PROFESSIONAL BURNOUT

SUMMARY: At any one time, the majority of practising clinicians are suffering burnout to lesser or greater degree. Research on causation of burnout is rudimentary, but some professional bodies of care-givers have policies for prevention. Burnout causes medical malpractice and being sued increases burnout. Health-care facilities should be routine sued for credentialing caregivers whose performance has become impaired.

The term "professional burnout" in response to excessive stress was coined by Freudenberger in 1975¹. Psychologist Christina Maslach² subsequently developed an Inventory³ for assessment in the 3 principal areas of deficit - Emotional Exhaustion, Depersonalization and Personal Accomplishment⁴.

Prevalence

Studies of various groups of physicians report burnout rates of 25-60%⁵ ^[]. General internists and family practitioners in Massachusetts in 1997 were less satisfied in every aspect of their professional life than physicians who had been asked 11 years earlier⁶. Results published in 2003 reported that a cross-specialty survey revealed late-stage burnout in 45.7% of Canadian physicians⁷.

Practice Point

As well as determining typical working and on-call hours, try to establish at Examinations for Discovery whether the Defendant physician is or was among the large minority of physicians who

feel that they are ineffective
are emotionally overrun
are exhausted by their work
are showing signs of depersonalisation in relationships

Causes

Research on causation of burnout is rudimentary, but some professional bodies of care-givers have policies for prevention.

Causes of physician burnout have been categorised as child development and personality factors, work and family stressors^7a: An unstable childhood predisposes, as does compulsive personality - doubt, guilt and an exaggerated sense of responsibility. Medical training fosters traits that create vulnerability - lack of awareness of, and dissociation from, physical and emotional needs, and chronic postponement in providing for them.

Feeling a lack of control over professional demands or that those demands are excessive, social isolation from colleagues and dissatisfaction with resources add to the toll, A supportive spouse can mitigate against burnout.

Female physicians are 60% more likely to report burnout⁸. Particular additional factors include sexual harassment by patients and colleagues and competing demands from home and children.

In 1998 the Canadian Medical Association developed a policy for Physician Health and Well-being^{8a

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Consequences

Burnout causes medical malpractice and being sued increases burnout^8b.

Using the Maslach Burnout Inventory³, Internal Medicine residents who fulfilled criteria for burnout were significantly more likely to self-report providing at least one type of suboptimal Patient Care Practices^9a or Attitudes^9b at leastmonthly^9c ^[].

More than a third of a sample of British hospital doctors and general practitioners recalled a recent incident in which stress symptoms had negatively affected their patient care¹⁰. Although the majority involved lowered standards of patient care or expression of anger or irritability, some incidents resulted in serious mistakes that occasionally were lethal.

Medicolegal Implications

Health-care facilities should be routine sued for credentialing caregivers whose performance has become impaired.

Caregivers can be profiled for high or low risk of malpractice claims. High risk features include increased age, surgical specialty, requirement to provide emergency department coverage, more days away from clinical practice, and the view that the litigation climate is "unfair." Low risk caregivers scheduled enough time to talk with patients, answered patients' telephone calls directly, felt "satisfied" with practice arrangements, and acknowledged greater emotional distress.¹¹

Hospitals and other health-care facilities may not be vicariously responsible for the professional standards of physicians who have contracted to provide services. However, they are generally legally responsible for credentialing such professionals. For instance in Canada, under the Public Hospitals Act^12a, the Medical Advisory Committee is required^12b to advise the hospital Board^12c about impairment of physicians who have admitting privileges.

Practice Point

When suing for medical malpractice in hospital practice, routinely Join the hospital for credentialing the physician when impaired
Establish at Deposition whether the Defendant physician was displaying indications of burnout

Patient Care Practices

I found myself discharging patients to make the service "manageable" because the team was too busy.

I did not fully discuss treatment options or answer a patient's questions.

I made treatment or medication errors that were not due to a lack of knowledge or inexperience.

I ordered restraints or medication for an agitated patient without evaluating him or her.

I did not perform a diagnostic test because of desire to discharge a patient. ^{[return to text]}

Patient Care Attitudes

I paid little attention to the social or personal impact of an illness on a patient.

I had little emotional reaction to the death of one of my patients.

I felt guilty about how I treated one of my patient from a humanitarian standpoint. ^{[return to text]}