Increasing concern over worker burnout among family physicians is no coincidence. The so-called burnout syndrome is increasingly described as the greatest threat to the health of practitioners in the helping and human service professions. It affects their health, quality of life and performance, and therefore has serious repercussions on the community. A burned out physician with persons under his or her care is not likely to uphold the quality standards that society requires.
The current debate, which has spread from scientific circles to more politicized arenas, should therefore come as no surprise. Because of its complexity and the controversy over an operative definition, the syndrome remains obscure. Moreover, its continuous spread is turning it into a tremendous threat to society.
The article by Molina, García, Alonso and Cecilia provides new information that helps clarify some points in the debate, and also gives rise to some reflections on certain issues. The data in the article that follows are a clear indication that we are facing a real problem of notable proportion. Prevalences range from 25% in earlier Spanish studies to nearly 70% in the study by Molina et al.
However, we must first ask exactly what burnout, or worker burnout syndrome, is. Do we really know? What hypotheses are now being examined regarding causes and diagnoses? Do all persons with high scores on the Maslach Burnout Inventory have burnout? Very succinctly, I will try here to comment on some of the most controversial issues relating to burnout.
It has become a cliché that burnout is poorly defined. We know it exists, that it is widespread in advanced western societies, that it is a multidimensional concept, and that it is a product of chronic stress. Beyond these considerations, the data are contradictory. Maslach describes six major interrelated areas considered simultaneously the cause and the consequence of deep social changes, and which help to understand the causes of burnout: workload, reward systems, control over the work, social support, degree of fairness in treatment by the organization, and values. Of these factors, the main element is probably the issue of values. Social changes and the appearance of new values that clash with those commonly held in the helping professions (productivity, efficiency, profitability and control are gaining in consideration, while altruism and self-sacrifice are losing ground) have gradually undercut the sense of «pride of practice» in medicine. These subtle but powerful changes have led to the emergence of considerable tensions in all members of society tensions which weigh twice as heavily on the professionals who care for these individuals. This situation has other repercussions, such as management styles that tend to increase workloads. Overwork, and especially lack of time for patients, are the elements most clearly involved as the direct causes of burnout in our health care setting. The article by Molina et al. confirms once again that burnout is closely related with size of the patient list or number of patients seen per day, and in general, with inefficiency in the running of primary care practices.
Studies of burnout face considerable problems with psychometrics. As noted, worker burnout is measured basically with the Maslach Burnout Inventory (MBI), designed more than 20 years ago by Jackson and Maslach. This instrument consists of three scales, only one of which emotional exhaustion has performed well. The significance and applicability of the other two scales depersonalization and personal accomplishment are questionable. We are measuring a phenomenon with an instrument that is highly sensitive but not very specific, which detects, basically, situations of emotional stress and perhaps not all emotional stress constitutes burnout. This may explain the discrepancies in the prevalence reported by different authors in Spain. Problems with definitions have become so intractable as to lead some researchers to attempt other, more operative approaches. For example, the Shirom-Melamed Burnout Model (S-MBM) instrument measures three different scales: physical fatigue, emotional exhaustion and cognitive weariness, which are clearly more homogeneous in conceptual terms. Other questionnaires have been used, but in all of them emotional exhaustion remains at the core of the syndrome.
The first impression one has when the pieces of this puzzle are assembled is that burnout syndrome exists as a broad nosological entity, with symptoms that range from subtle to dramatic. According to earlier authors, even a single scale for emotional exhaustion can comprise many degrees, from cases of mild stress to situations that presage complete burnout. The first stage, which may include a considerable proportion of workers, could be called the discouraged care-provider phenomenon. This might not in itself be a pathological situation, but rather an entity more appropriately analyzed as a sociocultural or ogranizational problem. This problem is characterized by pervasive feelings of dissatisfaction and distress, basically caused by conflicts between the day-to-day working conditions for care providers and their individual expectations. However, other social factors related with changing values in society also contribute to tension in ones personal and professional life, as noted above. This context is an excellent facilitator of worker demotivation, a state which opens the door to long-term burnout.
In more advanced cases, burnout can be described as a psychopathological entity. As shown by Molina et al., these persons suffer from a concomitant mental condition, a notion compatible with the reported prevalence of around 30%. Anxiety and symptoms of dysthymia suggest a chronic adaptive disorder traceable to work-related problems, although interesting hypotheses have also arisen from disorders that are related, to some extent. In fact, some authors have reported cases of burnout in non-work-related situations, i.e., in athletes or marriages. By analogy to the situation in the laboratory described in experimental animals with learned helplessness syndrome, burnout in its most serious form can be linked to situations that are too adverse for adaptation to be possible, and that have serious consequences for the organism, including, naturally, the brain. Constant, intense distress may make it more likely that the body´s own neurohormonal coping responses will lead to organic changes that include cerebral malfunction. Analyses at the cellular level have implicated the synaptic depletion of certain neurotransamitters, especially dopaminergic and endorphin receptors.
These psychological and physiopathological factors are probably common to a series of disorders, and thus suggest a hypothesis that includes within a single, broad category, a dimension that might be called neurasthenic syndrome, characterized by poor hedonic tone, sleep alterations, distress and physical and mental numbing, avoidance behaviors, high levels of anxiety and lack of energy. These features are accompanied by a greater or lesser degree of withdrawal in facing obligations and everyday tasks. This spectrum of symptoms includes many of the so-called somatomorphic disorders, certain types of depression related to adaptive disorders, chronic dysthymia and dysphoria, chronic fatigue syndrome, fibromyalgia, episodes of somatization, and naturally what we now call advanced phases of burnout. This proposal undeniably requires further study, but it opens up an interesting avenue of research on these currently poorly understood illnesses.
Much research remains to be done, and in this commentary I have pointed out some areas where progress is needed. Operative definitions are necessary to build more valid instruments that distinguish more clearly between burnout and other emotional reactions to stress. It is also necessary to identify those areas in the health care system that pose the greatest danger to employees´ health, and establish strategies for improvement. Little information is available on the direct and indirect social costs arising from the exposure of such a high percentage of physicians to a degree of stress that is, in the long term, unendurable. One more area of clinically-oriented work should investigate the relationships between mental disorders and burnout, and between the latter and other problems such as ischemic heart disease
Recommended bibliography
Carlson NR. Fisiología de la conducta. 4.ª ed. Barcelona: Ariel Neurociencia, 2001.
Hobfoll SE, Shirom A. Conservation of resources theory: applications to stress management in the workplace. En: Golembiewsky RT, editor. Handbook of organitation behavior. 2th ed. New York: Dekker, 2000.
Maslach C, Schaufeli WR, Leiter MP. Job burnout. Annu Rev Psicol 2001;52:397-422.
Moore JE. Why is this happening? A causal atribution approach to work exhaustion consequences. Acad Manag Rev 2000;25:335-49.
Pines A. Couple burnout. New York, London: Routledge, 2000.
Schaufeli WR, Enzmann D. The burnout companion to study and practice. A critical Analysis. Washington, DC: Taylor & Francis, 1998.
