Physician Health and Wellness

Physician health and wellness is a complex topic relevant to all pediatricians. Pediatricians experience burnout at comparable rates to colleagues across medical specialties, compounded by a range of emotional factors that may present when caring for medically vulnerable children and their families. The purpose of this clinical report is to update the reader on the accruing research relevant to pediatricians since publication of the initial clinical report from the American Academy of Pediatrics (AAP) in 2014¹  and to explore new approaches and resources available to support pediatrician well-being and reduce burnout risk at all stages of training and practice.

Topics covered include burnout prevalence and diagnosis; overview of national progress in physician wellness; update on physician wellness initiatives at the AAP; an update on pediatric-specific burnout and well-being; recognized drivers of burnout (organizational and individual); a review of the intersection of race, ethnicity, gender, and burnout; protective factors; and components of wellness (organizational and individual). Table 1 contains a list of definitions relevant to these topics.

World events, including the global COVID-19 pandemic, have precipitated a frameshift in the dialogue about physician wellness and amplified a collective sense of urgency to protect and support the health and well-being of all health care professionals. A wealth of literature relevant to pediatricians has accrued on the topic since publication of the initial AAP clinical report on physician wellness,¹  making it important for pediatricians to be up-to-date on research and resources that can help them build and sustain a healthy career.

Paraphrased by Maslach, a pioneer in the field, burnout starts when “energy turns into exhaustion, involvement turns into cynicism, and efficacy turns into ineffectiveness.”²  Its prevalence across medical specialties is striking and well documented.³  The etiology is complex and suggests interplay between multilevel factors, some intrinsic—for example, perfectionism, altruism, or excess empathy—and others extrinsic—largely outside the individual’s control, such as organizational culture, work-life balance,⁴  and catastrophic events such as the global pandemic.⁵ 

For this reason, the clean demarcation of organizational versus human factors driving burnout is overly simplistic and not supported by current literature.^6–10  In fact, accumulating research identifies both organizational and individual factors, often in combination, as key contributors to burnout.^11–16  Especially important is rejection of the perception that burnout is solely equated with weakness or insufficient resilience. This outdated mindset risks shaming and blaming and has hindered solution-focused problem solving,¹¹  although it is known that high levels of chronic stress may predispose any professional to burnout when pushed to extremes and that individual susceptibility to stress varies.¹  Further blurring the clean demarcation between organizational and individual drivers is the fact that medical organizations are not faceless entities, but complex businesses run by individuals, frequently physicians, who may be experiencing burnout themselves, compounded by pressure from special interest groups and regulatory bodies with substantial economic and political influence.

It follows that solutions are elusive and similarly complex. And, although studies have recently addressed solution-based occupational factors,^17–19  promising evidence supported by randomized controlled trials also exists for interventions focused on strengthening individual well-being and resilience.^20–23 

Ultimately, burnout is a complicated, human-driven problem that has come to be defined as an occupational syndrome.¹²  It requires an intelligent, well-coordinated, and multisystem approach, ideally led by physicians with high emotional intelligence and commitment to effective mentorship, with insight into the complex challenges faced by individuals, organizations, and multidisciplinary teams.²⁴ 

Burnout may be challenging to recognize in oneself or a colleague. As such, it may remain unrecognized until serious consequences result for the physician, patient, or institution.⁶  Although burnout may be exacerbated by a preexisting mental health condition,²⁶  it is critically important to distinguish burnout from mental illness for 2 reasons: first, to uncouple from the stigma that has long hindered timely and effective solutions; second, because discrete mental health conditions such as negativity, pessimism, depression, anxiety, and other disorders require a more targeted approach, whereas burnout has been defined as a situational problem with some elements out of the individual’s control, requiring multisystem solutions.¹¹ 

Another compounder inherent to the professional environment,^6,27,28  particularly in pediatrics, pertains to trauma-informed care.²⁹  Although many pediatricians have life-affirming practices where the majority of children thrive in loving intact homes, caring for children who are chronically ill, disabled, maltreated, neglected, or otherwise medically vulnerable can take a toll, especially if processed by the physician in isolation. As a result, pediatricians may experience overlapping symptoms of compassion fatigue, secondary traumatic stress, vicarious traumatization, moral distress, countertransference, and ultimately burnout (Table 1).³⁰  Self-awareness is paramount to physician well-being. To this end, research, education, and open discussion about the early warning signs of physician and trainee distress is needed. Physicians and organizations can also consider routine self-monitoring for symptoms using validated burnout assessment tools, which can be chosen based on the physicians’ preferred length, metrics, validation, and cost.^31,32  Within organizations, confidentiality must be ensured, and well-organized programs must be available to provide effective pathways to help physicians struggling with burnout³³  without fear of negative professional consequences.³⁴ 

Substantial efforts have been focused on reduction of burnout prevalence over the past decade.

To date, the national medical community has collectively:

• (A) Attempted to standardize a definition of physician wellness. This goal also remains elusive. Given the multifactorial nature of health, any approach to physician well-being necessarily requires a nuanced and multipronged approach.³⁵  A systematic review demonstrated that studies of physician wellness typically measure at least 1 aspect of physical, mental, social, spiritual, and integrated well-being.³⁵  A central theme of this clinical report is the recommendation and hope that organizational leaders and individual physicians will use a comprehensive approach to well-being and address the full range of factors affecting health, including mental, physical, emotional, spiritual, financial, and societal factors related to physician well-being.

• (B) Defined and measured burnout. The Maslach Burnout Inventory uses 3 scales (emotional exhaustion, depersonalization, and sense of personal accomplishment) to measure characteristics of burnout.^2,36,37  More recent burnout tools have also attempted to measure positive aspects of well-being and to identify those who are thriving—for example, the Stanford Professional Fulfillment Index and the 9-Item Well Being Index,³²  as well as emotional thriving and recovery scales that are components of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey.^22,38 

In addition, researchers have focused on reducing response burden in the measurement of burnout. For example, as part of the widely used Safety, Communication, Operational Reliability, and Engagement (SCORE) survey,^4,21,38–41  burnout is evaluated using a 5-item emotional exhaustion scale shown to have excellent psychometric properties,^21,22,39,42  external validity,^4,38,41  and responsiveness to interventions.^21,22,42 

• (C) Collected substantial research on burnout prevalence and trends across medical specialties, including pediatrics,^3,11  (although it is important to recognize limitations based on survey response rates and variability of training among respondents) and established that burnout is higher in physicians than in the general population and peaks during training⁴³  as well as mid-career.⁴⁴ 

• (D) Documented the serious sequalae of burnout. These sequelae include increased medical errors, litigation, substance abuse, motor vehicle accidents, increased cardiovascular mortality, decreased physician well-being including mental health conditions, difficult interpersonal relationships at home and work, and decreased life expectancy. Burnout often leads to reduction in work hours or physician separation from an organization. The effects of burnout extend beyond the physician to the health care team and to patients. These extended effects include increased staff turnover; decreased productivity, morale, and team cohesiveness; and increased health care costs. Perhaps most concerning, effects also include decreased patient satisfaction, lower adherence to physician recommendations, and worse patient outcomes.^45–50 

• (E) Established that the drivers of physician burnout are multifactorial, making both organizational and individual factors important to address.^{6,11,12,27,51} 

• (F) Broadly agreed that the prevalence of physician burnout is unacceptably, unnecessarily, and dangerously high across medical specialties.

The development of this clinical report has inevitably been shaped by the dramatic social, cultural, public health, and economic factors currently affecting nearly every aspect of our communities. The COVID-19 pandemic has layered new and significant stressors onto medical practice, including physical, mental, and logistical challenges. For example, some physicians are experiencing new levels of fear, guilt, concern for occupational hazard, and economic uncertainty,⁵²  even as they recognize their right to protect their own health, protect their own families, and preserve their ability to care for future patients.^53,54  The pandemic has also highlighted the multiple roles women disproportionately fulfill in many households where they often assume primary responsibility for child care and, during the pandemic, homeschooling children.

Some physicians are feeling a sense of betrayal because of the politicization of a public health emergency. Others feel unprepared accepting responsibility for life-saving resource allocation, exacerbating the potential for and impact of moral injury,^55–57  defined as “when people feel implicated in harm, whether inadvertently causing harm, witnessing it, or feeling helpless to prevent it” (Table 1).⁵⁸  Such emotions and experiences may be unfamiliar for many dedicated, service-driven physicians and drain the mental, physical, emotional, and spiritual resources necessary to accommodate to rapidly changing work demands and professional duties.

Physician leaders can buffer burnout for their teams by moving quickly to apply the lessons from the early wave of the pandemic: streamline systems, delegate nonessential tasks, and support the fundamental needs of their workers.⁵⁹  Media coverage has highlighted the juxtaposition of the vital services rendered and the assumption of personal risk by doctors and allied health professionals and has resulted in some measure of recognition and appreciation for our work.

Yet, evidence is emerging that the pandemic continues to take a deep toll on the well-being of health care workers. For example, Haidari et al found high levels of burnout among neonatal and maternity care health professionals. Two thirds of respondents reported symptoms of burnout, and 73% felt burnout among their coworkers had significantly increased. Only one third of respondents felt that workplace strategies to address their well-being were sufficient. Spillover effects into unprofessional behavior at work and patient safety lapses were apparent.⁵ 

Physicians must lead change to protect the vital human resource of all highly trained health care workers. To help support this mission internationally, the AAP is 1 of several global organizations lending leadership and support to the Women in Global Health Organization’s COVID 50/50 initiative, which advocates for women in leadership positions in health care.⁶⁰ 

It is hoped that this crisis will serve as a catalyst to break down silos between administration and frontline workers to eliminate inefficiencies, prioritize meaningful patient interaction, and help to restore trust and respect in the profession of medicine.

The primary goals of the original AAP clinical report¹  were to identify factors affecting career satisfaction and longevity among pediatricians, to shift the focus from burnout treatment to preventive physician health and wellness, and to serve as a catalyst for more open discussion of physician health and wellness within the AAP. Substantial progress within the AAP continues in the form of national and local educational programs and ongoing leadership training (Tables 2–4).

A focus on physician well-being remains a priority in the field of pediatrics, in which burnout is prevalent and sustained in pediatric trainees and practitioners. Survey data from a large 3-year national sample (2016–2018; n = 6050, with 49 programs participating by year 3) in the Pediatric Resident Burnout-Resilience Study Consortium show that burnout prevalence in pediatric residents was greater than 50% in all years of training. Compared with residents who did not report burnout, residents experiencing burnout had significantly worse mental health, greater perceived stress, and more sleepiness. They also reported statistically significant (P < .001 for all) lower mindfulness and self-compassion scores and lower levels of empathy and resilience.⁶¹ 

Not surprisingly, data from the same survey in spring 2019 (n = 1956) showed that 45% reported weekly or more frequent burnout symptoms, 33% reported mistreatment, 19% reported bullying, 18% reported discrimination, 5% reported sexual harassment, and 1% reported physical violence. Primary sources of burnout stemmed from clinical staff (60%), patient families (54%), and faculty (43%). Women reported mistreatment more often than men (36% versus 25%; P < .01) Residents experiencing mistreatment were more likely to report symptoms of burnout, higher stress levels, and lower quality of life and were less positive about their program’s educational and mentorship attributes (P < .001 for all).⁶² 

Burnout has also been correlated with decreased Pediatrics Milestones⁶³  performance for pediatric postgraduate year 1 residents in a survey of 1300 categorical pediatric residents whose programs were participating in the Pediatric Residency Burnout-Resilience Study Consortium.⁶⁴  Depersonalization and low sense of personal accomplishment were also associated with lower patient care score ratings in postgraduate year 1 residents.⁶⁵ 

The burnout rates recorded are consistent with prevalence recorded in studies on pediatric residents by Baer et al,⁴⁵  Starmer et al,⁶⁶  Pantaleoni et al,⁶⁷  and McClafferty et al.⁶⁸  Prevalence of burnout in pediatrics mirrors rates in other medical specialties (30% to 50%),^69,70  with higher rates documented in specialties such as pediatric hematology-oncology, neonatal intensive care, and pediatric surgery.^71–74 

Although pediatricians, overall, report less burnout than their adult primary care colleagues, the prevalence of burnout increased for all pediatric disciplines from 2011 to 2014. During that time, general pediatricians experienced a more than 10% increase in burnout, from 35.3% to 46.3%. Pediatric medical subspecialists and pediatric surgical specialists experienced slightly higher baseline rates of burnout in 2011 and similarly increased to just under 50%. All pediatricians surveyed reported a decrease in satisfaction with work-life balance. Relative to the general United States population, physicians have increasing disparity in burnout and satisfaction with work-life integration, even after adjusting for gender, age, hours worked, and relationship status.¹¹ 

Burnout remained relatively unchanged among general pediatricians between 2014 and 2017 and significantly decreased among pediatric medical subspecialists and pediatric surgical specialists during the same time period.³  During this same timeframe, however, satisfaction with work-life integration remained unchanged, with satisfaction among 46% of general pediatricians and 40% of pediatric medical subspecialists and pediatric surgical specialists.³ 

The US Department of Health and Human Services has predicted a shortage of up to 90 000 physicians by the year 2025. One important driver of this shortage will be the loss of practicing clinicians because of burnout. Efforts to replace lost physicians come at a steep cost to employers. One estimate of the lost revenue per full-time-equivalent physician is $990 000, and the cost of recruiting and replacing a physician can range from $500 000 to $1 million.⁷⁵  Physicians experiencing burnout are likely to reduce their work effort to part-time as a coping strategy. For example, in a longitudinal study of 2500 physicians at Mayo Clinic, each 1-point increase in burnout (on a 7 point scale) or 1 point decrease in professional satisfaction (on a 5 point scale) was associated with a 30% to 50% increase in likelihood that physicians would reduce their professional work effort over the following 24 months.⁷⁵ 

Health care professional burnout has been associated with several dimensions of reduced quality of patient care, including poor adherence to practice guidelines, impaired communication, increased medical errors, adverse patient outcomes, and poor safety metrics.^50,76–79  Cross-sectional studies of pediatricians consistently demonstrate moderate to strong associations between burnout and impaired quality of care.^45,80–86  Among physicians caring for adults, longitudinal studies evaluating this relationship suggest that it is bidirectional in that burned out physicians may provide lower-quality care,^87,88  and conversely, exposure to adverse events or environments where lower quality of care is present can result in emotional and psychological distress, which in turn drives burnout.^86,89  This suggests the value of highlighting a multipronged approach that simultaneously targets provider well-being and patient safety.⁴⁶ 

During times of increased financial pressure or in extraordinary times such as the COVID-19 pandemic, organizations may seek efficiency and reduction of expenses by asking more of physicians and allied health professionals. Pressure to complete more work more quickly and with fewer resources may lead to less engaged, more burned-out physicians.⁵⁰  Shanafelt et al identified imbalance in 7 broad categories that influence burnout within organizations: efficiency and resources, organizational culture and values, workload and job demands, meaning in work, social support and community at work, control and flexibility, and work-life integration.¹¹ 

A recent discussion paper¹²  synthesized input from the National Academy of Medicine consensus study, “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.”⁴⁹  Lack of transparency and commitment to the issue of burnout, lack of clarity regarding burnout prevalence within an organization, a vacuum of leadership accountability, inefficient workflows, lack of representation at the executive level, value misalignment, and insufficient physician support were also identified as important drivers of burnout. Others include the “glass ceiling” limiting female physician advancement, a bully culture, pay discrepancies, and educational debt stress.⁴⁸  Second victim phenomenon after an adverse event is another driver of burnout in a “no tolerance” culture in which systems failures are not recognized and blame is placed on the physician.^90–92  In a survey of 10 627 health care workers (1468 physicians; 81% response rate), 36.3% indicated they knew at least 1 work colleague who had been traumatized by an unanticipated clinical event. Support varied widely across work settings and was strongly correlated with emotional exhaustion, burnout climate, and work-life balance.⁹³ 

The caliber of leadership experienced by physicians also has a significant impact on burnout.^7,51  The strength of this correlation calls for more in-depth study of cause-and-effect factors in the leadership relationships that affect burnout and well-being, ideally leading to development of leadership benchmarks, skill development, and best practices in the service of sustainable change. Examples of national programs modeling this approach are provided in the Resources section.

Advances in electronic health records (EHRs) have created new abilities for pediatricians to document and retrieve unprecedented amounts of clinical information, coordinate care among providers, and communicate directly with families in new ways.⁹⁴  However, these advances have also come with the cost of increased clerical tasks and billing-related documentation demanded of providers, resulting in an imbalance between job demands and resources.^95,96  It is now estimated that physicians in outpatient settings spend half to two thirds of their professional time on activities other than direct patient care.^97–99  This evolution of time allocation has been associated with physician burnout, and those with higher EHR task load, lower EHR usability, and more longstanding EHR use have higher likelihood of burnout symptoms, greater intent to leave practice, and lower job satisfaction.^100–103  In addition, frustration with technology is strongly associated with emotional exhaustion independent of measures of job demands, suggesting that improved design, training, or deployment of technology may reduce burnout.¹⁰⁴ 

In general, institutional commitment is important to effectively mitigate negative experiences related to EHR use. Other strategies to mitigate this EHR contribution to burnout include transitioning to a model of team-based documentation or the use of scribes (nonlicensed team members specifically trained to document encounters with patients). Although not yet widely studied in pediatrics, the use of scribes in family practice clinics and emergency departments has been found to consistently improve practitioner satisfaction without adversely affecting patient satisfaction.^105–107 

Increased regulatory and competency requirements create significant restraints, despite physicians having unprecedented modern diagnostic and treatment options.¹⁰⁸  Research shows that clerical burdens amplify work inefficiencies, divert physician time away from patient care, and can result in loss of meaning in work.²⁷  Interpretation and enforcement of well-intentioned regulatory requirements without additional supports and resources contribute to excessive physician workloads. Maintenance of certification, licensure and credentialing requirements, and compliance obligations vary from state to state and amplify inefficiencies and time pressures in the current health care environment. Physician payment models are complex, change frequently, and vary widely in their requirements for documentation, communication processes, and incentives, all of which further contribute to administrative burden.⁴⁹ 

In particular, payment models related to incentives, productivity expectations, or poorly aligned quality metrics are tied to higher burnout rates compared with salaried physicians.¹⁰⁹ 

Documentation for malpractice prophylaxis and billing and coding further contribute to a sense of loss of autonomy.¹¹⁰  Physician-employees may experience additional loss of autonomy when shifting from private practices to large health care systems because of scheduling and workflow adjustments, restrictions on vacation and conference attendance, and time constrictions placed on other professional activities.¹¹¹ 

Similar to other professional industries, physician societies and lobbyists are active in advocating for healthier and safer work environments, and ongoing, organized change is needed.¹¹² 

Ironically, many of the character traits valued in pediatricians, such as compassion, altruism, and perfectionism, also can predispose to burnout when clinicians are pushed to mental or physical extremes.¹¹³  Success in medical education and training necessitates a high degree of competitiveness, compulsiveness, guilt, self-denial, delayed gratification, and denial of personal vulnerability. Long-term, these same qualities, rooted in a culture that historically stigmatizes weakness and self-care, can lead to burnout.^114–116  Fatigue is also a significant contributor to burnout, particularly for emergency department and other hospital-based and on-call physicians who work frequent nights and weekends. In the same vein, such shift workers may struggle to find time for meetings and conferences that do not align with their clinical schedule, which may have negative impact on long-term career development and job satisfaction, compounding burnout.¹¹⁷ 

Demographic characteristics that have been associated with increased risk for burnout include age younger than 55 years (double the risk), private practice (20%), midcareer stage (25%), female (20% to 60%), having a child younger than 21 years (54%), and having a nonphysician spouse or partner in health care (23%).²⁷ 

Conversely, physicians who are able to identify and spend a minimum of 20% of their professional time focused on work that is personally most meaningful are more likely to be engaged physicians and at a significantly lower risk for burnout.¹⁶  Self-awareness and a healthy ability to set firm boundaries and limits, including delegating, prioritizing personal and work demands, and being intentional can optimize work-life integration.⁶  Addressing chronic fatigue and sleep hygiene are foundational to health and well-being.

Because women now make up an equal number of medical school trainees and a majority of pediatricians, gender has particular relevance in pediatric burnout and deserves comprehensive discussion beyond the scope of this report. Surveys report a 20% to 60% higher prevalence of burnout in women physicians compared with their male counterparts.^118–120 

It is unclear whether gender is an independent variable associated with the risk of burnout, as the gender disparity in burnout is not apparent after adjustment for personal and professional factors,¹²¹  but these associations have not been widely studied.¹²²  There is a need to further analyze physician burnout by gender, including potential differences in prevalence, manifestation, driving factors, and mitigation strategies.²⁷ 

Driving factors that could disproportionally affect women physicians include gender discrimination and bias, particularly for mothers^{120,122–124} ; sexual harassment^125–132 ; disparities in professional development and promotion, including leadership positions, first authored publications, and earnings for comparable work^{125–127,133–137} ; and work-life integration with increased hours for domestic responsibilities, including caring for children or elderly parents and greater likelihood of having a partner or spouse employed full-time.^{120,122–124,136–143}  Despite the predominance of women in general pediatrics, this field features 1 of the largest disparities between men and women physicians, with women pediatricians reporting an average of 10 points worse work-life integration (on a 100-point scale), with this disparity particularly pronounced among mid-career physicians.¹⁴⁴ 

Women of color, as well as women of underrepresented ethnic or other minoritized groups (including the LGBTQ community), may be at higher risk of burnout at all stages of their careers as discrimination in the workplace can affect their sense of well-being.¹²⁴  Women physicians are more likely to express burnout in the domain of emotional exhaustion as compared with depersonalization, which is more likely among male colleagues.^118,145  Women also report lower satisfaction regarding professional fulfillment, perceived appreciation, workload, and schedule control and autonomy.^146,147  Women physicians spend an average of 2 minutes more with each patient visit¹⁴⁸  and are more likely to explore socioemotional and psychosocial issues,¹⁴⁸  to use EHRs more extensively,¹⁴⁹  and to face different patient expectations compared with men.¹⁵⁰ 

These factors may affect the burnout gap between genders, and more work is urgently needed to better understand the challenges encountered by women in medicine and how best to mitigate them. To address potential differences in burnout between women and men physicians, it is critical that demographics such as gender be included in physician wellness assessments and evaluations.

Sexism, racism, discrimination, microaggressions, and inequities may all influence the individual’s experience of burnout and often overlap. As compared with non-Hispanic White physicians, those in underrepresented and minoritized racial and ethnic groups have reported discrimination and repeated microaggressions by both colleagues and patients, feelings of exclusion and social isolation, and delegation to nonclinical “diversity activities” based on their ethnic backgrounds.¹⁵² 

Both gender and race predict salary range in a large national representative of United States physicians. The US Census American Community Survey reviewed data from 2000 to 2013, including 12 843 White male physicians, 518 Black male physicians, 3880 White female physicians, and 342 Black female physicians across all years. White male physicians had a higher median annual income than Black male physicians, whereas race was not consistently associated with median income among female physicians. For example, between 2010 and 2013, White male physicians had an adjusted median annual income of $253 042 (95% confidence interval, $248 670 to $257 413) compared with $188 230 for Black male physicians ($170 844 to $205 616; difference, $64 812; P < .001). White female physicians had an adjusted median annual income of $163 234 ($159 912 to 166 557) compared with $152 784 ($137 927 to $167 641) for Black female physicians (difference $10 450; P = .17). Although racial disparities are less pronounced among female physicians, this seems to be driven in part by the fact that female physicians earn significantly less than either White or Black male physicians.¹⁵³  Of note, a 2016 AAP survey of its members about their life and career experience as pediatricians showed that women pediatricians in early to mid-career earn less than male pediatricians, after adjustment for labor force, physician-specific job, and work-family characteristics.¹⁵⁴  More work is needed to better assess, define, and address the unique needs of pediatricians in these demographics.

The question: “Is it worth the professional risk to seek help?” should never be part of the conversation when a physician is in distress, yet it would be naïve to think otherwise. Slow culture change is driven by legitimate fear of serious consequences.

A survey of all 50 US states and the District of Columbia medical board applications comparing questions on mental health to determine which states are most physician friendly reveals the intrusive, outdated, and highly punitive approach to physician’s mental health still used in a majority of states.¹⁵⁵  Concerning findings include inappropriate inquiries about unrelated health matters, privacy violations, disclosure of medical details on social media, denial of privileges, and constant monitoring as examples of sequelae, raising concern for job security, ostracization for mental health conditions or substance abuse disorder, loss of medical license, and misplaced shame.¹⁵⁵ 

Physicians may also need to consider the potential negative impact of mental health treatment on cost and availability of future insurance policies, including professional liability, disability, life, and health.¹⁵⁵  Growing recognition of the role of shame in physician well-being, exacerbated by bullying, medical errors, and perfectionism, among other factors, reinforces the urgent need for culture change in medicine.¹⁵⁶ 

Physicians, like any member of our society, should be afforded respect, privacy, and the opportunity to be heard and treated without stigma or professional penalty.

At the extreme of the burnout spectrum, suicidal ideation and, tragically, death by suicide are not uncommon, making the urgency of accurate and timely identification of burnout self-evident.⁸⁰  It is a sobering fact that every year an estimated 300 to 400 physicians in the United States die by suicide,¹⁵⁷  and the impact of the ongoing global COVID-19 pandemic on this statistic remains to be determined. Women physicians are at highest risk, with an estimated relative risk ratio of 2.7 for suicide in relation to the general female population,¹⁵⁸  double that of male physicians, and cause for heightened awareness and action in pediatrics, a field in which women now make up the majority of trainees.^159,160  Compared with the general population, physician suicide risk is increased by patient and family demands, frequent high-stakes decision making, fear of illness, unprocessed trauma and grief, uncertain job security, administrative friction, financial stressors, perceived lack of control, sleep disruption, threat of lawsuits or active litigation, license and regulatory constraints, social isolation, and work-home conflict.¹⁶¹  Warning signs may include expressions of hopelessness, withdrawal, agitation, uncontrolled anger, reckless behavior, mood changes, increasing substance use, threats of hurting oneself, and talking and writing about dying and suicide.¹⁶² 

Shame and fear of professional consequences cost valuable time. Recognition of warning signs in ourselves and colleagues is of utmost importance and must be followed by safe action. Despite their alarm, some physicians may feel uncomfortable in directly expressing concern for a distressed colleague. It is necessary to move past hesitation with compassion and convey concern, despite potential discomfort.

There is no universally recognized solution for preventing burnout-associated suicide, but some personal protective factors include positive social support, cultivation of personal awareness and resilience measures, and treatment of unaddressed mental and physical medical conditions. Regular practice of structured debriefing with the medical team after difficult patient encounters or poor outcomes is important. This deliberate process normalizes the need for emotional processing, with potential to benefit physicians at all stages of training.¹⁶³ 

In one 2013 study by Zwack and Schweitzer examining factors associated with lower burnout scores, interviews with 200 physicians revealed several positive resilience factors, including spiritual practice, physician self-awareness, gratification in work, accepting personal limitations, and learning how to better balance and prioritize.¹⁶⁴ 

Physicians in distress may struggle with barriers to seeking care, including stigma, minimization of symptoms, stoicism, fear of negative career consequence, and knowledge gaps regarding local resources.^165–167  Denial can be a powerful force. and it may take intervention by a colleague to raise an alarm.

The American Medical Association’s Steps Forward material provides concrete examples and emphasizes: “While not every suicide may be preventable, suicide is not inevitable—people with suicidal feelings can be helped. It is also important to recognize that you do not need to be an expert to help.”¹⁶¹  The conversation need not be complicated. For example, one might say: “I am concerned about you. Have you had any thoughts about hurting yourself?”¹⁶¹  If the answer is yes, help the suicidal physician to identify resources or reach out to a trusted friend or family member. Ideally, remain with the colleague until a safety plan is in place. If the answer is no, let the colleague know that you are available to connect, listen, or talk and to serve as a resource for him or her at any time and that he or she is not alone. (See Resources for more information.)

Clearly, a proactive approach to this issue begins with destigmatizing, recognizing, and addressing physician mental health needs before they reach the crisis point. This includes teaching physicians at all stages of training to recognize risk factors and signs of depression, substance abuse, suicidal ideation, and other signs in both themselves and others.

Discussions about physician-specific risks should be openly discussed at all career stages and be routinely included in continuing medical education courses. Support resources must be made accessible and take into consideration the barriers of demanding and variable physician schedules.

Professional organizations, institutions, hospitals, state medical boards, and malpractice insurers should encourage, rather than quell, help-seeking behaviors by physicians. Further research to identify potential best practices to identify risk factors, prevention strategies, and treatment is critical. The serious unaddressed needs of physicians affect far more than just physicians and their families but also patients and the health care system as a whole.¹⁶⁸ 

Perhaps most importantly, individuals must strive to maintain sufficient self-awareness to recognize the true mental and physical cost of work in an unsupportive setting that resists change.

There is no professional position worth the pitfall of becoming a “second victim” to an unnecessarily toxic organization or institution. Despite the difficulties inherent in a job change or career shift, physicians can and should exercise self-efficacy, protect their mental and physical health, and demand healthy and supportive work settings.

In reality, “organizational interventions” and “individual interventions” convey an umbrella of potential interventions. Very few have been proven or disproven to be effective in either category, making these areas of active research. Each has some examples of promise, although study heterogenicity is high. Some health care organizational interventions showed encouraging results in improvement of physician well-being indices,^6,12,75,169  but longitudinal data are lacking. Some examples in pediatrics include Leadership Walk Rounds¹⁷⁰  and Positive Rounding.¹⁷¹  Organizational attention to work hours, shift scheduling, and realistic completion of nonclinical duties is another important area that ties back to management of chronic fatigue as a foundation of health.

On the other hand, 1 of the largest organizational studies to date, a randomized controlled trial in 32 974 nonhealth care workers consisting of education on nutrition, physical activity, and stress reduction failed to show significant effectiveness.¹⁸  Although more prospective experiments are needed to test the effectiveness of organizational interventions, it is important to realize that these are very difficult experiments to undertake, requiring large numbers of institutions willing to implement an intervention with high fidelity. Ultimately, an investment in physician well-being is an investment in the well-being of health care institutions, and the nature of health care as a team endeavor suggests that a more inclusive approach may be warranted over physician-specific interventions, although there will always be unique considerations based on discipline, workflows, career stages, and other factors. This inclusive approach requires organizations to build on strong foundations of cultural humility and intention to create and celebrate, equity, diversity, and inclusion. Ideally, organizational culture should support physicians with leadership development, engagement in problem solving, assessment, and utilization of individual strengths in meaningful work, reinforced by alignment of the organization’s aspirational mission and vision with its policies, procedures, and culture.¹⁶⁹ 

When considering how to best support physician wellness specifically, key drivers of physician’s engagement should be reviewed and reflected on, and then targeted interventions should be developed, by and for physicians, to address them. Sinsky et al¹²  describe a step-wise approach to choosing and implementing such interventions, which essentially lean on standard quality improvement methods:

1. Solicit ideas from all stakeholders.

2. Identify interventions that align with other organizational priorities.

3. Seek out interventions that address both clinician wellbeing and patient experience.

4. Identify appropriate metrics to track.

5. Engage front-line clinicians in all stages of the intervention trial.

6. Pilot with small groups.

7. Be transparent with outcome results and use these for continuous learning and improvement.

Thus, the path for physician or health care worker well-being may follow that of the broader clinical quality improvement enterprise or even integrate with it. Already, the SCORE survey includes scales on improvement readiness, next to those of burnout, emotional thriving, and work-life balance, safety culture, and local leadership.⁴¹  This approach requires continuous attention and integration of health care worker well-being and should include measures to identify and mitigate discriminatory practices.

Collaboration between physicians and executives is also necessary for these ideas to succeed—for example, addition of the Chief Wellness Officer and Health Care Chief Wellness Officer, ideally independently functioning C-suite level roles focused on improving work environment and culture.^172,173 

When considering individual components of wellness, it is important to acknowledge the ingrained culture of unrealistic endurance many experienced in training. New approaches and attitudes are needed. What follows are examples of emerging research that may benefit individuals at any stage of training.

For example, it has been shown that physicians who incorporate healthy lifestyle habits have been perceived as more credible and motivating to their patients as well as the residents under their supervision.^174–177  Physician wellness activities frequently include hobbies, physical activity, sleep, nutrition, and vacations.^113,178  Wellness behaviors are additive, and thus, physicians should be encouraged to adopt a variety of approaches to best suit their individual needs and preferences.¹⁷⁹ 

In the professional realm, components of wellness primarily focus on supporting a provider’s career engagement, centering on topics such as the professional fulfillment, meaning in work, and vitality of the physician and medical team.^180–182  These efforts must also acknowledge the importance of the physician’s unique personal and professional responsibilities and preferences.

In the personal realm, attention to well-being over time can enhance one’s ability to recognize his or her vulnerability to burnout and other types of distress, creating an “early warning system” that should not be ignored. When identified, immediate measures should be taken to overcome and manage fatigue, stress, lack of physical activity, and loss of social connection to help reinforce resiliency. These steps build healthy resilience associated with thriving and continued personal growth. This overarching definition of realistic resilience refers to the ability to rebound from stressful situations in skillful ways and, moreover, to emerge stronger from the experience,¹¹³  a characteristic strongly associated with physician well-being.

Hardiness is a facet of resilience relevant to work in the medical profession. The idea of hardy personality, or hardiness, was developed by Kobasa¹⁸³  and originates from the combination of 3 key dimensions: commitment to life and work, sense of control over events, and the aptitude to experience changes as challenges. In this context, hardiness can be understood as a protective resource that buffers health care professionals who face demanding situations and enables them to employ adaptive behaviors. Hardiness is inversely related to burnout symptoms, in particular the depletion of cognitive and emotional energy, emotional exhaustion, and cynicism.¹⁸⁴ 

Additional components of resilience include gratification, useful attitudes, and resiliency -building practices,¹⁶⁴  which may be fostered with deliberate, simple, and inexpensive wellness habits.^185,186  Gratification includes components of connection, communication, and maintaining meaning in work,^113,187  and it may be fostered through gatherings and discussions with colleagues, narrative medicine, and establishing a personal philosophy.^70,113,188  Useful attitudes include self-awareness, acceptance, and adaptability. These attitudes may be strengthened with mindfulness, gratitude, and positive psychology practices.¹¹³  Such strategies can be applied both in-the-moment during clinical practice, after-the-moment in reflection, or long-term to maintain well-being. Positive psychology approaches with substantial supporting literature, such as Three Good Things, have also shown promise in addressing components of burnout.²¹  A multifaceted low-intensity positive psychology intervention program (WISER) has been shown to reduce NICU health care worker burnout and other aspects of well-being, including work-life integration and depression.²³ 

Mindfulness is an ancient practice with modern relevance in medicine. Kabat-Zinn, a pioneer in the field, developed mindfulness based-stress reduction as a way to introduce and teach mindfulness skills to patients and clinicians.¹⁸⁹  In simplified terms, mindfulness refers to maintaining focused awareness by staying present in the moment, and it can be fostered by training and intentional practice.^113,189,190  Structured gratitude interventions, such as gratitude lists or letters used on a regular basis may also improve physician well-being.^42,113  Additional resiliency practices include self-care, self-compassion, and, as applicable, spirituality.

On the forward edge of this field of research are collaborative programs such as the Emory-Tibet Partnership at the Emory University Center for Contemplative Science and Compassion-Based Ethics¹⁹¹  and the Stanford Center for Compassion and Altruism Research and Education.¹⁹²  These programs provide research context for approaches, such as applied mindfulness and compassion and how these can benefit overall health. Particularly relevant to physicians are the themes of gaining perspective on challenges, loss, and suffering and learning to leverage strengths to expand capacity for healthy resilience in the course of medical training and practice.

Although individual approaches to well-being are inherently variable, a summary of individual components of wellness considers the following:

• Consistent attention to healthy lifestyle fundamentals, such as nutrition, physical activity, sleep, and stress management.

• Plan and take regular time off and vacation time.

• Develop a hobby outside of one’s regular medical practice.

• Cultivate a gratitude practice.

• Consciously build and maintain a supportive social and family network.

• Create a personal mission statement, what brings you joy in medicine, why did you choose the field, how will you thrive?

• Explore and practice mind-body approaches such as mindfulness that harness emerging research.

An optimal career fit values a physician’s specific professional interests and is associated with decreased rates of physician burnout,¹⁶  yet navigating personal and professional challenges can seem daunting for a time-stressed physician. Professional coaching is an area showing promise in improving physician well-being, either on an individual basis or within an organization, where it has been shown to help support physician challenges with work-life and work-work conflict.^193,194  For example, a longitudinal pilot study demonstrated significant individual and institutional financial benefit from a combination of physician coaching and time-banking for behaviors that support team success.¹⁹⁴ 

Within the business literature, coaching has demonstrated a positive return on investment and is associated with improved individual performance, coping skills, work attitude, goal orientation, and well-being.^195–197  Coaching capitalizes on the individual’s existing skills and strengths, improves self-awareness, enhances alignment of personal values with professional responsibilities, improves the individual’s internal locus of control,¹⁹⁸  and may help individuals to clarify personal and professional goals as they evolve and change over time.^193,194 

Substantial work has been accomplished in the field of physician wellness over the past decade. Some of the most promising progress has targeted development of more responsive and resilient organizations that prioritize clinician input, connection, and support. Selected topics reviewed in this report include updates on: burnout prevalence and diagnosis; national progress in physician wellness; physician wellness initiatives at the AAP; pediatric-specific burnout and well-being; recognized drivers of burnout (organizational and individual); the intersection of race, ethnicity, gender, and burnout; protective factors; and components of wellness (organizational and individual).

Pediatricians have been at the forefront of this work nationally. Robust ongoing initiatives within the AAP reinforce the commitment to ensure the health, protection, and support of all pediatricians, regardless of training level, gender, race, or chosen specialty. Continued progress depends on maintaining a sense of urgency and the desire to shape the field of pediatrics so it is healthier, safer, and more satisfying for future trainees and practitioners.

The COVID-19 pandemic has highlighted concerning gaps in the interface of health care systems and governmental institutions along with a lack of effective crisis-management protocols and communication. It has brought the topic of physician health and well-being into sharp focus and highlighted the pressing need for a well-organized, equitable, and well-staffed health care system to ensure safety for all. The profession of medicine needs courageous and insightful leaders to reimagine a culture that values humanity over invincibility and prioritizes peer support over competition. It is hard to envision a more critical time to address individual and organizational cultural well-being and accelerate the urgent need for culture change in medicine.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

• National Academy of Medicine: Action Collaborative on Clinician Well-Being and Resilience. https://nam.edu/action- collaborative-on-clinician-well- being-and-resilience-network- organizations/

• WellMD at Stanford Medicine and the Stanford Medicine Chief Wellness Officer Course https://wellmd.stanford.edu (accessed December 30, 2020). Stanford Medicine WellMD. n.d. Chief Wellness Officer Course. Available at: https://wellmd.stanford. edu/center1/cwocourse.html (accessed December 30 2020).

• Mayo Clinic: Program on Physician Well-Being https://www.mayo.edu/research/centers- programs/program-physician- well-being/mayos-approach- physician-well-being

• Duke University School of Medicine: https://medicine.duke.edu/medicinenews/our-well-being

• Vanderbilt Center for Professional Health, Vanderbilt University Medical Center. n.d. Center for Professional Health. Available at: https://med-sites.mc.vanderbilt.edu/cph/home

• American Medical Association: STEPS Forward modules.

  • − Shanafelt TD, Ripp J, Brown M, Sinsky CA. Creating a Resilient Organization: Caring for Healthcare Workers during Crisis. 2020. American Medical Association. Available at: https://www.ama-assn.org/system/files/2020-05/caring- for-health-care-workers-covid- 19.pdf

  • − Sinsky CA, Shanafelt TD, Murphy MM, et al. Creating the Organizational Foundation for Joy in Medicine. AMA STEPS Forward. 2019. Available at: https://edhub.ama-assn.org/steps-forward/module/2702510

• Action Collaborative on Clinician Well-Being and Resilience case study series

  • − Zindel M, Cappelucci K, Knight HC, Busis N, Alexander C. Clinician well-being at Virginia Mason Kirkland Medical Center: a case study. NAM Perspectives. August 26, 2019. https://doi.org/10.31478/201908c

• National Suicide Prevention Lifeline (1-800-273-8255)

• Suicide and Crisis Hotline: Call or text 988 or chat 988lifeline.org. This new, shorter hotline number is now active and makes it easier for people to remember and access mental health services.

• State hotlines: www.suicide.org/suicide-hotlines.html

• Crisis chat service: www.crisischat.org

• Substance Abuse and Mental Health Services Administration mental health provider locator: http://store.samhsa.gov/mhlocator; 1-800-662-HELP (4357)

• Federation of State Physician Health Programs maintains a listing of state physician health programs that can facilitate private and confidential care, evaluation, treatment, and referrals: https://www.fsphp.org/

Hilary McClafferty, MD, FAAP Dena Hubbard, MD, FAAP Dana Foradori, MD, MEd, FAAP Melanie Brown, MD, MSE, FAAP Jochen Profit, MD, MPH, FAAP Daniel Tawfik, MD, MS, FAAP

Melanie L. Brown, MD, FAAP, Chairperson Cora C. Breuner, MD, MPH, FAAP Anna Esparham, MD, FAAP Melanie Ariane Gold, DO Sanghamitra Moulik Misra, MD, FAAPC Claudia Regina Morris, MD, FAAP, Chairperson Elect Shiu-Lin Tsai, MD, FAAP Joy Arlyne Weydert, MD, FAAP, Immediate Past Chairperson

Hemangini C. Bhakta, MD, FAAP – AAP Section on Early Career Physicians

Teri Salus, MPA