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Sameer S. Chopra, AM
Vanderbilt University School of Medicine, Nashville, Tenn,

Wayne M. Sotile, PhD
Wake Forest University School of Medicine, Winston-Salem, NC

Mary O. Sotile, MA
Tulane University School of Medicine, New Orleans, LA

JAMA. 2004;291:633.

Burnout is a syndrome defined by the 3 principal components of emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.¹ Unlike major depressive disorder, which pervades all aspects of a patient's life, burnout is a distinct work-related syndrome.¹ Burnout is most likely to occur in jobs that require extensive care of other people.¹

The most commonly used tool for assessing burnout is the 22-item Maslach Burnout Inventory–Human Services Survey (MBI-HSS).² Burnout is established by the combination of high scores for emotional exhaustion and depersonalization and low score for personal accomplishment.²

We undertook a search in PubMed using the search terms physician, burnout, and Maslach. A review of abstracts identified a subset of studies that focused on physicians in the United States and Canada. Additional relevant studies were discovered by manual searches of bibliographies. The studies included in this review were conducted between 1984 and 2001, used the MBI-HSS to measure physician burnout, and had response rates of more than 60%.

The evidence, albeit from small and generally localized samples, suggests that the components of burnout may be common among practicing physicians, with 46% to 80% reporting moderate to high levels of emotional exhaustion, 22% to 93% reporting moderate to high levels of depersonalization, and 16% to 79% reporting low to moderate levels of personal achievement.^3-6 Studies of medical residents have yielded similar results.^7-10 In a survey of 119 academic obstetrics and gynecology department chairs in the United States and Puerto Rico (response rate, 91%), Gabbe et al¹¹ found that 56% of respondents demonstrated high levels of emotional exhaustion, 36% had high levels of depersonalization, and 21% reported low levels of personal accomplishment. In their longitudinal study, Mirvis et al^12-13 reported an increase in the prevalence of high levels of burnout (from 25.3% in 1989 to 38.1% in 1997) in a cohort of 83 administrators of Department of Veterans Affairs medical centers.

The specific consequences of physician burnout are less well known. Mirvis et al^12-13 identified loss of job satisfaction as both a primary consequence of burnout and a contributor to its further progression. Similarly, Grunfeld et al⁵ reported that emotionally exhausted Canadian oncologists were more likely to consider changing jobs or reducing work hours. Physician burnout may also be associated with major depressive disorder. Shanafelt et al⁷ reported that 51% and 31% of burned-out residents had a positive result on a depression screen and self-reported major depression, respectively, vs 29% and 11% of residents who were not burned out. Burned-out residents were also significantly more likely to indicate that they had been responsible for 1 suboptimal patient care practice at least weekly or monthly compared with non–burned-out residents.⁷

The specific risk factors for physician burnout also have not been clearly established. In their longitudinal study, Mirvis et al^12-13 found that younger age, lack of role clarity, and perceived inadequacy of resources all predicted the development and progression of burnout. Similarly, 2 cross-sectional studies have reported an inverse association between age and burnout.^{4, 11} These results, however, may reflect "survival bias," where "those who burn out early in their careers are likely to quit their jobs, thus selecting for older respondents with lower levels of burnout."¹ Burnout may also be associated with self-reported workload.^{7, 11} Finally, Gabbe et al¹¹ found that high emotional exhaustion in obstetrics and gynecology department chairs was inversely correlated with the self-reported level of spousal support.

Although the available evidence demonstrates that physicians are susceptible to burnout, the literature reports only 1 controlled North American study that used the MBI-HSS to evaluate the efficacy of a burnout intervention.⁸ Continued research in the form of prospective, longitudinal studies will be required to elucidate the consequences of this condition to identify risk factors for its development and to support the design of preventive strategies.

REFERENCES
1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422. FULL TEXT | ISI | PUBMED 2. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, Calif: Consulting Psychologists Press Inc; 1996. 3. Keller KL, Koenig WJ. Management of stress and prevention of burnout in emergency physicians. Ann Emerg Med. 1989;18:42-47. ISI | PUBMED 4. Lloyd S, Streiner D, Shannon S. Burnout, depression, life job satisfaction among Canadian emergency physicians. J Emerg Med. 1994;12:559-565. FULL TEXT | PUBMED 5. Grunfeld E, Whelan TJ, Zitzelsberger L, Willan AR, Montesanto B, Evans WK. Cancer care workers in Ontario. CMAJ. 2000;163:166-169. FREE FULL TEXT 6. Thommasen HV, Lavanchy M, Connelly I, Berkowitz J, Grzybowski S. Mental health, job satisfaction, and intention to relocate: opinions of physicians in rural British Columbia. Can Fam Physician. 2001;47:737-744. FREE FULL TEXT 7. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367. FREE FULL TEXT 8. McCue JD, Sachs CL. A stress management workshop improves residents' coping skills. Arch Intern Med. 1991;151:2273-2277. ABSTRACT 9. Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol. 1986;42:488-492. ISI | PUBMED 10. Michels PJ, Probst JC, Godenick MT, Palesch Y. Anxiety and anger among family practice residents. Acad Med. 2003;78:69-79. ISI | PUBMED 11. Gabbe SG, Melville J, Mandel L, Walker E. Burnout in chairs of obstetrics and gynecology. Am J Obstet Gynecol. 2002;186:601-612. FULL TEXT | ISI | PUBMED 12. Mirvis DM, Graney MJ, Kilpatrick AO. Burnout among leaders of the Department of Veterans Affairs medical centers: contributing factors as determined by a longitudinal study. J Health Hum Serv Adm. 1999;21:390-412. PUBMED 13. Mirvis DM, Graney MJ, Kilpatrick AO. Trends in burnout and related measures of organizational stress among leaders of Department of Veterans Affairs medical centers. J Healthc Manag. 1999;44:353-365. ISI | PUBMED

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