Burnout, which was once considered a personal problem, is now coming to be seen as a common occupational hazard for physicians. That shift has had a major effect on workplace well-being initiatives, medical education, and how the next generation of physicians understands the profession. But is it really all that different from depression? And can a focus on systems leave some individuals feeling helpless?

Clinicians, researchers, learners, and leaders at Michigan Medicine are all trying to answer these questions and help protect the mental health and well-being of physicians, now and into the future.

Burnout makes me not want to go to work. It makes me feel like I’m in despair, like there’s nothing I can do about the situation I’m in — for me, it’s being really, really tired. I am more tired than I usually am, and it’s because of all the thought processes. ‘What if we did this?’ But nobody’s really listening. And then that just leads to being like, ‘Well, that’s it. There’s nothing I can do.’

Michele Carney, M.D., associate professor of emergency medicine and of pediatrics 

It’s free care. It’s all the time. ‘Why not send a message [through the patient portal]?’ I become their Google. You used to have to call, and wait your turn, as opposed to just typing on a Friday night your question to the ether and knowing that I’m going to find it and potentially answer it Saturday night at 10 o’clock.

Longtime primary care physician who asked to remain anonymous 

How do we define burnout? 

We know burnout when we see it. And we know people are leaving medicine because of it. But can we actually define it? 

In a 2022 systematic review of 182 academic studies of burnout, a research team identified 142 unique definitions of the condition. Srijan Sen (M.D. and Ph.D. 2005), who was an author of the review, says the lack of consensus makes burnout much harder to study than other conditions, such as depression. Sen is the Frances and Kenneth Eisenberg Professor of Depression and Neuro- sciences and director of the Eisenberg Family Depression Center. 

The review notes that the most cited characteristics come from the Maslach Burnout Inventory: emotional exhaustion, depersonalization, and a lack of a sense of professional accomplishment. When it comes to emotional exhaustion, “measures which are normally restorative really no longer restore you,” says Louito Edje (M.D. 1995, MHPE 2017), senior associate dean for medical education of students, house officers, and faculty. “The second thing is depersonalization. An example is you’re working through your Epic In Basket just to get it done rather than seeing and caring for the patient who is behind the message or test result.” Of the last criterion, a lack of a sense of professional accomplishment, she says, “Regardless of what you’re doing and how hard you’re working, there’s a sense of futility.” 

Elizabeth Harry, M.D., chief well-being officer of Michigan Medicine, prefers to define burnout in terms of what she sees as its antithesis: professional fulfillment. This is achieved through three components of workplace well-being, which her position was created to address. The first component is organizational well-being, that is “How easy is it for me to do my job?” The second is the culture and climate of well-being. “This is how we treat each other,” Harry explains. And the third is personal resilience, which includes the skills and support that organizations can give to individuals to help them cope. When any one of these components of workplace well-being is out of balance, physicians can be at risk of burnout. (Note: All health care professionals — nurses, social workers, technicians, and others — can experience burnout related to their work. This article is focused primarily on physicians because this is the primary audience of Medicine at Michigan.) 

The biggest driver 

“The biggest driver of burnout is time — the overwhelming time it takes to care for a panel of patients,” says Eve Kerr, M.D., MPH, professor of internal medicine. And the biggest time-suck? Electronic health records and “asynchronous care,” where patients are asking questions through the patient portal. 

Kerr says full-time primary care physicians could be caring for 1,500–2,000 patients, and portal messages have increased by at least 50% at Michigan Medicine since the pandemic. In a way, the doctor’s visit never ends. This has been mostly great for patients, but support for physicians and reimbursement structures haven’t caught up. 

“We are delivering a boatload of medical care through that portal,” Kerr says. “And I think it can be good, but somebody’s going to have to pay for it.” 

Occupational hazards 

At the beginning of the pandemic, managing burnout “was all up to us as individuals,” says Deirdre Conroy, Ph.D., professor of psychiatry and wellness liaison for the department. “It was like, ‘Why aren’t you doing yoga?’” 

“That’s like asking the canary in the coal mine to do deep breathing,” Harry says. “Burnout is an occupational hazard. Organizations taking accountability for burnout is very important. Early on, we kind of blamed the victim.” 

But the conversation has rapidly shifted since the early days of the pandemic. “There’s been this evolution, from not talking about burnout at all to putting the focus on the clinician to take better care of themselves to understanding that burnout is a system-level problem,” Kerr says.

Although many are talking about burnout as an occupational hazard, there are some who say depression belongs in this category, too. 

“I completely agree with the sentiment and well-intentioned motivation to try and not blame the individual,” Sen says. “In that way, I’m grateful for the increased discussion of burnout and people willing to say that they’re suffering from burnout. 

“My concerns are that most of the time, certainly in the physician population, depression is due to the toxic system and working excessive, and sometimes inhumane, hours.” Sen leads the Intern Health Study, a longitudinal cohort study that assesses stress and mood in medical interns at institutions in the U.S. and China. Research from the Intern Health Study has shown that, for training physicians, depression goes up by sixfold just when internship begins. “They’re not more vulnerable people, but they’ve gone from living a normal life to working 80 hours a week and not sleeping enough,” Sen says. 

The burnout vs. depression debate 

The evolving understanding of burnout as, at least partly, a systems-level problem, has helped to reduce stigma. However, the destigmatization effort has revolved around distinguishing burnout from mental health conditions, such as depression, which are still characterized as individual problems. But what really distinguishes the two conditions? 

“Burnout can lead to mental illness, and it can be a precursor for depression,” says Nasuh Malas, M.D., MPH, associate professor of psychiatry and of pediatrics. For Harry, the distinction is more clearcut: “[Having burnout] doesn’t mean someone has a behavioral health or mental health issue. There are mental health concerns associated with being in health care … Nevertheless, there is also burnout, which is a completely separate concern.” 

She sees the distinction in the effect that burnout has on people’s relationship to their work. Physicians are leaving medicine, and it is her job to address the systems-level issues that are contributing to that. “We know if people have a higher cognitive load, they are much more likely to burnout. A 10% increase in load equals a 30% increase in burnout.” Seeing burnout as separate from depression has helped leaders focus on workplace well-being initiatives (see “Workplace well-being,” p. 22). But could that have unintended consequences? 

“Sometimes the emphasis that you’re suffering from burnout and that burnout is a system issue makes people feel helpless,” Sen says. “There’s broad agreement that we need to reform the system, but we’re probably still many years away from getting it right. If people believe they’ll be feeling this way until the system is better or perfect, it can feel hopeless.” When it comes to the available data, it’s hard to distinguish burnout from depression, especially among physicians. The Intern Health Study published research in the Journal of General Internal Medicine in 2020 showing that the factors that predict depression and burnout in this population are virtually identical. 

For Sen, this is good news. Burnout research is in its infancy, but “for depression, there’s a century of work in interventions that people can do to help.” 

Harry also believes individual supports — such as the coaching, leadership development, and other resources offered by the Office of Well-Being — can help with burnout by shoring up a physician’s personal resilience. 

National changes in medical education 

There have been several changes in medical education on the federal level that may make future physicians less vulnerable to burnout. Deb Weinstein, M.D., executive vice dean for academic affairs, says there was a sea change in 2003, when the Accreditation Council for Graduate Medical Education (ACGME) first limited the number of hours residents and interns could work. In 2011, ACGME adjusted shift lengths to a maximum of 16 consecutive hours for interns and 28 hours for other trainees. Another decrease in hours is expected in 2025.

There’s evidence that the limited hours have had a positive effect on well-being. The ACGME changes as well as reforms made by residency programs have reduced intern work hours by about 8-10 hours per week over the past 20 years. Sen says this has reduced depression by 25% among interns. “This progress highlights the potential of re- ducing workload in improving physician well-being,” he says. 

There’s also a sense that reduced hours have improved medical education. Weinstein says the limitations to trainee hours “required programs to really rethink the role of the learner and how patient care was delivered, and that was a healthy change.” She gives blood draws as an example. During her time in medical school, those were done almost exclusively by med students, who did many more than were necessary for competen- cy, she says. Now, medical schools are being more thoughtful about how they use learners’ time so that trainees are gaining skills continuously. 

“There’s really a delicate balance because our job is to prepare learners to be out there in their future world,” Edje says. “We want them to be as pluripotent as possible, just like a stem cell, being able to transform into any space they go into. Too few hours can be just as bad as too many hours.” 

Changes in medical education at Michigan Medicine 

One way the Medical School has started to implement systems-level change is by training medical students to prepare for burnout. Jennifer Imsande, Ph.D., director of the M-Home learning community at the Medical School, says we need to be discussing systems-based stress and vicarious trauma with students the way that paramedics or firefighters talk about it as part of their training. “We want to do a better job of connecting that to professional identity,” she says. 

“Stress is not a problem; it’s a healthy adaptation of the body.” Stress happens when a demand temporarily exceeds the resources we have to meet it, but stress becomes a problem only when “the demands consistently exceed our resources to meet them.” 

M-Home teaches students about the neurobiology of stress and helps them recognize their own indicators of stress. For example, one person might start breathing rapidly, while another is holding their breath. These can be early clues that they are getting overstressed. 

“If you’re training for a marathon but you haven’t prepared for mile 19 when you’re going to want to quit,” Imsande says, “then, when you hit mile 19, and you don’t have anything prepared, it’s too late.” 

An example of helping students prepare for “mile 19” happens when students are in their third year. As they prepare to apply for residency, M-Home encourages them to explore how their values could play out in their specialty choice and the culture of the system in which they aspire to work. For instance, if a student has religious beliefs and commitments that require doing prayers on a certain day, they might consider a specialty that allows flexibility. M-Home also helps students develop strategies for handling dissonance between their values and the values of the system in which they’re working. 

Another big change in medical education is students’ interest in mental health support. In 2021, medical students partnered with Medical School leaders, the Office of Counseling and Workplace Resilience (OCWR), and the Department of Psychiatry to create the Medical Student Mental Health Program, which offers counseling and psychiatry, free of charge, to all medical students. 

“What was unexpected was how highly utilized therapy services would be,” says Whitney Begeman, PsyD, director of OCWR. “There’s no shortage of stressors for medical students, and we encourage them to establish care with us in support of their personal and professional well-being. Therapy need not only be for students who have a mental health condition that rises to the level of meeting diagnostic criteria.” Given the current level of funding and student engagement with the program, Begeman says it’s not yet possible to offer unlimited therapy. However, the program does its best to accommodate those with high needs. 

Workplace well-being 

At Michigan Medicine, there are many efforts to enhance workplace well-being for faculty and staff. 

The Office of Well-being sponsors several initiatives and supports faculty in leading them. The office also provides $5,000 grants to faculty who have good ideas for promoting workplace well-being. A recent grant went to a project by Michele Carney, M.D., associate professor of emergency medicine and of pediatrics, and her colleagues: nurses Abi Garrison and Treasa Chmielewski, and Helena Wang-Flores, D.O., assistant professor of emergency medicine and of pediatrics. Their project, Decompress the Stress, is looking at ways to conduct debriefing sessions to help people leave some stressors at the hospital at the end of a workday and have more restorative time outside of work. 

With support from leadership, Kerr helped create Choosing Wisely, an initiative to preserve the clinician workforce by decreasing administrative burdens. Kerr sees one possible solution to the In Basket problem in having “highly functional teams, where all members are working to the top of their license.” This means working in the way they’ve been trained but not doing work that someone else could do. “Now what we’re seeing is that when there isn’t enough team support, physicians are picking it up and doing it at night and on weekends.” She advocates for more direct reimbursement for asynchronous care and value-based payments that consider the quality of care rather than just the quantity. Choosing Wisely is also looking at mandatory trainings to see if any could be streamlined. 

Physicians are also working on an individual level to find life hacks for managing stressors. Edje has come up with her own method for streamlining the time she’s spending with electronic health records. She created a compendium of 180 smart phrases that can be typed into a patient’s record and will then prompt the population of a note. “I get to work early and auto-populate my notes. I’m able to add information during patient visits and leave the office shortly after the last patient with all my notes completed,” she says. Edje acknowledges that she’s able to do this only because clinic work is a fraction of her current role. If she were seeing patients full time, she thinks she would be working weekends to catch up. 

Several physicians we spoke with pointed to AI as a promising solution to the In Basket problem. Researchers and clinicians at Michigan Medicine and across the country are working hard to realize that promise, but it won’t happen overnight. 

As a broader strategy, Harry has a vision for tapping into the renowned collaborative atmosphere at U-M. She mentions chief transformation officer Amy Cohn, Ph.D., who is an Arthur F. Thurnau Professor at the College of Engineering and is bringing her expertise to the problem of electronic health records. “She will use evidence-based processes from engineering to help us pull administrative burdens out,” Harry says. “It is only in collaboration that we are going to make headway on this.” 

Stigma is still a problem 

Psychiatrists and other physicians have been at the forefront of battling stigma related to mental health care, an effort that has been remarkably successful in the general population. Ironically, physicians themselves are not benefiting as much from destigmatization (See “Stopping the stigma”). 

“Stigma exists all over, even with mental health care providers,” says Conroy. 

Part of the problem has to do with state licensure questionnaires, many of which ask intrusive questions about a physician’s mental health history. This leads some physicians to worry that they may lose their licensure if they seek care. 

“We battle stigma by normalizing time away, by asking for help, by working on belonging, and really by making it psychologically safe to have mental health conditions,” says Edje. “That would mean not requiring physicians to report mental health diagnoses when we apply for licensure, if that diagnosis is being treated and is under control.” 

Weinstein believes addressing stigma is important in medical education as well. “All trainee institutions are working hard to make sure we do everything possible to eliminate stigma around seeking mental health care and to reduce barriers to seeking care,” she says. 

“If our leaders can thoughtfully model the behavior around mental health care seeking that they want to see, I think that will help,” says Malas. He notes that U-M president Santa Ono is open about his mental health journey. (Ono lives with bipolar disorder and is a survivor of two suicide attempts.) “I think that has inspired folks to seek help.” 

Hurdles 

Making lasting change to a complex system is a long process with many hurdles. Here are just a few that our experts noted: 

• Money 

“National drivers around reimbursement and finances are an issue for health care systems,” Harry says. “I have not seen a health care system that’s not struggling right now with how to manage outside financial pressures.” 

Justin Dimick, M.D., MPH (Residency 2007), the Frederick A. Coller Distinguished Professor of Surgery and chair of the department, also sees this as a big hurdle for systems-level change. “There aren’t the resources in our system to do a lot of things people are looking for.” Dimick gives the example of hiring more clinical nurse coordinators to relieve administrative burden. 

• Stigma 

“We still live in a culture that believes that willpower and self-discipline and intelligence are the keys to combating any problem in your life,” Imsande says. That may be especially true for physicians, whose training hinges on those very qualities. “For mental health, those things can’t help you. They may keep you sicker because they keep you from reaching out for help.” (See “Stigma is still a problem,” above.) 

• Fatigue 

“Change fatigue and overall fatigue after the COVID-19 pandemic is huge,” Harry says. She’s sensitive to the need for physicians to not be asked to do one more thing — even if that thing is to support them. “A lot of forces are at work, and none are unique to Michigan Medicine.”