Clarifying Constructs in the Muddled Field of Burnout Research

In its early stages, burnout research was focused on a holistic picture of job and personal factors.⁴  As methodologies and models advanced, research became more quantitative in nature, and the Maslach Burnout Inventory (MBI) became the gold standard for studying burnout.¹  The MBI was designed as a research tool that used 3 dimensions, namely, emotional exhaustion, depersonalization, and personal accomplishment, as individual indicators of burnout.²  In more recent studies, researchers tend to report a diagnostic burnout score (or similar based on numerous versions of the questionnaire) based on an arbitrary total score indicating being burned out or not burned out.² 

In addition to the misuse of the main research tool, studies often correlate burnout with transient stressors. For example, the Pediatric Resident Burnout-Resilience Study Consortium correlates burnout with sleepiness, being on a high-acuity rotation, not having a recent weekend off, and not having a recent vacation.⁵  Programs and hospitals are aware their residents are tired. Studies that reveal high levels of exhaustion add an important scientific data set to anecdotal knowledge, but authors of such studies do not clearly define the problem as one of burnout rather than one of sleepiness. Organizations are, therefore, left with a bleary picture of who may actually be burned out as well as a list of potential burnout causes that may or may not be relevant to their practitioners.

Additionally, other confounders may further confuse the picture. Correlational studies may suffer from sampling bias, low response rates, and subjective assessments of actual causes and predictors of burnout.⁴  The single-point, subjective nature of many of these studies may not be validly measuring the actual construct of burnout.

Distinguishing between levels of distress may seem inconsequential because any physician distress indicates the need for intervention, but failing to distinguish mild distress from burnout or depression could be the main cause of a lack of progress in the field. The overly broad current approach to studying burnout is likely preventing interventions targeting only one type of distress from being judged as effective.

Long-time burnout researchers note that “almost every personal problem one can think of was defined as ‘burnout’ at some point,” namely, overload, stress, dissatisfaction, tedium, midlife crises, conflict, and depression.⁴  As a construct, burnout has always encompassed a longitudinal quality as a syndrome that develops over time and includes exhaustion but also requires an element of depersonalization or cynicism as a way of coping with chronic work stress.¹ 

Scholars weaken the term by overestimating the prevalence of burnout by measuring exhaustion or depersonalization instead of exhaustion and depersonalization. The personal accomplishment dimension is more or less ignored in medical research.²  The construct itself becomes overused, and its meaning becomes unclear, leading practitioners and leaders to ignore it as fad science or downplay it as general job stress.

Symptoms of fatigue, stress, burnout, and depression can present in many of the same ways.⁴  Thus, practitioners who are experiencing more serious mental health conditions like depression or suicidal ideation can characterize their symptoms as relatively benign burnout, avoiding the stigma and reporting barriers that come with treatment but also living with a potentially debilitating but treatable illness. It may not matter that we are labeling fatigue as burnout, but the consequences of downplaying a more serious mental health illness as burnout can have more dire consequences.

Literature has established that physicians have higher rates of anxiety, addiction, burnout, and depression than those of many professions.^3,6  Coupled with a high tolerance of toxic coping mechanisms, self-medicating, and limited help-seeking,³  it should not be surprising that physician suicide rates are significantly higher than those in the general public.^3,6 

In light of the discussion above, longitudinal, qualitative, and other research that creates context-specific, nuanced, actionable causes is desperately needed. Larger categories of drivers (service and academic balance [role conflict], recognition, colleagues) likely transfer between organizations, but organization-specific characteristics should be studied and addressed.^2,6,7  These proposed transferrable categories as a model of burnout drivers are shown in Fig 1.² 

Studying the problem differently results in a drastically different list of interventions. In longitudinal burnout studies, authors confirm that role conflict, lack of support, and system-level stressors are more salient correlates or antecedents of burnout.^2,4,6,7  Residents who self-reported burnout also reported less personal and professional support.⁵  In short, physicians feel pulled in multiple directions without the support they need to fulfill growing demands. By studying the interplay of these demands within a unit, department, or organization, a more nuanced picture of burnout drivers and potential targets for mitigation emerges.

Because physicians who suffer from tiredness, stress, and more serious mental health conditions tend to be lumped together into the burnout pot, leaders end up with a muddled picture of the causes and effective interventions for those who need them. At the most basic level, using the MBI as prescribed naturally creates a pseudotiered system for separating exhaustion from more serious burnout or other treatable mental health issues. The current over-inclusiveness of the burned out or not burned out system has not led to better interventions or lower overall prevalence. I would argue the lack of differentiation is a large part of this lack of progress because different interventions are needed for different levels or types of distress.

Perhaps this array of stress levels is one of the reasons the construct of burnout is still so poorly understood, treated, and prevented. Additional time off or lower-acuity duties may be sufficient treatment of a tired physician. Those who are teetering on the edge of depersonalization in their work may benefit from mindfulness or resilience training with follow-up. But those dealing with substance abuse or mental illness should be encouraged to seek treatment without fear of stigma or repercussion.⁷  Physicians should also be trained to recognize symptoms of distress in their peers. Literature reveals distressed individuals are likely to self-stigmatize and withdraw from others.³ 

As the Pediatric Resident Burnout-Resilience Study and individual organizations move toward finding effective interventions for burnout, these contextualized factors should be considered instead of one-size-fits-all, individual-level interventions like universal mindfulness and resilience training. Although some of these interventions have shown limited success,⁷  research highlights the benefits of a supportive workplace culture, minimizing role conflict, and professional and social support.²  Within the existing literature, physicians ask for support, recognition of work, and protected time for meaningful duties.²  These interpersonal- and system-level domains might be more difficult for organizations to tackle than offering gym memberships, training workshops, and access to counseling, but they are likely to be a more broadly effective use of resources.

MBI

Maslach Burnout Inventory