The balance between a meaningful and rewarding medical practice versus a demanding and stressful one can be the difference between an engaged physician and a physician who is suffering burnout. First, we will take a look at what makes an engaged physician. What do you think some traits of an engaged physician are?  

Traits of engaged physicians

  • High levels of energy
  • Resilience
  • High job involvement
  • Enthusiasm in their work
  • Sense of significance
  • Full concentration
  • Engrossment in their job
  • Ability to provide extra effort when necessary

(Anandarajah et al, 2018)

Unfortunately, as physicians, we are not always engaged. Various stressors on the job can lead to burnout. Although burnout was described in detail in the preceding topic (Recognizing Burnout), we briefly outline here what exactly burnout is and how it happens. We will start with the risks for burnout.  

Workplace/Organizational factors

  • Excessive workload
  • Increased administrative tasks
  • Inefficient work processes/electronic health records
  • Work-home conflicts
  • Decreased control over practice
  • Competency maintenance requirements
  • Leadership culture

Individual factors

  • History of traumatic life events
  • Personal traits
    - Perfectionism
    - Exaggerated sense of responsibility
    - Compulsion for achievement
    - Difficulty asking for help
  • Young
  • Female
  • Stigma

(Maslach & Leiter, 1997; Shanafelt et al, 2016)

Burnout is a multifactorial, work-related phenomena that involves the interplay between one’s own personality style and coping strategies as well as the demands that are put on each one of us by our environments. Possible environmental contributors are listed in Figure 1.

Skill building exercise

Take a moment and reflect which one of these factors in Figure 1 have been difficult for you? Write this down below.

<strong>Figure 1.</strong> Environmental contributors to burnout

Figure 1. Environmental contributors to burnout

A recent study at the University of Rochester sent out a 15-question survey to 528 physicians in internal medicine, neurology, and psychiatry (Anandarajah et al, 2018). The response rate to survey was 80%. The authors noted a number of themes that were related to burnout as outlined in Figure 2 (Anandarajah et al, 2018).

Click here to learn more about these themes.

  • Lack of support
    - Lack of resources
    - Bureaucratic and unresponsive administration
  • Strong tone of complaints
    - Sample response: “E-record - The worst computer program that I ever have encountered!”
  • Concerning in terms of personal distress
    - Sample response: “... I frequently arrived home feeling as though I had given all my energy, all my patience, and all my problem-solving skills to my job...“
  • (Anandarajah et al, 2018)

<strong>Figure 2.</strong> Themes associated with increased burnout (Data derived from Anandarajah et al, 2018)

Figure 2. Themes associated with increased burnout (Data derived from Anandarajah et al, 2018)

The same study at the University of Rochester was able to show themes related to meaning in professional work, which may help us focus on improving life for physicians (Anandarajah et al, 2018) (see Figure 3).

"Maybe I’m just stressed…"

The difference between stress and burnout is the ability to recover and bounce back in the time off from work during stressful situations. Figure 4 shows the sequence from stress to burnout.

<strong>Figure 3.</strong> Themes reported as sustaining a sense of meaning in professional work (Data derived from Anandarajah et al, 2018)

Figure 3. Themes reported as sustaining a sense of meaning in professional work (Data derived from Anandarajah et al, 2018)

<strong>Figure 4.</strong> Path to burnout (Derived from Maslach & Leiter, 1997)

Figure 4. Path to burnout (Derived from Maslach & Leiter, 1997)

Many psychiatrists work with trauma survivors and this can induce its own particular variation of burnout, which include vicarious trauma and compassion fatigue. There are a number of differences between these two states.  

Vicarious trauma

Vicarious trauma is a non-pathological result of doing work with trauma survivors resulting in normal cognitive and emotional changes that can accumulate over time.

Symptoms include:
  • Becoming judgmental of others
  • Tuning out
  • Reduced sense of connection with loved ones
  • Rescue fantasies
  • Overly rigid boundaries with patients

Compassion fatigue

In contrast to vicarious trauma, compassion fatigue is more pathological. In compassion fatigue, the treater experiences posttraumatic stress disorder (PTSD) symptoms that mimic those the trauma survivor has. It is a state of exhaustion and dysfunction, both physiologically and emotionally, after prolonged exposure (Bhutani et al, 2012; Figley, 1995).

Symptoms include:
  • Hyperarousal
  • Intrusive symptoms
  • Avoiding or emotional numbing
  • Anxiety
  • Depression

To briefly recap about physician burnout symptoms, press on each symptom below. (Bianchi & Schonfeld, 2017)
Emotional exhaustion. Feeling “used up” at the end of the work day; feeling that one has nothing left to offer emotionally to another person.
Depersonalization. Patients treated as objects rather than human beings; increasing callousness and cynicism towards patients and their concerns.
Sense of reduced accomplishment. Feeling that one is unable to help patients or help provided is ineffective; lack of meaning or value in work-related activities such as patient interaction; seeing yourself as incompetent.

Did you know?

Much variability was found in studies around the world. Burnout is more common in medical students, residents and early career physicians than in the general population (see Table 1) (Anandarajah et al, 2018; Dyrbye, 2014; Ishak et al, 2009; Tijdink et al, 2014). In a recent study by Anandarajah et al (2018), 45.6% of academic physicians at the University of Rochester reported burnout. Burnout is increasing with time as the satisfaction with work decreases (see Figure 5) (Shanafelt et al, 2015). Burnout is rising for all physicians, but especially women. Burnout is reported 1.6 times more often in women (McMurray et al, 2000). It is related to physician's inability to meet both demands of home and work life, as well as a lack of workplace control; moreover, being a mother with young children adds extra stress to women (Tijdink et al, 2014).

Table 1. Burnout rates in various studies (Anandarajah et al, 2018; Dyrbye, 2014; Ishak et al, 2009; Tijdink et al, 2014)
GroupBurnout %
Medical students28-45
Practicing physicians45.6
<strong>Figure 5.</strong> Correlation between work satisfaction and burnout over time

Figure 5. Correlation between work satisfaction and burnout over time (Data derived from Shanafelt et al, 2015)


Phillipa is a third year resident who returned four months ago to a child psychiatry rotation, after maternity leave. Her son is one year old and continues to wake one to two times per night. Her husband travels at least monthly with his work. She feels exhausted many days of the week. Work has been more stressful than usual over the last two months, as she has been involved with two cases where the child has been apprehended by Children Services because of abuse and neglect. She feels especially sensitive to this as a new mother. She also has a presentation due next week and is worried that it will not be up to her usual standards. She has been staying up late to ensure it will be excellent. She would like to do a subspecialty in child psychiatry so wants to impress the faculty members.

Which of the following are risk factors for Phillipa to become burned out?

Excessive workload
Correct. It sounds like Phillpa has a busy workload and a presentation to prepare after hours. She has a baby at home and her partner is not always there to support her.
Increased administrative tasks
Incorrect. We have no evidence of this.
Inefficient work processes/electronic health records
Incorrect. We have no evidence of this.
Work-home conflicts
Correct. She has to take her work home with her and stay up late to complete it.
Decreased control over practice
Incorrect. We have no evidence of this.
Competency maintenance requirements
Incorrect. We have no evidence of this.
Leadership expectations
This is possibly correct. She may work in a culture where there are great expectations for her to have a great presentation to succeed.
History of traumatic life events
Incorrect. We have no evidence of this.
Personal traits
Correct. Phillipa sounds like a perfectionist who would like to achieve and to solidify her chance to get into child psychiatry.
Yes. Phillipa is young, which places her at risk.
Correct, Phillipa is female. Add to sex that she is a mother and you have a double whammy.
Incorrect. We have no evidence of this.

There are several negative consequences of burnout on physicians, patients, and healthcare system as described below.


Physicians face greater job stress and emotional distress than the general population (Wallace et al, 2009). A 2009 review by Wallace and colleagues published in the Lancet examined the stressful working conditions of physicians and hypothesized as to reasons why physicians struggle with their own wellness. They listed common impact of burnout on the physician (see Table 2). Table 3 lists some characteristic traits of burnout in physicians (Tijdink et al, 2014).

Physical health

Physicians’ cardiovascular mortality is higher than in general population.

Mental health

There are increased rates of depression, while suicide rates are 6 times higher for physicians than the general population. Approximately 8-12% of physicians develop substance use disorder at some point in their career. Another effect of burnout on the physician is the negative impact on interpersonal relationships. Additional studies as described below add more details to the effects on physician mental health.

Studies on physician depression and suicide
  • 740 interns followed up at 13 U.S. hospitals:
    - Incidence of depression increased from 3.9% to 25.7% in the first three months
  • 123 pediatrics residents followed up at three U.S. hospitals:
    - 20% were depressed
    - 74% were burned out
  • 381,614 residents followed up between 2000 and 2014; among those, the leading causes of death were:
    - Suicide in men
    - Malignancy in women
    - Added risk of suicide early in residency, and possibly medical school
Physician suicide
As stated previously, suicide is more common in physicians than the general population. Risk of dying by suicide is highest for the psychiatry specialty compared to the general population (standardized mortality ratio 4.46).

Relative risk for suicide compared to same sex in the general population is:
  • Women: 2.27
  • Men: 1.41 (remember that men have higher rate of suicide in the general population!) (Schernhammer & Colditz, 2004)

Table 2. Impact of burnout on physicians (Wallace et al, 2009)
Increased number of workdays missed
Less productivity and efficiency in the workplace
Interest in early retirement
Job turnover
Table 3. Specific traits of burnout in physicians (Tijdink et al, 2014)
Physical exhaustion
Mental exhaustion
Cynical attitude
Lack of sense of personal accomplishment
Decrease in empathy

Skill building exercise

Do you know which physicians complete suicide? Click here to find out.
  • 70-90% have psychiatric disorders (depression is the most common, but also bipolar disorder and substance misuse)
  • Divorced, widowed, or never married
  • Driven, competitive, or compulsive
  • Physicians have greater knowledge of lethality, leading to higher completion-to-attempt ratio
  • (Myers, 2017)


Firth-Cozens and Greenhaligh (1997) looked at the effect of stress on patient care; 225 physicians who participated in the study were from a group of 318 fourth year medical students who were followed up over 10 years and were asked questions on stress, coping, and their attitudes to work and career choice.

The survey by Firth-Cozens and Greenhaligh (1997) on physicians' perceptions of the links between stress and lowered clinical care has shown that:
  • 57% reported tiredness, exhaustion, and sleep deprivation to negatively impact on patient care
  • 50% reported reduced level of patient care due to work related stress
  • 40% reported irritability or anger towards patients
  • 7% reported serious mistakes not resulting in patients’ deaths
  • 2 participants described lack of care directly leading to patients’ deaths (see Figure 6)

Specific effects on patient care are:

  • Ordering unnecessary tests or procedures
  • Less time spent with patients
  • Job dissatisfaction among physicians correlated with:
    - Riskier prescribing profiles
    - Less adherence among patients
    - Less satisfaction among patients
  • Above point to poorer quality of patient care
  • (Wallace et al, 2009)
<strong>Figure 6.</strong> Survey of physicians' perceptions of the links between stress and lowered clinical care (Data derived from Firth-Cozens & Greenhaligh, 1997)

Figure 6. Survey of physicians' perceptions of the links between stress and lowered clinical care (Data derived from Firth-Cozens & Greenhaligh, 1997)

Now we will look at a study in resident physicians. Fahrenkopf et al (2008) looked at the rates of medication errors among depressed and burned out residents in a prospective cohort study; 123 residents in three pediatrics residency programs participated. The cohort study showed rates of medication errors in burned out or depressed residents; 74% of participants met criteria for burnout, whereas 20% met criteria for depression. Depressed residents made 6.2 times more medication errors per resident per month compared to residents who were not depressed. Those participants who were depressed or burned out reported poorer health and higher rates of errors compared to those not burned out or depressed. Table 4 shows the rates of medication errors in this study population (Fahrenkopf et al, 2008).

Table 4. Rates of medication errors among burned out and depressed residents (Fahrenkopf et al, 2008)
% of resident group Medication errors
Burnout 74% No statistically significant effect found
Depression 20% 6.2 times more often than non-depressed

Similarly, surgeons were also found to have more medical errors when they were experiencing burnout. In 2010, Shanafelt and colleagues sent surveys to members of the American College of Surgeons and had 7,905 responders. The survey included self-assessment of major medical errors, validated depression screening tool, and standardized assessment of quality of life.  

Reporting an error
In the study sample by Shanafelt et al (2010), 8.9% of participants had concerns that they made a major medical error in the last three months. Reporting an error had a large and statistically significant adverse correlation with mental quality of life, three domains of burnout (emotional exhaustion, depersonalization, and personal accomplishment) and symptoms of depression. With each point increase in depersonalization scores, there was an 11% increase in likelihood of reporting an error. Moreover, with each point increase in emotional exhaustion, there was a 5% increase in reporting of an error. Burnout and depression were found to be independent predictors of reporting major medical errors in the last three months (Shanafelt et al, 2010).


A survey of University of Ottawa physicians has found that 50% thought about leaving academic medicine every week, and 30% thought of leaving medicine altogether (Wallace et al, 2009).

With higher turnover rates, costs to recruit and retain physicians will also increase. Cost to replace a physician in the U.S. is estimated to be between $150,000 and $300,000 (the estimate includes searching and interviewing candidates and paying for a locum tenens physician, and does not include training medical students and residents, signing bonuses, and moving costs.)

In conclusion, there are a number of workplace stressors that can lead to physician burnout. As well, there are particular physician characteristics that can make it more likely to develop burnout. Physician burnout can lead to deleterious healthcare system outcomes. To combat these effects on the physician and the healthcare system, there are a number of potential interventions. Interventions in the workplace can change contextual factors. It is important to have a work culture that supports self-care and wellness. Interventions at the level of the physician, including self-care and psychosocial management, can lead to improved patient care and systems outcomes. They will be discussed further in the section Integrate New Lifestyles.

1 What are two factors of being an engaged physician?
A. Incorrect
In fact, engaged physicians have high levels of energy at work. Sounds great, right?
B. You are correct.
Engaged physicians are just that – engaged and involved.
C. Incorrect
While that is nice, engaged physicians are enthusiastic at work.
D. That’s right!
Engaged physicians feel good about the contribution they make.
D. Incorrect
Actually, engrossment at work is a sign that a physician is engaged and truly “in the moment” at work.

2 Which is a symptom of physician burnout?
A. This is a wrong answer.
Physicians with burnout have both mental exhaustion and physical exhaustion.
B. You are correct.
Burnout causes cynical attitude.
C. This is not correct.
Burnout causes a sense of lack of personal accomplishment.
D. This is a wrong answer.
Being late to work is not specific to burnout.
D. This is not correct.
Physicians with burnout lose their empathy.

3 With regard to physician burnout, which of the following is true?
A. Incorrect.
Burnout is more common in medical students, residents and early career physicians than the general population (IsHak et al, 2009; West et al, 2018). Unfortunately, burnout is an epidemic that starts early during the medical training and continues to manifest through the career practice years.
B. Incorrect.
Having young children at home increases your risk of burnout.
C. Incorrect.
Women report burnout 1.6 times more than men. West et al (2018) reported higher rates of burnout in female physicians compared with their male counterparts.
D. Correct.
In a review by IsHak et al (2009), there was variation among specialties but this was not statistically significant; however, burnout rates were as follows: 75% in obstetrics-gynecology, 63% in internal medicine, 63% in neurology, 60% in ophthalmology, 50% in dermatology, 40% in general surgery, 40% in psychiatry, and 27% in family medicine. Being in first year in residency, mood fluctuation, dissatisfaction with clinical faculty, recent family stress, and being single were all associated with increased likelihood to meet burnout criteria. Additional stressors for psychiatry residents were the fear and exposure to patient violence and suicide.

  • There are workplace and individual factors which place physicians at risk for burnout, especially if they cannot find the time to recharge their batteries.
  • Vicarious trauma and compassion fatigue are variations of burnout in physicians who work with trauma survivors.
  • Physicians with burnout experience emotional exhaustion, depersonalization, and reduced sense of accomplishment.
  • The prevalence of burnout is higher in physicians than the general public. It is increasing with time and is more pronounced in women.
  • Burnout affects the physician, the patient, and the health care system.
  • Physicians’ physical and mental health are affected.
  • Patients have poor quality of patient care, including unnecessary tests and medical errors.
  • If burnout is not addressed, the healthcare system must deal with increased job turnover and the cost for recruitment and retention of physicians.

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