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Understanding Burnout and Challenging Misconceptions

The workshop began with a discussion facilitated by planning committee member Elena Fuentes-Afflick (Association of American Medical Colleges) with two pioneering experts in burnout research: Christina Maslach (University of California, Berkeley) and Tait Shanafelt (Stanford University School of Medicine). The goal of this panel was to establish a shared definition and common understanding of burnout to guide all further workshop conversations. This panel did not take a specific science, technology, engineering, mathematics, and medicine (STEMM) focus, but rather aimed to set the stage by unpacking the phenomenon of burnout more generally.

PANEL DISCUSSION

Definition of Burnout

Maslach began by noting that there is an agreed-upon definition of burnout in the research literature. She referred to the classification by the World Health Organization (WHO) in its 11th Revision of the International Classification of Diseases (ICD) of burnout as an occupational phenomenon, which is based on decades of work. The ICD-11 states that “burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed” (WHO, 2019). She called attention to several salient points. It results from chronic stressors, and recovery from chronic conditions is often more difficult than from other, more intermittent, stressors. It results from conditions that “are not successfully managed,” which implies they could be better managed, and people would not necessarily experience burnout. She also called attention to WHO’s characterization of three dimensions as the “trifecta of burnout”:

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¹ “Pebbles in the shoe” and related concepts like “daily hassles” refer to seemingly small everyday challenges and inefficiencies at work that can build up over time to create much greater problems. For more on pebbles in the shoe and how this has been conceptualized in the medical field, see https://www.ama-assn.org/practice-management/physician-health/identifying-pebbles-contribute-physician-burnout.

exhaustion, increased negativism or cynicism, and reduced professional efficiency. WHO made clear that burnout is not a medical condition or illness, but rather an occupational phenomenon with health consequences, akin to how stress can lead to heart disease.

Shanafelt opened his remarks by dispelling the idea that a person either experiences burnout or does not. “The symptoms are on a continuum,” he clarified. “We look at the effect of changes on a scale.” He suggested thinking of the range akin to blood pressure, with thresholds above which undesirable consequences may be the outcome. He also cautioned against conflating depression and burnout, which he said is inconsistent with the literature. “Depression is a mental health condition with a biological basis that is treated at an individual level,” Shanafelt clarified. Miscategorizing burnout is also counterproductive in terms of interventions. Another misconception, he continued, is that burnout is the only form of occupational stress. An example of a source of stress that is distinct from burnout but related is moral distress. This was particularly prevalent in healthcare professions in the early days of COVID-19, as many people in these fields were without adequate personal protective equipment. Many employees felt betrayed that they were not sufficiently protected.

Many organizations have responded to burnout with individual solutions to create “more resilient workers.” He noted that the business world rejected a similar notion 50 years ago in trying to build “strong workers.” Looking for solutions like this “is like a first-aid station on a factory floor to help when people are injured,” rather than redesign processes so they do not get injured in the first place, he commented.

Measuring Burnout

Maslach provided context for her development of the Maslach Inventory, which she explained grew out of years of research with colleague Susan Jackson to develop a measurement of burnout (Maslach and Jackson, 1981). While she was setting up a new lab at the University of California, Berkeley, she began interviewing subjects on emotionally challenging work and how people deal with this during the workday. She heard a consistent story across hundreds of people in many occupations, who described the chronic stressors they experienced at work. At the time, the term “burnout” did not exist for the situation she was documenting but the interviews became the basis for creating a measure to capture what respondents were expressing. She stressed that the inventory was not designed as a diagnostic

tool and is used incorrectly when it is employed to diagnose individuals. It is a discovery tool for research. It can answer questions about what burnout is, under what conditions it might be aggravated, and interventions that might help.

Shanafelt also noted the need for effective measurement tools to understand whether and when interventions are effective. In many instances, well-constructed interventions do not have the hoped-for effect. Given organizations’ finite resources, it is important to quantify effectiveness before scaling or promulgating interventions. “I look at that as a very high risk for resource utilization and diverting resources away from things that are effective,” he said. He also urged anchoring around a good, common definition that ties into at least four decades of research on the mechanistic drivers of burnout, such as workload, community, and balance. This allows for understanding what fuels burnout in a particular setting, which may lead to improving upstream drivers.

Systemic Focus

Maslach commented on the tendency to ask “who questions,” such as “Who is burned out?” By focusing on individuals, the action becomes what is wrong with them, how to fix them, where to move them, and the like. It leads to interventions that do not address root causes² in the environment. Those who experience greater burnout are a signal that something is not working in general across the workplace. She urged changing to “what and why questions,” such as “What is causing burnout?” and “Why is it happening?” This encourages us to look at causes and proactive prevention of burnout, not just treating people when they have it.

She said research from herself and her colleagues has identified at least six challenges that can arise in the workplace and that can predict burnout problems in the workforce:

1. Overload (high demand, low resources)
2. Lack of control (no autonomy or choice to do the job right)
3. Insufficient rewards (in terms of praise and opportunities)

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² We use the term “root causes” to highlight the multiple causes that are at the heart of burnout. There is no singular cause that produces burnout; however, there are multiple factors that are central to producing burnout. It is these root causes that are referenced throughout this proceedings.

4. Breakdown of the workforce community (bullying, social toxicity, lack of clarity about who to turn to for help)
5. Absence of fairness (such as discrimination and barriers to advancement)
6. Values conflict (an environment where the worker feels the values are “eating away my soul”)

Stigma

Fuentes-Afflick commented that many medical professionals experience or fear stigma if they disclose feelings of burnout. She asked how a clear understanding of burnout could challenge norms and promote conversations that could break down this stigma. Shanafelt harkened back to the WHO definition of burnout that states the root issue is the work environment and workplace systems, not a problem with the individual. Stigma occurs when someone feels marginalized or feels they are not seen as dedicated or tough enough and if they were to acknowledge the challenges they are facing, they would be viewed negatively. He stated that anchoring to the fact that this is a structural rather than an individual issue is helpful to challenge that stigma. It also enables a tie-in to the literature that can provide motivation for organizations to act. For example, there is robust data that burnout in nurses and physicians can affect quality-of-care outcomes, costs of care, and access, all of which are healthcare priorities. When organizations recognize that burnout is linked to these priorities, acting on it is not just a “nice thing to do, but is essential to accomplishing the core mission.” Anchoring to burnout also allows interventions to be evidence-informed, albeit not evidence-based, since what works in one situation will not necessarily work elsewhere.

Why It Matters

Before turning to audience questions, Fuentes-Afflick asked both panelists to share one element about burnout that they wish was better understood and why it matters for organizations and individuals. Maslach underlined the need to understand that burnout involves job conditions as much as, if not more than, qualities of individuals. It is critical to reduce or eliminate chronic job stressors that are causing the problem. Solutions might be to redesign jobs, using new processes or technologies, and putting in positives and not just negatives. She offered an acronym for this: GROSS, or Get Rid of Stupid Stuff.

To Shanafelt, the important thing to point out was, “We can address this issue. It has been done.” He acknowledged a sense of nihilism that nothing can be done given large systemic issues such as national payment models or economic belt-tightening that might make it seem like certain interventions are not feasible or could not tackle the broader issues. “You do not need a lot of money. It has to be prioritized. The most important asset is not financial capital, but leadership attention and behaviors,” he said. Flexibility and control do not have to cost a lot, and aligning values and leaders’ behaviors are in scope for many quality improvement efforts. Building a community of support, as well as giving people agency and voice, can have huge effects in all organizations, not just well-financed ones.

OPEN DISCUSSION

Worker Agency

Fuentes-Afflick opened the conversation to audience questions. One questioner noted that workers are often “at the mercy of employers,” and asked how workers can have more control, as Maslach and Shanafelt suggested. Shanafelt agreed that individuals may feel they are at the mercy of organizations, and organizations are also at the mercy of regulatory agencies, accrediting bodies, payment structures, and other actors. He paid tribute to work by the National Academies of Sciences, Engineering, and Medicine, such as a 2019 report from the National Academy of Medicine on clinician burnout, that has led to engagement by legislative bodies, payors, and professional societies in different conversations than were happening a decade ago (NASEM, 2019). However, he noted, macro policy changes may not always have the intended benefit. As an example, after years of work, the Centers for Medicare and Medicaid Services redefined some billing codes for physicians with the goal to reduce burnout. He credited the effort, but said penetration was modest and did not affect the day-to-day experience in the clinic. He urged looking at the different levels of individual, work group, and organization to make changes, not just the overall health system. He also urged not being distracted by the large, structural factors that will take decades to change while more limited changes are attainable and can contribute to future structural change.

Maslach reflected on Shanafelt’s notion of pebbles in the shoe and suggested thinking about scale. Reducing burnout does not require transforming healthcare. Everyday things that pose obstacles can be improved without

costing a lot of money. Ask workers about the main things that bother them, she recommended, then collaborate with them to make changes. When she recently worked with an organization, interviews revealed that workers desired simple interventions such as not holding meetings during lunch hour or at the end of the day. “What I hear from the top and from employees often do not match,” she observed. She also suggested that conversations take place regularly to identify problems and solutions to make things better for everyone.

Shanafelt added that each department in an organization has different needs. A classic impact/feasibility grid would show that some changes could have high impact but low feasibility, while others may make less impact but are very feasible now. Start with the latter, he urged. Higher-impact changes may become more feasible over time. He clarified that these less feasible but greater impact changes should not be avoided but recommended not getting distracted in seeking changes that will take years; instead, do the things that can give workers a better experience in the next 3 months. At the work unit level, if people have meaningful work, a well-led team, and agency, what is happening in the broader organization matters less. Maslach added that these steps build optimism and breed a sense of more control.

Quality of Care

The next question came from a participant interested in the relationship between burnout and quality of care in healthcare settings. They noted that research shows strong linkages using subjective measures but mixed evidence using objective measures such as clinical charts and asked about this discrepancy. Shanafelt said the majority of studies are subjective, although some good objective studies have taken place as well. He suggested that the Maslach Inventory can predict measures like patient experience prospectively. Other studies have looked at links between burnout and objective measures such as line infections, quicker discharge of patients, and post-operational pain in ensuing weeks. In the aggregate, they tell a compelling and consistent story. He added that he does not think more studies about the problem are needed. He would rather see rigorous research to test interventions. He also noted that looking at patients’ charts to measure the effect of burnout should not be the gold standard in this regard. “Near misses are not documented in the chart,” he commented. As an example, Shanafelt highlighted that a doctor writing an incorrect dose of chemotherapy that is intercepted by a chemotherapy pharmacist before

affecting the patient does not end up in the chart, but if thousands of those events happen, some will sneak through and result in negative outcomes. As a new measure to look at burnout, he pointed to entries in electronic health records, and specifically when a potential medical error is retracted within 60 seconds.

Continued Confusion

In closing, a virtual participant brought up continued confusion or conflation of burnout with other conditions, despite the WHO definition. Maslach posited that part of the confusion is that the term “burnout” is commonly used for all kinds of things in everyday life, highlighting how the term can become muddled when it is applied to so many different scenarios, some of which look nothing like what the WHO defines as burnout. Understanding and addressing burnout, however, requires a shared definition about the issue.