Personal and Professional Factors Associated With Work-Life Integration Among US Physicians

Importance

Poor work-life integration (WLI) occurs when career and personal responsibilities come in conflict and may contribute to the ongoing high rates of physician burnout. The characteristics associated with WLI are poorly understood.

Objective

To identify personal and professional factors associated with WLI in physicians and identify factors that modify the association between gender and WLI.

Design, Setting, and Participants

This cross-sectional study was based on electronic and paper surveys administered October 2017 to March 2018 at private, academic, military, and veteran's practices across the US. It used a population-based sample of US physicians across all medical specialties. Data analysis was performed from November 2019 to July 2020.

Main Outcomes and Measures

WLI was assessed using an 8-item scale (0-100 point scale, with higher scores indicating favorable WLI), alongside personal and professional factors. Multivariable linear regressions evaluated independent associations with WLI as well as factors that modify the association between gender and WLI.

Results

Of 5197 physicians completing surveys, 4370 provided complete responses. Of the physicians who provided complete responses, 2719 were men, 3491 were White/Caucasian (80.8%), 3560 were married (82.4%), and the mean (SD) age was 52.3 (12.0) years. The mean (SD) WLI score was 55 (23). Women reported lower (worse) mean (SD) WLI scores than men overall (52 [22] vs 57 [23]; mean difference, -5 [-0.2 SDs]; P < .001). In multivariable regression, lower WLI was independently associated with being a woman (linear regression coefficient, -6; SE, 0.7; P < .001) as well as being aged 35 years or older (eg, aged 35 to 44 years: linear regression coefficient, -7; SE, 1.4; P < .001), single (linear regression coefficient, -3 vs married; SE, 1.1; P = .003), working more hours (eg, 50 to 59 hours per week vs less than 40 hours per week: linear regression coefficient, -9; SE, 1.0; P < .001) and call nights (linear regression coefficient, -1 for each call night per week; SE, 0.2; P < .001), and being in emergency medicine (linear regression coefficient, -18; SE, 1.6, P < .001), urology (linear regression coefficient, -11; SE, 4.0; P = .009), general surgery (linear regression coefficient, -4; SE, 2.0; P = .04), anesthesiology (linear regression coefficient, -4; SE, 1.7; P = .03), or family medicine (linear regression coefficient, -3; SE, 1.4; P = .04) (reference category, internal medicine subspecialties). In interaction modeling, physician age, youngest child's age, and hours worked per week modified the associations between gender and WLI, such that the largest gender disparities were observed in physicians who were aged 45 to 54 years (estimated WLI score for women, 49; 95% CI, 47-51; estimated WLI score for men, 57, 95% CI, 55-59; P < .001), had youngest child aged 23 years or older (estimated WLI score for women, 51; 95% CI, 48-54; estimated WLI score for men, 60; 95% CI, 58-62; P < .001), and were working less than 40 hours per week (estimated WLI score for women, 61; 95% CI, 59-63; estimated WLI score for men; 70; 95% CI, 68-72; P < .001).

Conclusions and Relevance

This study found that lower WLI was reported by physicians who are women, single, aged 35 years or older, and who work more hours and call nights. These findings suggest that systemic change is needed to improve WLI among physicians.

The Relationship Between Burnout and Help-Seeking Behaviors, Concerns, and Attitudes of Residents

PURPOSE

To evaluate the relationship between help-seeking concerns and attitudes and burnout among residents.

METHOD

In 2019, all residents across the 4 Mayo Clinic sites were surveyed. The survey included 2 items from the Maslach Burnout Inventory, an item from the National Comorbidity Survey Replication about likelihood of seeking professional help for a serious emotional problem, and items developed to explore residents' help-seeking behaviors and concerns. Multivariable logistic regression was conducted for each outcome variable and included age, gender, specialty, postgraduate year, site, and burnout.

RESULTS

Of the 1,146 residents to whom surveys were sent, 762 (66.5%) responded. Nearly half (342/747, 45.8%) were concerned about negative consequence to their career if they went on medical leave, and one-third (247/753, 32.8%) were reluctant to seek professional help for a serious emotional concern. Of the 437 residents who had never attended a personal health appointment during scheduled work, 34.6% (151) thought it would be difficult to tell a supervising physician they needed to miss work due to a scheduled appointment. On multivariable analysis, burnout was independently associated with reporting it would be difficult to tell a supervising physician of a need to attend an appointment (odds ratio [OR] 2.32; 95% confidence interval [CI] 1.46, 3.67; P < .001), being concerned about negative consequence to their career if they went on medical leave (OR 2.09; 95% CI 1.49, 2.93; P < .001), and reluctance to seek professional care for a serious emotional problem (OR 1.65; 95% CI 1.17, 2.34; P = .004).

CONCLUSIONS

Barriers to self-care and help-seeking are common among residents and may be worse among those with burnout. Strategies to reduce stigma and promote a culture of well-being are needed.

Faculty Disclosure of Personal Mental Health History and Resident Physician Perceptions of Stigma Surrounding Mental Illness

PROBLEM

Distress, depression, and burnout are common during medical training. Stigma surrounding seeking help for mental illness during medical training may involve fear of negative peer perceptions, academic jeopardy, and adverse future career consequences. Faculty disclosure of personal mental health illness may reduce stigma surrounding mental health disorders and reassure and encourage trainees to seek help when needed.

APPROACH

The authors aimed to assess the impact of faculty disclosure of mental health issues on stigma toward help-seeking during training, self-reflection about mental health, and resident physician awareness of mental health resources. Three self-selected faculty members shared their personal experiences with depression and mental health during a confidential noon conference intended for internal medicine residents at Mayo Clinic Rochester as part of their core curriculum in December 2016. Institutional and community mental health resources were provided. After the conference, attendees completed an anonymous survey assessing self-reported knowledge, attitudes, and behaviors surrounding mental health during medical training.

OUTCOMES

One hundred percent of residents (39/39) agreed that they enjoyed the conference. Thirty-five of 39 (89.7%) respondents agreed that their knowledge of available mental health resources increased and 33/39 (84.6%) agreed they were more likely to pursue mental health resources after attending the conference. Thirty-eight of 39 (97.4%) residents agreed that faculty sharing their personal struggles destigmatizes mental health issues during training, and the same percentage reported engaging in postconference self-reflection regarding their own mental health and well-being.

NEXT STEPS

Resident conference sessions during which faculty self-disclose personal mental health experiences may help decrease the stigma of mental health issues during medical training and increase the likelihood residents will seek assistance when needed. The authors encourage further study of longer-term outcomes and actual help-seeking behaviors across learner levels and training environments.

Perceived Electronic Health Record Usability as a Predictor of Task Load and Burnout Among US Physicians: Mediation Analysis

BACKGROUND

Electronic health record (EHR) usability and physician task load both contribute to physician professional burnout. The association between perceived EHR usability and workload has not previously been studied at a national level. Better understanding these interactions could give further information as to the drivers of extraneous task load.

OBJECTIVE

This study aimed to determine the relationship between physician-perceived EHR usability and workload by specialty and evaluate for associations with professional burnout.

METHODS

A secondary analysis of a cross-sectional survey of US physicians from all specialties was conducted from October 2017 to March 2018. Among the 1250 physicians invited to respond to the subsurvey analyzed here, 848 (67.8%) completed it. EHR usability was assessed with the System Usability Scale (SUS; range: 0-100). Provider task load (PTL) was assessed using the mental demand, physical demand, temporal demand, and effort required subscales of the National Aeronautics and Space Administration Task Load Index (range: 0-400). Burnout was measured using the Maslach Burnout Inventory.

RESULTS

The mean scores were 46.1 (SD 22.1) for SUS and 262.5 (SD 71.7) for PTL. On multivariable analysis adjusting for age, gender, relationship status, medical specialty, practice setting, hours worked per week, and number of nights on call per week, physician-rated EHR usability was associated with PTL, with each 1-point increase in SUS score (indicating more favorable) associated with a 0.57-point decrease in PTL score (P<.001). On mediation analysis, higher SUS score was associated with lower PTL score, which was associated with lower odds of burnout.

CONCLUSIONS

A strong association was observed between EHR usability and workload among US physicians, with more favorable usability associated with less workload. Both outcomes were associated with the odds of burnout, with task load acting as a mediator between EHR usability and burnout. Improving EHR usability while decreasing task load has the potential to allow practicing physicians more working memory for medical decision making and patient communication.

How do we assess resilience and grit among internal medicine residents at the Mayo Clinic? A longitudinal validity study including correlations with medical knowledge, professionalism and clinical performance

BACKGROUND

There has been limited research on the positive aspects of physician wellness and to our knowledge there have been no validity studies on measures of resilience and grit among internal medicine (IM) residents.

OBJECTIVES

To investigate the validity of resilience (10 items Connor-Davidson Resilience Scale (CD-RISC 10)) and grit (Short Grit Scale (GRIT-S)) scores among IM residents at a large academic centre, and assess potential associations with previously validated measures of medical knowledge, clinical performance and professionalism.

METHODS

We evaluated CD-RISC 10 and GRIT-S instrument scores among IM residents at the Mayo Clinic Rochester, Minnesota between July 2017 and June 2019. We analysed dimensionality, internal consistency reliability and criterion validity in terms of relationships between resilience and grit, with standardised measures of residents' medical knowledge (in-training examination (ITE)), clinical performance (faculty and peer evaluations and Mini-Clinical Evaluation Examination (mini-CEX)) and professionalism/dutifulness (conference attendance and evaluation completion).

RESULTS

A total of 213 out of 253 (84.2%) survey-eligible IM residents provided both CD-RISC 10 and GRIT-S survey responses. Internal consistency reliability (Cronbach alpha) was excellent for CD-RISC 10 (0.93) and GRIT-S (0.82) overall, and for the GRIT subscales of consistency of interest (0.84) and perseverance of effort (0.71). CD-RISC 10 scores were negatively associated with ITE percentile (β=-3.4, 95% CI -6.2 to -0.5, p=0.02) and mini-CEX (β=-0.2, 95% CI -0.5 to -0.02, p=0.03). GRIT-S scores were positively associated with evaluation completion percentage (β=2.51, 95% CI 0.35 to 4.67, p=0.02) and conference attendance (β=2.70, 95% CI 0.11 to 5.29, p=0.04).

CONCLUSIONS

This study revealed favourable validity evidence for CD-RISC 10 and GRIT-S among IM residents. Residents demonstrated resilience within a competitive training environment despite less favourable test performance and grittiness that was manifested by completing tasks. This initial validity study provides a foundation for further research on resilience and grit among physicians in training.

A national study of personal accomplishment, burnout, and satisfaction with work-life integration among advance practice nurses relative to other workers

BACKGROUND

There is a high prevalence of burnout among health care professionals, but little remains known about burnout and satisfaction with work-life integration (WLI) among advance practice nurses (APNs).

PURPOSE

To evaluate burnout and satisfaction with WLI among APNs compared with other US workers.

METHODS

A national sample of APNs and a probability-based sample of US workers completed a survey that measured burnout and satisfaction with WLI.

RESULTS

Of the 976 (47%) APNs who completed the survey 64% had high personal accomplishment, 36.6% had symptoms of overall burnout, and 60.6% were satisfied with their WLI. In multivariable analysis, work hours (for each additional hour odds ratio [OR] 1.03, 95% confidence interval [CI] 1.02-1.04, p < .001) and working in an outpatient setting (overall p = .03; referent hospital: outpatient, OR 1.80, 95% CI 1.17-2.18; other/unknown, OR 1.41, 95% CI 0.90-2.22, p = .13) were independently associated with having higher odds of burnout. Work hours were also independently associated with lower odds of satisfaction with WLI (for each additional hour OR 0.94, 95% CI 0.94-0.95, p < .001). Advance practice nurses were not more likely to have burnout or have greater struggles with WLI than other workers.

IMPLICATIONS FOR PRACTICE

Findings from this study suggest APNs have high levels of personal accomplishment and a favorable occupational health profile. Advance practice nurses do not appear at higher risk of burnout or dissatisfaction with WLI than other US workers.

The Relationship Between Residents' Perceptions of Residency Program Leadership Team Behaviors and Resident Burnout and Satisfaction

PURPOSE

To explore the relationship between residents' perceptions of residency program leadership team behaviors and resident burnout and satisfaction.

METHOD

In February 2019, the authors surveyed all residents across the 77 graduate medical education training programs at Mayo Clinic's multiple sites. Survey items measured residents' perceptions of program director and associate program director behaviors (using a composite residency program leadership team score), resident burnout, and resident satisfaction with the program and organization. Multivariable logistic regression was performed to evaluate relationships between these variables at the individual resident (adjusting for age, sex, postgraduate training year, program location, and specialty) and program (including only programs with at least 5 respondents) levels.

RESULTS

Of the 1,146 residents surveyed, 762 (66.5%) responded. At the individual resident level, higher composite leadership team scores were associated with lower emotional exhaustion and depersonalization and higher overall satisfaction with the residency program and organization (all P < .001). In adjusted logistic regression models, each 1-point gain in composite leadership team score was associated with 9% lower odds of burnout, 20% higher odds of program satisfaction, and 19% higher odds of satisfaction with the organization (all P < .001). At the residency program level, higher mean composite leadership team scores were associated with a lower rate of burnout (r = -0.35, P = .03) and higher program and organization satisfaction (r = 0.67 and 0.74, respectively, both P < .001).

CONCLUSIONS

The behaviors of residency program leadership teams influence residents' burnout and satisfaction. Additional studies are needed to determine if leadership training results in improved resident well-being and satisfaction.

Disparities in Burnout and Satisfaction With Work-Life Integration in U.S. Physicians by Gender and Practice Setting

PURPOSE

To explore the interaction between practice setting (academic practice [AP], private practice [PP]) and gender in relation to physician burnout and satisfaction with work-life integration (WLI).

METHOD

In 2017, the authors administered a cross-sectional survey of U.S. physicians and characterized rates of burnout and satisfaction with WLI using previously validated and/or standardized tools. They conducted multivariable logistic regression to determine the interaction between the included variables.

RESULTS

Of the 3,603 participants in the final analysis, female physicians reported a higher prevalence of burnout than male physicians in both AP (50.7% vs 38.2%, P < .0001) and PP (48.1% vs 40.7%, P = .001). However, the multivariable analysis found no statistically significant gender-based differences in burnout (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.76-1.17, P = .60). Women and men in AP were less likely to report burnout than men in PP (OR 0.70, 95% CI 0.52-0.94, P = .01 and OR 0.69, 95% CI 0.53-0.90, P < .01, respectively); women in PP did not report different burnout rates from men in PP (OR 0.89, 95% CI 0.68-1.16, P = .38). Women in both AP and PP were less likely to be satisfied with WLI than men in PP (OR 0.62, 95% CI 0.47-0.83, P < .01 and OR 0.75, 95% CI 0.58-0.97, P = .03, respectively); men in AP did not report different satisfaction with WLI than men in PP (OR 1.05, 95% CI 0.82-1.33, P = .71).

CONCLUSIONS

Gender differences in rates of burnout are related to practice setting and other differences in physicians' personal and professional lives. These results highlight the complex relationships among gender, practice setting, and other personal and professional factors in their influence on burnout and satisfaction with WLI.

Burnout, Depression, Career Satisfaction, and Work-Life Integration by Physician Race/Ethnicity

IMPORTANCE

Previous research suggests that the prevalence of occupational burnout varies by demographic characteristics, such as sex and age, but the association between physician race/ethnicity and occupational burnout is less well understood.

OBJECTIVE

To investigate possible differences in occupational burnout, depressive symptoms, career satisfaction, and work-life integration by race/ethnicity in a sample of US physicians.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, data for this secondary analysis of 4424 physicians were originally collected from a cross-sectional survey of US physicians between October 12, 2017, and March 15, 2018. The dates of analysis were March 8, 2019, to May 21, 2020. Multivariable logistic regression, including statistical adjustment for physician demographic and clinical practice characteristics, was performed to examine the association between physician race/ethnicity and occupational burnout, depressive symptoms, career satisfaction, and work-life integration.

EXPOSURES

Physician demographic and clinical practice characteristics included race/ethnicity, sex, age, clinical specialty, hours worked per week, primary practice setting, and relationship status.

MAIN OUTCOMES AND MEASURES

Physicians with a high score on the emotional exhaustion or depersonalization subscale of the Maslach Burnout Inventory were classified as having burnout. Depressive symptoms were measured using the Primary Care Evaluation of Mental Disorders instrument. Physicians who marked "strongly agree" or "agree" in response to the survey items "I would choose to become a physician again" and "My work schedule leaves me enough time for my personal/family life" were considered to be satisfied with their career and work-life integration, respectively.

RESULTS

Data were available for 4424 physicians (mean [SD] age, 52.46 [12.03] years; 61.5% [2722 of 4424] male). Most physicians (78.7% [3480 of 4424]) were non-Hispanic White. Non-Hispanic Asian, Hispanic/Latinx, and non-Hispanic Black physicians comprised 12.3% (542 of 4424), 6.3% (278 of 4424), and 2.8% (124 of 4424) of the sample, respectively. Burnout was observed in 44.7% (1540 of 3447) of non-Hispanic White physicians, 41.7% (225 of 540) of non-Hispanic Asian physicians, 38.5% (47 of 122) of non-Hispanic Black physicians, and 37.4% (104 of 278) of Hispanic/Latinx physicians. The adjusted odds of burnout were lower in non-Hispanic Asian physicians (odds ratio [OR], 0.77; 95% CI, 0.61-0.96), Hispanic/Latinx physicians (OR, 0.63; 95% CI, 0.47-0.86), and non-Hispanic Black physicians (OR, 0.49; 95% CI, 0.30-0.79) compared with non-Hispanic White physicians. Non-Hispanic Black physicians were more likely to report satisfaction with work-life integration compared with non-Hispanic White physicians (OR, 1.69; 95% CI, 1.05-2.73). No differences in depressive symptoms or career satisfaction were observed by race/ethnicity.

CONCLUSIONS AND RELEVANCE

Physicians in minority racial/ethnic groups were less likely to report burnout compared with non-Hispanic White physicians. Future research is necessary to confirm these results, investigate factors contributing to increased rates of burnout among non-Hispanic White physicians, and assess factors underlying the observed patterns in measures of physician wellness by race/ethnicity.

Effect of a Brief Mindfulness-Based Program on Stress in Health Care Professionals at a US Biomedical Research Hospital: A Randomized Clinical Trial

IMPORTANCE

Stress among health care professionals is well documented. The use of mindfulness-based interventions to reduce stress has shown promising results; however, the time commitment of typical programs can be a barrier to successful implementation in health care settings.

OBJECTIVE

To determine the efficacy and feasibility of a brief mindfulness-based program to reduce stress during work hours among health care professionals.

DESIGN, SETTING, AND PARTICIPANTS

This intent-to-treat randomized clinical trial was conducted among full-time health care professionals at the Clinical Center at the National Institutes of Health in Bethesda, Maryland, between September 2017 and May 2018. Participants were randomized to receive mindfulness-based self-care (MBSC) training or life-as-usual control. Data were analyzed from June 2018 to January 2020.

INTERVENTIONS

The MBSC intervention included 5 weekly, 1.5-hour in-class mindfulness practice sessions.

MAIN OUTCOMES AND MEASURES

Stress level was the primary outcome, assessed with the Perceived Stress Scale 10-Item version. Secondary outcomes included anxiety, burnout, positive and negative affect, mindfulness (trait and state), and self-care. Assessments were taken at baseline and at the end of the intervention (week 5) in the intervention and control groups, and at follow-up (week 13) in the intervention group to test for a maintenance effect. A postprogram evaluation was also obtained.

RESULTS

Of 82 randomized participants, 78 who completed the study at week 5 were included in the modified intent-to-treat analysis (median [interquartile range] age, 32 [23-48] years; 65 [83%] women), including 43 participants in the MBSC group and 35 participants in the control group. At the end of the intervention, compared with the control group, the MBSC group had reduced levels of stress (mean [SD] score, 17.29 [5.84] vs 18.54 [6.30]; P = .02) and anxiety (mean [SD] score, 2.58 [1.52] vs 4.23 [1.73]; P < .001), and improved positive affect (mean [SD] score, 35.69 [7.12] vs 31.42 [7.27]; P < .001), state mindfulness (mean [SD] score, 3.74 [1.18] vs 2.78 [1.16]; P < .001), and mindful self-care (mean [SD] score, 7.29 [2.44] vs 5.54 [2.77]; P < .001). Burnout, negative affect, and trait mindfulness levels did not differ between groups. Changes within the MBSC group through follow-up included sustained reductions in stress (change, -6.14; 95% CI, -7.84 to -4.44; P < .001), anxiety (change, -1.46; 95% CI, -1.97 to -0.94; P < .001), trait mindfulness (change, 0.63; 95% CI, 0.36 to 0.90; P < .001), and state mindfulness (change, 1.89; 95% CI, 1.39 to 2.39; P < .001).

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that this brief mindfulness-based intervention was an effective and feasible means to reduce stress in health care professionals. Larger studies are needed to assess the effects on clinical care and patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03781336.

Diagnosing COVID-19 in the Emergency Department: A Scoping Review of Clinical Examinations, Laboratory Tests, Imaging Accuracy, and Biases

Objective

Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) emerged as a global pandemic in early 2020 with rapidly evolving approaches to diagnosing the clinical illness called coronavirus disease (COVID‐19). The primary objective of this scoping review is to synthesize current research of the diagnostic accuracy of history, physical examination, routine laboratory tests, real‐time reverse transcription–polymerase chain reaction (rRT‐PCR), immunology tests, and computed tomography (CT) for the emergency department (ED) diagnosis of COVID‐19. Secondary objectives included a synopsis of diagnostic biases likely with current COVID‐19 research as well as corresponding implications of false‐negative and false‐positive results for clinicians and investigators.

Methods

A Preferred Reporting Items for Systematic Reviews and Meta‐Analyses–Scoping Review (PRISMA‐ScR)–adherent synthesis of COVID‐19 diagnostic accuracy through May 5, 2020, was conducted. The search strategy was designed by a medical librarian and included studies indexed by PubMed and Embase since January 2020.

Results

A total of 1,907 citations were screened for relevance. Patients without COVID‐19 are rarely reported, so specificity and likelihood ratios were generally unavailable. Fever is the most common finding, while hyposmia and hypogeusia appear useful to rule in COVID‐19. Cough is not consistently present. Lymphopenia is the mostly commonly reported laboratory abnormality and occurs in over 50% of COVID‐19 patients. rRT‐PCR is currently considered the COVID‐19 criterion standard for most diagnostic studies, but a single test sensitivity ranges from 60% to 78%. Multiple reasons for false‐negatives rRT‐PCR exist, including sample site tested and disease stage during which sample was obtained. CT may increase COVID‐19 sensitivity in conjunction with rRT‐PCR, but guidelines for imaging patients most likely to benefit are emerging. IgM and IgG serology levels are undetectable in the first week of COVID‐19, but sensitivity (range = 82% to 100%) and specificity (range = 87% to 100%) are promising. Whether detectable COVID‐19 antibodies correspond to immunity remains unanswered. Current studies do not adhere to accepted diagnostic accuracy reporting standards and likely report significantly biased results if the same tests were to be applied to general ED populations with suspected COVID‐19.

Conclusions

With the exception of fever and disorders of smell/taste, history and physical examination findings are unhelpful to distinguish COVID‐19 from other infectious conditions that mimic SARS‐CoV‐2 like influenza. Routine laboratory tests are also nondiagnostic, although lymphopenia is a common finding and other abnormalities may predict severe disease. Although rRT‐PCR is the current criterion standard, more inclusive consensus‐based criteria will likely emerge because of the high false‐negative rate of PCR tests. The role of serology and CT in ED assessments remains undefined.

Resilience and Burnout Among Physicians and the General US Working Population

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.

Association of Perceived Electronic Health Record Usability With Patient Interactions and Work-Life Integration Among US Physicians

This cross-sectional survey assesses the association of perceived electronic health record usability with patient interaction and work-life integration among US physicians.

Relationship Between Burnout, Professional Behaviors, and Cost-Conscious Attitudes Among US Physicians

BACKGROUND

Despite the importance of professionalism, little is known about how burnout relates to professionalism among practicing physicians.

OBJECTIVE

To evaluate the relationship between burnout and professional behaviors and cost-conscious attitudes.

DESIGN AND PARTICIPANTS

Cross-sectional study in a national sample of physicians of whom a fourth received a sub-survey with items exploring professional behaviors and cost-conscious attitudes. Responders who were not in practice or in select specialties were excluded.

MEASURES

Maslach Burnout Inventory and items on professional behaviors and cost-conscious attitudes.

KEY RESULTS

Among those who received the sub-survey 1008/1224 (82.3%) responded, and 801 were eligible for inclusion. Up to one third of participants reported engaging in unprofessional behaviors related to administrative aspects of patient care in the last year, such as documenting something they did not do to close an encounter in the medical record (243/759, 32.0%). Fewer physicians reported other dishonest behavior (e.g., claiming unearned continuing medical education credit; 40/815, 4.9%). Most physicians endorsed cost-conscious attitudes with over 75% (618/821) agreeing physicians have a responsibility to try to control health-care costs and 62.9% (512/814) agreeing that cost to society is important in their care decisions regarding use of an intervention. On multivariable analysis adjusting for personal and professional characteristics, burnout was independently associated with reporting 1 or more unprofessional behaviors (OR 2.01, 95%CI 1.47-2.73, p < 0.0001) and having less favorable cost-conscious attitudes (difference on 6-24 scale - 0.90, 95%CI - 1.44 to - 0.35, p = 0.001).

CONCLUSIONS

Professional burnout is associated with self-reported unprofessional behaviors and less favorable cost-conscious attitudes among physicians.

Relationship Between Organizational Leadership and Health Care Employee Burnout and Satisfaction

OBJECTIVE

To explore the relationship between immediate supervisor leadership behaviors and burnout and professional satisfaction of health care employees.

PARTICIPANTS AND METHODS

From October 2 to 20, 2017, we surveyed nonphysician health care employees. The survey included 2 items from the Maslach Burnout Inventory and items on their immediate supervisor leadership behaviors. Logistic regression was performed to evaluate the relationship between the leadership score and the prevalence of burnout and satisfaction after adjusting for age, sex, duration of employment, and job category. Sensitivity analysis was performed using mixed models with a random intercept for work unit to assess the impact of the correlation within work units on burnout and satisfaction with the organization.

RESULTS

Of the 57,414 employees surveyed, 39,896 (69.5%) responded and answered the leadership questions. Supervisor scores in each dimension and composite leadership scores correlated with burnout and satisfaction of employees (P<.001 for all). In logistic regression, each 1-point increase in leadership score was associated with a 7% decrease in odds of burnout and an 11% increase in odds of satisfaction (P<.001 for both) of employees. The mean composite leadership score rating of each immediate supervisor correlated with rate of burnout (r=-0.247; P<.001) and the satisfaction with the organization (r=0.416; P<.001) at the work unit level.

CONCLUSION

Leadership qualities of immediate supervisors relate to burnout and satisfaction of nonphysician health care employees working in a large organization. Further studies are needed to determine whether strategies to monitor and improve supervisor leadership scores result in reduction in burnout and improved satisfaction among health care employees.

The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians

OBJECTIVE

To describe and benchmark physician-perceived electronic health record (EHR) usability as defined by a standardized metric of technology usability and evaluate the association with professional burnout among physicians.

PARTICIPANTS AND METHODS

This cross-sectional survey of US physicians from all specialty disciplines was conducted between October 12, 2017, and March 15, 2018, using the American Medical Association Physician Masterfile. Among the 30,456 invited physicians, 5197 (17.1%) completed surveys. A random 25% (n=1250) of respondents in the primary survey received a subsurvey evaluating EHR usability, and 870 (69.6%) completed it. EHR usability was assessed using the System Usability Scale (SUS; range 0-100). SUS scores were normalized to percentile rankings across more than 1300 previous studies from other industries. Burnout was measured using the Maslach Burnout Inventory.

RESULTS

Mean ± SD SUS score was 45.9±21.9. A score of 45.9 is in the bottom 9% of scores across previous studies and categorized in the "not acceptable" range or with a grade of F. On multivariate analysis adjusting for age, sex, medical specialty, practice setting, hours worked, and number of nights on call weekly, physician-rated EHR usability was independently associated with the odds of burnout with each 1 point more favorable SUS score associated with a 3% lower odds of burnout (odds ratio, 0.97; 95% CI, 0.97-0.98; P<.001).

CONCLUSION

The usability of current EHR systems received a grade of F by physician users when evaluated using a standardized metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed.

A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses

Background

Studies suggest a high prevalence of burnout among nurses. The aim of this study was to evaluate the relationship between burnout among nurses and absenteeism and work performance.

Methods

A national sample of U.S. nurses was sent an anonymous, cross-sectional survey in 2016. The survey included items about demographics, fatigue, and validated instruments to measure burnout, absenteeism, and poor work performance in the last month.

Results

Of the 3098 nurses who received the survey, 812 (26.2%) responded. The mean age was 52.3 years (SD 12.5), nearly all were women (94.5%) and most were married (61.9%) and had a child (75.2%). Participating nurses had a mean of 25.7 (SD 13.9) years of experience working as nurse and most held a baccalaureate (38.2%) or masters of science (37.1%) degree in nursing. A quarter worked in the inpatient setting (25.5%) and the average hours worked per week was 41.3 (SD 14.1). Overall, 35.3% had symptoms of burnout, 30.7% had symptoms of depression, 8.3% had been absent 1 or more days in the last month due to personal health, and 43.8% had poor work performance in the last month. Nurses who had burnout were more likely to have been absent 1 or more days in the last month (OR 1.85, 95% CI 1.25–2.72) and have poor work performance (referent: high performer; medium performer, OR 2.68,95% CI 1.82–3.99; poor performer, OR 5.01, 95% CI 3.09–8.14). After adjusting for age, sex, relationship and parental status, highest academic degree, practice setting, burnout, depression, and satisfaction with work-life integration, nurses who were more fatigued (for each point worsening, OR 1.22, 95% CI 1.10–1.37) were more likely to have had absenteeism while those who worked more hours (for each additional hour OR 0.98, 95% CI 0.96–1.00) were less likely to have had absenteeism. Factors independently associated with poor work performance included burnout (OR 2.15, 95% CI 1.43–3.24) and fatigue (for each point of worsening, OR 1.22, 95% CI 1.12–1.33).

Conclusions

These findings suggest burnout is prevalent among nurses and likely impacts work performance.