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The Impact of Burnout on the Obstetrics and Gynecology Workforce

VETTER, MONICA HAGAN MD*; SALANI, RITU MD, MBA*; WILLIAMS, THOMAS E. JR MD, PhD; ELLISON, CHRISTOPHER MD; SATIANI, BHAGWAN MD, MBA

Clinical Obstetrics and Gynecology: September 2019 - Volume 62 - Issue 3 - p 444–454
doi: 10.1097/GRF.0000000000000452
Burnout and Resilience in Obstetrics and Gynecology
Free

Although there has been discussion of a shortage of surgical specialties including OB/GYN, consensus is difficult because of the multiple variables involved in estimating both supply and demand. In addition, burnout has become more recognized as a variable that has not been taken into account in estimating a shortage of OB/GYNs. We estimate OB/GYN physician shortages of 17%, 24%, and 31% by 2030, 2040, and 2050, respectively. Here, we examine the impact of burnout on the OB/GYN workforce. Specifically, we address the associations of burnout, reduction in clinical productivity as well as early retirement. We also discuss the implications of the substantial increase of female OB/GYNs to ∼66% of workforce over the next 10 years and how this may impact the impending OB/GYN shortage. Finally, we briefly consider possible solutions to workforce issues causing burnout.

Departments of *Obstetrics/Gynecology, Division of Gynecologic Oncology

Surgery, The Ohio State University College of Medicine, Columbus, Ohio

R.S.: Advisory Board & or Speakers Bureau of Tesaro, Clovis, Genentech Ethicon, Gen Mab. T.E.W.: none. C.E., B.S.: Johnson & Johnson consulting; McGraw Hill Co-editor contributions atlas. M.H.V. declares that there is nothing to disclose.

Correspondence: Monica Hagan Vetter, MD, 320 W. 10th Avenue, Starling Loving M210, Columbus, OH. E-mail: monica.vetter@osumc.edu

I am retiring completely in one month—mostly because of burnout. I find it stressful to adequately treat my patients and keep up with all of the insurance red tape and government regulations.1

I’m still paying off loans and am over-extended financially…No end in sight…Feeling sad to be burning out after only 11 years in practice.1

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Introduction

Only over the past decade has the impact of physician burnout on the health care workforce started to be elucidated. Studies have demonstrated that US physicians are experiencing a burnout epidemic with over 50% of physicians meeting the diagnostic criteria of burnout in 2014.2,3 Furthermore, physicians with higher burnout rates are experiencing worsening work-life balance satisfaction and professional satisfaction. A recent study found that almost 1 in 5 US physicians intended to reduce clinical work hours in the next year, whereas 1 in 50 intended to leave medicine completely.4 In that study, burnout was found to be an independent predictor of reported intent to reduce work hours or leave the current practice (odds ratio [OR], 1.81; 95% CI, 1.49-2.19; P<0.001). If these physicians truly choose to follow through with their plans to reduce their clinical activity, this could have a substantial impact on the projected shortfall of US physicians.

In this report, we seek to discuss the projected demand and supply and estimated shortages of OB/GYNs, detail the impact of burnout on OB/GYN physician’s productivity, retention, and workplace causes of burnout and professional dissatisfaction. In addition, we will briefly review the available literature as well as discuss possible solutions to mitigating common workplace risk factors for burnout to avoid shortages.

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Anticipated Shortage of US Physicians

The Association of American Medical Colleges (AAMC) has predicted a physician shortage of up to 120,000 physicians by 2030.5 This impending shortage is particularly notable in Obstetrics and Gynecology (OB/GYN) due to the increasing adult female population in the United States in addition to health care reform that has increased access to insurance and subsequently increased the overall demand for services on physicians.6–8 The American College of Obstetricians and Gynecologists projects there will be a shortage of up to 8800 obstetricians and gynecologists (OB/GYNs) by 2020 and up to 22,000 by 2050.9 These projected shortages may be further compounded by new trends in OB/GYN practice patterns including part-time employment and early retirement leading to few active clinical years per physician. Given the wide range of services that OB/GYNs provide including primary health care management and the large number of patients served, this shortfall will likely have a significant impact on the nation’s health.

The impending shortfall of OB/GYN in the United States is a complex issue impacted by both flow of physicians into and out of the workplace (Fig. 1). To increase the number of physicians in the workforce, the AAMC called for an increase in medical school enrollment in 2006. Since this time, first-year enrollment levels have increased by almost 30%.10 Despite the increased medical school enrollment, the number of Accreditation Council for Graduate Medical Education-approved first-year residency positions in OB/GYN have increased minimally resulting in a stagnant yearly graduation rate.11 This has led to a gradual decline in the number of OB/GYN graduates per 100,000 population (Table 1). This is largely in part because the number of residency programs funded by Congress is still frozen since 1996 by the Balanced Budget Act of 1997 based upon previous faulty estimates of a surplus of physicians. Although, some have projected a US allopathic categorical residency positions annual growth rate of 2.55%, enough for our needs, all the additional positions not funded by Congress are being funded since 1997 by the teaching hospitals from their operating margins, which vary from year to year and are at risk.12

FIGURE 1

FIGURE 1

TABLE 1

TABLE 1

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Extent of Obstetrician-Gynecologist Shortages

In 2011, we estimated the shortage of OB/GYNs as 20,135 by the year 2030 for a US population of 364 million people.13 Based upon a ratio of OB/GYNs to population of 27.10/100,000 women, we have now updated our estimates and projected shortages to the year 2050 using assumptions used previously.14 Assumptions used for these calculations are 27.1 OB/GYNs per 100,000 women, 30 years of practice on average and the AAMC numbers for practicing OB/GYNs in 2015—41,481.15 We divided 41,481 by 30 to get the number retirees each year—1383. We then added the average of new Board Certifications from 2012 to 2016—1229 for our calculations.16 Projection of the Population by Sex and Selected Age Groups for the United States: 2015 to 2060 was used for population estimates.6 Therefore, shortages are estimated to be 8% and 31% by years 2020 and 2050, respectively (Table 2).

TABLE 2

TABLE 2

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Consequences of Burnout on the Obstetrics and Gynecology Workforce and Workplace

With the growing recognition of the problem of physician burnout, there is increasing interest in understanding the impact of burnout on the available workforce and on the access for obstetric and gynecologic care. Although the consequences of burnout are many, productivity outcomes are of concern as they may have the most immediate effects on the health care system. Productivity outcomes usually studied in the literature are use of sick leave, academic output, reduction in clinical hours, and the intent to change jobs/continue in health care.17

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SICK LEAVE

The literature regarding use of sick leave is conflicting. In a study of family medicine practitioners in 12 European countries, Soler et al18 found that use of at least 1 sick day was associated with higher odds of reporting high emotional exhaustion or depersonalization or low personal accomplishment. In addition, a study of female physicians from Sweden also demonstrated that high scores of the Oldenburg Burnout Inventory increased the risk of future long-term sickness absence (≥90 d).19 This is in contrast to the findings of Siu et al20 there was no statistically significant difference in average sick day use between physicians with and without high burnout scores in a public hospital in Hong Kong.

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REDUCTION OF WORK HOURS DUE TO BURNOUT

Several studies have demonstrated a relationship between burnout and profession satisfaction with reduction of clinical work hours.4,21 An interesting study was performed by Shanafelt et al22 in which administrative/payroll records were used to assess the professional work effort as measured in full-time equivalents units of attending physicians at the Mayo Clinic over an 8-year period. Within that time frame, the proportion of physicians working less than fulltime increased from 13.5% to 16.0% (P=0.05). When controlling for factors such as age, sex, site, and specialty, every 1-point increase on a 7-point emotional exhaustion scale was associated with an increased likelihood (OR 1.43; 95% CI, 1.23-1.67) for reduction in full-time equivalents over the next 24 months as was each 1-point decreased on a 5-point professional satisfaction scale (OR 1.34; 95% CI, 1.03-1.74). Although it is likely that the reduction of work hours may have served as a beneficial strategy for individual physicians experiencing burnout, the loss of professional work effort is likely to compound the physician workforce shortage and possibly increase the burnout in the remaining full-time physicians by further increasing workload.

Another factor that could impact the available workforce is the inability to perform full-time duties due to depression associated with burnout. Approximately 30% of surgeons screened positive for depression on a survey of American surgeons.23 Of the 7905 surgeons responding to the survey, 10% to 15% would have qualified to have a major depressive disorder at the time of the survey assuming they had undergone a psychiatric evaluation. Even if half of this cohort either completely or partially stopped working, the impact of OB/GYNs providing care would be significant.

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ASSOCIATION OF BURNOUT AND EARLY RETIREMENT

Better elucidated and more concerning is the association of burnout with job dissatisfaction and the intent to leave practice. A systematic review of physician retirement planning demonstrated common reasons for early retirement included low job satisfaction, medicolegal issues, health concerns, and financial trouble.24 Low job satisfaction was impacted by perceptions of low job control, low morale, and dissatisfaction with the internal justice system of medicine. Both excessive workload and burnout were associated with reported intentions to retire (both early and delayed) across a wide range of specialties.25–28 The findings of this systematic review were further confirmed in a cross-sectional study of more than 37,000 physicians across all specialties as 69% of physicians reportedly thoughts of early retirement due to feelings of being overworked and stressed.29

Data regarding the link between burnout and early retirement in individual specialties also exist. In a landmark study, Shanafelt et al30 surveyed over 7500 members of the American College of Surgeons and found that 32.0% of respondents reported at least a moderate likelihood of leaving their current practice in the next 2 years, whereas 17.6% reported their likelihood of leaving was likely or definite. Only 6.6% of these surgeons were planning to retire. Of those reporting at least, a moderate likelihood of leaving their current practice, only 41.5% planned to continue working as a surgeon, whereas 58.5% planned to leave the field of surgery. Burnout was identified as the single strongest predictor of reported intent to leave with an OR of 2.5. Since the publication of this study, the negative impact of burnout on job satisfaction and increased intention to leave work has been confirmed across a wide range of medical specialties including general practitioners, neurologists, emergency medicine physicians, and palliative care physicians.

Currently, there are no studies specifically focusing on burnout and physician production and retention among general OB/GYN. However, data does exist from subgroup analysis of larger studies of the general physician population. According to the Medscape Lifestyle Report from 2017, in which 56% of OB/GYNs reported burnout, participants were asked to rate the severity of their burnout on a scale of 1 to 7.31 One was defined as “It does not interfere with my life” whereas 7 equaled “It is so severe that I am thinking of leaving medicine altogether.” Among OB/GYNs reporting burnout, the average severity rate was 4.3 which was slightly above the mean severity rate across all specialties suggesting that OB/GYNs may be more likely to consider early retirement when compared with the general US physician population.

Despite the lack of data linking burnout and retirement among the general OB/GYN population, some data do exist for several individual groups within OB/GYN including gynecologic oncologists, academic chairs, and residents. A cross-sectional study of members of the Society for Gynecologic Oncology by Rath and colleagues found that 32% of respondents met the criteria for burnout. Female sex (OR 1.86; 95% CI, 1.18-2.91) was found to be a risk factor for burnout while age 50 years and above (OR 0.48; 95% CI, 0.29-0.81), and reporting that they would not become a physician again (OR 0.30; 95% CI, 0.16-0.59).32 These findings were similar to a previously conducted study of Canadian gynecologic oncologists where 34% of respondents had high emotional exhaustion, whereas 14.3% had high depersonalization rates.33 Approximately 46% of physicians reported they were considering decreasing the number of hours they work while 14% were planning to leave their current job.

In addition to gynecologic oncologists, burnout and job satisfaction among chairs of academic OB/GYN departments have also been closely studied. A 2002 survey of members of the Council of University Chairs of Obstetrics and Gynecology found that 56% of participants had high emotional exhaustion, whereas 36% had high depersonalization.34 Degree of burnout was not significant different based on the chair’s subspecialty. Approximately 33% of respondents reported they were at least “moderately likely” to step down from their position, and of these 40 respondents, 16 reported they were likely to leave their job due to excessive workload and excessive stress. Although the rates of academic chairs with high emotional exhaustion and depersonalization scores (30.7% and 6.2%, respectively) were lower on a 2017 survey of Council of University Chairs of Obstetrics and Gynecology members, over 30% of respondents continue to report that they are likely to step down from their position.35 Drawing firm conclusions based on the intent of these academic leaders to work less or retire is impossible, but if a substantial portion of these OB/GYN chairs do follow through, the future of the OB/GYN leadership workforce could be in jeopardy.

Although, it is hard to speculate on the exact impact of burnout on both the loss of productivity and early retirement and therefore workforce shortages, the incidence of severe depression would make it more likely that the affected OB/GYN may be unable to work on a regular basis or choose to retire early. In the American College of Surgeons study by Shanafelt, 40% of surgeons, which included 105 OB/GYNs, were estimated to have burnout.24 Of the respondents, 10% to 15% would have “met the criteria for major disorder at the time of the survey if they had undergone a full psychiatric examination.” If there are about 40,000 practicing OB/GYNs in the United States and 40% (16,000) have burnout, this would mean that at a minimum 10% of those would unable to work consistently. This may lead to about 1600 or 4% of the OB/GYN workforce being unable to work at any one time or retire. In another study measuring the potential impact of burnout on the US physician workforce, higher emotional exhaustion could result in an 18% absolute reduction in professional work effort equating to a net loss of 1.2% of the physician workforce.36 Therefore, burnout may, along with other factors, have a sizeable impact on workforce shortages.

Rates of burnout and job satisfaction among OB/GYN residents have also been studied in several studies. In 1 such study, Becker et al37 studied residents at 23 randomly selected OB/GYN residency programs in the United States and found that 89.9% showed evidence of moderate burnout while 34.2% had a positive depression screen. Residents who reported high levels of job satisfaction were significantly less likely to be emotionally exhausted (44% vs. 80%, P=0.003) and had higher personal accomplishment scores (56% vs. 15%, P=0.0008). As with other studies of physicians, emotional exhaustion was found to be strongly predictive of diminishing career satisfaction. Interestingly, this study also demonstrated that decreased career satisfaction was also associated with consideration of a fellowship due to malpractice concerns. This finding certainly warrants further study to determine the impact of burnout on the decision to subspecialize as this could ultimately decrease the pool of general OB/GYN.

Currently, there is no data about the impact of burnout on OB/GYN resident attrition; however, research conducted by Kennedy et al38 found that the average annual rate of attrition among OB/GYN residents was 4.2% from 2000 to 2009. This was like the rates of attrition in other core specialties (mean 4.0%). The most common reasons for attrition were transition to another specialty (30.0%), withdrawal/dismissal (28.2%), transfer to another OB/GYN program (2.54%), and a leave of absence (2.2%). Both male respondents and international medical school graduates had higher rates of attrition (5.3% and 7.6%, respectively). As efforts to recruit and retain resident physicians is critical for the stability of the OB/GYN workforce, attempts to better understand the influence of burnout on resident attrition and career choice should be undertaken.

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IMPACT OF SEX ON THE OBSTETRICIAN-GYNECOLOGIST SHORTAGE

One unique factor that may further impact the OB/GYN shortage is the increasing number of women entering the medical field and subsequently OB/GYN. According to the AAMC, women comprised 50.9% of medical school matriculants in 2018 with an increase in female medical student applicants of 5% since 2017.39 In addition, the percentage of women matching into OB/GYN residency programs continues to increase with over 82% of OB/GYN interns being female in 2016.9 This has led to a higher proportion of females in OB/GYN (58.7% as of 2017) compared with any other group of active surgeons. In the next 10 years, the percentage of female OB/GYNs is expected to further increase to 66%.9 This is of concern as female physicians are more likely to retire early than male physicians with this sex difference more noticeable among OB/GYNs.40,41

One hypothesized reason for this difference in likelihood of early retirement is that female OB/GYNs are more likely to be younger and balance career-building with childbearing.9 In 1 study of OB/GYN subspecialists, only 26% of women reported having children before or during residency compared with 48% of men.42 Approximately 83% of women felt their career “somewhat or very much” affected the timing of becoming a parent compared with 48% of men (P<0.0001). Stressed caused by the decision regarding the timing of childbearing was higher in women but was statistically significant. Finally, a higher percentage of women felt that having children decreased their clinical (76% compared with 65% respectively, P<0.0001) and academic performance (76% vs. 54%, P<0.0001). These findings are consistent with prior literature in general trainee and physician populations that demonstrated significant differences in work-life balance by sex.43–45

The conflict in work-life balance noted in the above studies is likely a contributor to the decreased career satisfaction, increased burnout, and the likelihood of early retirement. In a study of work-home conflict in members of American College of Surgeons, having children and greater work hours were associated with increased odds of reporting work-home conflict (OR 1.71 and 1.02, respectively) in female respondents.46 Those reporting work-home conflict or imbalance subsequently reported higher emotional exhaustion and depersonalization scores as well as more frequent symptoms of depression. Surgeons reporting recent work-life conflict were more likely to report a moderate or higher likelihood of intent to reduce clinical work hours than colleagues without recent work-home conflict (24.4% vs. 21.6%). For female surgeons, this association was actually higher during their 40s likely during a time when child-rearing activities are most intense.

As the proportion of female OB/GYNs continues to increase over the next several years, we must remain cognizant of the impact of sex on work-life balance. Furthermore, we must be aware of the relationship of lack of work-life integration and burnout as this may put our female physicians at a higher risk of burnout and subsequent reductions in productivity.

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ECONOMIC IMPACT OF BURNOUT

Not only does physician burnout and associated depression directly impact the health care work force, there are also significant costs to the health care system. Dewa and colleagues sought to quantify these health care costs by creating an economic model based on 2 national surveys of Canadian physicians.18 This model consisted of comparing 2 scenarios in which physicians experienced burnout and in physicians who did not. Physicians experiencing job dissatisfaction could potentially experience 1 of 3 outcomes: (1) reduction in clinical hours, (2) plan to retire, or (3) no change in work hours. The total “cost of burnout” for all physicians was estimated to be $213.1 million with $185.17 million lost due to early retirement and $27.91 million due to reduced clinical hours.

Currently, no studies exist assessing the economic impact of burnout and subsequent loss of OB/GYNs due to reduction in work hours or early retirement. However, a decision analysis was recently published demonstrating the impact of burnout on total relative value (RVU) production of gynecologic oncologists.47 This model, using data from the Society of Gynecologic Oncology practice survey, determined that without burnout, RVU production for a cohort of 250 gynecologic oncologists was 26.2 million RUVs over a period of 15 years. When rates of burnout were factored in, there was a loss of 1.6 million RVUs with a disproportionate loss of RVUs among female physicians. Furthermore, burnout also resulted in an estimated 1383 fewer publications over 15 years which was a 14.9% decrease.

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Possible Solutions to Workforce Issues Causing Burnout

It is important to recognize that factors that contribute to burnout are multifactorial in nature. Addressing possible solutions to workforce issues may help mitigate the impact of burnout and its consequences.

One major potential solution to the workforce issues facing OB/GYN is the addition of nonphysicians to clinical teams. These clinicians may include advanced practice providers (APPs) including certified nurse-midwives, nurse practitioners, and physician assistants. Over the past several years, APPs have been increasingly incorporated into clinical practice in order to facilitate access to care and improve clinical productivity. In the outpatient setting, APPs perform history and physical exams, develop management plans and can manage urgent/acute care needs.48 Their scope of practice allows for writing and managing prescriptions as well as performing specific office procedures. In addition, the APP may be able to provide in depth counseling on topics that may not otherwise be addressed such as sexual/menopausal health, postoperative care, and a multitude of other topics. In the inpatient setting, APPs can reduce physician work burden by assisting with admission intake, writing orders, coordinating care, and even being credentialed to assist in the operating room. Lastly, APPs may play a role in the research or quality improvement projects, enhancing practice flow and outcomes. Although the true impact on productivity and financial aspects have yet to be determined, it appears evident that the increasing work burden on OB/GYN physicians will be lessened with the addition of APPs with a direct impact on improving burnout.

Another potential solution to workforce issues impacting burnout is improving and optimizing the implementation of the electronic medical record (EMR). For some time, physicians have hypothesized that the increased use of EMR, electronic prescribing, electronic patient portals and computerized physician order entry has caused frequent workplace interruptions/distractions and has increased the clerical burden on physicians.49,50 Furthermore, a national study found the physicians’ satisfaction with their EMR and computerized physician order entry was overall very low.51 Physicians who used EMRs (OR 0.67l; 95% CI, 0.57-0.79; P<0.001) were less likely to be satisfied with time spent on clerical tasks. In addition, use of a computerized physician order entry was associated with a higher risk of burnout on multivariate analysis (OR 1.29; 95% CI, 1.12-1.48; P<0.001).

There have been several suggestions on how to mitigate the negative impact of the EMR on physicians. Promising approaches that have been proposed include assistant order entry and documentation support.51–53 This can either be performed by medical scribes who document the encounter in the EMR under the direction of a physician. Although current evidence about is limited, a recent systematic view found that use of scribes increased multiple factors including efficiency, enhanced patient satisfaction, patient throughput, and increased WRVUs.54 Advanced care team models where clinically trained practitioners such as nurses or medical assistants who can assist with note documentation, order entry, inbox management, and care coordination offer another possible solution.55–57 Not only does this decrease physician documentation but this approach also allows for triage of patient communications by a health care professional. Further studies are needed to quantify the impact of these interventions on job satisfaction and physician burnout.

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Conclusions

The main drawback of most, if not all, estimates of the surgical workforce has been mostly on the demand side with the uncertainty associated with changes in technology, insurance coverage, and new models of care such as telemedicine or group appointments. On the supply side we point out that the pipeline of new OB/GYNs has been mostly static. Furthermore, there have been additional changes in practice patterns including a larger proportion of female physicians, increased subspecialization as well as generational differences with reduced work hours or part-time surgeons.

At this point, little attention has been paid to burnout and its effect on the supply of OB/GYNs. With a steady increase in the US population, it has become necessary to pay attention to burnout causing a decrease in the supply of OB/GYNs to care for the population. As mentioned, the impact of depression, substance abuse and suicides associated with burnout have been shown to be costly in terms of not only life and the pursuit of happiness, but labor costs and sunk costs associated with the lengthy training of OB/GYNs. Although, many techniques have been suggested to alleviate burnout the fact remains that these are ex ipso facto. Factors leading to burnout have been well-studied and prevention seems to be the best way forward to stop this silent epidemic.

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Keywords:

shortages; burnout; depression; workforce; workplace; OBGYN

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