA
      Potential impact of burnout on the US physician workforce.
      Occupational stress has resulted in concern about burnout rates among emergency room physicians,
      • Bragard I
      • Dupuis G
      • Fleet R
      Quality of work life, burnout, and stress in emergency department physicians.
      anesthesiologists,
      • van der Wal RAB
      • Wallage J
      • Bucx MJL
      Occupational stress, burnout and personality in anesthesiologists.
      radiologists,

      Parikh JR, Wolfman D, Bender CE, Arleo E. Radiologist burnout according to surveyed radiology practice leaders [epub ahead of print]. J Am Coll Radiol. doi:10.1016/j.jacr.2019.07.008. Accessed August 30, 2019.

      general internists,
      • Linzer M
      • Poplau S
      • Babbott S
      • et al.
      Worklife and wellness in academic general internal medicine: results from a national survey.
      family physicians,
      • Buck K
      • Williamson M
      • Ogbeide S
      • Norberg B
      Family physician burnout and resilience: a cross-sectional analysis.
      oncologists,
      • Yates M
      • Samuel V
      Burnout in oncologists and associated factors: a systematic literature review and meta‐analysis.
      psychiatrists,

      Howard R, Kirkley C, Baylis N. Personal resilience in psychiatrists: systematic review. BJPsych Bull. 2019: 209-215.

      general surgeons,
      • Patti MG
      • Schlottmann F
      • Sarr MG
      The problem of burnout among surgeons.
      trauma surgeons,
      • Jackson TN
      • Morgan JP
      • Jackson DL
      • et al.
      The crossroads of posttraumatic stress disorder and physician burnout: a national review of united states trauma and nontrauma surgeons.
      physiatrists,
      • Sliwa JA
      • Clark GS
      • Chiodo A
      • et al.
      Burnout in diplomates of the American Board of Physical Medicine and Rehabilitation-prevalence and potential drivers: a prospective cross-sectional survey.
      cardiologists,
      • Nicholls M
      Cardiologists and the burnout scenario.
      dermatologists,
      • Dorrell DN
      • Feldman SR
      • Huang WW
      The most common causes of burnout among us academic dermatologists based on a survey study.
      obstetrician-gynecologists,
      • Atallah F
      • McCalla S
      • Karakash S
      • Minkoff H
      Please put on your own oxygen mask before assisting others: a call to arms to battle burnout.
      gastroenterologists,
      • Gleeson D
      • O'Shea C
      • Ellison H
      • Tham TC
      • Douds AC
      • Goddard AF
      Stress and its causes in UK gastroenterologists: results of a national survey by the British Society of Gastroenterology.
      residents, and even medical students.
      • Dyrbye L
      • Shanafelt T
      A narrative review on burnout experienced by medical students and residents.
      In addition to worsened patient outcomes and satisfaction, physician health may be at risk. Recent research has focused on the link between work effort (the effort required to meet job demands) and the reward for job performance. An imbalance in the relationship between effort and reward (effort-reward imbalance, or ERI) has been linked to negative health outcomes. Hypothalamic-pituitary axis dysregulation may be the mechanism by which job stress causes physical illness. Elevated ERI was found to be linked to a significant decrease in peak, average, and total cortisol production among Buffalo, New York, police officers.
      • Violanti JM
      • Fekedulegn D
      • Gu JK
      • et al.
      Effort–reward imbalance in police work: associations with the cortisol awakening response.
      A very recent study found similar outcomes in a broader population sample.
      • Penz M
      • Siegrist J
      • Wekenborg MK
      • Rothe N
      • Walther A
      • Kirschbaum C
      Effort-reward imbalance at work is associated with hair cortisol concentrations: prospective evidence from the Dresden Burnout Study [epub ahead of print].
      Effort-reward imbalance has been linked to increased risk of depression (odds ratio [OR] 1.49; 1.23-1.80, P < .001) in a meta-analysis of 8 cohort studies involving almost 85,000 subjects.
      • Rugulies R
      • Aust B
      • Madsen IE
      Effort-reward imbalance at work and risk of depressive disorders. a systematic review and meta-analysis of prospective cohort studies.
      In addition, markers of abnormal glucose metabolism are found in physicians with symptoms of burnout.
      • Deneva T
      • Ianakiev Y
      • Keskinova D
      Burnout syndrome in physicians-psychological assessment and biomarker research.
      A roughly two-fold increase in the rate of new employment disability was found in individuals with ERI among over 40,000 workers followed for 3 years.
      • Juvani A
      • la Oksanen T
      • Virtanen M
      • et al.
      Clustering of job strain, effort−reward imbalance, and organizational injustice and the risk of work disability: a cohort study.
      Effort-reward imbalance has been associated with increased risk of coronary events in secondary
      • Aboa-Éboulé C
      • Brisson C
      • Maunsell E
      • et al.
      Effort-Reward Imbalance at Work and Recurrent Coronary Heart Disease Events.
      and, more recently, in primary event populations. In the latter case, more than 90,000 European workers were followed prospectively. Those who reported either ERI or job strain had a statistically significant 16% increase in relative risk for symptomatic coronary heart disease, and those who reported both job strain and ERI had a 41% increase in risk for coronary events relative to those workers who reported neither risk factor.
      • Dragano N
      • Siegrist J
      • Nyberg ST
      • et al.
      Effort–reward imbalance at work and incident coronary heart disease: a multicohort study of 90,164 individuals.

      Causes and Solutions

      Authors have proposed several categories of causal factors in the development of burnout among physicians and review of these reveals several consistent findings. In the 2018 Medscape survey, 56% of physicians who reported burnout cited excess bureaucracy with other causes being long working hours, lack of respect from colleagues, increasing computerization of practice, insufficient compensation, and a lack of clinical autonomy.
      • Nicholls M
      Cardiologists and the burnout scenario.

      Time

      Total time working is less commonly cited as a contributor to burnout than is time spent on non-clinical tasks. This is not unexpected; the mission of the physician (and their natural tendency) is to care for patients, not spend time explaining the need for a particular drug or test, responding to a billing query or explaining to an insurance company why a colonoscopy is needed. In part to address issues of burnout and the impact these have on the primary care physician workforce, the Board of Regents of the American College of Physicians has adopted a formal position paper focused on decreasing the amount of time physicians spend on non-clinical tasks.
      • Erickson SM
      • Rockwern B
      • Koltov M
      • McLean RM
      Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.

      Information Technology

      “I am no longer a physician but the data manager, data entry clerk and steno girl… I became a doctor to take care of patients. I have become the typist.”
      • Bodenheimer T
      • Sinsky C
      From triple to quadruple aim: care of the patient requires care of the provider.
      Information technology-related stress is pervasive (about 70% of survey respondents report it) and independently predicts burnout symptoms in physicians.
      • Gardner RL
      • Cooper E
      • Haskell J
      • et al.
      Physician stress and burnout: the impact of health information technology.
      Electronic medical record (EMR) systems were designed and implemented by technologists, they are not user-friendly, and most employ user interfaces that would be unacceptable in other applications. Steve Jobs would not have tolerated the user interface provided in our EMR by General Electric. General Electric can build the most powerful turbofan engine in history with a thrust exceeding 100,000 pounds (significantly more powerful than the rocket that launched Alan Shepard into Earth's orbit), but it still takes 14 mouse clicks to refill an antihypertensive medication. Physicians are generally not satisfied with EMR systems. Physicians who use EMRs spend more time on clerical tasks and are felt to be at higher risk for burnout.
      • Shanafelt TD
      • Dyrbye LN
      • Sinsky C
      • et al.
      Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction.
      Primary care physicians spend on average about 2 hours interacting with an EMR for every hour of patient contact, including 4.5 hours during the clinic day and an additional hour and a half in the evening.
      • Arndt BG
      • Beasley JW
      • Watkinson MD
      • et al.
      Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations.
      Even when in the examination room with a patient, they spend 37% of their time interacting with the EMR rather than the patient.
      • Sinsky C
      • Colligan L
      • Li L
      • et al.
      Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
      More after-hours time spent working in EMR charts has been associated with lower satisfaction and higher rates of burnout among primary care physicians
      • Robertson SL
      • Robinson MD
      • Reid A
      Electronic health record effects on work-life balance and burnout within the I3 population collaborative.
      and psychiatrists,
      • Domaney NM
      • Torous J
      • Greenberg WE
      Exploring the association between electronic health record use and burnout among psychiatry residents and faculty: a pilot survey study.
      and in the latter case, the relationship between EMR time and burnout was stronger than the relationships between EMR time and other factors, including sleep and exercise. Some have suggested that the primary root cause of physician burnout is the EMR.
      • Downing NL
      • Bates DW
      • Longhurst CA
      Physician burnout in the electronic health record era: Are we ignoring the real cause?.
      The impact of scribes on burnout has not been studied directly; however, their implementation in primary care decreases the time spent by physicians on EMR documentation tasks and improves physician work efficiency and satisfaction.
      • Mishra P
      • Kiang JC
      • Grant RW
      Association of medical scribes in primary care with physician workflow and patient experience.
      Furthermore, the use of scribes does not decrease patient satisfaction.
      • Danak SU
      • Guetterman TC
      • Plegue MA
      • et al.
      Influence of scribes on patient-physician communication in primary care encounters: mixed methods study.
      One recent study found that the use of scribes in primary care increased the number and intensity of patients seen per hour, increased patient-facing time, increased total physician-patient interaction time, decreased the time physicians spent interacting with a computer, and decreased the after-hours time spent in EMR documentation.
      • Zallman L
      • Finnegan K
      • Roll D
      • Todaro M
      • Oneiz R
      • Sayah A
      Impact of medical scribes in primary care on productivity, face-to-face time, and patient comfort.
      Other physician-driven changes in EMR processes may improve usability, patient safety, and physician job satisfaction, and decrease physician burnout.
      • Guo U
      • Chen L
      • Mehta PH
      Electronic health record innovations: helping physicians - one less click at a time.
      In a paper entitled, “The Electronic Elephant in the Room,” Philip Kroth and colleagues describe findings of structured interviews on the impact of EMR use on physicians (with the majority reporting EHR proficiency but also regularly spending “excessive” time at home documenting patient details in electronic charts). Concerns included “inefficient user interfaces, unpredictable system response times, poor interoperability between systems and excessive data entry.” The authors proposed organizational changes to improve EMR usability, the adoption of scribes, and “personal resilience strategies” focused on self-care (such as exercise, positive thinking, and consideration of work-life boundaries).
      • Kroth PJ
      • Morioka-Douglas N
      • Veres S
      • et al.
      The electronic elephant in the room: physicians and the electronic health record.

      Other Specific Interventions

      Meditation has been used to combat burnout symptoms
      • Thimmapuram JR
      • Grim R
      • Bell T
      • et al.
      Factors influencing work–life balance in physicians and advance practice clinicians and the effect of heartfulness meditation conference on burnout.
      and mindfulness training
      • van Wietmarschen H
      • Tjaden B
      • van Vliet M
      • Battjes-Fries M
      • Jong M
      Effects of mindfulness training on perceived stress, self-compassion, and self-reflection of primary care physicians: a mixed-methods study.
      may be modestly beneficial in decreasing anxiety and perceived work stress. Some have advocated for the wholesale adoption of Buddhist philosophy in healthcare practitioner wellness and stress management.
      • Kalra S
      • Priya G
      • Grewal E
      • et al.
      Lessons for the health-care practitioner from Buddhism.
      Individualized professional coaching for stress management was successful over a 6-month pilot trial; however, the outcome may have been influenced by selection bias as the physicians who undertook coaching were volunteers.

      Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a professional coaching intervention on the well-being and distress of physicians [epub ahead of print]. JAMA Intern Med. https://doi.org/10.3390/medicina55050209. Accessed August 20, 2019.

      There is little data to suggest long-term benefit of any particular stress management intervention in the prevention of burnout symptoms,
      • Venegas CL
      • Nkangu MN
      • Duffy MC
      • Fergusson DA
      • Spilg EG
      Interventions to improve resilience in physicians who have completed training: a systematic review.
      reinforcing the absolute necessity of system-based interventions rather than (or in addition to) those targeted to affected individuals.

      Programmatic Approaches

      “I want to be a doctor so that I can see more patients per hour with higher patient satisfaction scores than any of my peers, said no medical school applicant ever.”
      Researchers at Penn State University have proposed an approach based on a modification of Maslow's hierarchy of needs. Their strategy begins with a focus on basic physical and mental health needs and safety, followed by higher-order needs such as respect, appreciation, connection, and process changes in the way physicians interact with electronic systems, including electronic medical records.
      • Shapiro DE
      • Duquette C
      • Abbott LM
      • Babineau T
      • Pearl A
      • Haidet P
      Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level.
      Because workplace-related factors are associated with physician burnout,
      • Rassolian M
      • Peterson LE
      • Fang B
      • et al.
      Workplace factors associated with burnout of family physicians.
      an emphasis on system changes has been suggested.
      • Melnick ER
      • Powsner SM
      Empathy in the time of burnout.
      The Mayo Clinic system has taken a proactive approach to include study of physician burnout and the creation of a multi-faceted strategy to address the problem.
      • Shanafelt TD
      • Noseworthy JH
      Executive leadership and physician well-being.
      Though none of the specific interventions are revolutionary (eg, “align values and strengthen culture”) the Mayo approach is remarkably aggressive; the publication referenced was co-authored by the director of the Program on Physician Well-Being and the chief executive officer of the health system.

      Barriers to Change

      Burnout symptoms are common among physicians. Depression is much more common among physicians than other professions; among residents training in general surgery, the rate of depression approaches 40%.
      • Williford ML
      • Scarlet S
      • Meyers MO
      • et al.
      Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training.
      An earlier study found that more than 6% of surgeons reported suicidal ideations in the prior 12 months (at least double the rate in the general adult population) and of those, only 26% had sought help, largely due to concerns about how seeking treatment could affect their medical license.
      • Shanafelt TD
      • Balch CM
      • Dyrbye L
      • et al.
      Special report: suicidal ideation among American surgeons.
      In addition to fear of professional consequences, physicians report having limited time to seek medical care and stigma associated with treatment for mental illness.
      • Clough BA
      • March S
      • Leane S
      • Ireland MJ
      What prevents doctors from seeking help for stress and burnout? A mixed-methods investigation among metropolitan and regional-based Australian doctors.
      Some authors have noted an overlap between symptoms of post-traumatic stress disorder and burnout.
      • Jackson T
      • Provencio A
      • Bentley-Kumar K
      • et al.
      PTSD and surgical residents: Everybody hurts. . . sometimes.
      Others believe that burnout is a “depressive condition” and that screening instruments used for depression per se can detect signs of burnout.
      • Bianchi R
      • Schonfeld IS
      Defining physician burnout, and differentiating between burnout and depression-I.
      Among surgeons, burnout (OR 1.910, P < .001) and depression (OR 7.012, P < .001) were independently associated with suicidal ideations after controlling for personal and professional characteristics.
      • Shanafelt TD
      • Balch CM
      • Dyrbye L
      • et al.
      Special report: suicidal ideation among American surgeons.
      However, depression is a disease, whereas burnout is a syndrome that is job-related and situation-specific.
      • Maslach C
      • Leiter MP
      Understanding the burnout experience: recent research and its implications for psychiatry.
      Depression and burnout have common symptoms, which are also shared by hypothyroidism, and these should not be conflated.
      • Melnick ER
      • Powsner SM
      • Shanafelt TD
      In Reply-defining physician burnout, and differentiating between burnout and depression.
      Others further stress that though potentially challenging, the differentiation between burnout and major depression is critical, particularly given increasing rates of substance misuse and suicide among physicians:Physicians today experience unprecedented stress and distress, as evidenced by reports of escalating rates of burnout, dissatisfaction with life-work balance and career choice, occurrence of major depressive disorder (MDD) and substance use and misuse, and unacceptable rates of physician suicide. While efforts to ameliorate physician burnout are heartening, a major concern remains: physician depression and suicide prevention are relatively ignored, in part fueled by the fact that burnout and MDD have overlapping symptoms and clinical features. This imbalance may also reflect the ongoing stigma, even among physicians, of mental illness and its treatment. In contrast, the term burnout, which indicates a human reaction to something outside oneself, is less stigmatized, allowing it to become a catchall term for emotional distress. However, erroneously labeling a physician's distress as burnout may prevent or delay appropriate treatment of MDD, a serious and sometimes life-threatening mental disorder.

      Oquendo MA, Bernstein CA, Mayer LES. A key differential diagnosis for physicians-Major depression or burnout?[epub ahead of print]. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2019.1332. Accessed August 15, 2019.

      Discussion

      Driven by changes in health systems, reimbursement pressure, and dramatically increased demand for interaction with electronic systems, physicians are working longer hours and finding less joy in the practice of medicine. The distinction between “burnout” and depression per se is debated, but most authors distinguish between the two and some argue that to not do so places physician health in further jeopardy. That physician burnout has economic and public health consequences is certain; the only controversy lies in quantification of the associated harm. Thomas and colleagues
      • Thomas LR
      • Ripp JA
      • West CP
      Charter on physician well-being.
      propose a “Charter on Physician Well-being” wherein they detail guiding principles: effective patient care and physician well-being are inexorably linked; physician well-being is related to that of other members of the healthcare team; physician well-being is a quality marker; and physician well-being is a responsibility shared by individuals, organizations, and society.
      • Thomas LR
      • Ripp JA
      • West CP
      Charter on physician well-being.
      The often-repeated goals of the Triple Aim (enhancing patient experience, improving population health, and reducing costs) may be unreachable until we recognize and address burnout in healthcare provider, reframing the discussion to include interventions to address physician burnout (a Quadruple Aim strategy).
      • Bodenheimer T
      • Sinsky C
      From triple to quadruple aim: care of the patient requires care of the provider.
      Without our own oxygen mask in place, we cannot help those around us.

      References

        • Rotenstein LS
        • Torre M
        • Ramos MA
        • et al.
        Prevalence of burnout among physicians: a systematic review.
        JAMA. 2018; 320: 1131
        • Han S
        • Shanafelt TD
        • Sinsky CA
        • et al.
        Estimating the attributable cost of physician burnout in the United States.
        Ann Intern Med. 2019; 170: 784-790
        • Patel R
        • Bachu R
        • Adikey A
        • Malik M
        • Shah M
        Factors related to physician burnout and its consequences: a review.
        Behav Sci. 2018; 8: 98
        • Nicholls M
        Cardiologists and the burnout scenario.
        Eur Heart J. 2019; 40: 5-6
      1. Medscape. Medscape national physician burnout, depression & suicide report 2019. Available at: https://www.medscape.com/2019-lifestyle-burnout. Published 2019. Accessed August 17, 2019.

        • Shanafelt TD
        • Sinsky C
        • Dyrbye LN
        • Trockel M
        • West CP
        Burnout among physicians compared with individuals with a professional or doctoral degree in a field outside of medicine.
        Mayo Clin Proc. 2019; 94: 549-551
        • Tawfik DS
        • Profit J
        • Morgenthaler TI
        • et al.
        Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.
        Mayo Clinic Proc. 2018; 93: 1571-1580
        • Panagioti M
        • Geraghty K
        • Johnson J
        • et al.
        Association between physician burnout and patient safety, professionalism, and patient satisfaction.
        JAMA Intern Med. 2018; 178: 1317
        • Shanafelt TD
        • Mungo M
        • Schmitgen J
        • et al.
        Longitudinal study evaluating the association between physician burnout and changes in professional work effort.
        Mayo Clin Proc. 2016; 91: 422-431
        • Willard-Grace R
        • Knox M
        • Huang B
        • Hammer H
        • Kivlahan C
        • Grumbach K
        Burnout and health care workforce turnover.
        Ann Fam Med. 2019; 17: 36-41
        • Shanafelt TD
        • Dyrbye LN
        • West CP
        • Sinsky CA
        Potential impact of burnout on the US physician workforce.
        Mayo Clin Proc. 2016; 91: 1667-1668
        • Bragard I
        • Dupuis G
        • Fleet R
        Quality of work life, burnout, and stress in emergency department physicians.
        Eur J Emerg Med. 2015; 22: 227-234
        • van der Wal RAB
        • Wallage J
        • Bucx MJL
        Occupational stress, burnout and personality in anesthesiologists.
        Curr Opin Anaesthesiol. 2018; 31: 351-356
      2. Parikh JR, Wolfman D, Bender CE, Arleo E. Radiologist burnout according to surveyed radiology practice leaders [epub ahead of print]. J Am Coll Radiol. doi:10.1016/j.jacr.2019.07.008. Accessed August 30, 2019.

        • Linzer M
        • Poplau S
        • Babbott S
        • et al.
        Worklife and wellness in academic general internal medicine: results from a national survey.
        J Gen Intern Med. 2016; 31: 1004-1010
        • Buck K
        • Williamson M
        • Ogbeide S
        • Norberg B
        Family physician burnout and resilience: a cross-sectional analysis.
        Family Med. 2019; 51: 657-663
        • Yates M
        • Samuel V
        Burnout in oncologists and associated factors: a systematic literature review and meta‐analysis.
        Eur J Cancer Care (Engl). 2019; 28: e13094
      3. Howard R, Kirkley C, Baylis N. Personal resilience in psychiatrists: systematic review. BJPsych Bull. 2019: 209-215.

        • Patti MG
        • Schlottmann F
        • Sarr MG
        The problem of burnout among surgeons.
        JAMA Surg. 2018; 153: 403-404
        • Jackson TN
        • Morgan JP
        • Jackson DL
        • et al.
        The crossroads of posttraumatic stress disorder and physician burnout: a national review of united states trauma and nontrauma surgeons.
        Am Surg. 2019; 85: 127-135
        • Sliwa JA
        • Clark GS
        • Chiodo A
        • et al.
        Burnout in diplomates of the American Board of Physical Medicine and Rehabilitation-prevalence and potential drivers: a prospective cross-sectional survey.
        PM R. 2019; 11: 83-89
        • Dorrell DN
        • Feldman SR
        • Huang WW
        The most common causes of burnout among us academic dermatologists based on a survey study.
        J Am Acad Dermatol. 2019; 81: 269-270
        • Atallah F
        • McCalla S
        • Karakash S
        • Minkoff H
        Please put on your own oxygen mask before assisting others: a call to arms to battle burnout.
        Am J Obstet Gynecol. 2016; 215: 731.e1-731.e6https://doi.org/10.1016/j.ajog.2016.08.029
        • Gleeson D
        • O'Shea C
        • Ellison H
        • Tham TC
        • Douds AC
        • Goddard AF
        Stress and its causes in UK gastroenterologists: results of a national survey by the British Society of Gastroenterology.
        Frontline Gastroenterol. 2019; 10: 43-49https://doi.org/10.1136/flgastro-2018-100984
        • Dyrbye L
        • Shanafelt T
        A narrative review on burnout experienced by medical students and residents.
        Med Educ. 2016; 50: 132-149https://doi.org/10.1111/medu.12927
        • Violanti JM
        • Fekedulegn D
        • Gu JK
        • et al.
        Effort–reward imbalance in police work: associations with the cortisol awakening response.
        International Archives of Occupational and Environmental Health. 2018; 91: 513-522
        • Penz M
        • Siegrist J
        • Wekenborg MK
        • Rothe N
        • Walther A
        • Kirschbaum C
        Effort-reward imbalance at work is associated with hair cortisol concentrations: prospective evidence from the Dresden Burnout Study [epub ahead of print].
        Psychoneuroendocrinology. 2019; 109 (Accessed August 30, 2019)104399https://doi.org/10.1016/j.psyneuen.2019.104399
        • Rugulies R
        • Aust B
        • Madsen IE
        Effort-reward imbalance at work and risk of depressive disorders. a systematic review and meta-analysis of prospective cohort studies.
        Scand J Work Environ Health. 2017; 43: 294-306
        • Deneva T
        • Ianakiev Y
        • Keskinova D
        Burnout syndrome in physicians-psychological assessment and biomarker research.
        Medicina (Kaunas). 2019; 55: 209https://doi.org/10.3390/medicina55050209
        • Juvani A
        • la Oksanen T
        • Virtanen M
        • et al.
        Clustering of job strain, effort−reward imbalance, and organizational injustice and the risk of work disability: a cohort study.
        Scand J Work Environ Health. 2018; 44: 485-495
        • Aboa-Éboulé C
        • Brisson C
        • Maunsell E
        • et al.
        Effort-Reward Imbalance at Work and Recurrent Coronary Heart Disease Events.
        Psychosom Med. 2011; 73: 436-447
        • Dragano N
        • Siegrist J
        • Nyberg ST
        • et al.
        Effort–reward imbalance at work and incident coronary heart disease: a multicohort study of 90,164 individuals.
        Epidemiology. 2017; 28: 619-626
        • Erickson SM
        • Rockwern B
        • Koltov M
        • McLean RM
        Putting patients first by reducing administrative tasks in health care: a position paper of the American College of Physicians.
        Ann Intern Med. 2017; 166: 659-661
        • Bodenheimer T
        • Sinsky C
        From triple to quadruple aim: care of the patient requires care of the provider.
        Ann Fam Med. 2014; 12: 573-576
        • Gardner RL
        • Cooper E
        • Haskell J
        • et al.
        Physician stress and burnout: the impact of health information technology.
        J Am Med Inform Assoc. 2019; 26: 106-114
        • Shanafelt TD
        • Dyrbye LN
        • Sinsky C
        • et al.
        Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction.
        Mayo Clin Proc. 2016; 91: 836-848
        • Arndt BG
        • Beasley JW
        • Watkinson MD
        • et al.
        Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations.
        Ann Fam Med. 2017; 15: 419-426
        • Sinsky C
        • Colligan L
        • Li L
        • et al.
        Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties.
        Ann Intern Med. 2016; 165: 753-760
        • Robertson SL
        • Robinson MD
        • Reid A
        Electronic health record effects on work-life balance and burnout within the I3 population collaborative.
        J Grad Med Educ. 2017; 9: 479-484
        • Domaney NM
        • Torous J
        • Greenberg WE
        Exploring the association between electronic health record use and burnout among psychiatry residents and faculty: a pilot survey study.
        Acad Psychiatry. 2018; 42: 648-652
        • Downing NL
        • Bates DW
        • Longhurst CA
        Physician burnout in the electronic health record era: Are we ignoring the real cause?.
        Ann Intern Med. 2018; 169: 50-51
        • Mishra P
        • Kiang JC
        • Grant RW
        Association of medical scribes in primary care with physician workflow and patient experience.
        JAMA Intern Med. 2018; 178: 1467-1472
        • Danak SU
        • Guetterman TC
        • Plegue MA
        • et al.
        Influence of scribes on patient-physician communication in primary care encounters: mixed methods study.
        JMIR Med Inform. 2019; 7: e14797https://doi.org/10.2196/14797
        • Zallman L
        • Finnegan K
        • Roll D
        • Todaro M
        • Oneiz R
        • Sayah A
        Impact of medical scribes in primary care on productivity, face-to-face time, and patient comfort.
        J Am Board Fam Med. 2018; 31: 612-619
        • Guo U
        • Chen L
        • Mehta PH
        Electronic health record innovations: helping physicians - one less click at a time.
        Health Inf Manag. 2017; 46: 140-144
        • Kroth PJ
        • Morioka-Douglas N
        • Veres S
        • et al.
        The electronic elephant in the room: physicians and the electronic health record.
        JAMIA Open. 2018; 1: 49-56
        • Thimmapuram JR
        • Grim R
        • Bell T
        • et al.
        Factors influencing work–life balance in physicians and advance practice clinicians and the effect of heartfulness meditation conference on burnout.
        Glob Adv Health Med. 2019; 8 (2164956118821056): 1-8
        • van Wietmarschen H
        • Tjaden B
        • van Vliet M
        • Battjes-Fries M
        • Jong M
        Effects of mindfulness training on perceived stress, self-compassion, and self-reflection of primary care physicians: a mixed-methods study.
        BJGP Open. 2018; 2 (bjgpopen18X101621)
        • Kalra S
        • Priya G
        • Grewal E
        • et al.
        Lessons for the health-care practitioner from Buddhism.
        Indian J Endocrinol Metab. 2018; 22: 812-817
      4. Dyrbye LN, Shanafelt TD, Gill PR, Satele DV, West CP. Effect of a professional coaching intervention on the well-being and distress of physicians [epub ahead of print]. JAMA Intern Med. https://doi.org/10.3390/medicina55050209. Accessed August 20, 2019.

        • Venegas CL
        • Nkangu MN
        • Duffy MC
        • Fergusson DA
        • Spilg EG
        Interventions to improve resilience in physicians who have completed training: a systematic review.
        PLoS One. 2019; 14e0210512
        • Shapiro DE
        • Duquette C
        • Abbott LM
        • Babineau T
        • Pearl A
        • Haidet P
        Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level.
        Am J Med. 2019; 132: 556-563
        • Rassolian M
        • Peterson LE
        • Fang B
        • et al.
        Workplace factors associated with burnout of family physicians.
        JAMA Intern Med. 2017; 177: 1036-1038
        • Melnick ER
        • Powsner SM
        Empathy in the time of burnout.
        Mayo Clin Proc. 2016; 91: 1678-1679
        • Shanafelt TD
        • Noseworthy JH
        Executive leadership and physician well-being.
        Mayo Clin Proc. 2017; 92: 129-146
        • Williford ML
        • Scarlet S
        • Meyers MO
        • et al.
        Multiple-institution comparison of resident and faculty perceptions of burnout and depression during surgical training.
        JAMA Surg. 2018; 153: 705-711
        • Shanafelt TD
        • Balch CM
        • Dyrbye L
        • et al.
        Special report: suicidal ideation among American surgeons.
        Arch Surg. 2011; 146: 54-62
        • Clough BA
        • March S
        • Leane S
        • Ireland MJ
        What prevents doctors from seeking help for stress and burnout? A mixed-methods investigation among metropolitan and regional-based Australian doctors.
        J Clin Psychol. 2019; 75: 418-432
        • Jackson T
        • Provencio A
        • Bentley-Kumar K
        • et al.
        PTSD and surgical residents: Everybody hurts. . . sometimes.
        Am J Surg. 2017; 214: 1118-1124
        • Bianchi R
        • Schonfeld IS
        Defining physician burnout, and differentiating between burnout and depression-I.
        Mayo Clin Proc. 2017; 92: 1455
        • Maslach C
        • Leiter MP
        Understanding the burnout experience: recent research and its implications for psychiatry.
        World Psychiatry. 2016; 15: 103-111
        • Melnick ER
        • Powsner SM
        • Shanafelt TD
        In Reply-defining physician burnout, and differentiating between burnout and depression.
        Mayo Clin Proc. 2017; 92: 1456-1458
      5. Oquendo MA, Bernstein CA, Mayer LES. A key differential diagnosis for physicians-Major depression or burnout?[epub ahead of print]. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2019.1332. Accessed August 15, 2019.

        • Thomas LR
        • Ripp JA
        • West CP
        Charter on physician well-being.
        JAMA. 2018; 319: 1541-1542