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It's not me, it's you

Should we abandon the idea of burnout?

Section Editor(s): Reed, Harrison MMSc, PA-C

Journal of the American Academy of PAs: December 2018 - Volume 31 - Issue 12 - p 8
doi: 10.1097/01.JAA.0000547756.69170.17

Harrison Reed practices critical care medicine at the University of Maryland Medical Center's R. Adams Cowley Shock Trauma Center in Baltimore, Md., is an adjunct instructor in the School of Medicine and Health Sciences at George Washington University in Washington, D.C., and is associate editor of JAAPA. The author has disclosed no potential conflicts of interest, financial or otherwise.



The physician assistant (PA) profession rarely goes in for a checkup. After all, it is in great shape these days.

The number of PAs has grown while legislative barriers to PA practice have fallen. Patients are satisfied with our care and data support our value in healthcare.1

But the PA profession still shows up for yearly physicals, so to speak, in the form of massive annual surveys by the American Academy of PAs (AAPA). A group of researchers led by Bettie Coplan, MPAS, PA-C, performed a secondary analysis of the data from the 2016 AAPA survey and recently published the results in JAAPA (“Burnout, job satisfaction, and stress levels of PAs,” September 2018).

And, like some unfortunate checkups, they found something interesting.

The authors aimed to quantify burnout and job satisfaction throughout the PA profession. Their results revealed a complicated picture. Overall, PAs reported low rates of three symptoms chosen as surrogates for burnout: emotional exhaustion, lack of enthusiasm for work, and cynicism. In fact, the survey data suggested that the overwhelming majority of PAs appear to be satisfied with their careers. But that finding makes the next set of numbers all the more perplexing.

Despite reporting high levels of professional fulfillment, 30% of responding PAs say they have quit their jobs due to stress or a toxic work environment. Another 12% have quit multiple jobs due to stress and toxicity, and an additional 13% are considering quitting their jobs right now.

As we squint to find broader meaning in these statistical tea leaves, one question emerges: if you can love your career but hate your job, how useful is the concept of burnout?

Even the term burnout suffers from inconsistent usage. The research tools, methodology, and criteria used to explore the topic have varied over years of discussion.2

In medicine, we prefer research with a focus on patient-centered outcomes, those that have meaningful implications for real human beings. Surrogate markers are our best guess at a reliable proxy; they often are imperfect road signs on the way to our real destination. At worst, they can be pure distractions, statistical blebs masquerading as reliable correlates. Our job as critical appraisers of research is to avoid arbitrary data points and focus on the most meaningful outcomes. The critical analysis of workforce issues should follow the same logic. If the majority of PAs can test negative for the nebulous syndrome of burnout while they still quit their jobs in distress, perhaps the very idea of burnout is a misguided surrogate.

But there is an even deeper problem with the focus on burnout. Survey questions about burnout—probing for emotional exhaustion, apathy, depersonalization, and cynicism—focus on uncovering damage within the individual. They give respondents two choices: I am broken or everything is fine. This approach frames the discussion as an abnormality in the healthcare professional rather than a normal reaction to a corrosive system.

Of course, the 55% of PAs who quit their jobs (or plan to) due to work-related stressors cannot all be abnormal. An outcome this common hints at a ubiquitous and troubling problem. If the majority of our patients suffered an ailment, we would look for a unifying thread. In the case of PAs and other healthcare providers who suffer professional distress, the common element is obvious: the environment.

Coplan and colleagues' research suggests that dissatisfied PAs can feel pushed to the point of resignation without ever considering themselves victims of burnout. And if the relationship between symptoms of burnout and the important outcome of employee turnover is inconsistent, is the measure of burnout really a useful tool or is it just a highly publicized confounder?

Perhaps it is time to move from a paradigm focused on examining the victims of workplace stress to one that analyzes the underlying causes. Then we will have an opportunity to address primary prevention rather than merely take blind stabs at damage control.

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1. Roblin DW, Becker ER, Adams EK, et al Patient satisfaction with primary care: does type of practitioner matter. Med Care. 2004;42(6):579–590.
2. Eckleberry-Hunt J, Kirkpatrick H, Barbera T. The problems with burnout research. Acad Med. 2018;93(3):367–370.
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