Read the attached articles and answer the below questions for each article Consider the set of three research articles linked in Resourcesfor this assignment. Prepare a paper in which you completethe

Patients and Methods:From August 28, 2014, to October 6, 2014, we surveyed both US physicians and a probability-based sample of the general US population using the methods and measures used in our 2011 study. Burnout was measured using validated metrics, and satisfaction with work-life balance was assessed using standard tools.

Results:Of the 35,922 physicians who received an invitation to participate, 6880 (19.2%) completed surveys. When assessed using the Maslach Burnout Inventory, 54.4% (n¼3680) of the physicians reported at least 1 symptom of burnout in 2014 compared with 45.5% (n¼3310) in 2011 (P<.001). Satisfaction with work-life balance also declined in physicians between 2011 and 2014 (48.5% vs 40.9%;P<.001).

Substantial differences in rates of burnout and satisfaction with work-life balance were observed by specialty. In contrast to the trends in physicians, minimal changes in burnout or satisfaction with work-life balance were observed between 2011 and 2014 in probability-based samples of working US adults, resulting in an increasing disparity in burnout and satisfaction with work-life balance in physicians relative to the general US working population. After pooled multivariate analysis adjusting for age, sex, rela- tionship status, and hours worked per week, physicians remained at an increased risk of burnout (odds ratio, 1.97; 95% CI, 1.80-2.16;P<.001) and were less likely to be satisfied with work-life balance (odds ratio, 0.68; 95% CI, 0.62-0.75;P<.001).

Conclusion:Burnout and satisfaction with work-life balance in US physicians worsened from 2011 to 2014. More than half of US physicians are now experiencing professional burnout. ª2015 Mayo Foundation for Medical Education and Research nMayo Clin Proc. 2015;90(12):1600-1613 M edicine is both a demanding and a rewarding profession. Physicians spend more than a decade in postsec- ondary education, work substantially more hours than most US workers in otherfields, and often struggle to effectively integrate their personal and professional lives. 1They engage in highly technical and intellectually demanding work that often requires complex, high-stakes decision making despite substantial uncertainty.

These challenges are offset by meaningful rela- tionships with patients, the intellectual stimula- tion of the work, and the satisfaction of helping fellow human beings. 2-4 Physicians are also wellcompensated relative to many professions, are part of a fraternity of supportive colleagues, and often enjoy the respect and appreciation of their community.

The cumulative effect of these forces on the personal and professional satisfaction of each physician is unique. Although future physicians begin medical school with mental health profiles better than those of college graduates pursuing otherfields, 5this profile is reversed 1 to 2 years into medical school. 6 Once in practice, physicians have generally high degrees of satisfaction with their career choice but experience high degrees of For editorial comment, see page 1593; for a related article, see page 1694 From the Division of Hematology (T.D.S.), Division of Primary Care Internal Medicine (L.N.D.), Division of Biomedical Statistics and Informatics Affiliations continued at the end of this article.

ORIGINAL ARTICLE 1600 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org nª2015 Mayo Foundation for Medical Education and Research professional burnout and dissatisfaction with work-life integration. 1,7 Burnout is a syn- drome of emotional exhaustion, loss of mean- ing in work, feelings of ineffectiveness, and a tendency to view people as objects rather than as human beings. 8Burnout has profound implications for individual physicians and their families. 9,10 In addition, burnout appears to impact the quality of care physicians pro- vide 11-16 and physician turnover, 17,18 which have profound implications for the quality of the health care delivery system. 15,19,20 In 2011, we conducted a national study measuring burnout and other dimensions of well-being in US physicians as well as the gen- eral US working population. 1At the time of that study, approximately 45% of US physi- cians met criteria for burnout. Substantial vari- ation in the rate of burnout was observed by specialty, with the highest rates observed among many specialties at the front line of access to care (eg, family medicine, general internal medicine, and emergency medicine).

Burnout among physicians also varied by career stage, with the highest rate among mid- career physicians. 21 Burnout was more com- mon among physicians than among the general US working population, afinding that persisted after adjusting for age, sex, hours worked, and level of education. 1 The landscape of medicine continues to rapidly evolve. Technology, legislation, and market forces have contributed to consolida- tion of medical practices,fluctuating reim- bursement, new care delivery models, increased productivity expectations for physi- cians, and more widespread use of electronic medical records over the past several years. 22 The study of US physicians wefirst reported on in 2011 was designed to reevaluate the well-being and satisfaction of US physicians approximately every 3 years to assess changes in burnout and satisfaction with work-life bal- ance (WLB) over time. Here, we report results of the 2014 survey in comparison to the 2011 findings.

PATIENTS AND METHODS The 2014 survey used methods similar to those of the 2011 study. 1At both time points, we assessed a range of personal and profes- sional characteristics as well as personal well- being in several dimensions (described below).Participants Physician Sample.A sample of physicians from all specialty disciplines was assembled using the American Medical Association (AMA) Physician Master File (PMF). The PMF is a nearly complete record of all US phy- sicians independent of AMA membership. To ensure an adequate sample of physicians from each specialty area, we oversampled phy- sicians infields other than family medicine, general pediatrics, general internal medicine, and obstetrics/gynecology. Canvassing e-mails stating the purpose of the study (eg, to better understand the factors that contribute to satis- faction in US physicians), along with an invita- tion to participate and a link to the survey, were sent to 94,032 physicians in August 2014 with 3 reminder requests sent over the ensuing 6 weeks. The 35,922 physicians who opened at least 1 invitation e-mail were considered to have received the invitation to participate in the study. 23 Participation was voluntary, and all responses were anonymous.

Population Control Sample.For comparison to physicians, we surveyed a probability-based sample of individuals from the general US pop- ulation in October 2014. Although the initial population comparison (December 2010) used modest oversampling of individuals younger than 34 years (to allow comparison to medical students and residents), 1the 2014 population survey oversampled individuals between the ages of 35 and 65 years to better match the age range of practicing US physicians. The population survey was conducted using the Knowledge Panel, a probability-based panel (http://www.

knowledgenetworks.com/knpanel/index.html andhttp://www.knowledgenetworks.com/ganp/ reviewer-info.html) designed to be representa- tive of the US population. On the basis of the intent to compare workers in otherfields to physicians, only employed individuals were surveyed. The Mayo ClinicInstitutional Review Board reviewed and approved the study.

Study Measures Both the physician and population controls pro- vided information on demographic characteris- tics (age, sex, and relationship status), hours worked per week, burnout, symptoms of depression, suicidal ideation, and satisfaction with WLB. Physician professional characteristics INCREASING BURNOUT AMONG US PHYSICIANS, 2011 TO 2014 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org 1601 were ascertained by asking physicians about their practice. Population controls also provided information about the highest level of education completed and occupation.

Burnout.Burnout among physicians was measured using the Maslach Burnout Inventory (MBI), a validated 22-item questionnaire consid- ered the criterion standard tool for measuring burnout. 8,24-26 Consistent with convention, 27-29 we considered physicians with a high score on the depersonalization and/or emotional exhaus- tion subscales of the MBI as having at least 1 manifestation of professional burnout. 8 Although the 22-item MBI is the criterion standard for the assessment of burnout, 8its length and the expense of administration limit feasibility for use in long surveys addressing multiple content areas or in large population samples. Thus, to allow comparison of burnout between physicians and population controls, we measured burnout in both groups using 2 single-item measures adapted from the full MBI (ie, physicians completed the full MBI and the 2-item instrument; controls completed just the 2-item instrument). These 2 items correlated strongly with the emotional exhaustion and depersonalization domains of burnout as measured by the full MBI in a sample of more than 10,000 individuals 30,31 with an area under the receiver operator characteristic curve of 0.94 and 0.93 for emotional exhaustion and deper- sonalization, respectively, for these single items relative to the full MBI. This approach has also been used in previous large-scale national studies of US physicians collectively enrolling more than 20,000 physicians.

1,32 Symptoms of Depression and Suicidal Ideation.Symptoms of depression among physicians were assessed using the 2-item Pri- mary Care Evaluation of Mental Disorders, 33 a standardized and validated assessment for depression screening that performs as well as longer instruments. 34 It should be noted that this tool has a high sensitivity but lower spec- ificity such that approximately 1 of every 4 individuals screening positive would meet criteria for major depression if they were to undergo full psychiatric assessment. Recent suicidal ideation was evaluated by asking par- ticipants,“During the past 12 months, have you had thoughts of taking your own life?”Thisitem was designed to measure somewhat recent, but not necessarily active suicidal idea- tion. 35 These questions have been used exten- sively in other studies and allow ready comparison to the prevalence of suicidal idea- tion in other studies of the US population 36-38 and US physicians. 1,39 Satisfaction With WLB.Satisfaction with WLB was assessed by the item“My work schedule leaves me enough time for my personal/family life”(response options: strongly agree, agree, neutral, disagree, and strongly disagree). 1In- dividuals who indicated“strongly agree”or “agree”were considered to be satisfied with their WLB, whereas those who indicated“disagree”or “strongly disagree”were considered to be dissatisfied with their WLB.

Statistical Analyses Standard descriptive summary statistics were used to characterize the physician and control samples. Associations between variables were evaluated using the Kruskal-Wallis test (contin- uous variables) or the chi-square test (categorical variables), as appropriate. All tests were 2-sided with type I error rates of .05. Multivariate analysis of differences across physician specialties was per- formed using logistic regression. Similarly, a pooled multivariate logistic regression analysis of physicians and population controls was per- formed to identify demographic and professional characteristics associated with the dependent out- comes. For all comparisons with population con- trols, physician data were restricted to responders who were between the ages of 29 and 65 years and not retired to match the age of the population sample. Comparisons between physicians in 2011 and 2014 were made using the chi-square test or the Kruskal-Wallis tests, as appropriate.

These data were not paired and were treated as in- dependent samples. Comparisons in the propor- tions of burnout and satisfaction with WLB between physicians and populations controls in 2011 relative to 2014 were performed using Breslow-Day tests. All analyses were done using SAS version 9 (SAS Institute Inc).

RESULTS Well-being of US Physicians Of the 35,922 physicians who received an invi- tation to participate, 6880 (19.2%) completed MAYO CLINIC PROCEEDINGS 1602 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org TABLE 1. Demographic Characteristics of Responding Physicians Compared With All US Physicians Characteristic2014 Responders (N¼6880)All US physicians 2014 (n¼835,451)2011 Responders (N¼7288) Sex Male 4497 (67.5%) 557,063 (66.8%) 5241 (71.9%) Female 2162 (32.5%) 277,271 (33.2%) 2046 (28.1%) Missing 221 1117 1 Age (y) Median 56 51.5 a 55 <35 332 (5.0%) 59,849 (7.2%) 321 (4.5%) 35-44 1223 (18.4%) 219,394 (26.3%) 1299 (18.0%) 45-54 1416 (21.3%) 219,492 (26.3%) 1842 (25.6%) 55-64 2193 (33.0%) 211,056 (25.3%) 2586 (35.9%) 65 1491 (22.4%) 125,660 (15.0%) 1162 (16.1%) Missing 225 75 Primary care b Primary care 1596 (23.3%) 277,425 (32.1%) a 1907 (26.4%) Nonprimary care 5249 (76.7%) 585,507 (67.9%) a 5326 (73.6%) Specialty Anesthesiology 236 (3.5%) 309 (4.3%) Dermatology 164 (2.4%) 174 (2.4%) Emergency medicine 355 (5.2%) 333 (4.6%) Family medicine 540 (7.9%) 752 (10.4%) General surgery 259 (3.8%) 276 (3.8%) General surgery subspecialty c 381 (5.6%) 374 (5.2%) Internal medicine-general 453 (6.6%) 578 (8.0%) Internal medicine subspecialty b 784 (11.5%) 1019 (14.1%) Neurology 246 (3.6%) 252 (3.5%) Neurosurgery 58 (0.9%) 82 (1.1%) Obstetrics and gynecology 246 (3.6%) 312 (4.3%) Ophthalmology 241 (3.5%) 199 (2.8%) Orthopedic surgery 239 (3.5%) 269 (3.7%) Otolaryngology 165 (2.4%) 193 (2.7%) Other 255 (3.7%) 329 (4.6%) Pathology 170 (2.5%) 184 (2.5%) Pediatrics-general 362 (5.3%) 286 (4.0%) Pediatric subspecialty c 321 (4.7%) 239 (3.3%) Physical medicine and rehabilitation 170 (2.5%) 97 (1.3%) Preventive medicine, occupational medicine, or environmental medicine 112 (1.6%) 76 (1.1%) Psychiatry 566 (8.3%) 488 (6.8%) Radiation oncology 64 (0.9%) 55 (0.8%) Radiology 261 (3.8%) 216 (3.0%) Urology 119 (1.7%) 136 (1.9%) Missing 66 60 Hours worked per week Median 50 (40-60) 50 (40-60) <40 1172 (17.4%) 985 (14.3%) 40-49 1340 (19.9%) 1459 (21.1%) 50-59 1667 (24.7%) 1852 (26.8%) 60-69 1526 (22.6%) 1659 (24.0%) 70-79 535 (7.9%) 455 (6.6%) 80 509 (7.5%) 497 (7.2%) Missing 131 381 No. of nights on call per week Median (interquartile range) 1 (0-3) 1 (0-3) Primary practice setting Private practice 3605 (52.6%) 4087 (57.7%) Continued on next page INCREASING BURNOUT AMONG US PHYSICIANS, 2011 TO 2014 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org 1603 surveys. The demographic characteristics of participants relative to all 835,451 US physi- cians were generally similar, although partici- pants were slightly older (Table 1). The 2014 participants were also similar to the 2011 par- ticipants (Supplemental Table 1, available on- line athttp://www.mayoclinicproceedings.org) other than a slight increase in women physi- cians (2011: 28.1%; 2014: 32.5%), consistent with the increased proportion of women among US physicians overall (2011: 30.7%; 2014: 33.2%). Analysis of early responders compared with late responders (a standard approach to evaluate for response bias) by age, sex, and specialty found no statistically significant differences when comparing sex and specialty (primary care vs nonprimary care) and only a minor difference in age (median, 56.0 years vs 57.0 years), providing further evidence that the sample was generally representative of US physicians from a demographic perspective.

Rates of burnout, symptoms of depression, suicidal ideation in the last 12 months, and satis- faction with WLB among participating physi- cians are summarized inTable 2.When assessed using the full MBI, 46.9% of US physi- cians had high emotional exhaustion, 34.6% high depersonalization, and 16.3% a low sense of personal accomplishment in 2014. In aggre- gate, 54.4% of the physicians had at least 1 symptom of burnout based on a high emotional exhaustion score and/or a high depersonaliza- tion score. Only 40.9% of the physicians felt that their work schedule left enough time for personal/family life, with 14.6% neutral and 44.5% disagreeing with this assertion.When compared with 2011, rates of burnout among physicians were higher (54.4% vs 45.5%; P<.001) in 2014 and satisfaction with WLB was lower (40.9% vs 48.5%;P<.001). In contrast, minimal differences were observed in the pro- portion of physicians reporting symptoms of depression (39.8% vs 38.2%;P¼.04) and no difference in the rates of suicidal ideation was observed (6.4% vs 6.4%;P¼.98).

As in 2011, substantial variation in the prev- alence of burnout was observed by specialty.

Compared with 2011, the prevalence of burnout was higher for all specialty disciplines in 2014 (Figure 1, A). Family medicine (51.3% vs 63.0; P<.001), general pediatrics (35.3% vs 46.3%; P¼.005), urology (41.2% vs 63.6%;P<.001), orthopedic surgery (48.3% vs 59.6%;P¼.01), dermatology (31.8% vs 56.5%;P<.001), phys- ical medicine and rehabilitation (47.4% vs 63.3%;P¼.01), pathology (37.6% vs 52.5%; P¼.006), radiology (47.7% vs 61.4%;P¼.003), and general surgery subspecialties (42.4% vs 52.7%;P¼.005) each experienced a more than 10% increase in burnout.

Substantial variation in satisfaction with WLB was also observed by specialty. Satisfaction with WLB was lower in 2014 for all specialty dis- ciplines with the exception of obstetrics and gynecology and general surgery (Figure 1,B).

Categorization of the 24 specialty disciplines basedonwhethertheprevalenceofburnout and satisfaction with WLB in their specialty was above or below the prevalence of all US physicians in each dimension is shown inFigure 1,C.

We next conducted multivariate analysis to identify factors associated with burnout TABLE 1. Continued Characteristic2014 Responders (N¼6880)All US physicians 2014 (n¼835,451)2011 Responders (N¼7288) Primary practice setting, continued Academic medical center 1625 (23.7%) 1494 (21.1%) Veterans hospital 104 (1.5%) 184 (2.6%) Active military practice 58 (0.8%) 65 (0.9%) Not in practice or retired 160 (2.3%) 89 (1.3%) Other 1303 (19%) 1164 (16.4%) Missing 25 205 aAs of March 11, 2015.bPhysicians in subspecialty areas were intentionally oversampled to provide an adequate number of responses from physicians from each specialty to allow comparison across specialties. Primary care specialties include the following: Internal medicine-general, general practice, family medicine, obstetrics/gynecology, and pediatrics-general.

cFor further subspecialty breakdown, see the Supplemental Material, available online athttp://www.mayoclinicproceedings.org. MAYO CLINIC PROCEEDINGS 1604 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org and satisfaction with WLB. Age, sex, specialty, hours worked per week, and practice setting were independently associated with both burnout and satisfaction with WLB (all P<.05;Supplemental Table 2, available online athttp://www.mayoclinicproceedings.org).

Comparison of Physicians With the General US Working Population To compare the professional experience of practicing physicians relative to working US adults, 5313 nonretired physicians aged 29 to 65 years were compared with 5392 employed, nonphysician population control subjects aged 29 to 65 years (Table 3). The overall prevalence of burnout on the 2-item burnout measure for the general US working population was similar to that for the 2011 sample (28.4% vs 28.6%; P¼.85). Satisfaction with WLB for the general US working population in 2014 was slightly more favorable than for the 2011 sample (61.3% vs 55.1%;P<.001).

Compared with population controls, physi- cians were older (median, 53 years vs 52 years; P<.001), more likely to be men (62.2% vs 54.4%), and more likely to be married (82.9% vs 67.5%;P<.001). Similar to the 2011find- ings, physicians worked a median of 10 hours more per week than US workers in general (50 vs 40 hours), with 41.8% of the physicians and 6.4% of the controls working 60 hours or more per week (P<.001 for both). On the 2- item burnout measure, physicians had higher rates of emotional exhaustion (43.2% vs 24.8%;P<.001), depersonalization (23.0% vs 14.0%;P<.001), and overall burnout (48.8% vs 28.4%;P<.001) (Figure 2, A). After adjusting for age, sex, relationship status, and hours worked per week, physicians remained at increased risk for burnout compared with the population (odds ratio, 1.97; 95% CI, 1.80- 2.16;P<.001) (Figure 2, B). Physicians also had a lower rate of satisfaction with WLB than did the general US working population (36.0% vs 61.3%;P<.001). After adjusting for age, sex, relationship status, and hours worked per week, physicians remained less likely to be satis- fied with WLB compared with the population (odds ratio, 0.68; 95% CI, 0.62-0.75;P<.001).

DISCUSSION Burnout is a pervasive problem among physi- cians that appears to be getting worse. Ourfindings suggest a 10% increase in the preva- lence of burnout among US physicians over the last 3 years. More than half of the US phy- sicians in our survey had symptoms of burnout when assessed using the full MBI, with increased rates of burnout observed across all specialties. A substantial erosion in satisfaction with WLB has also been observed among US physicians over the past 3 years, despite no increase in the median number of hours worked per week. In contrast to the in- crease in burnout and decrease in satisfaction TABLE 2. Physician Career Satisfaction, Burnout, Depression, and Quality of Life 2014 Relative to 2011 Variable 2014 2011P Burnout indices a Emotional exhaustion Median 25.0 21.0<.001 % low score 2299 (34.1%) 3041 (42.2%)<.001 % intermediate score 1283 (19.0%) 1433 (19.9%) % high score 3165 (46.9%) 2734 (37.9%) Depersonalization Median 7.0 5.0<.001 % low score 2951 (44.0%) 3601 (50.1%)<.001 % intermediate score 1434 (21.4%) 1476 (20.5%) % high score 2325 (34.6%) 2116 (29.4%) Personal accomplishment Median 41 42<.001 % high score 4064 (61.2%) 4758 (66.6%)<.001 % intermediate score 1495 (22.5%) 1495 (20.9%) % low score 1085 (16.3%) 887 (12.4%) Burned out b 3680 (54.4%) 3310 (45.5%)<.001 Depression Screen positive for depression 2715 (39.8%) 2753 (38.2%) .04 Suicidal ideation Suicidal ideation in the last 12 mo 438 (6.4%) 466 (6.4%) .98 Career satisfaction Would choose to become a physician again 4476 (67.0%) 5081 (70.2%)<.001 Would choose the same specialty again 4727 (70.8%) 5119 (70.8%) .94 Satisfaction with work-life balance Work schedule leaves me enough time for my personal and/or family life Strongly agree 706 (10.6%) 1233 (17.0%)<.001 Agree 2012 (30.3%) 2279 (31.5%) Neutral 973 (14.6%) 1046 (14.4%) Disagree 2004 (30.1%) 1775 (24.5%) Strongly disagree 956 (14.4%) 911 (12.6%) Missing 229 44 aAs assessed using the full Maslach Burnout Inventory. Per the standard scoring of the MBI for health care workers, physicians with scores of 27 on the Emotional Exhaustion subscale, 10 on the Depersonalization subscale, or 33 on the Personal Accomplishment subscale are considered to have a high degree of burnout in that dimension.

bHigh score on Emotional Exhaustion and/or Depersonalization subscales of the Maslach Burnout Inventory (seeMethods). INCREASING BURNOUT AMONG US PHYSICIANS, 2011 TO 2014 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org 1605 with WLB, minimal or no changes were observed in the prevalence of symptoms of depression or suicidal ideation.

It is notable that the increase in burnout and decrease in satisfaction with WLB in physiciansover the last 3 years runs counter to trends in the general US working population over the same interval. These disparate trends have resulted in a further widening in the rates of burnout and satisfaction with WLB among aaaaaaaaaaa 0 10 20 30 40 50 60 7080 Preventive medicine/occupational medicineOther Radiation oncologyGeneral pediatrics Pediatric subspecialtyPsychiatr y Neurosurger y Opthalmology General surger y Obstetrics and gynecologyPathology General surger y subspecialty Internal medicine subspecialtyOtolar yngology Mean burnout among all physicians par ticipatingAnesthesiologyDermatologyNeurology General internal medicineOr thopedic surger yRadiology Family medicine Physical medicine and rehabilitiationUrology Emergency medicine % Reporting burnout2011 2014 A FIGURE 1.Burnout (A) and satisfaction with WLB (B) by specialty 2014 vs 2011. For 1A and 1B, specialty discipline is shown on the y axis and burnout (A) and satisfaction with WLB (B) are shown on the x axis. For 1C, satisfaction with WLB is shown on they axis and burnout on the x axis. GIM¼general internal medicine; OBGYN¼obstetrics and gynecology; PM&R¼physical medicine and rehabilitation; Prev¼Preventive medicine, occupational medicine, or environmental medicine; WLB¼work-life balance. aP<.05 from com- parison 2014 to 2011. MAYO CLINIC PROCEEDINGS 1606 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org aaaaaaaaaaaaa 020406080 Neurosurger y Urologic surger yNeurology General surger y subspecialtyFamily medicine Internal medicine subspecialtyOr thopedic surger y General internal medicineAnesthesiology Pediatric subspecialtyGeneral surger yOtolar yngologyRadiology Mean satisfactionPathology Obstetrics and gynecologyRadation oncology Physical medicine and rehabilitationDermatology General pediatricsPsychiatr y Emergency medicineOpthalmologyOther Preventive medicine/occupational medicine % Satisfied that work leaves enough time for personal and/or family life2011 2014 B FIGURE 1.(continued).

INCREASING BURNOUT AMONG US PHYSICIANS, 2011 TO 2014 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org 1607 physicians relative to the US working popula- tion, even after adjustment for differences in hours worked, age, sex, and relationship status.

What are the possible solutions to this prob- lem? More than 75% of the physicians are now employed by large health care organizations and meaningful progress will require an effective response at both the individual level and the or- ganization or system level. 40Health care organi- zations should focus on improving the efficiency and support in the practice environment, 41-43 select and develop leaders with the skills to fos- ter physician engagement, 44 help physicians optimize“careerfit,” 45 and create an environ- ment that nurtures community,flexibility, and control, all of which help cultivate meaning in work. 2,3,41,42,46 Given the high number of hours worked by physicians as well as the unpredict- able nature of work hours in some settings (eg, surgery, hospital-based care), health care organizations must also establish principles that help facilitate work-life integration. 47,48 Organizational approaches to help physicians self-calibrate and promote their own wellness may also be beneficial. 49,50 There are also a number of steps physicians can take at the individual level to promote their own wellness. This often begins by identi- fying personal and professional values and determining how they will be prioritized when conflicts between personal and professional re- sponsibilities arise. 51-53 This exercise requires self-awareness, limit setting, and reframing. 51,53 Training in mindfulness-based stress reduction, which involves self-awareness, a focus on the present, and intentionality in thoughts and ac- tions, has also been shown to be an effective approach to reduce physician stress and burnout. 54-56 Scientific studies have also identi- fied the habits and qualities that promote resil- ience in challenging situations, which are skills that can be learned and developed. 57,58 Atten- tion to self-care, developing personal interests, and protecting and nurturing relationships are also essential. 42,47,51,59 Our study is subject to several limitations.

First, most of the physicians did not even open the e-mails informing them of the study and hence never received the invitation to participate. The participation rate among those Pediatric subspecialty Anesthesiology General surger y Radiation oncology OBGYN Otolar yngology Pathology Psychiatr yOpthalmology PM&R General intermal medicineRadiology Family medicineEmergency medicine Dermatology Prev/occupational medicine Other General pediatrics GIM subspecialty General surger y subspecialty Neurosurger y Average burnout Average satisfaction WLBOr thopedic surger y Neurology Urologic surger y 60 55 50 45 40 35 % Satisfied with work-life balance 30 25 20 15 35 40 45 50 55 % Burned out60 65 70 75 C FIGURE 1.(continued). MAYO CLINIC PROCEEDINGS 1608 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org TABLE 3. Comparison of Employed Physicians in the Sample Aged 29 to 65 y With a Probability-Based Sample of the Employed US Population Aged 29 to 65 y Characteristic Physicians N¼5313 Population N¼5392P Sex Male 3291 (62.2%) 2934 (54.4%)<.001 Female 1996 (37.8%) 2458 (45.6%) Age (y) Median 53 52<.001 29-34 324 (6.1%) 526 (9.8%)<.001 35-44 1220 (23.0%) 1076 (20.0%) 45-54 1411 (26.6%) 1550 (28.7%) 55-65 2358 (44.4%) 2240 (41.5%) Relationship status Single 632 (11.9%) 1300 (24.1%)<.001 Married 4387 (82.9%) 3642 (67.5%) Partnered 223 (4.2%) 354 (6.6%) Widowed/widower 52 (1.0%) 96 (1.8%) Missing 19 0 Hours worked per week Mean SD 55 16.7 40 11.3<.001 Median 50 40<.001 <40 627 (11.9%) 1412 (26.2%)<.001 40-49 1042 (19.7%) 2927 (54.4%) 50-59 1400 (26.5%) 702 (13.0%) 60-69 1285 (24.4%) 268 (5.0%) 70-79 477 (9.0%) 36 (0.7%) 80 445 (8.4%) 39 (0.7%) Missing 37 8 Highest level of education completed Less than high school graduate 174 (3.2%) High school graduate 1159 (21.5%) Some college, no degree 1054 (19.5%) Associate degree 657 (12.2%) Bachelor’s degree 1341 (24.9%) Master’s degree 745 (13.8%) Professional or doctorate degree (other than MD/DO) 262 (4.9%) Missing0 Occupation Professional a 2397 (45%) Health care b 390 (7.3%) Service c 342 (6.4%) Sales d 414 (7.8%) Office and administrative support 428 (8.0%) Farming, forestry,fishing 22 (0.4%) Precision production, craft and repair e 341 (6.4%) Transportation and material moving 158 (3.0%) Armed services 26 (0.5%) Other804 (15.1%) Missing107 Distress Burnout f Emotional exhaustion g Never 491 (9.4%) 718 (13.3%)<.001 A few times a year 1075 (20.5%) 1566 (29.1%) Once a month or less 663 (12.6%) 736 (13.7%) A few times a month 750 (14.3%) 1027 (19.1%) Once a week 626 (11.9%) 356 (6.6%) Continued on next page INCREASING BURNOUT AMONG US PHYSICIANS, 2011 TO 2014 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org 1609 who opened the invitation e-mails was only 19%. Although the participation rate is gener- ally consistent with other national survey studies of physicians, 7,60,61 it is lower than that of physician surveys in general. 62 We did not use monetary or other incentives to improve participation. 63 Nonetheless, several cross-sectional studies have failed to identify significant differences between responding and nonresponding physicians, 64with evidencethat nonresponse may be of less concern in physicians surveys than in surveys of the gen- eral public. 65 We found no statistically signifi- cant differences between early responders and late responders (a standard approach to eval- uate for response bias) with respect to sex or specialty (primary care vs nonprimary care) and minimal differences by age (median, 56 years vs 57 years), providing support that re- sponders were representative of US physicians. TABLE 3. Continued Characteristic Physicians N¼5313 Population N¼5392P Distress, continued A few times a week 908 (17.3%) 634 (11.8%) Every day 736 (14.0%) 344 (6.4%) Missing 64 11 % High score f 2270 (43.2%) 1334 (24.8%)<.001 Depersonalization h Never 1454 (27.7%) 2368 (44.3%)<.001 A few times a year 1308 (24.9%) 1255 (23.5%) Once a month or less 647 (12.3%) 492 (9.2%) A few times a month 631 (12.0%) 487 (9.1%) Once a week 461 (8.8%) 223 (4.2%) A few times a week 555 (10.6%) 311 (5.8%) Every day 193 (3.7%) 214 (4.0%) Missing 64 42 % High score f 1209 (23.0%) 748 (14.0%)<.001 Burned out i 2550 (48.8%) 1529 (28.4%)<.001 Suicidal ideation Suicidal ideation in the past 12 mo 383 (7.2%) 213 (4.0%)<.001 Work-life balance Work schedule leaves me enough time for my personal/family life:

Strongly agree 402 (7.6%) 1227 (22.8%)<.001 Agree 1500 (28.4%) 2071 (38.5%) Neutral 782 (14.8%) 1012 (18.8%) Disagree 1738 (32.9%) 817 (15.2%) Strongly disagree 865 (16.4%) 249 (4.6%) Missing 26 16 aBusiness/financial, management, computer/mathematical, architecture/engineering, lawyer/judge, life/physical/social sciences, community/ social services, teacher nonuniversity, teacher college/university, and other.

bNurse, pharmacist, paramedic, laboratory technician, nursing aide, orderly, and dental assistant.cProtective service, food preparation/service, building cleaning/maintenance, and personal care/service.dSales representative, retails sales, and other sales.eConstruction and extraction, installation/maintenance/repair, precision production (machinist, welder, backer, printer, and tailor).fAs assessed using the single-item measures for emotional exhaustion and depersonalization adapted from the full Maslach Burnout Inventory. Area under the receiver operating characteristic curve for the emotional exhaustion and depersonalization single items relative to that of their respective full Maslach Burnout Inventory domain score in previous studies was 0.94 and 0.93 and the positive predictive value of the single-item thresholds for high levels of emotional exhaustion and depersonalization was 88.2% and 89.6%, respectively. 30 g Individuals indicating emotional exhaustion symptoms weekly or more often have median emotional exhaustion scores of>30 on the full MBI and have a>75% probability of having a high emotional exhaustion score as defined by the Maslach Burnout Inventory ( 27).

hIndividuals indicating depersonalization symptoms weekly or more often have median depersonalization scores of>13 on the full Maslach Burnout Inventory and have a>85% probability of having a high depersonalization score as defined by the Maslach Burnout Inventory ( 10).

iHigh score ( weekly) on emotional exhaustion and/or depersonalization scales. MAYO CLINIC PROCEEDINGS 1610 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org Second, our survey was anonymous and we were unable to assess changes over time at the individual physician level. Third, although the age of individuals in the comparison sample of population controls was generally similar to that of physicians, they were more likely to be women. This was expected because of the demographic characteristics of US physicians and was adjusted for in the multivariateanalysis; however, it remains possible that other unmeasured confounders exist.

Our study also has several important strengths. The physician sample was derived from the AMA PMF, which is a near complete registry of all US physicians. The sample included physicians from all specialty disci- plines, practice settings, and environments.

Overall, the characteristics of participating 100% Burned out (%) 80% 60% 40% 20% 0% 2011 2014 YearBreslow-day P value <.001 Population Physicians 100% Satisfied with WLB (%) 80% 60% 40% 20% 0% 2011 2014 YearBreslow-day P value <.001 Population Physicians Burnout Satisfaction with WLB A B FIGURE 2.Changes in burnout and satisfaction with WLB in physicians and population year are shown on the x axis. Burnout (A) and satisfaction with WLB (B) are shown on the y axis. WLB¼work-life balance.

INCREASING BURNOUT AMONG US PHYSICIANS, 2011 TO 2014 Mayo Clin Proc. nDecember 2015;90(12):1600-1613 nhttp://dx.doi.org/10.1016/j.mayocp.2015.08.023 www.mayoclinicproceedings.org 1611 physicians appear similar to those of both US physicians overall and the 2011 comparison sample of physicians. The same validated instruments were used to study physicians in both 2011 and 2014, facilitating direct compar- ison. We also studied a sample of population controls at both time points to allow compari- son of the physician experience with the gen- eral US working population and provide context to how the physician experience com- pares to that of US workers in general.

CONCLUSION Burnout and satisfaction with WLB among US physicians are getting worse. American medicine appears to be at a tipping point with more than half of US physicians experi- encing professional burnout. Given the extensive evidence that burnout among physicians has effects on quality of care, pa- tient satisfaction, turnover, and patient safety, thesefindings have important implications for society at large. 11-20 There is an urgent need for systematic application of evidence- based interventions addressing the drivers of burnout among physicians. These interventions must address contributing factors in the practice environment rather than focusing exclusively on helping physicians care for themselves and training them to be more resilient.

SUPPLEMENTAL ONLINE MATERIAL Supplemental material can be found online at http://www.mayoclinicproceedings.org. Sup- plemental material attached to journal articles has not been edited, and the authors take re- sponsibility for the accuracy of all data. Abbreviations and Acronyms:AMA =American Medical Association;MBI =Maslach Burnout Inventory;PMF = Physician Master File;WLB =work-life balance Affiliations (Continued from thefirst page of this article.):(D.S., J.S.), and Division of General Internal Medi- cine (C.P.W.), Mayo Clinic, Rochester, MN; and American Medical Association, Chicago, IL (O.H., C.S.).

Grant Support:The work was supported by the Mayo Clinic Program on Physician Well-being.

Potential Competing Interests:Dr Shanafelt is co-inventor of the Physician Well-being Index.

Mayo Clinic holds the copyright on this technology and accordingly Mayo Clinic and Dr Shanafelt have a potential financial interest in this technology. The PhysicianWell-Being Index has been licensed to a commercial entity, although no royalties have been received to date.

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