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Linzer M, Smith CD, Hingle S, et al. Evaluation of Work Satisfaction, Stress, and Burnout Among US Internal Medicine Physicians and Trainees. JAMA Netw Open. 2020;3(10):e2018758. doi:10.1001/jamanetworkopen.2020.18758
The clinician burnout epidemic has prompted calls for action by many national organizations.1,2 Few baseline data are available on the state of burnout among internal medicine physicians and trainees.3 Beginning in 2015, we developed a Well-being Champion (WC) program through the American College of Physicians (ACP) to train leaders to support well-being and measure change throughout the ACP membership worldwide. Herein we describe the survey responses from 1305 internists and internal medicine trainees who participated in the program across 18 ACP chapters and identify potential contributors to burnout as well as sex-based differences in burnout.
This study was approved by the Partners Healthcare Institutional Review Board, which waived the requirement for informed consent because only deidentified data were used. A well-being curriculum was delivered (in 2018 and 2019) to approximately 150 ACP chapter-designated WC programs. To understand well-being among chapter members, some WC programs asked members to complete the Mini Z worklife survey. Some WC programs included residents, fellows, and students among those surveyed, whereas others did not. The Mini Z survey measures satisfaction, stress, and burnout and their risk factors, and it is validated against the Maslach Burnout Inventory.4 The most recent version of the Mini Z survey (2.0) (Figure) aligns positive scores for the 10 items with a possible summary score of 50. Two 5-item subscales have total scores of 25. A joyful workplace is defined by a summary score of 40 or higher; a supportive work environment is represented by a subscale score of 20 or higher (score range, 5-25) , and a reasonable work pace and stress level associated with electronic medical record (EMR) use is represented by a subscale score of 20 or higher. Data from 1305 Mini Z surveys were summarized using counts and frequencies with predetermined cutoffs.5 Multiple logistic regression models were used to assess risk factors of burnout and satisfaction. Risk factors of burnout included stress, work control, atmosphere (chaos), documentation time pressure, teamwork, values alignment, EMR work at home, and EMR frustration; these items were transformed from 5-point Likert scale responses to binary variables by grouping positive responses (eg, strongly agree and agree) and neutral and negative responses (eg, neither agree nor disagree, disagree, and strongly disagree). Sex-based differences in summary scores, burnout, satisfaction, and all of the previously mentioned risk factors for burnout were tested in separate, single logistic regression models. The level of statistical significance was P < .05.
Response rates in the 8 chapters and 2 cohorts of WC programs for whom sampling data were available (n = 11 625) ranged from 2% to 76% (median 9.5%). Among 1270 respondents who indicated their sex, 665 were men (52.4%) and 605 were women (47.6%); 680 respondents (52.1%%) reported symptoms of burnout.
For the single logistic regression models, the reference group was male. Although 938 of 1305 respondents (71.9) reported career satisfaction, the burnout level (52.1%) was high in this sample of ACP members. One-third of participants (n = 419) reported poor or marginal work control, and approximately one-half (n = 673) reported time pressure associated with EMR documentation (Table). In the regressions, burnout was associated with lack of work control (OR, 2.32 [95% CI, 1.66-3.26]; P < .001) and documentation time pressure (OR, 1.64 [95% CI, 1.20-2.24]; P = .002). Job satisfaction was associated with professional values alignment with those of clinical leaders (OR, 4.24 [95% CI, 3.05-5.81]; P < .001) and efficient teamwork (satisfactory to optimal) (OR, 2.47 [95% CI, 1.59-3.87]; P < .001). The odds of burnout among women were 56% higher compared with men (Table), and women had 61% lower odds of having a joyous workplace, 39% lower odds of having supportive work environments, and 61% lower odds of having a manageable work pace and manageable EMR-related stress.
Although most of the surveyed ACP members reported career satisfaction (71.9%), burnout levels were high. Risk factors of burnout included documentation time pressure and lack of work control, whereas satisfaction was associated with alignment of professional values with those of the respondents’ clinical leaders and efficient teamwork. As in previous studies,6 female clinicians had higher odds of burnout than male clinicians, and were less likely to describe supportive environments or manageable work conditions. This study is limited by the absence of demographic data other than sex and the need for additional validation of the Mini Z 2.0 survey. Although the study is also limited by nonrandom sampling, data from this cohort of ACP members may still be generalizable to other populations for assessment of sex-based differences in potential associations between work conditions and burnout.
Accepted for Publication: July 19, 2020.
Published: October 14, 2020. doi:10.1001/jamanetworkopen.2020.18758
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Linzer M et al. JAMA Network Open.
Corresponding Author: Mark Linzer, MD, Department of Medicine (G5), Hennepin Healthcare, 701 Park Ave, Minneapolis, MN 55415 (Mark.Linzer@hcmed.org).
Author Contributions: Dr Linzer and Ms Frees had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Linzer, Smith, Hingle, Poplau, Miranda, Palamara.
Acquisition, analysis, or interpretation of data: Linzer, Hingle, Poplau, Miranda, Freese.
Drafting of the manuscript: Linzer, Hingle, Miranda, Freese, Palamara.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Linzer, Freese.
Obtained funding: Linzer.
Administrative, technical, or material support: Linzer, Smith, Hingle, Poplau, Palamara.
Supervision: Linzer, Smith, Hingle, Palamara.
Conflict of Interest Disclosures: Dr Linzer reported receiving grants from the American College of Physicians (ACP) during the conduct of the study; grants from the American Medical Association (AMA), the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality, and the American Board of Internal Medicine Foundation outside the submitted work; serving as a consultant to Harvard University and CRICO Medical Malpractice insurer; and receiving honoraria for grand rounds lectures. Dr Smith reported spousal employment by Merck and is an employee of the ACP. Ms Poplau reported receiving grant support from the ACP for the Well-being Champion training program and a grant from the AMA for burnout prevention research programs. Ms Freese reported receiving a grant from the National Institutes of Health during the conduct of the study. Dr Palamara reported receiving consulting fees and travel reimbursement for work with the ACP. No other disclosures were reported.
Funding/Support: This study was supported by the ACP and by the National Institutes of Health’s National Center for Advancing Translational Sciences grant No. UL1TR002494 (Ms Freese).
Role of the Funder/Sponsor: The funders 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.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences.
Additional Contributions: Cheryl Rusten, MPA, and Clare Sipler, BA, from the ACP, contributed to the data collection and organization of the annual training sessions. Maria L. Walter, MSOD, from the ACP, performed data management and obtained follow-up data from Well-being Champions. They were paid as staff from ACP on this project, but not specifically for their contributions to this article.
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