The physician suicide rate is among the highest of any profession and over double the general population rate. During training, suicide is the second most common cause of death overall and the leading cause of death among male trainees. Poor physician wellness and reports of high physician suicide rates are not new, studies have reported high rates since the 1970’s, however, the willingness to discuss and investigate physician suicidality has only recently intensified. Burnout, a concept that describes occupational wellness, has taken center stage as a main potentiator of poor wellness. Indeed, strong associations have been reported between frequent burnout symptoms and suicidal ideation. As a result, programs across the country have rushed to implement wellness interventions designed to lower the frequency of burnout symptoms. Unfortunately, to date, these interventions have shown limited success in reducing burnout symptoms. The reasons are multifactorial and include burnout definition variability, lack of a diagnostic threshold, and a variable-centered analytic approach that simplifies the individual experience. A person-centered approach that identifies patterns of burnout symptoms will better inform interventions to reduce burnout symptoms.
The current approach to burnout analytics within the medical community has several limitations. First, burnout lacks a concensus definition and clear measurement standard. For example, The National Academy of Medicine lists multiple validated measures to examine burnout and they are all conceptually different. Second, burnout is not a diagnosis, and there is no clinically validated threshold for any of the measures. The Maslach Burnout Inventory (MBI), by far the most commonly used measure to examine burnout symptoms, classifies burnout into high, moderate, and low thirds based on normative data cut-offs/thresholds. However, the MBI was developed as a research measure and not a diagnostic one. In fact, the best rebuttal against using the MBI as a diagnostic tool may be from the creators themselves when they state the following regarding the tercile cut-offs, “arbitrary ‘cut-off’ scores do not have any diagnostic validity. In other words, the upper third of a large population is not a definition of people experiencing a severe case of burnout” (emphasis theirs). As a result, prevalence estimates vary widely. Within the surgical community alone, burnout prevalence rates range from 28-69%. In our large national study that included 99% of all general surgery residents, burnout ranged from 6-56%, depending on the definition selected.
Third, burnout dichotomization masks important dimensionality. Burnout is commonly reported as either present or absent. This variable-centered approach simplifies the burnout experience and does not offer any information on how individuals experience burnout symptoms differently. For example, an individual may report frequent symptoms of emotional exhaustion on the MBI, another, frequent symptoms of depersonalization, and a third that reports frequent symptoms of both emotional exhaustion and depersonalization. Although each individual experiences a different pattern of burnout, in a variable-centered approach they are all classified as burned out. Conversely, a person-centered analytic approach would place these individuals into three distinct groups or classes with other individuals that report similar patterns of burnout symptoms.
Latent variable analysis is one example of a person-centered analytic approach. We have previously demonstrated that there are five distinct classes of residents: Burned Out (high on both emotional exhaustion and depersonalization), Overextended (high on emotional exhaustion), Detached (high on depersonalization), Partially Engaged (minimal on both emotional exhaustion and depersonalization), and Engaged (low on both emotional exhaustion and depersonalization). Furthermore, differential experiences exist based on gender. Females are overrepresented in the Burned Out and Overextended classes but report less frequent depersonalization symptoms compared to men in these classes. These findings may have intervention implications. For example, prior research suggests that workload is the driving issue for individuals in the Overextended class. Conversely, individuals in the Detached class are most concerned with values and social relationships. Therefore, interventions designed to reduce workload may be effective for individuals in the Overextended class but not the Detached class.
Burnout is a leading driver of poor wellness and suicidal ideation in medical professionals. The lack of a clear measurement standard and clinically validated cut-offs means imprecise dichotomization results in a heterogenous burnout group where there is a lack of specificity regarding who will benefit most from which interventions. A person-centered approach more accurately describes the individual burnout experience. As research in this area grows, programs need to focus their limited resources on class-targeted and gender-sensitive interventions to most effectively reduce burnout symptoms in medical professionals.