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Why Physician Burnout May Not Be Created Equally

Article In Brief

A new paper from the National Academy of Medicine found that women and men do not experience burnout in the same way and women tend to feel more stressors in the work environment.

Burnout may be different for women physicians than it is for their male counterparts, and addressing those differences is crucial for attracting and retaining women in medical practice, according to a National Academy of Medicine discussion paper published online on May 28.

While doctors of both sexes may feel stretched thin by electronic medical records, packed schedules, and shrinking support staff, women may experience added factors that contribute to workplace burnout.

Women physicians “may lack role models, face challenges of dual career couples, have to reconcile having only a finite number of years for childbearing, face lack of parity in salaries, receive a lower number of promotions to leadership positions, confront both unconscious and conscious biases, and experience higher rates of sexual harassment,” the author of the discussion paper wrote.

The paper isn't original research but rather brings together research from various sources on physician burnout. The paper noted that while “women now account for half of new medical school students and an increasingly larger number of practicing physicians, there is a paucity of information about gender-related differences in physician burnout.”

Neil A. Busis, MD, FAAN, the senior author who represents the American Academy of Neurology on the National Academy of Medicine Action Collaborative on Clinician Well-being and Resilience, said “physician burnout has been hiding in plain sight for years. It is now is getting the attention of medical organizations, physician groups and others concerned about the changing dynamics of the healthcare field and what some see as a loss of autonomy by physicians. The AAN, for one, has started initiatives around physician well-being and women in leadership and sponsored a series of surveys and reports around the topic of burnout.”

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“The emotional exhaustion could be in part because patients expect more from their female physicians than their male physicians. They expect them to spend time with them and be more empathetic.”—DR. NEIL A. BUSIS

Dr. Busis, professor of neurology at University of Pittsburgh, said a better understanding of physician burnout, including gender differences, is important for ensuring high quality of “patient care and care for caregivers.”

“Burned-out physicians either cut back their workload, leave the profession early or make more errors,” Dr. Busis said. The specialty of neurology is particularly concerned about losing practitioners or failing to attract medical students to the profession because of predicted neurologist shortages in the years ahead.

The National Academy of Medicine paper, which acknowledged that burnout is a concern for not only physicians but also for nurses and other health care workers, used a commonly accepted definition of burnout to frame the discussion: “Emotional exhaustion, depersonalization or cynicism, and feelings of diminished personal efficacy or accomplishment in the context of the work environment.”

While it is not clear whether women physicians have more burnout than their male colleagues, gender-based research suggests that “women physicians are more likely to suffer from emotional exhaustion, whereas men are more likely to describe depersonalization,” Dr. Busis said.

Dr. Busis said “the emotional exhaustion could be in part because patients expect more from their female physicians than their male physicians. They expect them to spend time with them and be more empathetic.”

Dr. Busis said he hoped the National Academy of Medicine's paper on gender differences will help raise awareness and identify interventions and programs that might be useful for individuals and organizations to adopt. Among the paper's recommendations for medical leadership: “Leaders can play an important part in leveling the playing field for women at every stage of their careers by addressing disparities in opportunities, pay, and support staff and by working to eliminate gender discrimination and harassment.”

Organizations can “positively address the needs of women clinicians through hiring decisions, career advancement, leadership development, negotiation skills training, and mentorship programs,” the paper said. Making sure women are well-represented on hospital committees and have adequate support staff is also key, as well as providing family leave and peer support programs.

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“Twenty years ago, most of the decisions about what happens in a practice were made by physicians for physicians. Some burnout could be dealt with by giving people back their autonomy.”—DR. JACQUELINE A. FRENCH

Burnout in Neurologists

Research has shown that neurologists in general are especially likely to experienced burnout compared to other medical specialists. A 2016 survey of U.S. neurologists who were members of the American Academy of Neurology found that 64.6 percent of women and 57.8 percent of men had at least one symptom of burnout. But when researchers dug deeper into the survey numbers, they found that age, not necessarily gender, may be the determining factor, with younger neurologists more likely to report burnout while older neurologists reported more job satisfaction and better quality of life.

The National Academy of Medicine cited survey research by Kathrin LaFaver, MD, FAAN, assistant professor of medicine at University of Louisville School of Medicine, that found that compared with men, “women physicians more often reported less job dissatisfaction, a lower likelihood that they would again choose medicine as their life's work, and a higher likelihood of thoughts about leaving the profession.” Burnout can be a factor in depression, substance abuse and suicide, the paper noted.

“As much as men and women go through the same training in medicine and start out equally in practice, their career paths often do diverge,” Dr. LaFaver said in an interview with Neurology Today. “Our data and that of others has shown that more women face greater challenges in career advancement, facing unconscious bias, being asked to do more uncompensated work, and have greater difficulties balancing work and home life, especially if they have children as well.”

“As a patient, you want the best care possible and I think having physicians and other health care providers who are constantly overworked and underappreciated is a problem,” she said.

In a report in April in the Journal of Women's Health, Dr. LaFaver reported the results of survey responses from 181 women neurologists that found that “working in a high stress environment, lack of control over the work schedule, a high number of hours at work, and self-reported gender discrimination were independent predictive factors for burnout.” Having more children was associated with decreased likelihood of becoming a physician again, especially if the respondent had three or more children. The survey respondents were members of the Women Neurologists Group on Facebook, which now has more than 2,600 members.

Dr. LaFaver, who was part of the AAN”s Gender Disparity Task Force, said some health care centers have initiated on-site classes such as yoga, meditation, and mindfulness to counter staff stress, but she said that many women neurologists report that they don't have time to participate. Stigma around going to “relaxation” classes or even acknowledging feelings of burnout may also be an issue.

“People try to find easy solutions and I think it's a misunderstanding (of the problem) to say we just need to do meditation and we'll be fine,” she said. Issues that may matter especially for women physicians, such as availability of childcare, parental leave, flex time and salary disparities are more difficult to tackle, she said.

“We need to look toward changing the conversation to how we can create a satisfying workplace for physicians rather than talking about how we can make individuals more resilient.”

Physician Experiences

Heidi B. Schwarz, MD, FAAN, professor of clinical neurology at University of Rochester Medical Center, who has been in medical practice since the 1980s, said she can relate to the findings that younger women physicians are more likely to have feelings of burnout or job dissatisfaction than older physicians.

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“I think we (women) approach the relationships with our patients differently. Its rare for an encounter to boil down to ‘Ok, well see you in six months.’”—DR. HEIDI B. SCHWARZ

When medical school and residency is over, “People think, ‘Now it should be clear sailing,’ but the reality is no one is going to tell you that you can only work 60 hours a week,” she said. Dr. Schwarz said there is no getting around the fact that the time when most women enter medical practice aligns with childbearing years. She recalls days when she “got home at 8 o'clock, my kids were starved, and then I'd get paged. I could see the look on their faces, ‘Come on, you're finally home. I want you all to myself.’”

Dr. Schwarz, co-chair of the AAN Wellness Joint Coordinating Council, said she took two brief hiatuses during her career, once during a change in department leadership and once when she was switching practices and took time off to care for her aging father.

She said addressing burnout among women physicians, including the impact of unconscious bias on career advancement, is critical because having diverse providers is important to patient care. She noted that data gathered on burnout among women physicians typically does not include those who left the profession because of career dissatisfaction or burnout, so that perspective may be missing.

“I think we (women) approach the relationships with our patients differently,” Dr. Schwarz said. “It's rare for an encounter to boil down to ‘Ok, we'll see you in six months.’”

She said every time a woman leaves patient care or cuts back dramatically, “We lose something that never gets replaced from the patient perspective.”

Blaming the Victim

Jacqueline A. French, MD, FAAN, professor of neurology at NYU Langone School of Medicine, said she dislikes the word burnout because it seems to be “blaming the victim” and suggests that somehow doctors are coming up short. She prefers to talk instead about the consequences of the “increased work requirement,” saying that “doctors are increasingly asked to do more work over more hours.”

She said it is not surprising that significant numbers of doctors report workplace dissatisfaction given that they have less autonomy over their practices, with insurance companies and administrators increasingly calling the shots. She noted that they sometimes spend more hours on electronic medical records than they do directly caring for patients and have to worry about whether they score high on patient satisfaction surveys, which may or may not reflect good patient care.

“Twenty years ago, most of the decisions about what happens in a practice were made by physicians for physicians,” she said. “Some burnout could be dealt with by giving people back their autonomy.”

Dr. French said there is a lingering sentiment among both men and women that the “male doctor is God.” She cites the fact that fewer women physicians hold professorships or department chairs, while at the same time “women tend to step up and do whatever needs to get done” on administrative-like issues because old gender roles haven't changed that much.

She worries that physicians, particularly women, may assume “helplessness” in the increasingly demanding health care environment, and perhaps stop advocating for their needs.

Dr. French said that while health care organizations need to reexamine policies on workloads, scheduling and other issues that can lead to overload for physicians, women physicians need to build support networks through mentoring and seeking out women as collaborators in research.

She said that when women physicians make the decision to end their careers early or move into more 9-to-5 roles that don't involve patient care, “that is a cost” to the overall quality of patient care.

Jennifer Molano, MD, FAAN, associate professor of neurology at University of Cincinnati, said she has experienced feelings of burnout similar to what's described in the National Academy of Medicine's paper, but has learned some strategies that help make burnout transient. She is a big believer in “self -care” (things like exercise and meditation and building a support system at work and home life) and adopting a mindset that involves reframing issues so that she can better identify ways to deal with a circumstance she finds difficult.

“The health care system is very challenging and that is a reality,” said Dr. Molano, who coauthored some of the studies on burnout among neurologists and and serves as co-chair of the AAN's Wellness Joint Coordinating Council. But rather than being pessimistic and convinced nothing will change, she prefers a mindset where “if you believe things can get better with persistence and effort, then that opens up the opportunity for looking for possible solutions,” both on an individual and organizational level.

Dr. Molano, who did fellowship training in behavioral neurology and sleep medicine, said she also embraces the concept of joy, even now making a habit of asking her patients what brings them joy.

“Doctors got into medicine to reduce human suffering,” she said. “Let's talk more about what brings us joy in what we do. What do we love about the patients we care for? How can we focus more on that as we also try to work on organizational and systemic changes?”

Link Up for More Information:

• Templeton K, Bernstein CA, Sukhera J, et al Gender-based differences in burnout: Issues faced by women physicians. NAM Perspectives. Discussion paper. http://bit.ly/NAM-burnout. Accessed June 1, 2019.
    • Moore LR, Ziegler C, Hessler A, et al. Burnout and career satisfaction in women neurologists in the United States https://www.liebertpub.com/doi/abs/10.1089/jwh.2017.6888. J Womens Health (Larchmt) 2019; 28(4): 515–525.