Physician Burnout: Designing Strategies Based on Agency and Subgroup Needs [Response to Letter]

Dear editor

Thank you for sharing our interest in physician burnout and contributing constructive recommendations to prevent burnout and increase belonging. In the spirit of expanding evidence-based dialogue on the drivers, perpetuators, and mitigators of burnout within medical groups, consider the positive perspectives presented in recent research:

Demographic Differences

A literature review of 33 empirical studies published between 2015 and 2023 on family physician burnout in the United States¹ correlated physician female gender with burnout. This issue warrants continuing research and presents opportunities for administrative remediation, such as offering structural supports to enable female family doctors to maintain work-life balance and reduce conflicts between work and non-work roles.

EHR Impact

While the literature correlates burnout with excessive administrative and electronic health record use, managers and health care systems can proactively address contributing factors through system-level process changes.¹ In an observational study of primary care physicians, Tawfik et al² noted unit-level EHR use measures may help organizations identify clinics where physicians are at higher risk for burnout. Research data were provided by STARR (STAnford medicine Research data Repository) a clinical data warehouse containing live Epic data from Stanford Health Care, the Stanford Children’s Hospital, the University Healthcare Alliance, and Packard Children’s Health Alliance clinics and other auxiliary data from hospital applications, such as radiology PACS; additional studies are warranted to identify actionable predictors. Exploring the potential of artificial intelligence (AI) to assist with medical documentation compliance, Miao et al³ posited that software vendors’ collaboration with Epic electronic health records may significantly reduce physician workloads, thereby reducing factors contributing to burnout.

Agency, Autonomy, Belonging, and the Medical Humanities

Definitions of agency may vary, yet nuances express the frustration associated with loss of control: Physician leader agency, defined “as an inability, or unwillingness, to address the pressing factors that led to burnout”,⁴ “control over medical practice”⁵ and sense of morals and control.⁶ Enzmann links burnout to erosion of physicians’ cultural authority, manifested as “challenges to professionalism and its associated powers, specifically autonomy, respect, and personal agency”.⁵ The “moral injury” depicted by Dean et al⁷ (2019) synthesizes agency, autonomy, and lost sense of belonging: “Moral injury describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control”⁷ Echoing Enzmann’s “value-added activity of interacting with patients”⁵ Gunderman emphasizes patient-centric medicine to eliminate burnout: “What is needed is to become attuned to what most merits attention - namely, the patient and what the patient needs”.⁸

The Good News

Evidence-based studies suggest transactional approaches of healthcare system management misinterpret underlying factors contributing to burnout and exacerbate physician frustrations. Physicians deny being characterized as burned out, citing a disconnect between their situation and what constitutes burnout. Collaborative steps toward change begin with identifying more accurate language to describe physicians’ experience and reframe both problem and solution. Moral injury, a term introduced in 2018, depicts the challenge of not being able to prioritize healing over profit due to the business framework of health care; burnout, in contrast, suggests an individual problem, solved by individual-centric solutions. Invitations to change include bringing clinicians and health care administrators together to understand the other party’s perspective and challenges and introduce system-level interventions.