ARTICLE IN BRIEF
A new analysis of a survey on burnout identifies the different ways in which women and men experience burnout. And it suggests strategies for addressing contributing factors across practices and institutions.
Burnout, satisfaction, and well-being among neurologists varies significantly by age and sex, suggesting that strategies to combat burnout and improve professional fulfillment cannot be “one size fits all.” Rather, initiatives should be targeted at particular demographic subgroups.
A new analysis of an AAN survey published online October 10 in Neurology found.
Primary results from the survey, published in 2017 in Neurology, found that more women than men — 64.6 percent vs. 57.8 percent, respectively — had at least one symptom of burnout. However, age but not sex was an independent predictor of burnout.
“We thought, ‘This is peculiar,’” said one of the principal authors, Neil A. Busis, MD, FAAN, a clinical professor of neurology at the University of Pittsburgh School of Medicine, who helped to launch the AAN's Burnout Task Force in 2015 and serves as the AAN representative to the National Academy of Medicine's Action Collaborative on Clinician Well-Being and Resilience. “Women are more burned out than men, but sex is not an independent predictor of burnout? We should look at this more carefully.”
So the original study authors took a deeper dive into their data using both qualitative and quantitative methods. They soon found an explanation for their seemingly contradictory findings. The age distribution of women in neurology is skewed younger: Women responding to the survey were about seven years younger than male respondents.
“Once you adjust for age, the burnout rates for men and women in neurology are exactly the same,” said Dr. Busis. “We found that factors associated with burnout such as emotional exhaustion, depersonalization, and fatigue were generally higher among younger neurologists and then started to improve as they got older.”
But that doesn't mean that burnout among male and female neurologists looks the same. The survey team conducted a gender-specific analysis of the survey's voluntary, open-ended final question: “Is there anything else you would like to share with AAN regarding burnout and well-being?” A panel of five neurologists and two non-neurologists coded these free-text responses to identify relevant themes related to burnout, career satisfaction, and well-being as they differed by gender, looking for the top four themes that had the highest difference in comments between men and women.
COMMON THEMES FOR MEN AND WOMEN
Some themes were universal among men and women. For example, both men and women mentioned that linking physician payment to physician satisfaction surveys has made them wary of “speaking the truth” or giving diagnoses that patients do not want to hear. “But overall, we found that the experience of burnout is significantly different for women than men,” Dr. Busis said.
While men and women both mentioned taking leaves of absence, switching to part-time work, early retirement, or leaving medicine altogether, women mentioned more unpaid work (teaching and administration) than expected by their job description, while men did not. Men mentioned hobbies and lacking sufficient time to pursue them, while women did not mention hobbies at all.
On the topic of leadership, women's concerns focused on lack of pay equity and professionalism — threats to doctors' expertise, trust, autonomy, and authority to place the medical interests of their patients first. Women made more negative comments about professionalism than men, and only women mentioned erosion of the academic mission due to pursuit of relative value units even in academia. Men's concerns included loss of autonomy in their practice by hospital and practice administrators not meeting their needs, and insurance and government mandates eroding their ability to practice.
Women were more likely to mention suicidal ideation, leaves of absence, closing their practices, and mental health impacts, using terms like “drowning,” “demoralized,” and “emotional exhaustion.” Women mentioned child care and family responsibilities as additional work that added to their stress, while men associated family time with enjoyable activities and regretted sacrificing family time for work. Men mentioned the suicide of colleagues, but not suicidal ideation themselves. One finding from the report that was particularly illuminating: Fully 10 percent more women than men indicated that they would not choose their profession again.
“The difficulties inherent in successful neurologic practice may be intensified in women who, on average, spend more time with their patients than men physicians and may display a more compassionate attitude, potentially increasing the risk for emotional exhaustion and compassion fatigue,” the authors wrote.
“Compounding matters, patient expectations differ for women and men physicians. Female patients, compared to male patients, seek longer and more empathic encounters, especially if their physician is a woman. Women physicians have more women patients and more psychosocially complex patients compared to men physicians. However, physician schedules are not adjusted either for the sex of the physician or the patient's characteristics. Women in our study also practiced more often in lower earning subspecialties, which may contribute to lower feelings of accomplishment or recognition.”
“These findings demonstrate that women neurologists experience the workplace differently than men,” said study first author Kathrin LaFaver, MD, FAAN, Raymond Lee Lebby Endowed Professor of Parkinson's Disease Research and director of the Movement Disorder Clinic at the University of Louisville. She noted that one shortcoming of the primary survey is that gender discrimination, harassment, pay differences, and lack of leadership opportunities could all contribute to this different experience, but questions about those issues were not specifically asked.
“In addition to serving on the AAN Gender Disparity Task Force, I also serve as administrator of a large social media group for women neurologists, and I had heard colleagues bring this up after the initial survey results were published: The common thread? “‘Well, they didn't even ask about the things that actually burn me out,’” she said. “Many factors influencing different experiences for men and women in the workplace such as pay differences, gender discrimination, family and caregiving obligations were not directly captured in the survey questions, so this closer analysis of the qualitative comments was important to bring out those issues.”
Women also reported less institutional support, noted Allison Brashear, MD, FAAN, professor and chair of neurology at Wake Forest School of Medicine, who co-authored a commentary that accompanied the new analysis. “The lack of support staff for clerical tasks affected women more and was a significant driver of their burnout concerns, as was the absence of mentorship and sponsorship. We have lots of women entering neurology, but same old ways of supporting our faculty members' careers aren't necessarily going to make this new generation of neurologists successful. It is incumbent on chairs and institutional leaders to understand the diverse drivers of burnout and how these may differ by age and gender. This is how we can create actionable plans to make an impact.”
‘A PANOPLY’ OF OPTIONS
While a substantial body of research, including the previous publications from the AAN's survey, has confirmed that burnout represents a significant problem in medicine in general and neurology in particular, successful interventions have been lacking. The authors suggested a panoply of options for institutions and departments of neurology to consider, including:
- Fostering communication and support within peer groups
- More assistance with administrative and clerical duties that is equitably assigned, and giving physicians more control over their work schedules
- Increased physician autonomy and avoidance of top-down decision making
- Improved focus on work-life balance
- Attitudinal change in leadership to provide pay equity, mentorship, and equitable opportunities for academic advancement
- Schedule flexibility to reflect professional responsibilities at different career stages and the characteristics and expectations of the physicians' patients
- Ample, unbiased, and transparent administrative support
- Organizational initiatives that offer career-life counseling and time banking
“Our latest findings confirm that a lot of the issues driving burnout are systemic ones, and that leadership in our health care institutions and at the policy level has to buy into the importance of developing solutions that address not only burnout in general, but gender- and age-specific drivers of burnout,” Dr. Busis said.
“If you want an evidence-based mitigation/prevention strategy to increase the health of the neurology workforce, you will have some strategies that apply to all neurologists and some that should be customized to different genders and age groups if you are really going to be successful. General principles can guide you, but in your individual institution, the hot button issues and the steps you take may be different.”
Study co-author Jennifer Rose V. Molano, MD, FAAN, associate professor of neurology and of rehabilitation medicine at the University of Cincinnati College of Medicine, agreed. “Leaders have an opportunity to find ways to foster autonomy, meaning in work, reasonable workloads, and effective support staff at their organizations. That being said, each organization, even each clinic, has unique barriers towards these goals,” she said.
“Surveys may provide a snapshot of what may be happening, but in order to take action, it is essential for leaders to delve more deeply to understand these barriers. The qualitative comments provide an example of this point, clearly showing different drivers for burnout in men and women. Understanding these barriers will allow us to start the conversation towards solutions, which are essential for change.”