Physician Burnout in Physical Medicine and Rehabilitation (PM&R): Should We Focus More on Physiatrists' Mission?

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A recent report by Shanafelt et al.1 found that physician burnout is significantly increasing and physical medicine and rehabilitation (PM&R) was the third highest-ranked specialty reporting burnout following emergency medicine and urology, respectively. This same study found that of the 3680 physicians surveyed, 54.4% reported at least one symptom of burnout as assessed by the Maslach Burnout Inventory.
There is no doubt that many physiatrists experience symptoms of burnout; yet in our literature, it is rarely addressed. In 1979, Emener2 called burnout “rehabilitation's hidden handicap.” In 1988, Osborn et al.3 published a commentary on burnout in rehabilitation medicine from a psychoanalytic point of view and wrote, “Recognition of burnout is the first and most important aspect of prevention and treatment.” Burnout in rehabilitation medicine is not unique to Americans, and there are a few scattered international reports.4,5 A recent poster presentation titled “Evaluating Burnout in Physical Medicine and Rehabilitation Residents” by Kao et al.6 reported burnout rates that ranged from 22.2% to 83.3% in a single institutional study of 53 residents and fellows. We congratulate Kao et al. for their contribution to the sparse burnout literature in PM&R. They highlighted that burnout often begins during medical training, and their findings are consistent with literature from numerous other specialties.
Although definitions of burnout vary, they tend to share three characteristics: emotional exhaustion, depersonalization (also sometimes termed cynicism), and lack of professional efficacy (a sense of reduced personal accomplishment). Relevant to the work that many physiatrists are engaged in, a recent survey of pain medicine physicians (n = 207) found that approximately 60% reported high emotional exhaustion, 36% reported high depersonalization, and nearly 20% reported low personal accomplishment.7
According to a review by Bianchi et al., there is controversy in the literature as to whether burnout is a form of depression or a distinct syndrome.8 However, Wurm et al.9 published a recent systematic review calling burnout a “distinct phenomenon rather than a type of depression” and investigated the depression-burnout relationship. In this study, 40,093 Austrian physicians were invited to participate, and a total of 6351 (15.8%) accepted the invitation. Of the study participants, 10.3% were affected by major depression and 50.7% had symptoms of burnout. In the depressed physicians, 87.5% also suffered from burnout. Of the physicians who had burnout symptoms, 26.2% were also affected by major depression.
Unresolved stress at work is a hallmark of burnout. A likely factor is the mismatch between what the job requires compared to the individual values, goals, and available resources of the physician. Numerous studies have provided information that supports this theory of a “mismatch” or “disconnect” with physicians' values and goals compared to what they are experiencing in their work. For example, Pololi et al.10 studied nearly 2400 academic faculty from 26 US representative medical schools and found that more than a quarter had seriously considered leaving academic medicine altogether. Dissatisfaction was by far the leading issue, with personal/family issues only a small minority. Some of the significant predictors included negative perceptions of culture (eg, relatedness or feeling moral distress at work) and perceptions of values incongruence.
Physician burnout is an issue that affects health care delivery at every level; and in a systematic review and meta-analysis on interventions to prevent and reduce work burnout, West et al.11 reported that the literature supports both individual and organizational strategies can result in clinically meaningful reductions in burnout among physicians. Clearly, there is an urgent need to find better ways to support doctors for many reasons including, but not limited to, finding solutions to overcome predicted physician workforce shortages.
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