Section Editor
®
WriteClick Editor’s Choice
Robert C. Griggs, MD
Editors’ Note: In response to “Physician burnout: A neurologic crisis,” Dr. Sethi points to absent support systems, loss of control over work hours, and high student loan debt as potential contributors to burnout in young neurologists. Dr. Bianchi makes the case that the lack of established diagnostic criteria and cutpoints for grading severity makes studying burnout in physicians problematic. Authors Sigsbee and Bernat respond. Dr. Lesser and author Bernat discuss accuracy in electronic health records. —Megan Alcauskas, MD, and Robert C. Griggs, MD
PHYSICIAN BURNOUT: A NEUROLOGIC CRISIS
Nitin K. Sethi, New York: Drs. Sigsbee and Bernat1 identified many reasons for neurologist dissatisfaction and resulting burnout with this chosen specialty. Neurologists are burning out faster and at an earlier stage in their careers. Young neurologists frequently lack the support system that more senior (not in age but in experience) colleagues had. Many neurologists begin careers burdened with enormous student loan debts and quickly have to adapt to the pressures of working either in academic or other practice settings. Lengthy neurology residency training does not prepare trainees for the pressures of the real world. At this tender stage, trainees lack the emotional maturity, patience, and ability to handle stress and many fall prey to depression and feelings of helplessness. Many of my colleagues contend that the lack of control over their work hours leads to career dissatisfaction and have stated that—given a second chance—they would not have chosen neurology as a career. There is not a comfortable retirement outlook for younger neurologists. If physician burnout is not addressed, neurology risks the loss of some its brightest young talent. Renzo Bianchi, Besançon, France: Drs. Sigsbee and Bernat1 affirmed that the prevalence of burnout is high among physicians, particularly among neurologists. While I applaud the authors’ interest in physicians’ ill-being at work, I think that their affirmation is questionable. Currently, there are neither consensual diagnostic criteria for burnout nor clinically valid cutpoints for 2098
Neurology 84
grading the severity of burnout symptoms.2,3 The authors rightfully mention that the Maslach Burnout Inventory (MBI) is the instrument of reference for assessing burnout. However, the MBI’s cutpoints have been arbitrarily defined.3,4 As indicated by MBI’s developers, “neither the coding nor the original numerical scores should be used for diagnosis purposes.”4 Moreover, heterogeneous criteria have been used to identify burnout in past research,3,5 making between-study comparisons problematic. As a result, such comparisons rarely provide exploitable information for guiding interventions or health policies. As the definition of burnout is unclear, its prevalence cannot be established. Clarifying burnout’s nosologic status is indispensable if burnout is to become a privileged construct in the study of neurologists’ health. In the meantime, focusing on (job-related) depression may be more informative.5 Author Response: Bruce Sigsbee, Rockport, ME; James L. Bernat, Lebanon, NH: The authors thank Dr. Sethi and Dr. Bianchi for their comments. We would like to address Dr. Bianchi’s concerns. Physicians and specifically those in primary care and neurology recognize the increasing prevalence of career dissatisfaction and other features of burnout in colleagues if not themselves.3 While the initial developers of the MBI thought that some of the components of the inventory were arbitrary, subsequent studies found value in the instrument. As evidenced by articles cited (references 2 and 4– 8),1 the MBI identified a cohort with consistent characteristics summarized as career dissatisfaction and poor perception of job performance. Additionally, the few studies looking at interventions found the instrument valuable as a marker for improvement (references 17–19).1 Furthermore, degradation of patient care and career satisfaction are substantially higher in this cohort. The operating definition as applied to not just physicians has existed for over 50 years. We endorse the need for greater clarity and specificity in the diagnosis and definition of the syndrome yet the profession as represented by specialty organizations and the American Medical Association identify burnout as a major problem. The consequences of burnout are sufficiently pervasive and concerning
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
enough that there must be active efforts to address the syndrome. © 2015 American Academy of Neurology 1. 2. 3.
4.
5.
Sigsbee B, Bernat JL. Physician burnout: a neurologic crisis. Neurology 2014;83:2302–2306. Weber A, Jaekel-Reinhard A. Burnout syndrome: a disease of modern societies? Occup Med 2000;50:512–517. Schaufeli WB, Enzmann D. The Burnout Companion to Study and Practice: A Critical Analysis. London: Taylor & Francis; 1998. Maslach C, Jackson S, Leiter MP. Maslach Burnout Inventory Manual, 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996. Bianchi R, Schonfeld IS, Laurent E. Is burnout a depressive disorder? A re-examination with special focus on atypical depression. Int J Stress Manag 2014;21:307–324.
CHALLENGES TO ETHICS AND PROFESSIONALISM FACING THE CONTEMPORARY NEUROLOGIST
Ronald P. Lesser, Baltimore: I appreciate Dr. Bernat’s1 thoughtful comments regarding current medical practice and agree with most of them. There may be overuse of cut and paste in electronic records, but this is not unique, it is just easier. When notes were written by hand, histories also con-
tained information from previous histories, which might or might not have been accurate. Daily progress notes may contain 20% copied information but it is likely that 20% of a patient’s condition has not changed from the previous day. Copying can ease the burden for physicians already desperate to get their work done, despite inefficient electronic records. Checklists ensure that all questions were asked and answered, including history. From my perspective, it would be better for the lists to be retained vs being transformed into stilted sentences. The original lists are easier for the next person to read and their sources are clear. Author Response: James L. Bernat, Lebanon, NH: I have no necessary objection to any of the electronically facilitated actions offered by electronic health records as long as the finished product is edited for accuracy. The problem is that time-stressed physicians may become careless and not edit cloned notes or templates adequately, thereby producing inaccurate records that ultimately harm patients. © 2015 American Academy of Neurology 1.
Bernat JL. Challenges to ethics and professionalism facing the contemporary neurologist. Neurology 2014;83:1285–1993.
WriteClick® rapid online correspondence The editors encourage comments about recent articles through WriteClick: Go to Neurology.org and click on the “WriteClick” tab at the top of the page. Responses will be posted within 72 hours of submission. Before using WriteClick, remember the following:
• WriteClick is restricted to comments about studies published in Neurology within the last eight weeks • Read previously posted comments; redundant comments will not be posted • Your submission must be 200 words or less and have a maximum of five references; reference one must be the article on which you are commenting • You can include a maximum of five authors (including yourself)
Author disclosures are available upon request ([email protected]). Neurology 84
May 19, 2015
2099
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Physician burnout: A neurologic crisis Nitin K. Sethi, Renzo Bianchi, Bruce Sigsbee, et al. Neurology 2015;84;2098-2099 DOI 10.1212/WNL.0000000000001630 This information is current as of May 18, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/20/2098.full.html
References
This article cites 3 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/20/2098.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
®
WriteClick Editor’s Choice
Robert C. Griggs, MD
Editors’ Note: In response to “Physician burnout: A neurologic crisis,” Dr. Sethi points to absent support systems, loss of control over work hours, and high student loan debt as potential contributors to burnout in young neurologists. Dr. Bianchi makes the case that the lack of established diagnostic criteria and cutpoints for grading severity makes studying burnout in physicians problematic. Authors Sigsbee and Bernat respond. Dr. Lesser and author Bernat discuss accuracy in electronic health records. —Megan Alcauskas, MD, and Robert C. Griggs, MD
PHYSICIAN BURNOUT: A NEUROLOGIC CRISIS
Nitin K. Sethi, New York: Drs. Sigsbee and Bernat1 identified many reasons for neurologist dissatisfaction and resulting burnout with this chosen specialty. Neurologists are burning out faster and at an earlier stage in their careers. Young neurologists frequently lack the support system that more senior (not in age but in experience) colleagues had. Many neurologists begin careers burdened with enormous student loan debts and quickly have to adapt to the pressures of working either in academic or other practice settings. Lengthy neurology residency training does not prepare trainees for the pressures of the real world. At this tender stage, trainees lack the emotional maturity, patience, and ability to handle stress and many fall prey to depression and feelings of helplessness. Many of my colleagues contend that the lack of control over their work hours leads to career dissatisfaction and have stated that—given a second chance—they would not have chosen neurology as a career. There is not a comfortable retirement outlook for younger neurologists. If physician burnout is not addressed, neurology risks the loss of some its brightest young talent. Renzo Bianchi, Besançon, France: Drs. Sigsbee and Bernat1 affirmed that the prevalence of burnout is high among physicians, particularly among neurologists. While I applaud the authors’ interest in physicians’ ill-being at work, I think that their affirmation is questionable. Currently, there are neither consensual diagnostic criteria for burnout nor clinically valid cutpoints for 2098
Neurology 84
grading the severity of burnout symptoms.2,3 The authors rightfully mention that the Maslach Burnout Inventory (MBI) is the instrument of reference for assessing burnout. However, the MBI’s cutpoints have been arbitrarily defined.3,4 As indicated by MBI’s developers, “neither the coding nor the original numerical scores should be used for diagnosis purposes.”4 Moreover, heterogeneous criteria have been used to identify burnout in past research,3,5 making between-study comparisons problematic. As a result, such comparisons rarely provide exploitable information for guiding interventions or health policies. As the definition of burnout is unclear, its prevalence cannot be established. Clarifying burnout’s nosologic status is indispensable if burnout is to become a privileged construct in the study of neurologists’ health. In the meantime, focusing on (job-related) depression may be more informative.5 Author Response: Bruce Sigsbee, Rockport, ME; James L. Bernat, Lebanon, NH: The authors thank Dr. Sethi and Dr. Bianchi for their comments. We would like to address Dr. Bianchi’s concerns. Physicians and specifically those in primary care and neurology recognize the increasing prevalence of career dissatisfaction and other features of burnout in colleagues if not themselves.3 While the initial developers of the MBI thought that some of the components of the inventory were arbitrary, subsequent studies found value in the instrument. As evidenced by articles cited (references 2 and 4– 8),1 the MBI identified a cohort with consistent characteristics summarized as career dissatisfaction and poor perception of job performance. Additionally, the few studies looking at interventions found the instrument valuable as a marker for improvement (references 17–19).1 Furthermore, degradation of patient care and career satisfaction are substantially higher in this cohort. The operating definition as applied to not just physicians has existed for over 50 years. We endorse the need for greater clarity and specificity in the diagnosis and definition of the syndrome yet the profession as represented by specialty organizations and the American Medical Association identify burnout as a major problem. The consequences of burnout are sufficiently pervasive and concerning
May 19, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
enough that there must be active efforts to address the syndrome. © 2015 American Academy of Neurology 1. 2. 3.
4.
5.
Sigsbee B, Bernat JL. Physician burnout: a neurologic crisis. Neurology 2014;83:2302–2306. Weber A, Jaekel-Reinhard A. Burnout syndrome: a disease of modern societies? Occup Med 2000;50:512–517. Schaufeli WB, Enzmann D. The Burnout Companion to Study and Practice: A Critical Analysis. London: Taylor & Francis; 1998. Maslach C, Jackson S, Leiter MP. Maslach Burnout Inventory Manual, 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996. Bianchi R, Schonfeld IS, Laurent E. Is burnout a depressive disorder? A re-examination with special focus on atypical depression. Int J Stress Manag 2014;21:307–324.
CHALLENGES TO ETHICS AND PROFESSIONALISM FACING THE CONTEMPORARY NEUROLOGIST
Ronald P. Lesser, Baltimore: I appreciate Dr. Bernat’s1 thoughtful comments regarding current medical practice and agree with most of them. There may be overuse of cut and paste in electronic records, but this is not unique, it is just easier. When notes were written by hand, histories also con-
tained information from previous histories, which might or might not have been accurate. Daily progress notes may contain 20% copied information but it is likely that 20% of a patient’s condition has not changed from the previous day. Copying can ease the burden for physicians already desperate to get their work done, despite inefficient electronic records. Checklists ensure that all questions were asked and answered, including history. From my perspective, it would be better for the lists to be retained vs being transformed into stilted sentences. The original lists are easier for the next person to read and their sources are clear. Author Response: James L. Bernat, Lebanon, NH: I have no necessary objection to any of the electronically facilitated actions offered by electronic health records as long as the finished product is edited for accuracy. The problem is that time-stressed physicians may become careless and not edit cloned notes or templates adequately, thereby producing inaccurate records that ultimately harm patients. © 2015 American Academy of Neurology 1.
Bernat JL. Challenges to ethics and professionalism facing the contemporary neurologist. Neurology 2014;83:1285–1993.
WriteClick® rapid online correspondence The editors encourage comments about recent articles through WriteClick: Go to Neurology.org and click on the “WriteClick” tab at the top of the page. Responses will be posted within 72 hours of submission. Before using WriteClick, remember the following:
• WriteClick is restricted to comments about studies published in Neurology within the last eight weeks • Read previously posted comments; redundant comments will not be posted • Your submission must be 200 words or less and have a maximum of five references; reference one must be the article on which you are commenting • You can include a maximum of five authors (including yourself)
Author disclosures are available upon request ([email protected]). Neurology 84
May 19, 2015
2099
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Physician burnout: A neurologic crisis Nitin K. Sethi, Renzo Bianchi, Bruce Sigsbee, et al. Neurology 2015;84;2098-2099 DOI 10.1212/WNL.0000000000001630 This information is current as of May 18, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/20/2098.full.html
References
This article cites 3 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/20/2098.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
