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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 16-23

Impacting pediatric cardiologist burnout: The role of targeted work unit interventions


1 Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
2 Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
3 Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA

Date of Submission11-Apr-2021
Date of Acceptance07-Nov-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Soham Dasgupta
Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_28_20

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  Abstract 


Introduction: Burnout among physicians may impact productivity and result in suboptimal patient care. Studies looking at burnout in a specific pediatric subspecialty are extremely limited. In a previous study, the authors evaluated the work–life balance and burnout among pediatric cardiology attending at our institution. This demonstrated early signs of reduced work engagement and possible burnout in the near future. To address this, the authors implemented a number of targeted interventions and conducted a follow-up survey to assess the effects of such changes. The objective of this study was to evaluate the current status of work–life balance and burnout among pediatric cardiologists at the author's institution compared to the general population and to the prior survey.
Materials and Methods: Pediatric cardiology attending physicians were surveyed at the author's institution to assess their perception of burnout and work–life balance using the Maslach burnout inventory and the areas of work–life survey.
Results: Forty-seven of the 52 pediatric cardiologists responded to the survey. They were divided into groups by their respective subspecialty: interventional/electrophysiology (n = 2), cardiac intensive care unit/inpatient (n = 9), noninvasive imaging (n = 6), outpatient (n = 22), and other (n = 8). When compared to the previous survey, the Maslach burnout inventory scores were significantly lower in the area of emotional exhaustion. However, most scores in the areas of work–life survey were lower than the prior survey.
Conclusion: This follow-up study focusing on pediatric cardiology attending physicians demonstrated worsening burnout and signs of reduced work engagement compared to the previous survey 4 years ago. Interventions did not include bolstering our physician support systems and developing resiliency training for our physicians, which is an area the authors are going to focus on going forward.
The following core competencies are addressed in this article: Medical knowledge, Practice-based learning, Systems-based practice.

Keywords: Burnout, cardiology, pediatrics, work–life


How to cite this article:
Parsons C, Dasgupta S, Mohl L, Sachdeva R, Border W. Impacting pediatric cardiologist burnout: The role of targeted work unit interventions. Int J Acad Med 2022;8:16-23

How to cite this URL:
Parsons C, Dasgupta S, Mohl L, Sachdeva R, Border W. Impacting pediatric cardiologist burnout: The role of targeted work unit interventions. Int J Acad Med [serial online] 2022 [cited 2022 Oct 5];8:16-23. Available from: https://www.ijam-web.org/text.asp?2022/8/1/16/341186




  Introduction Top


Physicians are exposed to workplace factors that may result in acute or chronic stress, resulting in burnout. This may impact productivity and result in suboptimal patient care practices. Recent studies suggest that burnout may affect professionalism, influence quality of care, increase the risk for medical errors, and promote early retirement.[1],[2],[3],[4],[5] In addition, burnout may affect the personal lives of physicians and lead to broken relationships, excessive alcohol use, and suicidal ideation.[6],[7],[8] A study looking at burnout and work–life balance among physicians in the United States relative to the general population found that the prevalence of burnout among United States physicians is at a high level, with physicians in specialties such as emergency medicine, general internal medicine, and family medicine being at greatest risk. A study reported that after adjusting for hours worked per week, higher levels of education and professional degrees outside the field of medicine seemed to reduce the risk for burnout, whereas a degree in medicine increased the risk.[9] The same study reported that physicians work longer hours. In addition, recent data demonstrated that more than 25% of adult cardiologists in the United States reported feelings of burnout.[10]

However, limited studies have looked at burnout among physicians in the field of pediatric medicine, and the studies looking at burnout in a specific pediatric subspecialty are further limited. In a previous study, we evaluated the work–life balance and burnout specifically among pediatric cardiology attending at our institution.[11] The study demonstrated early signs of reduced work engagement and possible burnout in the near future, especially in full-time physicians and those in practice greater than 10 years. To address this, we implemented a number of targeted interventions based on the feedback received and conducted a follow-up survey after 4 years to assess the effects of such changes. This study evaluates the current status of work–life balance and burnout among pediatric cardiologists at our institution compared to the general population and to the prior survey.


  Materials and Methods Top


Based on the results of the previous survey in 2015, we had implemented a number of changes within our organization [Table 1]. These included but were not limited to physician-friendly enhancements to the electronic medical record, patient scheduling changes, more favorable “paid leave of absence” policies, and changes related to administrative time for physicians. A follow-up anonymous survey was sent out by e-mail to the pediatric cardiology faculty at our institution. Compared to the last survey, we had 15 new physicians and 45/50 physicians had taken the 2015 survey. We used the Maslach burnout inventory and the areas of work–life survey to assess their perception of burnout and work–life balance. Participation was voluntary, and all the responses were anonymous. The anonymous nature of the two surveys prevented us from comparing and contrasting specific demographics of the study participants in both the surveys. Participants were divided into five groups based on their primary clinical area of interest: Interventional/electrophysiology, cardiac intensive care/inpatient, noninvasive imaging, outpatient, and other (respondents who did not fit into a specific category or who worked in more than one subspecialty area). Physician demographic variables including gender, years of employment, years in current position, and employment status were collected. The study was determined to be exempt by Institutional Review Board / Ethics Committee.
Table 1: Interventions made based on the results of the 2015 survey

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The Maslach burnout inventory

Burnout among physicians was measured using the Maslach burnout inventory for medical personnel, a validated 22-item questionnaire for measuring burnout.[1],[12],[13],[14] The Maslach burnout inventory “General Population Norm” that is referenced in the Maslach burnout inventory-HSS and Maslach burnout inventory-HSS (MP) individual and group reports includes frequency scores from a general population of 11,000+ people in the human service professions. Occupations represented include 4163 teachers (elementary and secondary, grades K-12); 635 postsecondary educators (college, professional schools); 1538 social service workers (social workers, child protective service workers); 1104 medical workers (physicians, nurses); 730 mental health workers (psychologists, psychotherapists, counselors, mental hospital staff, and psychiatrists); and 2897 others (legal aid employees, attorneys, police officers, probation officers, ministers, librarians, and agency administrators). The Maslach burnout inventory for medical personnel has three subscales to evaluate each domain of burnout, including emotional exhaustion, depersonalization, and low personal accomplishment. The nine-item emotional exhaustion scale measures feelings of being emotionally overextended and exhausted at one's work. Higher scores correspond to experiencing greater burnout. The five-item depersonalization scale measures an impersonal response toward recipients of one's service, care, treatment, or instruction. Higher scores correspond to experiencing greater degrees of burnout. The eight-item personal accomplishment scale measures feelings of competence and successful achievement in one's work with people. Lower scores correspond to experiencing greater burnout. The Maslach burnout inventory for medical personnel is a variation of the original Maslach burnout inventory and is specifically directed toward medical personnel. The most notable alteration is that this form refers to “patients” instead of “recipients.” All Maslach burnout inventory scales are scored using a 7-point frequency scale, and each scale measures its own unique dimension of burnout. The 7-point frequency scale for all Maslach burnout inventory scales is as follows: never, a few times a year or less, once a month or less, a few times a month, once a week, a few times a week and every day.

The areas of work–life survey

The areas of work–life survey was created to assess employees' perceptions of work–setting qualities that play a role in whether they experience work engagement or burnout. It is a companion piece to the Maslach burnout inventory. The areas of work–life survey is a short questionnaire with demonstrated reliability and validity across a variety of occupational settings.[15] It produces a profile of scores that permit users to identify key areas of strength or weaknesses in their organizational settings. It applies to small workgroups or summary profiles across large organizations. The areas of work–life survey evaluates six areas of work–life including workload, control, reward, community, fairness, and values. The areas of work–life survey contains 28 separate questions, and the response options are “strongly disagree,” “disagree,” “hard to decide,” “agree,” or “strongly agree.”

Statistical analysis

Data were summarized using descriptive statistics including counts and percentages for categorical variables or means and standard deviations for continuous variables, as appropriate. Before statistical analyses, areas of work–life survey responses were collapsed into two levels: participants endorsing “agreed” or “strongly agreed” were grouped together and compared to those endorsing “strongly disagree,” “disagree,” or “hard to decide.” Similarly, Maslach burnout inventory responses were further collapsed into two groups: Those who responded at least a few times a month or more and those who responded once a month or less. Concerning areas in the Maslach burnout inventory survey were defined as more than 50% of the respondents answering “yes” to a question at least a few times a month or more. Based on these binary classifications, responses to questions were compared among physician characteristic subgroups (e.g., gender or years of experience). Continuous variables, such as each domain of burnout from the Maslach burnout inventory, were compared to the general population Maslach burnout inventory scores and the Maslach burnout inventory scores from the previous survey using one-sample t-tests and the sign test procedure. Statistical analyses were performed using SAS v. 9.4 (SAS Institute, Cary, NC, USA), and significance was assessed at the 0.05 level.


  Results Top


Of the 52 pediatric cardiologists who received the survey, 47 responded (response rate 90.4%). These respondents were broken down by their respective subspecialty: interventional/electrophysiology physicians (n = 2), cardiac intensive care unit/inpatient physicians (n = 9), noninvasive imaging physicians (n = 6), outpatient physicians (n = 22), and other (n = 8). Further physician characteristics are described in [Table 2].
Table 2: Characteristics of the physicians who responded to the survey

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The Maslach burnout inventory group scores were compared to the general population and to the scores of the previous survey. When compared to the general population [Figure 1], group-specific scores were higher in the area of emotional exhaustion (2.6 vs. 2.3); however, this did not achieve statistical significance (P = 0.09). In contrast, group-specific scores were significantly better in the areas of depersonalization (1.03 vs. 1.7; P < 0.0001) and personal accomplishment (5.09 vs. 4.3; P < 0.0001). When compared to the Maslach burnout inventory scores from the previous survey [Figure 2], there was a significant increase in the group-specific scores in the area of emotional exhaustion (2.57 vs. 1.8; P < 0.001). However, the group-specific scores were not significantly different in the areas of depersonalization (1.03 vs. 0.9; P = 0.17) and personal accomplishment (5.09 vs. 5.2; P = 0.56). Concerning areas in the Maslach burnout inventory were limited to the area of emotional exhaustion. The most concerning finding was 85% of physicians reporting “I feel used up at the end of the workday” at least a few times a month. Further concerning responses included the following at least a few times a month or more: “I feel emotionally drained from my work” (74%), “I feel fatigued when I get up in the morning and have to face another day on the job” (72%), “I feel I am working too hard on my job” (68%), and “I feel burned out from my work” (62%). Concerning results were further stratified by gender, area of work and interest, years of employment, and employment status [Figure 3]. All interventional/electrophysiology and noninvasive imaging physicians felt used up at the end of the workday at least a few times/month, while 89% of cardiac intensive care/inpatient and 82% of outpatient physicians felt the same way at least a few times/month. Full-time physicians were more likely to complain of feeling used up at the end of the workday as compared to part time physicians (90% vs. 71%); however, no significant differences were noted based on gender or years of employment.
Figure 1: The overall Maslach burnout inventory results compared to the general population

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Figure 2: The overall Maslach burnout inventory results compared to the results from the 2015 survey

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Figure 3: Concerning areas of the Maslach burnout inventory stratified by location, gender, years, and type of employment

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The areas of work–life survey scores were compared to the general population and to the scores of the previous survey. When compared to the general population [Figure 4], the scores in the areas of workload (2.5 vs. 3; P < 0.0001), community (4.2 vs. 3.4; P < 0.0001), fairness (3.5 vs. 2.8; P < 0.0001), and values (4.1 vs. 3.2; P < 0.0001) were significantly different. Scores in the areas of control (3.3 vs. 3.3; P = 0.5424) and reward (3.5 vs. 3.2; P = 0.0789) were not significantly different when compared to the general population. When compared to the areas of work–life scores from the previous survey [Figure 5], only the scores in the areas of fairness (3.5 vs. 3.8; P = 0.0315) and values (4.1 vs. 4.5; P = 0.0037) were significantly different and lower. Concerning areas in the areas of work–life survey (i.e., >50% of the respondents endorsing agree/strongly agree to a question) were stratified further and were limited to the area of workload [Figure 6]. In this category, 89% of the respondents felt that they “worked intensely for prolonged periods of time,” 72% felt that “they had so much work on the job that it took them away from their personal interests,” 66% felt that they “left their work behind when they went home at the end of the workday,” and 57% felt that they “did not have the time to do the work that must be done.” The complete responses of the Maslach burnout inventory and the areas of work–life survey are described in [Tables S1[Additional file 1]] and [Table S2[Additional file 2]].
Figure 4: The overall areas of work–life survey scores compared to the general population

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Figure 5: The overall areas of work–life survey scores compared to the results from the 2015 survey

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Figure 6: Concerning areas of the areas of work–life survey stratified by location, gender, years, and type of employment

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  Discussion Top


This follow-up study examined burnout and work–life balance among pediatric cardiologists at our institution, 4 years after targeted interventions were enacted. Our study compared the rates of burnout among pediatric cardiologists at out center with the general medical community and with the results of the previously published study.[11] Burnout can lead to multiple problems in practicing physicians which may impact both patient care and personal and professional relationships. Hence, it is important to elucidate the causes of burnout to form and implement better strategies to effectively cope with it. One of the accepted standards for a diagnosis of burnout is the Maslach burnout inventory, developed by Maslach and Leiter at the University of San Francisco in the 1970s.[16] Similar to the previous study, we used two tools to assess physician burnout and work–life balance; the Maslach burnout inventory and areas of work–life survey.

The Maslach burnout inventory showed group-specific scores which were significantly better than the general population in the areas of depersonalization and personal accomplishment but were worse in the area of emotional exhaustion (not statistically significant). However, the scores in the area of emotional exhaustion were significantly worse when compared to the previous survey. The most concerning area in the Maslach burnout inventory was a majority of physicians reporting that they felt used up at the end of the workday and was more likely in full time employed physicians. In addition to the Maslach burnout inventory, the areas of work–life survey was significant for a worse score in the area of workload when compared to the general population. What was more concerning was that most scores were lower when compared to the prior survey.

It was quite surprising and disappointing to note that higher scores in the Maslach burnout inventory and lower scores in the areas of work–life survey after changes were implemented within our organization following the prior survey. Our institution has seen a steady increase in the number of patients over the past 4 years, adding to the workload of existing physicians. Second, we underwent changes with respect to leadership and staff members over the same time period. This may have negated a lot of the changes which were implemented. In a recent paper, Shanafelt and Noseworthy grouped the main drivers of burnout into four categories.[17] These included individual factors, work unit factors, organization factors, and national factors. A lot of the changes that were made based on the prior survey were geared toward work unit (division of cardiology) factors, precisely for the reason that these are easier to control and implement. However, the changes were not geared toward individual factors, and we hypothesize that this may be another reason why the survey results did not demonstrate an improvement in spite of implemented changes. We do have a wellness program that includes the physicians, but we did not do any extensive physician-targeted educational interventions around personal resilience.

Changes we plan to implement moving forward following this recent survey include the hiring of more physicians in the areas of cardiac intensive care/inpatient, noninvasive imaging, and outpatient. We also plan to increase the number of allied professionals in these three areas to reduce the feeling of burnout among individuals. We continue to make improvements to the clinical note templates, smart phrases in the electronic medical record, and enhanced electronic dictation services. We are trying to be more stringent with protecting administrative time for every employed professional and increasing the support staff at our call centers to help with the screening and burden of questions from patients and parents. Most importantly, we plan to implement changes geared toward individual factors of burnout which we believe to be a significant driver for a reduction in resiliency among our physicians. Resiliency may be defined as the acquired ability to regularly recover, adapt, and grow from stress. Research is being conducted to determine factors that may affect physician resiliency, and this term has received a lot of spotlight in the recent past.[18] Resiliency interventions have been met with cynicism by physicians in the past and lumped together with ineffectual generic wellness programs often created by human resource executives. However, we are planning to form a physician task force with a physician representative for each domain of the areas of work–life survey – workload, control, reward, community, fairness, and values. These physician leaders can then tailor interventions to improve the resiliency and stamina of the physician group. By bolstering the strength of our division and physicians in the domains of control, reward, community, fairness and values, we hope to be able to defend ourselves against the threat of workload (since this is often out of our direct control).

An important limitation of this study is that it is a relatively small sample representing a single model of pediatric cardiology practice. Although this study is not generalizable to other programs or other subspecialties, it enlightens our field regarding the potential factors that could play an important role in physician burnout. In addition, it is challenging to discern the specific interventions that may or may not have been helpful, since a large number of interventions were performed based on the results of the prior survey.


  Conclusion Top


Our single-center follow-up study focusing on pediatric cardiology attending physicians demonstrated worsening burnout and signs of reduced work engagement compared to the previous survey 4 years ago. This is disappointing, given the number of targeted work unit interventions which we implemented. Our interventions did not include bolstering our physician support systems and developing resiliency training for our physicians, which is an area we are going to focus on going forward. Alternatively, this trend may in fact represent a national trend, which is in of itself concerning. This study will hopefully inform other pediatric cardiology programs in some of the unique factors that threaten resilience among their faculty. Our study also highlights the importance of conducting follow-up surveys after implementation of changes to guide further intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to be exempt by the Institutional Review Board/Ethics Committee.



 
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Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377-85.  Back to cited text no. 9
    
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Mehta LS, Lewis SJ, Duvernoy CS, Rzeszut AK, Walsh MN, Harrington RA, et al. Burnout and career satisfaction among U.S. Cardiologists. J Am Coll Cardiol 2019;73:3345-8.  Back to cited text no. 10
    
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Leiter M, Durup J. The discriminant validity of burnout and depression: A confirmatory factor analytic study. Anxiety Stress Coping 1994;7:357-73.  Back to cited text no. 14
    
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Leiter M, Maslach C. Areas of work life: A structured approach to organizational predictors of job burnout. Res Occup Stress Well Being 2004;3:91-134.  Back to cited text no. 15
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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