Hospital Medicine’s successful growth in the United States concurrently poses challenges to its sustainability. Its growth has occurred in response to the demand of managed care for dedicated inpatient generalists to serve in various roles, including boundary spanners, communicators, quality enhancers, and care givers. The combination of roles and the often shifting work requirements demand flexibility from hospitalists who are also collectively working harder each year according to the biannual productivity surveys administered by the Society of Hospital Medicine. Moreover, many of the ranks are being filled by young physicians at the beginning of their medical careers. The characteristic stressors related to the work environment and demographics of the hospitalist workforce create conditions under which job burnout has emerged as a valid concern.

The scope of burnout among hospitalists was exposed in 1999 when a nationwide survey of the National Association of Inpatient Physicians (NAIP) identified 12.9% of respondents feeling “burned out” and an additional 24.9% “at risk of burnout.” In 2005, a survey of hospitalist leaders ranking the top challenges to their groups identified 7 areas directly related to burnout situated at the top of the list (Table 30-1). Other site-based medical specialties like critical care and Emergency Medicine have seen burnout rates as high as 40% to 60% and have taken proactive steps in trying to reduce burnout rates through job design and focus on the individuals. Not in spite of, but because of its rapid growth leaders in the field have deliberated over the sustainability of hospitalist practice models. To retain the best physicians capable of delivering the highest quality of care, understanding burnout and ways to address it remains an essential task for the discipline.

Definition

Burnout is a psychological syndrome leading to a worker’s erosion of engagement with their job due to long-term exposure to emotionally demanding work. It is a condition observed predominantly, though not exclusively, among those in the helping professions, like health and social services, where direct, frequent, and intense interactions with people are common and where the outcomes of work are not totally dependent on the actions of the worker. The most frequently cited conceptualization of burnout comes from Christina Maslach and colleagues who describe three constitutive dimensions. The first, emotional exhaustion, is a literal depletion of the worker’s energy due to the work demands. It may manifest in hospitalists as “compassion fatigue” or the tendency to distance themselves, cognitively and emotionally, from their work as they realize they cannot continue to give of themselves to patients and coworkers. In essence, it is a coping response to work overload. The second is depersonalization, marked by a detached emotional callousness or cynicism and manifests as indifference or dysfunctional attitudes and behaviors toward patients. It is often a protective response to emotional exhaustion. The final component of burnout, diminished personal accomplishment, is the erosion of a worker’s sense of personal effectiveness, which brings on a feeling of powerlessness and the tendency to negatively evaluate oneself. This may manifest as a hospitalist not completing assigned tasks or worsening professional self-esteem. Emotional exhaustion is usually considered necessary for burnout to be diagnosed, the other components may occur in parallel, sequentially, or not at all.

Burnout is distinct from related concepts like stress, depression, and dissatisfaction. The definitions of each have been established empirically, and while they overlap significantly, burnout is specific to the context of the workplace as an ongoing emotional response to chronic demands and interpersonal stressors. Job dissatisfaction is a predictor of burnout; workers who are dissatisfied are more likely to be burned out. However, it is not fully clear whether dissatisfaction always precedes burnout or is a result of burnout (or other workplace conditions that also produce burnout). Individuals who are depression-prone have higher rates of burnout and even though burnout is specific to the workplace, it can also affect homelife. Job stress can be conceptualized by two models: the demand-control-support model and the effort-reward imbalance model. In the first model, job stress is more likely when there are high job demands (usually workload and time pressure), low control over job (autonomy in decision making, patient outcomes) and low support (from colleagues, supervisor, organization; inadequate resources). Given the high job demands inherent in the medical profession, control and support are important mediators. With effort-reward imbalance, there is a discrepancy between the demands and obligations of the job (effort) and the rewards offered like salary, career opportunities, esteem, and job security. For workers who are very committed to their jobs, this imbalance leads to job stress. Again, given the high demands associated with hospitalist jobs and the professional commitment displayed by most physicians, rewards are very important to mediate stress.

Across a wide variety of professions, burnout has been associated with negative work outcomes including decreasing work hours or job turnover, decreased work effectiveness and productivity, reduced job and organizational commitment, and stress-related health outcomes such as alcohol and drug use or depression. In addition, the negative attitudes and actions of burned out workers can negatively impact others in and out of the workplace. These outcomes and the impact on Hospital Medicine are considered in depth in the proceeding section.

Physician Burnout and Job Performance

Burnout predicts poor physician job performance. For example, providers who are happy with their work are known to increase patients’ satisfaction and adherence to physician advice. On the other hand, patients of depersonalized physicians have been shown to take longer to recover from their illness. Physicians in Great Britain report providing lower standards of care, being more angry and sometimes abusive with patients as a result of chronic stress. Similarly, burned out general internists and medicine residents have reported engaging in suboptimal patient care such as making errors not due to a lack of knowledge or inexperience. Additionally, a strong negative correlation has been found between emotional exhaustion and quality of care among hospital-based medical subspecialists in Israel.

Although the mechanisms connecting burnout to poor-quality patient care have not been empirically proven, one proposed causal pathway involves the providers’ emotional state. One measure of emotions—positive affect—is associated with enhanced decision making and problem solving as well as higher levels of patient centeredness in health care providers. Therefore, burned out hospitalists may be less cognitively vigilant and less likely to put forth the extra effort necessary to deliver the highest quality, patient-centered care.

Reduced Organizational Commitment and Job Turnover