Is It Stress, Depression, or Burnout? One might think that identifying burnout is obvious, but the topic itself has become controversial. There's a lot of heated debate swirling around the question of what burnout is, how it should be measured, and what's causing it. And different experts and physicians have different answers. Some people are using the terms "depression," "stress," and "burnout" interchangeably; others insist that there needs to be more precision in identifying stress, depression, or burnout in order to treat them effectively. A recent analysis in JAMA of more than 180 studies of physician burnout conducted in 45 countries over the past 27 years highlights just how complex the topic has become. The analysis found estimates of physician burnout that range from 0% to 80.5%, based on arbitrary and inconsistent criteria for labeling individuals "burned out."[1] The varying definitions and thresholds for measuring burnout and a lack of prospective studies mean that researchers can't even establish whether burnout is a growing problem, says Douglas Mata, MD, MPH, a pathologist at Brigham and Women's Hospital and one of the authors of the study. When it comes to burnout, the conversation is "almost reaching a frenzy, but I don't know what we're frenzied about," says Jodie Eckleberry-Hunt, PhD, director of health psychology, executive health, and wellness for Beaumont Health System in Royal Oak, Michigan. "We've got to start with knowing what we're measuring." Is There a Precise Definition of Burnout? The concept of burnout as a "psychological syndrome resulting from prolonged response to chronic interpersonal stressors on the job" arose in the mid-1970s.[2] Christina Maslach, PhD, one of the early researchers in the field, developed the Maslach Burnout Inventory (MBI), a frequently used tool to measure what she determined to be the three dimensions of burnout: emotional exhaustion, depersonalization, and a low sense of personal accomplishment. But as the JAMA study found, the definition of burnout is far from cut-and-dried. Not everyone uses the MBI to determine burnout, and those who do may apply it differently and not agree on the threshold at which a person becomes "burned out." Because of these inconsistencies, "burnout" is often used colloquially rather than scientifically. Some have come to use the term as a synonym for stress, but burnout goes deeper than stress, insists Michael Privitera, MD, director of the Medical Faculty and Clinician Wellness Program at the University of Rochester Medical Center and chair of the Medical Society of the State of New York's task force on physician stress and burnout. Not only is it a specific type of stress—chronic workplace stress—but it probably has specific triggers, he says. Physicians Face New Kinds of Stress "Medicine has always been a stressful profession," Privitera says, "but we have new kinds of stress now. In the past, if you stayed late because you were worried about a patient, that was autonomy. You chose to stay late. Now, if you have to stay late because you have to chart or because there was a problem with the EHR, that is an entirely different form of stress. The whole issue is the work stress getting out of control." Others, including Irwin Schonfeld, PhD, a professor in the department of psychology at City University of New York, argue that burnout is a form of depression. That's doesn't mean that everyone who suffers from burnout suffers from major depression or that chronic work stress doesn't exacerbate the problem, Schonfeld insists. And equating burnout with depression does not alleviate employers of their responsibility to improve working conditions. "It simply recognizes the overlap between depression and burnout," he says. "Depression has been viewed as a present/absent phenomenon, when it is actually better to conceptualize depression on a continuum, like temperature," Schonfeld explains. Many individuals suffering from burnout may never reach the threshold of depression as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), but they still experience depressive symptoms and psychic distress. Many physicians say the relation between depression and burnout may resemble a Venn diagram, where the conditions are different but share significant overlap. Others says the conditions must be considered distinctly. Calling burnout "depression" blames doctors, rather than the workplace, for their own distress, they say. It may prevent doctors from speaking up or seeking help, for fear that they will be deemed impaired and referred to a physician assistance program. Privitera says it's more helpful to consider burnout in the context of occupational medicine. "If someone has an injury related to work, they may say it's carpal tunnel," he says. "Their physician will understand that to mean the median nerve is inflamed due to overuse and will treat them accordingly, but there's a lot of utility in the work-world language," he says. Understanding the work connection helps identify both the likely cause of and the potential solutions to the problem. "If you start calling burnout 'depression,' you are losing all of that rich work information. You don't get to the cause of the problem." Action Is Vital, No Matter What You Call It Whatever their point of view, experts say that by focusing attention on burnout, the debate has the potential to fuel interventions, despite different opinions about nomenclature. Whether the larger cause is workplace stressors or physicians' reactions to those stressors, experts tend to agree that burnout may be the result of several factors. Responding effectively may depend less on nailing down specifics than on simply taking action. If someone is clinically depressed, doctors can diagnose the problem and address it using evidence-based treatments, including medication and cognitive-behavioral therapy. But if a physician's psychological distress is rooted in workplace conditions, then the onus is on employers to address workplace concerns. If the problem is the workplace, "You can't say, 'let's teach physicians mindfulness' and expect it to fix the problem," Eckleberry-Hunt says. "I think mindfulness is a great skill to have, but it implies that you are the problem and you have to change." Many interventions that have the potential to reduce physician burnout—such as increasing staffing, providing physicians with space for reflection, or addressing problematic EHR issues—don't pose any sort of risk, notes Carol Bernstein, MD, vice chair of the department of psychiatry at New York University School of Medicine/NYU Langone Health. She feels that if a strategy might alleviate physician distress and doesn’t pose any risk to patients, it is worth trying. Bernstein notes that many potentially meaningful interventions can happen at the hospital and even at the department level. We have some people who are less resilient or more pessimistic, and we absolutely have things going on in the practice of medicine that are making people miserable. "We have some people who are less resilient or more pessimistic, and we absolutely have things going on in the practice of medicine that are making people miserable," says Eckleberry-Hunt. "I think we need research, but my bias is we've been researching burnout—flawed or not—for years." Privitera says, "We can quibble about the quality of the data, but we are decades behind doing something about burnout. We can't wait for the perfect tool for measuring burnout." "Medicine has always focused on pathology, and so that is naturally where things have gone in terms of burnout and I think we've gotten stuck there," says Eckelberry-Hunt. She says it's time to approach the subject from the other direction. "There are physicians out there who are thriving. What is making them thrive? If I were a CEO, my goal would not be 'How do I make sure my employees are not burned out?' I'd want to explore, 'How do I make sure my employees are content and happy to come to work?'" The Importance of Getting the Words Right The debate over what to call burnout is more than a matter of semantics. "The reason the confound is so concerning is that we don't want to be treating people who are clinically depressed by changing things at work, and we don't want to address burnout as if someone has a mental health condition," says Bernstein. Without a common language, the healthcare community doesn't know where to target interventions or how to design and measure the effectiveness of those interventions, says Brigham and Women's Dr. Lisa Rotenstein, MD, MBA, first author on the JAMA study. "If you read the literature and media, a consensus has emerged that physician burnout is an 'epidemic' and that the 'rate' of physician burnout is on the rise," Mata says. But the language surrounding the topic has gotten so sloppy—burnout is an endemic condition, he says, and "prevalence" is frequently misconstrued as "rate"—that even those assertions are inaccurate, he says. "I'm not trying to argue that physicians and other medical professionals aren't under a great deal of stress, or that the term 'burnout' is an invalid way to colloquially describe that stress," he says, but "there is no evidence to support these widely repeated truisms." References Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: a systematic review. JAMA. 2018;320:1131-1150. doi:10.1001/jama.2018.12777. Source Accessed October 1, 2018. Maslach C, Schaufeli W, Leiter M. Job burnout. Ann Rev Psychol. 2001;52:397-422. SourceAccessed October 2, 2018. Source
