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Figure.  Association Between Sleep Disorder Screening and Occupational Burnout
Association Between Sleep Disorder Screening and Occupational Burnout
Table.  Number of Participants From Each Hospital Groupa
Number of Participants From Each Hospital Groupa
1.
Netzer  NC, Stoohs  RA, Netzer  CM, Clark  K, Strohl  KP.  Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.   Ann Intern Med. 1999;131(7):485-491. doi:10.7326/0003-4819-131-7-199910050-00002 PubMedGoogle ScholarCrossref
2.
Soldatos  CR, Dikeos  DG, Paparrigopoulos  TJ.  The diagnostic validity of the Athens Insomnia Scale.   J Psychosom Res. 2003;55(3):263-267. doi:10.1016/S0022-3999(02)00604-9 PubMedGoogle ScholarCrossref
3.
Allen  RP, Picchietti  D, Hening  WA, Trenkwalder  C, Walters  AS, Montplaisi  J; Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health; International Restless Legs Syndrome Study Group.  Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology: a report from the Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health.   Sleep Med. 2003;4(2):101-119. doi:10.1016/S1389-9457(03)00010-8 PubMedGoogle ScholarCrossref
4.
Barger  LK, Ogeil  RP, Drake  CL, O’Brien  CS, Ng  KT, Rajaratnam  SM.  Validation of a questionnaire to screen for shift work disorder.   Sleep. 2012;35(12):1693-1703. doi:10.5665/sleep.2246 PubMedGoogle ScholarCrossref
5.
West  CP, Dyrbye  LN, Erwin  PJ, Shanafelt  TD.  Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.   Lancet. 2016;388(10057):2272-2281. doi:10.1016/S0140-6736(16)31279-X PubMedGoogle ScholarCrossref
6.
Sullivan  JP, O’Brien  CS, Barger  LK, Rajaratnam  SM, Czeisler  CA, Lockley  SW; Harvard Work Hours, Health and Safety Group.  Randomized, prospective study of the impact of a sleep health program on firefighter injury and disability.   Sleep. 2017;40(1):40. doi:10.1093/sleep/zsw001 PubMedGoogle ScholarCrossref
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    Sleep disorder and burnout in physician
    Tomoyuki Kawada, MD | Nippon Medical School
    The authors identified the prevalence of sleep disorders and estimated the association between sleep disorders and burnout symptoms of physician (1). More than 90% of sleep disorders were undiagnosed and untreated. In addition, nearly 4-fold increase in odds ratio of sleep disorders for occupational burnout was recognized in physicians. They recommended to evaluate the effectiveness of keeping good sleep for reducing burnout symptoms in physicians. I present information regarding their study.

    Stewart and Arora discussed the role of sleep and circadian disorders in physician burnout (2). Although potential causative mechanisms of sleep disturbances on burnout may be considered as
    (a) a chronic depletion of energy stores, or (b) activation of the hypothalamic-pituitary-adrenal axis and increasing levels of bodily stress, studies showing that sleep extension can improve burnout recovery are lacking. They recommended that interventions should be directed not only by setting individual outcomes but also by changing working environment and health care system.

    Kancherla et al. presented an American Academy of Sleep Medicine position statement regarding the roles of sleep disruption, sleep deprivation, and circadian misalignment in physician well-being and burnout (3). They also mentioned the need for addressing burnout at both individual and organizational levels (4), which was the same recommendation by Stewart and Arora (2). In addition, they presented questions "What is the role of sleep in physician burnout?" and "Can burnout be (partly) controlled by healthy sleep via fundamental psycho-physiological mechanism?" I think that the role of sleep disorders for the present crisis in physician burnout should be specified by further studies.


    References
    1. Weaver MD, Robbins R, Quan SF, et al. Association of sleep disorders with physician burnout. JAMA Netw Open. 2020 Oct 1;3(10):e2023256.
    2. Stewart NH, Arora VM. The impact of sleep and circadian disorders on physician burnout. Chest. 2019 Nov;156(5):1022-1030.
    3. Kancherla BS, Upender R, Collen JF, et al. Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2020 May 15;16(5):803-805.
    4. Kancherla BS, Upender R, Collen JF, et al. What is the role of sleep in physician burnout? J Clin Sleep Med. 2020 May 15;16(5):807-810.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    Occupational Health
    October 30, 2020

    Association of Sleep Disorders With Physician Burnout

    Author Affiliations
    • 1Sleep Matters Initiative, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
    JAMA Netw Open. 2020;3(10):e2023256. doi:10.1001/jamanetworkopen.2020.23256
    Introduction

    Physicians’ mental health concerns affect the quality of life of caregivers, patient safety, health care expenditures, and occupational turnover. More than half of US physicians report burnout. Sleep deficiency is common—often a consequence of rotating or extended-duration shifts, night call, and competing demands. Sleep disturbance is a predictor of depression, and insufficient sleep may contribute to the development of burnout. Medical residents report that prolonged work hours negatively affect their quality of life. These factors suggest that sleep deficiency may be an underlying contributor to poor mental health in physicians.

    We sought to identify the prevalence of sleep disorders and estimate the cross-sectional association between sleep disorders and burnout symptoms among faculty and staff in a large teaching hospital system.

    Methods

    For this cross-sectional study, we developed a Sleep Health and Wellness (SHAW) program that was offered to hospital groups (eg, Anesthesiology, Orthopedics, and Radiology) through a series of 40-minute presentations during times typically reserved for grand rounds. The presentations were followed by tablet-based sleep disorder screening from May 2018 to May 2019. Participants received immediate screening results with an option to directly schedule sleep clinic appointments. Validated survey instruments were used to evaluate risk of obstructive sleep apnea,1 insomnia,2 restless legs syndrome,3 and shift work disorder.4 Burnout was assessed using the Maslach Burnout Inventory Human Services Survey. Consistent with prior work, we defined burnout as an emotional exhaustion score of 27 or higher and/or a depersonalization domain score of 10 or higher. Professional fulfillment was evaluated using the Professional Fulfillment Index.5 The association between sleep disorder screening status and burnout symptoms was tested using multivariable logistic regression models that controlled for group. These activities met institutional review board criteria for waiver of informed consent and were deemed exempt from institutional review board review by the Partners Human Research Committee because the activities were related to quality improvement.

    Results

    One thousand four hundred thirty-six employees attended the SHAW program, and 1047 completed the sleep disorder screening (Table). More than a quarter of employees (306 [29%]) screened positive for at least 1 sleep disorder. The prevalence of sleep disorders varied across groups (maximum, 48%; minimum, 12%). The most common sleep disorder was insomnia (n = 140, 14%), followed by obstructive sleep apnea (n = 122, 12%), shift work disorder (n = 112, 11%), and restless legs syndrome (n = 26, 2%). In total, 58 (19%) of the 304 employees who had positive screening results for 1 or more sleep disorders scheduled an appointment during the session. Most (n = 280, 92%) of those who had a positive finding for a sleep disorder were previously undiagnosed and untreated.

    Of the 1074 employees who completed screening for burnout, 313 (29%) had a positive result. Of the 1031 employees who completed the professional fulfillment index, 508 (49%) reported low levels of professional fulfillment. The prevalence of burnout varied across groups (maximum 59%, minimum 10%). A positive sleep disorder screening result was associated with increased odds of burnout (odds ratio, 3.67; 95% CI, 2.75-4.89) and reduced odds of professional fulfillment (odds ratio, 0.53; 95% CI, 0.40-0.70) (Figure). Hospital group was not associated with burnout or professional fulfillment after adjustment for sleep disorder status.

    Discussion

    The findings of this cross-sectional study suggest that undiagnosed sleep disorders are common among faculty and staff employed in a teaching hospital system. A positive screening result for a sleep disorder was associated with nearly 4-fold increased odds of occupational burnout. Those who had a positive screening result for a sleep disorder were half as likely to report professional fulfillment. More than 90% of sleep disorders were undiagnosed and untreated.

    Treatment of sleep disorders may provide a novel means of intervening to reduce physician burnout, which has been resistant to other treatment approaches.5 We previously found that a similar sleep health and wellness program was effective in increasing the rates of evaluation, diagnosis, and treatment for sleep disorders among first responders.6 The current effort is limited by its cross-sectional design and limited collection of potential confounders. Further research is needed to determine whether facilitating treatment for common sleep disorders would reduce burnout in physicians.

    This study suggests that undiagnosed and untreated sleep disorders are associated with occupational burnout among health care providers. Future studies should be conducted to evaluate the effectiveness of a sleep health and wellness program on reducing burnout symptoms.

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    Article Information

    Accepted for Publication: July 23, 2020.

    Published: October 30, 2020. doi:10.1001/jamanetworkopen.2020.23256

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

    Corresponding Author: Matthew D. Weaver, PhD, Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, 401 Park Dr, Ste 3W, Boston, MA 02215 (mdweaver@bwh.harvard.edu).

    Author Contributions: Dr Weaver 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: Weaver, Quan, O'Brien, Viyaran, Czeisler, Barger.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Weaver, Quan, Viyaran.

    Critical revision of the manuscript for important intellectual content: Weaver, Robbins, Quan, O'Brien, Czeisler, Barger.

    Statistical analysis: Weaver.

    Obtained funding: Czeisler, Barger.

    Administrative, technical, or material support: Robbins, Quan, O'Brien, Viyaran, Czeisler, Barger.

    Supervision: Quan, Viyaran, Czeisler, Barger.

    Conflict of Interest Disclosures: Dr Weaver reported receiving grants from Brigham and Women's Physician's Organization during the conduct of the study and grants from Brigham Research Institute, National Institute for Occupational Safety and Health, and the National Heart, Lung and Blood Institute outside the submitted work. Dr Robbins reported receiving personal fees from Denihan Hospitality, Rituals Cosmetics, and Asystem outside the submitted work. Dr Quan reported receiving grants from Brigham and Women's Physician Organization and the National Institute for Occupational Safety and Health during the conduct of the study; serving as a consultant for Jazz Pharmaceuticals, Whispersom, Amerisleep, and Best Doctors; as chair of the American Academy of Sleep Medicine Scoring Manual Committee and a member of its Hypopnea Taskforce; and receiving personal fees from Jazz Pharmaceuticals, Whispersom, and Best Doctors outside the submitted work. In addition, Dr Quan reported having a patent to Neural-Network Based Electrocardiography Monitor and Associated Methods pending. Dr Viyaran reported receiving grants from Brigham and Women's Physician's Organization during the conduct of the study and grants from the National Institute of Occupational Safety and Health and the National Heart, Lung and Blood Institute outside the submitted work. Dr Czeisler reported receiving grants from Brigham and Women's Physician's Organization during the conduct of the study; being a paid consultant to Bose, Boston Celtics, Boston Red Sox, Cephalon, Institute of Digital Media and Child Development, Jazz Pharma, Merck, Purdue Pharma, Samsung, Teva, and Vanda Pharmaceuticals where he also holds an equity interest; receiving research or education support from Cephalon, Mary Ann & Stanley Snider via Combined Jewish Philanthropies, NFL Charities, Jazz Pharma, Optum, ResMed, San Francisco Bar Pilots, Sanofi, Schneider, Simmons, Sysco, Philips, Vanda Pharmaceuticals, Dayzz Ltd, and Teva Pharma Australia PTY Ltd; and, since 1985, serving as an expert witness in a number of legal cases, including those involving Amtrak, Bombardier, C&J Energy, Casper Sleep, Inc, Columbia River Bar Pilots, Dallas Police Association, Enterprise Rent-A-Car, FedEx, Greyhound, Purdue Pharma, UPS, and Vanda Pharmaceuticals. Dr Czeisler serves as the incumbent of a professorship endowed by Cephalon (which was acquired in 2011 by Teva Pharmaceutical Industries) and reported receiving royalties from McGraw Hill and Philips Respironics (for the Actiwatch-2 & Actiwatch Spectrum devices). Dr Czeisler’s interests were reviewed and managed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their conflict of interest policies. Dr Barger reported receiving personal fees from the University of Pittsburgh, CurAegis, Casis, Puget Sound Pilots, and Boston Children's Hospital; grants from the National Institute for Occupational Safety and Health during the conduct of the study; and personal fees from CurAegeis, the University of Pittsburgh, National Institutes of Health/Centers for Disease Control (NIH/CDC), CASIS, Puget Sound Pilots, Liberty Mutual, and Dr Czeisler outside the submitted work.

    Funding/Support: This project was supported by the Brigham and Women’s Physician Organization Be-Well MD Program. This research was also supported in part by grants R01OH011773, R01OH010300 from the National Institute for Occupational Safety and Health and T32HL007901 from the National Heart, Lung, and Blood Institute, and by the Brigham Research Institute.

    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.

    Additional Contributions: We thank Salim Qadri, BS (Division of Sleep and Circadian Disorders, Brigham and Women's Hospital), for his critical contributions in programming the survey and supporting the sessions, Doris L. Ruiz and Claudia Rojas (Brigham and Women’s Sleep Medicine and Endocrinology Center) for facilitating scheduling of sleep clinic appointments, and faculty for electing to participate in this study. None were financially compensated.

    References
    1.
    Netzer  NC, Stoohs  RA, Netzer  CM, Clark  K, Strohl  KP.  Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.   Ann Intern Med. 1999;131(7):485-491. doi:10.7326/0003-4819-131-7-199910050-00002 PubMedGoogle ScholarCrossref
    2.
    Soldatos  CR, Dikeos  DG, Paparrigopoulos  TJ.  The diagnostic validity of the Athens Insomnia Scale.   J Psychosom Res. 2003;55(3):263-267. doi:10.1016/S0022-3999(02)00604-9 PubMedGoogle ScholarCrossref
    3.
    Allen  RP, Picchietti  D, Hening  WA, Trenkwalder  C, Walters  AS, Montplaisi  J; Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health; International Restless Legs Syndrome Study Group.  Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology: a report from the Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health.   Sleep Med. 2003;4(2):101-119. doi:10.1016/S1389-9457(03)00010-8 PubMedGoogle ScholarCrossref
    4.
    Barger  LK, Ogeil  RP, Drake  CL, O’Brien  CS, Ng  KT, Rajaratnam  SM.  Validation of a questionnaire to screen for shift work disorder.   Sleep. 2012;35(12):1693-1703. doi:10.5665/sleep.2246 PubMedGoogle ScholarCrossref
    5.
    West  CP, Dyrbye  LN, Erwin  PJ, Shanafelt  TD.  Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis.   Lancet. 2016;388(10057):2272-2281. doi:10.1016/S0140-6736(16)31279-X PubMedGoogle ScholarCrossref
    6.
    Sullivan  JP, O’Brien  CS, Barger  LK, Rajaratnam  SM, Czeisler  CA, Lockley  SW; Harvard Work Hours, Health and Safety Group.  Randomized, prospective study of the impact of a sleep health program on firefighter injury and disability.   Sleep. 2017;40(1):40. doi:10.1093/sleep/zsw001 PubMedGoogle ScholarCrossref
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