Editorials

Physician burnout undermines safe healthcare

Matthias Weigl

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o2157 (Published 14 September 2022)Cite this as: BMJ 2022;378:o2157

Urgent action is required to protect patients, physicians, and health systems

A substantial proportion of healthcare professionals report symptoms of burnout.12 Research into the negative ramifications of physician burnout is abundant, with key insights already established long before the onset and ongoing burden of the covid-19 pandemic.34 In a linked paper adding to this work,5 Hodkinson and colleagues (doi:10.1136/bmj-2022-070442) collate 170 observational studies of 239 246 physicians in a large systematic review and meta-analysis examining associations of physician burnout with career engagement and the quality of care provided to patients.

The authors found that burnout was associated with a threefold to almost fourfold increase in the odds of job dissatisfaction and regrets about career choice, that physicians with burnout were three times more likely to consider quitting than staying in their jobs, and that burnout was associated with significantly lower productivity. These findings are a compelling testimony to the pivotal role of burnout in physicians’ career disengagement. Burnout was also associated with doubled odds of patient safety incidents, low levels of professionalism, and significant decreases in patient satisfaction. Hodkinson and colleagues’ research adds to growing evidence that the poor mental health of healthcare providers jeopardises the quality and the safety of patient care.6

A notable strength of this review are the meta-regressions, which allow a deeper understanding of contextual influences. These analyses support that relations vary with respect to specialty, age, career stage, clinical setting, and level of national income and resources. Hodkinson and colleagues’ findings suggest that the consequences of burnout are exacerbated by acute healthcare environments, such as emergency departments and intensive care units.

These authors provide a much needed synthesis of evidence and affirm that physician burnout can be a catalyst for career disengagement and unsafe patient care. The challenges for patients, practitioners, researchers, and leaders in healthcare management and policy fall into three broad themes.

Firstly, burnout undermines professional engagement and results in loss of commitment and high turnover and absenteeism.7 Physician’s wellbeing must be prioritised in all efforts to resolve these problems.89

Secondly, burnout is fundamentally rooted in the work environment. Although manifesting in individuals, burnout is an indicator of a dysfunctional workplace.10 A broad evidence base in occupational health research has detailed various related adverse characteristics in work clinical environments.11 Excessive workloads, and work intensity in particular, have been shown to increase physician fatigue and deplete both motivation and engagement.1112Burnout is the inevitable result of physicians coping with exceedingly high workload caused by understaffing, inadequate support, and poor leadership, combined with imbalances between effort and reward, and moral injury stemming from the inability to provide adequate standards of care.

Thirdly, healthcare provider burnout is a risk to patient safety and must be treated like any other patient safety risk. Effective, evidence based interventions to reduce burnout are available at individual, workplace, and organisational levels.13 Work design and organisation level interventions are often neglected but are the key to meaningful progress on burnout.1415 Reducing any preventable harm requires understanding the underlying causes of that harm, changing practices and culture, promoting staff engagement through peer learning, and aligning policy efforts around common goals and measures.16 Systems engineering approaches are needed to successfully design and secure these improvements, in full partnership with healthcare professions.1718 Advocacy and policy changes that address burnout on a societal level are also pivotal.89

A deeper understanding of how burnout contributes to unsafe care is needed. Patient care is complex and suboptimal outcomes are multifactorial. Therefore, better research methods are needed to explore and quantify the specific contribution of physician burnout.1819 Long term investigations with sophisticated designs will improve our understanding of how work stress influences physicians’ experiences of engagement over time.20Research is needed that goes beyond observational studies and self-reported safety outcomes to establish effects of burnout and disengagement on patient outcomes.621 Discrepancies between physicians’ perceived functioning and their actual performance in terms of reliability and safety are a further challenge.22 Finally, qualitative studies are also required to explore the complex relationships between physicians and their working environments.23

The mental wellbeing of physicians is vital for safe healthcare systems. The pervasive nature of physician burnout indicates a defective work system caused by deep societal problems and structural problems across the sector. Urgent action is imperative for the safety of physicians, patients, and health systems, including interventions that are evidence based and system oriented, to design working environments that promote staff engagement and prevent burnout.