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Original Investigation
September 9, 2020

Evaluating the Association of Multiple Burnout Definitions and Thresholds With Prevalence and Outcomes

Author Affiliations
  • 1Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Department of Surgery, Northwestern University, Chicago, Illinois
  • 2Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
  • 3Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
  • 4Feinberg School of Medicine, Department of Psychiatry, Northwestern University, Chicago, Illinois
JAMA Surg. Published online September 9, 2020. doi:10.1001/jamasurg.2020.3351
Key Points

Question  What is the association of multiple burnout definitions and thresholds with prevalence and wellness outcomes?

Findings  In this national study of 6956 general surgery residents, burnout prevalence estimates varied from 3.2% to 91.4%, depending on the burnout definition selected. Frequent burnout symptoms were significantly associated with thoughts of both attrition and suicide, regardless of the definition selected.

Meaning  Research on burnout should include a clear description of the burnout definition used and the justification for its use.


Importance  Physician burnout is a serious issue, given its associations with physician attrition, mental and physical health, and self-reported medical errors. Burnout is typically measured in health care by assessing the frequency of symptoms in 2 domains, emotional exhaustion and depersonalization. However, the lack of a clinically diagnostic threshold to define burnout has led to considerable variability in reported burnout rates.

Objective  To estimate the prevalence of burnout using a range of definitions (ie, requiring symptoms in both domains or just 1) and thresholds (ie, requiring symptoms to occur weekly vs a few times per year) and examine the strength of the association of various definitions of burnout with suicidal thoughts and thoughts of attrition among general surgery residents.

Design, Setting, and Participants  A cross-sectional national survey of clinically active US general surgery residents administered in conjunction with the 2019 American Board of Surgery In-Training Examination assessed burnout symptoms, thoughts of attrition, and suicidal thoughts during the past year. Multivariable logistic regression models were used to assess the association of burnout symptoms with thoughts of attrition and suicidal thoughts. Values of R2 and C statistic were used to evaluate multivariable model performance.

Exposures  Burnout was evaluated with a 6-item, modified, abbreviated Maslach Burnout Inventory for 2 burnout domains: emotional exhaustion and depersonalization.

Main Outcomes and Measures  The primary outcome was prevalence of burnout. Secondary outcomes were thoughts of attrition and suicidal thoughts within the past year.

Results  Among 6956 residents (a 85.6% response rate; including 3968 men [57.0%] and 4041 non-Hispanic White individuals [58.1%]) from 301 surgical residency programs, 2329 (38.6%) reported at least weekly symptoms of emotional exhaustion, and 1389 (23.1%) reported at least weekly depersonalization symptoms. Using the most common definition, 2607 general surgery residents (43.2%) reported weekly burnout symptoms on either subscale. Subtle changes in the definition of burnout selected resulted in prevalence estimates varying widely from 3.2% (159 residents; most stringent: daily symptoms on both subscales) to 91.4% (5521 residents; least stringent: symptoms a few times per year on either subscale). In multivariable models, all measures of higher burnout symptoms were associated with increased thoughts of attrition (depersonalization: R2, 0.097; C statistic, 0.717; emotional exhaustion: R2, 0.137; C statistic, 0.758; both: R2, 0.138; C statistic, 0.761) and suicidal thoughts (depersonalization: R2, 0.077; C statistic, 0.718; emotional exhaustion: R2, 0.102; C statistic, 0.750; both: R2, 0.106; C statistic, 0.751) among general surgery residents (all P < .001).

Conclusions and Relevance  In a national evaluation of general surgery residents, prevalence estimates of burnout varied considerably, depending on the burnout definition selected. Frequent burnout symptoms were strongly associated with both thoughts of attrition and suicide, regardless of the threshold selected. Future research on burnout should explicitly include a clear description and rationale for the burnout definition used.

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    1 Comment for this article
    Dissatisfaction with Practice Better Term Than 'Burnout'
    Edward Volpintesta, MD | Retired general practice
    The definition of burnout should be kept as simple as possible. It is used so often in medicine that it risks becoming a cliché devoid of what most physicians consider it to be—especially those who have experienced it.
    Burnout is hard to define but one recognizes when one sees it in a colleague or when one personally experiences it.
    Physicians who are burned out have many different symptoms but the most important and the one that catalyzes the rest is the loss of satisfaction in their practices and in their personal lives.
    Why loss of satisfaction? Because insurance companies’ increasing
    control over their fees and time-consuming regulations have made many lose their independent practices and compelled them to join hospital networks, where in return for financial security and administrative help, they are required to meet productivity goals seeing more patients in a day than they would normally and are forced to live and practice within the corporate guidelines of the hospital network or whatever large medical group they may have joined.
    OF course frivolous malpractice suits increase physician’s dissatisfaction as do personal problems like divorce, illness of a family member, or a problem with addiction.
    There are others but at the risk of over-simplifying and misconstruing what experts consider burnout, I suggest that ‘dissatisfaction with practice’ is the term that may be more useful than burnout because it may resonate more with the public and politicians and with policymakers.