How can neurologists avoid burnout?

Over the last decade, surveys of American physicians have shown an alarming decrease in professional satisfaction and well-being accompanied by an increase in the symptoms of burnout.¹ Physician burnout is a dysfunctional syndrome comprising emotional exhaustion, cynicism, depersonalization, and loss of empathy, accompanied by career dissatisfaction, from a feeling of meaninglessness of work and a sense of low personal esteem and accomplishment.² Burnout represents a growing problem because it leads to serious harm to both physicians and patients. It produces physician impairment with poor judgment, treating patients as objects, medical errors, and poorer patient outcomes. Burned-out physicians exhibit work–life imbalance and conflicts, abandon the profession, elect premature retirement, and experience higher rates of depression, substance abuse, and suicide.³

Physician burnout has a multifactorial etiology encompassing both internal and external factors. The primary drivers of burnout and professional dissatisfaction can be divided into individual, work unit, organizational, and national factors, each of which has components of workload, efficiency, professional autonomy/control, work–life integration, and meaning in work.⁴ Particularly noteworthy causative factors include physician overwork with poor work–life balance⁵ and the harmful effects on professional satisfaction when physicians are forced by circumstance or regulation to perform substandard work or to conduct busywork, such as the increasing documentation requirements for electronic health record completion, which diverts time from good patient care.⁶

Following reports of a high rate of burnout among neurologists,³ American Academy of Neurology (AAN) President Terrence Cascino empaneled a work force to study its nature and prevalence. In this issue of Neurology®, the AAN Burnout Task Force reports the results of their extensive survey of over 4,000 American neurologists.⁷ Consistent with previous surveys, they found that 60% of neurologist respondents reported at least one symptom of burnout. Risks factors for burnout included higher numbers of hours worked, nights on call, patients examined, and hours of clerical work performed. They found that academic neurologists had a lower rate of burnout and a higher degree of professional satisfaction than clinical practice neurologists, and that these lower rates of burnout and higher rates of professional satisfaction correlated with effective staff support, professional autonomy, and older physician age.

These and previous findings that burnout affects neurologists more than other specialists (including oncologists, who care for at least as many ill and dying patients)³ raised an important question: What is special about neurologists or their practices that accounts for their particularly high rate of burnout? By my own career-long observations, I offer an untested hypothesis. Neurologists are trained to be thorough in history-taking and physical examination. Our specialty traditionally attracts young physicians who are conscientious and detail-oriented, and may select for those with obsessive traits that are adaptive in assuring thoroughness. Such physicians may become particularly frustrated when, because of the time constraints of a busy practice, it becomes impossible for them to perform work up to their personal standards. They may be additionally irritated by the time-consuming requirements of insurance documentation on electronic health records that usurp time from proper patient care. It is also possible that these personality traits make neurologists less able than other physicians to say no and, as a result, they assume an excessive patient workload, as revealed in the survey.

The current survey provides data beneficial for planning interventions to prevent and lessen neurologist burnout. Busis et al.⁷ explained that the inverse of burnout is engagement, the “positive state of fulfillment that is characterized by vigor, dedication, and absorption.” One goal to prevent burnout then becomes how to promote neurologist engagement so as to increase professional satisfaction.

Commentators have proposed several corrective strategies.^3,8,–,10 Neurologist workflows should be redesigned to promote excellent patient care. An optimal design includes scheduling office visit time sufficient for neurologists to perform a proper history, physical examination, assessment, and patient education, and providing them with adequate support staff. This change would permit conscientious neurologists to be satisfied that their patient care met their personal quality standards. Busywork, particularly involving the electronic health record, must be minimized or exported to others to complete. New technologies that automatically import conversations with the patient into the electronic record should be perfected, which would eliminate the need for neurologists to retroactively enter patient data after every visit.

Monitoring the ongoing status of physician engagement and wellness (a fashionable buzzword encompassing well-being) should be elevated in importance to that of other quality metrics.⁸ This action would allow prompt initiation of focused interventions should these metrics decline.¹¹ Hospitals and practices should implement programs of self-care that promote engagement and well-being for physicians at risk of burnout. For neurologists who already have burnout, counseling individually or in groups can help provide them adaptive skills. If external conditions predominate, workflow redesign is essential. Mentoring from a senior associate can help redirect maladaptive behaviors and infuse meaning. Requiring physician leadership of academic, hospital, and practice groups will assure the continuation of the Hippocratic tradition of sanctity of the patient–physician relationship and patient-centered care proven to diminish burnout and increase physician satisfaction.¹²

The finding of Busis et al. that clinical practice neurologists have higher rates of burnout than academic neurologists may result from their greater clinical demands and less protection from market forces than their academic colleagues. Academic neurologists also practice in a culture that fosters professional growth and that offers tangible recognition of accomplishments through research grants, publications, invited presentations, teaching awards, and academic promotion. The creation of means of greater professional recognition for practicing neurologists can enhance their engagement and should become a component of any physician burnout prevention program.³

• © 2017 American Academy of Neurology