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Figure.  Emotional Exhaustion Scores, Depersonalization Scores, and Overall Burnout Proportions Across Levels of Resilience Among US Physicians
Emotional Exhaustion Scores, Depersonalization Scores, and Overall Burnout Proportions Across Levels of Resilience Among US Physicians

Error bars indicate standard error of the mean.

Table 1.  Resilience Scores Across Demographic and Professional Factors Among 4705 Physiciansa
Resilience Scores Across Demographic and Professional Factors Among 4705 Physiciansa
Table 2.  Resilience of Employed Physicians and the General US Population Aged 29 to 65 Yearsa
Resilience of Employed Physicians and the General US Population Aged 29 to 65 Yearsa
Table 3.  Resilience Scores and Burnout Symptoms Among 4660 Physicians Responding to Both Resilience and Burnout Itemsa
Resilience Scores and Burnout Symptoms Among 4660 Physicians Responding to Both Resilience and Burnout Itemsa
Table 4.  Multivariable Logistic Regression Model of the Association Between Physician Resilience Score and Burnout Symptoms
Multivariable Logistic Regression Model of the Association Between Physician Resilience Score and Burnout Symptoms
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Shanafelt  TD, Hasan  O, Dyrbye  LN,  et al.  Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.   Mayo Clin Proc. 2015;90(12):1600-1613. doi:10.1016/j.mayocp.2015.08.023 PubMedGoogle ScholarCrossref
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Davidson JRT. Connor-Davidson resilience scale (CD-RISC) manual. Posted January 1, 2020. Accessed May 30, 2020. http://www.connordavidson-resiliencescale.com/aRISC%20Manual%2001-01-20_F.pdf
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Vaishnavi  S, Connor  K, Davidson  JRT.  An abbreviated version of the Connor-Davidson Resilience Scale (CD-RISC), the CD-RISC2: psychometric properties and applications in psychopharmacological trials.   Psychiatry Res. 2007;152(2-3):293-297. doi:10.1016/j.psychres.2007.01.006 PubMedGoogle ScholarCrossref
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West  CP, Dyrbye  LN, Shanafelt  TD.  Physician burnout: contributors, consequences and solutions.   J Intern Med. 2018;283(6):516-529. doi:10.1111/joim.12752 PubMedGoogle ScholarCrossref
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    2 Comments for this article
    EXPAND ALL
    Confirming what we know: moral injury not lack of resilience drives distress
    Wendy (Brown) Dean, MD; Simon G. Talbot, MD | Moral Injury of Healthcare, LLC; Brigham and Women’s Hospital, Boston, MA
    We read the article ‘Resilience and Burnout Among Physicians and the General US Working Population’ by Colin West, et al, with great interest.(1) The findings confirm common wisdom that physicians are more resilient than the general public. Unfortunately, the article also confirms that resilience is no protection from burnout.

    This research strongly supports our assertion that a lack of resilience is not the cause of burnout.(2) We have spoken with thousands of clinicians who endorse that a fundamental cause of their distress is not a lack of resilience, but moral injury –the inescapable double binds in corporate medicine
    that increasingly conflict with the oaths they took to put patients first. When moral injury is unacknowledged and unattended, the end result is burnout.(3)
    We have written about the four concepts that are key to mitigating moral injury: autonomy, mastery, respect, and fulfillment.(4)

    Dr. West’s article confirms that efforts to improve physician resilience are ‘bringing coals to Newcastle.’ Addressing the crisis of clinician distress—moral injury—requires courageous leadership to stop ‘fixing’ individual physicians and to start joining with physicians to do the, admittedly harder, work of fixing the system. When there is recognition, renegotiation, and realignment of the goals pursued by each side of the House of Medicine—clinical and business—we will see better care for patients, which is more sustainable for physicians.

    Wendy (Brown) Dean, MD, Moral Injury of Healthcare, Carlisle, PA
    Simon G. Talbot, MD, Brigham and Women’s Hospital, Boston, MA

    References
    1. West CP, Dyrbye LN, Sinsky C, Trockel M, Tutty M, Nedelec L, Carlasare LE, Shanafelt TD. Resilience and Burnout Among Physicians and the General US Working Population. JAMA Netw Open. 2020 Jul 1;3(7):e209385.
    2. Talbot SG, Dean W. Physicians aren’t ‘burnout out.,’ They’re suffering from moral injury. Stat. 2018 July 26. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/
    3. Dean W, Talbot SG, Caplan A. Clarifying the Language of Clinician Distress [published online ahead of print, 2020 Jan 31]. JAMA. 2020;10.1001/jama.2019.21576. doi:10.1001/jama.2019.21576
    4. Talbot SG, Dean W. Autonomy, mastery, respect, and fulfillment are key to avoiding moral injury in physicians. Br Med J (Opinion). 2020 Jan 16. https://blogs.bmj.com/bmj/2020/01/16/autonomy-mastery-respect-fulfillment-key-avoiding-moral-injury-physicians/
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Electronic Medical Records Main Pain Point in Burnout
    Edward Volpintesta, MD | Retired general practice
    The authors did a good thing by bringing resilience and burnout to our attention.
    However there was no discussion of how—more than any other factor—electronic health records have caused physician burnout.
    In fact, a 2018 physician survey identified electronic health records as the “single most important pain point” in their practices. [1]
    I recently retired from my work as a primary care physician because I could not deal with electronic health records (EHR). They completely changed the way I dealt with my patients. My office visits felt like business transactions. I was distracted and the
    joy of practice left me after 4 months. I lost my “personal touch” with my patients.
    If we are going to talk about burnout, EHR must be the main focus.
    I know that having used pen and paper for my office records for 45 years as a general practitioner played a role in my disgust with EHR.
    And I know that the younger generation may adapt to EHR.
    But that doesn’t diminish the malignant effect that electronic health records have on the practice of medicine for both doctors and patients.

    Edward Volpintesta MD
    Bethel, CT 06801

    1. Hawkins M. 2018 Survey of America’s Physicians: Practice Patterns &Perspectives. 2018.https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    Psychiatry
    July 2, 2020

    Resilience and Burnout Among Physicians and the General US Working Population

    Author Affiliations
    • 1Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
    • 2Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
    • 3Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
    • 4American Medical Association, Chicago, Illinois
    • 5Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California
    • 6Department of Primary Care and Population Health, Department of Medicine, Stanford University, Palo Alto, California
    • 7Division of Hematology, Department of Medicine, Stanford University, Palo Alto, California
    JAMA Netw Open. 2020;3(7):e209385. doi:10.1001/jamanetworkopen.2020.9385
    Key Points español 中文 (chinese)

    Question  How resilient are physicians compared with US workers, and what is the association between resilience and burnout among physicians?

    Findings  In this cross-sectional survey study of 5445 respondents from among 30 456 physicians, the physicians had significantly higher resilience scores than the general employed US population. Higher resilience scores were associated with lower burnout rates, but even the most resilient physicians had substantial rates of burnout.

    Meaning  The findings suggest that, although maintaining and strengthening resilience is important, physicians overall do not have a deficit in resilience; additional solutions, including efforts to address system issues in the clinical care environment, are needed to reduce burnout and promote physician well-being.

    Abstract

    Importance  The prevalence of physician burnout is well documented, and resilience training has been proposed as an option to support physician well-being. However, the resilience of physicians compared with that of the US working population is not established, and the association between resilience and physician burnout is not well understood.

    Objectives  To evaluate resilience among physicians and US workers, and to determine the association between resilience and burnout among US physicians.

    Design, Setting, and Participants  A cross-sectional national survey study of 5445 US physicians and a probability-based sample of 5198 individuals in the US working population was conducted between October 12, 2017, and March 15, 2018.

    Main Outcomes and Measures  Resilience was measured using the 2-item Connor-Davidson Resilience Scale (total scores range from 0-8; higher scores indicate greater resilience); burnout was measured using the full Maslach Burnout Inventory with overall burnout indicated by a score of at least 27 on the 0 to 54 emotional exhaustion subscale and/or at least 10 on the depersonalization subscale (higher scores indicate greater burnout).

    Results  Of 30 456 physicians who received an invitation to participate, 5445 (17.9%) completed surveys (2995 men [62.1%]; median [IQR] age of 53 [42-62] years). In multivariable analysis, mean (SD) resilience scores were higher among physicians than the general employed population (6.49 [1.30] vs 6.25 [1.37]; adjusted mean difference, 0.25 points; 95% CI, 0.19-0.32; P < .001). Among physicians, resilience was associated with burnout. Physicians without overall burnout had higher mean (SD) resilience scores than physicians with burnout (6.82 [1.15] vs 6.13 [1.36]; adjusted mean difference, 0.68 points, 95% CI, 0.61-0.76; P < .001). Each 1-point increase in resilience score was associated with 36% lower odds of overall burnout (odds ratio, 0.64; 95% CI, 0.60-0.67; P < .001). However, 392 of 1350 physicians (29%) with the highest possible resilience score had burnout.

    Conclusions and Relevance  The findings of this national survey study suggest that physicians exhibited higher levels of resilience than the general working population in the US. Resilience was inversely associated with burnout symptoms, but burnout rates were substantial even among the most resilient physicians. Additional solutions, including efforts to address system issues in the clinical care environment, are needed to reduce burnout and promote physician well-being.

    Introduction

    The prevalence of physician distress has been well documented in recent years, with recent national data suggesting that 44% of US physicians experience symptoms of burnout, characterized by emotional exhaustion and/or depersonalization, at least weekly.1 Solutions to reduce distress and promote professional well-being have been broadly categorized into individual-focused and organization-oriented domains.2-4 Among individual-focused approaches, resilience training has been proposed as one means to support well-being.5,6

    Resilience is the collection of personal qualities that enable a person to adapt well and even thrive in the face of adversity and stress.7,8 The physician training process is lengthy and rigorous. Given the intensity of this experience, resilience might be expected to be greater among practicing physicians than among workers in other careers. Among physicians, those with higher levels of resilience might be expected to navigate the demands of their professional life more effectively and experience lower levels of burnout. Preliminary evidence in support of the latter hypothesis has been reported in previous studies of 584 US9,10 and 247 UK11 physicians, although these studies included physicians in training and did not include concurrent population comparators. To our knowledge, no large-scale evaluation of resilience among physicians compared with the general working population or of the association between resilience and burnout among practicing physicians has been performed.

    To evaluate resilience among physicians and how it compares with resilience among other US workers, we conducted a national survey in 2017. This study also measured burnout symptoms to allow analysis of the association between resilience and burnout among physicians.

    Methods

    We conducted a national survey of US physicians as well as US workers in other career fields in 2017. Complete details of the 2017 survey methodology have been previously reported.1 The 2017 survey used methods similar to the previous 2011 and 2014 studies.12,13 At all 3 time points, we assessed a range of personal and professional characteristics as well as several dimensions of well-being. The institutional review boards of Stanford University, Palo Alto, California, and the Mayo Clinic, Rochester, Minnesota, reviewed and approved this study. Informed consent of study participants was indicated by voluntary completion of the survey. This study followed the American Association for Public Opinion Research (AAPOR) reporting guideline.

    Participants
    Physician Sample

    A sample of physicians from all specialty disciplines was developed from the American Medical Association Physician Masterfile, a nearly complete record of all US physicians independent of membership with the American Medical Association. A greater proportion of participants were sampled from specialties other than primary care to provide representation across specialties. Email correspondence stating the purpose of the study (ie, to better understand the factors that contribute to satisfaction among US physicians), along with an invitation to participate and a link to the survey, were sent to 83 291 physicians on October 12, 2017, with 4 reminder requests sent during the ensuing 6 weeks. A total of 27 071 physicians opened at least 1 invitation email. After these 6 weeks, a random sample of 5000 physicians who did not respond to the electronic survey were mailed a paper version of the survey on December 6, 2017 (1426 physicians had opened an email invitation and 3574 physicians had not). Of these, 269 surveys were returned as undeliverable (80 physicians had opened an email invitation and 189 physicians had not).

    To evaluate for response bias, we also conducted a secondary survey with intensive follow-up in a random sample of 500 physicians who did not respond to the electronic survey. These individuals were mailed a paper copy of the survey with a $20 incentive to participate. Individuals in the secondary survey who did not respond to the first mailing were sent a second mailing 3 weeks later (without additional compensation). Twenty-four mailed surveys were returned as undeliverable, yielding a final sample of 476 surveys. Those who did not respond to the second mailing within 3 weeks were mailed a brief postcard survey requesting basic demographic characteristics and measures of well-being. Completed surveys returned by March 15, 2018, were included in the analysis. The 30 456 physicians who opened at least 1 invitation email and/or received a paper mailing of the survey were considered to have received an invitation to participate in the study.14 Participation was voluntary and all responses were anonymous.

    Population Sample

    For comparison with physicians, we surveyed a probability-based sample of individuals in the general US population from October 13 through October 21, 2017. The population survey was conducted using the KnowledgePanel (Ipsos),15 a probability-based panel designed to be representative of the US population. Based on the intent to compare workers in other career fields to physicians, only employed individuals were surveyed.

    Study Measures

    Both the physician and population samples provided information on demographic characteristics (age, sex, and relationship status), hours worked per week, resilience, and symptoms of burnout. Physician professional characteristics were ascertained by asking physicians about their medical practice.

    Resilience

    Resilience among both physicians and other US workers was assessed using the 2-item Connor-Davidson Resilience Scale (CD-RISC), a standardized and validated instrument measuring “bounce-back” and adaptability aspects of resilience.16,17 This scale has been studied and applied across diverse populations, including physicians and medical students, with consistently strong psychometric properties.16 Scoring of this scale is based on the sum of scores from 0 to 4 for each item (0 indicates the characteristic is not true at all; 4, it is true nearly all the time), for a total score range of 0 to 8 (0 indicates the lowest resilience level; 8, the highest resilience level).

    Burnout

    Burnout among physicians was measured using the full emotional exhaustion and depersonalization scales of the Maslach Burnout Inventory (MBI), a validated 22-item questionnaire considered the criterion standard tool for measuring burnout.18-21 Consistent with convention,22-24 we considered physicians with a high score on the emotional exhaustion subscale (≥27 on a 0-54 scale, with 0 indicating no emotional exhaustion and 54 indicating the greatest possible emotional exhaustion) and/or depersonalization subscale (≥10 on a 0-30 scale, with 0 indicating no depersonalization and 30 indicating the greatest possible depersonalization) of the MBI as having at least 1 manifestation of professional burnout.18

    To minimize survey burden for general population respondents, we measured burnout in analyses comparing physicians with the general working population using 2 single-item measures adapted from the full MBI. These 2 items have been shown to be associated with the emotional exhaustion and depersonalization domains of burnout measured by the full MBI in a sample of more than 10 000 individuals. The area under the receiver operating characteristic curve is 0.94 for emotional exhaustion and 0.93 for depersonalization for these single items relative to the full MBI.25,26

    Statistical Analysis

    Standard descriptive summary statistics were used to characterize the physician and comparison samples. Associations between resilience and demographic and professional factors were evaluated using Kruskal-Wallis tests. Multivariable models comparing resilience scores of physicians with those of the general population used multiple linear regression adjusted for sex, age, relationship status, hours worked per week, and burnout status. For all comparisons with population comparators, physician data were restricted to responders who were between the ages of 29 and 65 years and not retired to match the population sample. Multivariable models examining the association between resilience and physician burnout used multiple logistic regression adjusted for sex, age, hours worked per week, practice setting, and specialty. All tests were 2-sided, with type I error rates of .05. All analyses were completed using R, version 3.4.2 (R Project for Statistical Computing).27

    Results

    Of the 30 456 physicians who received an invitation to participate either electronically and/or by mail, 5445 (17.9%) completed a survey (2995 were men [62.1%]; median [IQR] age was 53 [42-62] years). Previous analysis comparing these responders with the participants in the secondary survey of nonresponders, which achieved a more than 50% response rate, supported participant representativeness of US physicians across domains of well-being.1 As previously reported, the demographic characteristics of participants relative to all 890 083 practicing US physicians were generally similar, although participants were slightly older (eTable 1 in the Supplement).1

    The mean (SD) resilience score among the 4705 physicians who completed the CD-RISC was 6.51 (1.29) (Table 1). Resilience scores varied modestly across demographic and professional factors, with slightly higher resilience among male and older physicians. Across specialties, resilience scores were highest in emergency medicine, neurosurgery, and preventive and occupational medicine, and lowest in general pediatrics, neurology, and obstetrics and gynecology (Table 1).

    Next, we compared resilience scores among physicians aged 29 to 65 years with those of the general US working population of the same age range (Table 2). Demographic differences between the physician and general population samples in 2017 have been published previously1 and are summarized in eTable 2 in the Supplement. Briefly, physicians were more likely to be male, younger, and married and reported working longer hours. Among the 3971 responding nonretired physicians aged 29 to 65 years, the mean (SD) resilience score was 6.49 (1.30) compared with 6.25 (1.37) for the 5198 nonretired individuals aged 29 to 65 years from the general US working population (mean difference, 0.24; 95% CI, 0.19-0.29; P < .001) (Table 2). After adjustment for sex, age, relationship status, hours worked per week, and burnout status, the higher resilience score among physicians persisted (mean difference, 0.25; 95% CI, 0.19-0.32; P < .001).

    Among physicians, resilience was associated with burnout symptoms (Table 3 and Figure). Mean (SD) resilience was 6.82 (1.15) among physicians without burnout symptoms, and 6.13 (1.36) among those with burnout symptoms (mean difference, 0.68; 95% CI, 0.61-0.76; P < .001). On multivariable analysis adjusted for sex, age, hours worked per week, practice setting, and specialty, each 1-point increase in resilience score was associated with 36% lower odds of burnout (OR, 0.64; 95% CI, 0.60-0.67; P < .001) (Table 4). Forty-nine of 60 (82%) physicians with resilience scores of 3 or less had burnout symptoms, and 392 of 1350 (29%) with the highest possible resilience score of 8 had burnout symptoms (Figure).

    When the individual domains of burnout were examined separately, physicians with higher resilience scores had lower emotional exhaustion scores. Each 1-point increase in resilience score was associated with a 3.18-point decrease in emotional exhaustion score (95% CI, 2.90-3.45; P < .001) (eTable 3 in the Supplement) and 36% lower odds of high emotional exhaustion (OR, 0.64; 95% CI, 0.61-0.68; P < .001) (eTable 4 in the Supplement). Physicians with higher resilience scores also had lower depersonalization scores. Each 1-point increase in resilience score was associated with a 1.43-point decrease in depersonalization score (95% CI, 1.29-1.57; P < .001) (eTable 5 in the Supplement) and 35% lower odds of high depersonalization (OR, 0.65; 95% CI, 0.61-0.68; P < .001) (eTable 6 in the Supplement).

    Discussion

    In this national survey study in the US, levels of resilience were greater among physicians than among the general working population. In addition, physician resilience was inversely associated with burnout symptoms, and symptoms of burnout were common even among physicians with the highest possible resilience score.

    These results suggest that, although higher levels of resilience might protect against burnout to a degree, physicians are not collectively deficient in resilience and even the most resilient physicians are at substantial risk of burnout. Therefore, although efforts to maintain or strengthen resilience are appropriate, equal or greater emphasis should be placed on alternative and complementary efforts, especially those addressing characteristics of the practice and external environments (eg, regulatory requirements) that contribute to burnout.4,28-30 For example, targets for improvement include inefficient workplace processes, excessive workloads, and negative leadership behaviors.30 This approach aligns with evidence to date supporting equal or greater effectiveness of organizational solutions to reduce burnout and promote well-being relative to individual-focused solutions such as those oriented around personal resilience.2,3

    Although many of the specialties with the highest resilience scores in this study have shown lower burnout rates and many of the specialties with the lowest resilience scores in this study have shown higher burnout rates,1 there were notable exceptions. For example, the specialty with the highest adjusted mean resiliency score in the present study—emergency medicine—has had the highest burnout rate in previous research.1 The set of disciplines with the lowest burnout rate in previous research—pediatric subspecialties1—also had below-average resilience in the present study. The observed differences in resilience across specialties and the association of resilience with burnout within each specialty are intriguing and merit further study.

    Limitations

    Our study had several limitations. First, the participation rate among physicians who opened the invitation email was only 18%, raising concern for nonresponse bias. Although in line with response rates of other national survey studies of physicians,31-33 this rate was lower than response rates of some physician surveys.34 To address the concern for nonresponse bias, as previously reported1 we used a robust double survey approach using incentives to compare participants with nonresponders.35 The results revealed no statistically significant differences with respect to age, years in practice, burnout, or satisfaction with work-life integration, suggesting that the responders were representative of US physicians for at least these variables. Second, more detailed resilience instruments exist, including 10- and 25-item versions of the CD-RISC.16 These versions were not applied in this study to limit participant survey burden but could provide more nuanced insight into physician resilience. Third, the cross-sectional survey method does not allow assessment of the direction of effect for the associations described in this study.

    Conclusions

    In summary, in this national cross-sectional survey study in the US, physicians exhibited greater resilience than the general working population. Resilience was inversely associated with burnout symptoms. Although maintaining and strengthening resilience is important, physicians are not generally resilience-deficient and burnout rates are substantial even among the most resilient physicians. Additional solutions, including efforts to address system issues in the clinical care environment, are needed to reduce burnout and promote physician well-being.

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    Article Information

    Accepted for Publication: April 23, 2020.

    Published: July 2, 2020. doi:10.1001/jamanetworkopen.2020.9385

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 West CP et al. JAMA Network Open.

    Corresponding Author: Colin P. West, MD, PhD, Division of General Internal Medicine, Department of Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (west.colin@mayo.edu).

    Author Contributions: Drs West and Nedelec had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: West, Dyrbye, Sinsky, Shanafelt.

    Acquisition, analysis, or interpretation of data: West, Sinsky, Trockel, Tutty, Nedelec, Carlasare, Shanafelt.

    Drafting of the manuscript: West, Tutty, Shanafelt.

    Critical revision of the manuscript for important intellectual content: West, Dyrbye, Sinsky, Trockel, Nedelec, Carlasare, Shanafelt.

    Statistical analysis: Nedelec.

    Obtained funding: Shanafelt.

    Administrative, technical, or material support: Dyrbye, Tutty, Carlasare, Shanafelt.

    Supervision: West, Shanafelt.

    Conflict of Interest Disclosures: Dr Dyrbye reported receiving royalties from the Well-Being Index from Med Ed Solutions outside the submitted work. Dr Shanafelt reported having a patent to the Physician Well-being Index with royalties paid. No other disclosures were reported.

    Funding/Support: Funding for this study was provided by Stanford WellMD Center, Palo Alto, California; the American Medical Association, Chicago, Illinois; and the Mayo Clinic Department of Medicine Program on Physician Well-being, Rochester, Minnesota.

    Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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