Reading the Smoke Signals: What Is the Meaning of Burnout Among Pediatric Critical Care Physicians?*

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The epidemic of burnout, a persistent, negative, work-related state of mind, among healthcare professionals has now been extensively documented in the literature, leading to a recent call to action by the Critical Care Societies Collaborative (1). But what exactly is “burnout”? The most commonly reported measure is the Maslach Burnout Inventory (MBI), a validated tool that addresses three domains by subscales: emotional exhaustion, depersonalization, and low personal accomplishment. However, the number or choice of subscales used to define burnout in the literature has been inconsistent. The reported prevalence of burnout among critical care clinicians ranges from 40% to 70% (1–3), with factors such as moral distress, long work hours, and the burdens of end-of-life decision-making and care cited as the drivers of this especially high prevalence (1, 3–5). Further causes for concern are associations with increased medical errors (6), suboptimal patient attitudes (7), decreased safety climate (8), poor job satisfaction, and decreased job retention (1). Even more worrisome is an association with increased alcohol use and dependence (9), depression, and suicidal ideation (10). However, this strong correlation with depression, as well as overlap in the tools used to measure both syndromes, has raised questions about whether they are distinct entities at all (11).
In this issue of Critical Care Medicine, Shenoi et al (12) report on burnout and psychological distress in a cohort of PICU physicians surveyed using the MBI and the General Health Questionnaire. They describe a sample of 253 physicians (37% of the 686 invited), 60.5% male, and the majority between the ages of 41 and 60 years. One of the first studies reporting Burnout Syndrome (BOS) in a large cohort of PICU physicians in the United States found a prevalence of 49% burnout in at least one of the three subscales of the MBI (12). The survey also measured psychological distress and found a very strong association with severe burnout. Interestingly, they did not find any association between burnout and PICU type, size, or on-call burden (12). These findings are similar to a prior study of U.S. PICU physicians that found no difference between burnout scores providers taking in-house call compared to from-home coverage models (13).
Disturbingly, female respondents in the present study by Shenoi et al (12) were twice as likely to report burnout, with 60% of women respondents scoring high for any burnout subscale, at an odds ratio of 2.1 compared with their male counterparts. Furthermore, 30% of female PICU attendings in this cohort reported self-perceived low personal accomplishment, almost twice as high as the male respondents. Factors that may influence work-life balance and its impact on BOS, such as marital status and children, were not found to be significant in this cohort. These findings point to a clear gender discrepancy in burnout in pediatric critical care medicine (12).
Why would such a significant proportion of women practicing in largely academic centers have a low opinion of their own accomplishment? A recent report on U.S. medical school faculty demonstrated that more than twice as many men as women hold full-professor appointments, and women counterparts had lower publication numbers and National Institutes of Health grants (14). Could these disparities in academic accomplishments underlie this sense of low self-efficacy, or is it vice versa? A recent survey demonstrated that almost 50% of female early medical students had imposter syndrome—a persistent fear of being exposed as a “fraud” (over twice the rate in their male counterparts), which was highly associated with burnout (15).

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