We became neurologists with great enthusiasm and idealism. To us, a more interesting specialty or frontier of science was unimaginable. The practice of neurology can be personally meaningful and fulfilling but can also be especially demanding and stressful. We spend long hours with challenging patients with lifethreatening acute diseases and the most debilitating chronic illnesses. Like all physicians, we now face an accelerating
landscape of unprecedented practice changes where the initials themselves strike fear: EHR, MU, PQRS, ACA, HITECH, ACO, and ICD-10-CM. All of this rests on top of capricious E&M coding, pre-certifications for medications and scanning, and threats of malpractice. There are audits upon audits. Violations of the new rules are punishable by large fines. Who has time to keep up with the medical literature when there are so many practice issues to learn? Although all physician salaries are under siege, as neurologists, we are particularly undervalued with cuts to cognitive services and the gargantuan cuts to electrodiagnostic studies this year. We’re threatened with the SGR reductions and had the recent sequestration cut. It’s all enough to lead to burnout.
Professional burnout is common among physicians and has only recently been studied among neurologists. Maslach and colleagues define burnout as the increased feelings of emotional exhaustion, an unfeeling and impersonal response toward patients, and dissatisfaction with work accomplishments.1 Burnout can be harmful for patients and result in a lack of professionalism, increased risk for medical errors, ordering unnecessary tests and procedures, and a decreased quality of care 2 Burnout can also be harmful for physicians and lead to early retirement, job change (such as switching jobs or leaving academic medicine), medical malpractice suits, depression and suicidal ideation, increased absenteeism, increased alcohol use, and problems with relationships, including divorce.
In order to learn more about the professional stress of neurologists and their attitudes about practice issues, we performed a survey of Texas neurologists.
SUBJECTS AND METHODS
A survey was developed by one of the authors (RE). Three hundred and ten neurologists attending the Texas Neurological Society 16th Annual Winter Conference continuing medical education meeting February 22-24, 2013 in Austin, TX were supplied the survey titled, “Neurologist Survey on Physician Satisfaction,” with their registration materials. Completed instruments were submitted at the end of the meeting. The survey asked 45 questions organized into the following three sections: demographics, professional quality of life and satisfaction, and burnout. Burnout was measuring using the Maslach Burnout Inventory (MBI), which is a validated 22-item questionnaire considered the gold standard for measuring burnout3(Table 1).
The MBI has three subscales to evaluate each domain of burnout, including emotional exhaustion (EE; assesses feelings of being emotionally overextended and exhausted by one’s work), depersonalization (DP; measures an unfeeling and impersonal response toward patients), and personal accomplishment (PA; assesses feelings of competence and successful achievement in one’s work with people). Each item was answered on a 7-point Likert scale from “never” (0 points) to “daily” (6 points). A score was then generated for each of the three sections, and results were then stratified into high, moderate, or low levels of burnout based on published values (low EE ≤ 18, high EE≥27; low DP≤5, high DP≥ 10; high PA≥ 40, low PA≤ 33).4 A neurologist was considered to be suffering burnout if he or she had high emotional exhaustion and/or depersonalization scores similar to prior physician studies of burnout 5
There were 101 respondents for a response rate of 33 percent.
Demographics. The participants reported the following demographics (Table 2): 71 percent male; 66 percent over the age of 50 years; 54 percent in practice for over 20 years; 33 percent in subspecialties; 79 percent married; 42 percent in solo practice, 45 percent in a private group; 87 percent worked more than 40 hours per week; 57 percent have five or fewer days of call per month; 33 percent spend more than 11 hours per week on administrative tasks; 53 percent take two weeks or less vacation per year; and 85 percent have had no malpractice suits in the last five years.
Career satisfaction.Table 3 provides responses to the 12 career satisfaction questions.
Burnout.Results of the MBI are summarized in Table 4. The median scores for EE, DP, and PA were 24.5, 5, and 40, respectively. Overall, 43 percent had high emotional exhaustion, 16 percent had high depersonalization, and 18 percent had a low sense of personal accomplishment. Forty six percent of respondents were burned out.
The only significant correlations between demographics and MBI subscales were between malpractice lawsuits and emotional exhaustion (r=.22, p=.03) and malpractice lawsuits and depersonalization (r=.30, p<.01).
A regression analysis was performed with the career satisfaction questions that had a correlation with the MBI subscales that was significant at a <.01 level as the independent variable for each of the three subscales as the dependent variable. Forty three percent of the variance in emotional exhaustion is explained by the following three questions: My work schedule leaves me enough time for my personal and/or family life; Insurance company policies (such as authorizations for medications and imaging) contribute to my dissatisfaction with neurologic practice; and If I were a fourth year medical student, I would go into neurology again. Eighteen percent of the variance in depersonalization is explained by the following two questions: I am appreciated by my patients and If I were a fourth year medical student, I would go into neurology again. Thirteen percent of the variance in personal accomplishment was explained by the following two questions: I am appreciated by my patients and I would recommend that my child or close relative become a neurologist.
Respondents’ comments.Selected respondents’ comments to the survey are provided in Table 5.
The response rate was 33 percent, which is comparable to other physician surveys6 and the response rate of 27 percent in another neurologist burnout survey.5Response bias cannot be excluded with those more dissatisfied and with higher degrees of burnout completing the survey. However, this pilot survey of neurologists in Texas may be representative of neurologists in the United States, as the burnout rates are similar to two nationwide surveys. The American Academy of Neurology may wish to consider performing similar nationwide surveys periodically to evaluate the effect of escalating healthcare changes.
Forty six percent of respondents had burnout. This is similar to two recent nationwide studies. In Shanafelt and colleagues’ 2010 study, 53 percent of neurologists had burnout, which was the third highest of all specialties with only emergency medical and general internal medicine having higher rates.5Family medicine had a burnout rate just below neurology with dermatology and preventive/occupational medicine having the lowest. A 2012 Medscape survey found a burnout rate of 41 percent, which was also among the highest of the specialties.7Neurologists tied with gastroenterologists and internists for the least happy of all specialists. In two studies, burnout was present among 45 percent5 and 27 percent8 of neurosurgeons. Burnout is more prevalent among physicians than other US workers.
In our survey, the only demographic item that was significantly associated with MBI subscales was a higher number of malpractice suits in the last five years. In the Medscape survey,7 burnout was lowest in the youngest and oldest neurologists and more common in female than males physicians (56 percent vs. 40 percent). Shanafelt and colleagues’ analysis of all specialists found a higher risk for burnout with greater number of hours worked per week and a lower risk of burnout with older age and being married.5
In our survey, career satisfaction items significantly associated with burnout include work schedule, insurance company policies, appreciation by patients, would recommend that a relative become a neurologist, and would go into neurology again. In the Medscape survey,7 the top four stressors that were reported as causing burnout among neurologists were the following: too many bureaucratic tasks; spending too many hours at work; income not high enough; and present and future impact of the Affordable Care Act.
The 12 career satisfaction questions reflect widespread dissatisfaction with work schedules, government regulations, implementation of the Affordable Care Act, and compensation.
Neurologists in other states may have more malpractice suits and more concern over malpractice. (Texas enacted malpractice reform in 2003. Since then, the number of suits has significantly dropped and the number of physicians has increased by over 30 percent. One of the authors [RE] own malpractice premium has dropped by about 50 percent.) Fifty three percent of neurologists concur that the practice of neurology is becoming more complicated without patient benefit.
The responses to the last two questions of our survey are the most disturbing and reflect an alarming level of discontent. Only 17 percent of respondents say they would go into neurology again if they were a fourth year medical student and only seven percent would recommend that their child or close relative become a neurologist. By comparison, 88 percent of neurosurgeons would choose neurosurgery again as a career and 55 percent would recommend it to a child.With a growing shortage of neurologists, how can we encourage interest in neurology as a specialty among medical students when we wouldn’t even recommend neurology as a career for ourselves again or our family members?
Is neurologist career satisfaction decreasing? In a 1996-1997 survey on career satisfaction and dissatisfaction in all physician specialties, 39 percent of neurologists were very satisfied and 16 percent dissatisfied with a little less very satisfied as compared to other specialists on average.9
Increasing numbers of neurologists are becoming hospital employees. By 2014, about 50 percent of physicians will be working for a hospital or hospital-owned health system. Younger neurologists may wish to avoid the uncertainties involved with joining a group or starting their own practice and desire what might be a better lifestyle, and older neurologists may choose to enter hospital employment as a way out of the hassles of physician ownership.
However, it is possible that some may find less personal accomplishment and happiness as employees with the loss of professional and personal autonomy.10A Gallup Poll on wellbeing found small business owners as being the happiest of professions:11“The findings, psychologists say, reflect the importance of being free to choose the work you do and how you do it, the way you manage your time, and the way you respond to adversity.” An increasing number of hospital employed neurologists may even compound the increasing shortage of neurologists. Some estimates find that productivity of hospital employed physicians decreases, sometimes by more than 25 percent.12
How can we deal with these issues? Can we hope to restore control or autonomy and meaning to neurology practice? For advocacy, we can join and be active in BrainPAC and the AAN Grassroots Alliance, contact our legislators, attend Neurology on the Hill and the Palatucci Advocacy Leadership Forum, contact our legislators, and be active in our state neurological societies.
For burnout, stress reduction training13 or combining mindfulness mediation, narrative medicine, and appreciative inquiry-based dialogues 14 may be effective but may be too time consuming and not appealing to some physicians. The study of physician resilience or the capacity to respond to stress in a healthy way such that goals are achieved at minimal psychological and physical cost is a new area.15 A number of factors may be important, including individual, community, and institutional factors. Interviews with 200 physicians suggest resilience strategies including the capacity for mindfulness, self-monitoring, limit setting, and attitudes that promote constructive and healthy engagement with (rather than withdrawal from) the difficult challenges at work.16
It is essential that we actively engage these issues. The health and well-being of our patients, ourselves, and the future of neurology are at stake.
The authors thank the Texas Neurological Society members for participating in the survey. We also thank Ky Camero, TNS Executive Director, and Amy Lawson, Society Administrator, for survey reproduction, distribution, and initial data analysis.
Licensing fee: A fee was paid to Mind Garden for a license to administer the Maslach Burnout Inventory by one of the investigators (RE).
The authors have no conflicts of interest. Randolph W. Evans, MD, is Clinical Professor of Neurology at Baylor College of Medicine in Houston.
Christina L. Upchurch, MA, is in the Department of Psychology at Rice University in Houston.
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- Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377-1385.
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- Joshi S, Nehaul R, Broome MA. Declining proportion of physician-owned practices possibly related to increasing burnout. JAMA Intern Med. 2013;173:710.
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- Gottlieb S. The doctor won’t see you now. He’s clocked out. Wall Street Journal. 2013, http://online.wsj.com/article/ SB10001424127887323628804578346614033833092.html. Accessed 5/26/13.
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