Abstract
Objective To identify organization-directed strategies that could be implemented to prevent burnout among rheumatologists.
Methods A search of English language articles published 2011 or later was conducted on Cochrane Database of Systematic Reviews, Embase, Medline, and PsycInfo on January 25, 2022. Included reviews had ≥ 1 primary studies with ≥ 10% of participants who were physicians, recorded burnout as an outcome, and described an organization-directed intervention to prevent burnout. Overlap of primary studies across reviews was assessed. The final review inclusion was determined by study quality, minimization of overlap, and maximization of intervention breadth. The A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 tool was used for quality assessment. Included studies and interventions were assessed by rheumatologists for their applicability to rheumatology.
Results A total of 17 reviews, including 15 systematic reviews, 1 realist review, and 1 umbrella review were included. AMSTAR 2 quality ratings classified 5 systematic reviews as low quality, 1 as moderate, and 9 as critically low. There was significant heterogeneity between and within reviews. Six conducted a metaanalysis and 11 provided a qualitative summary of findings. The following intervention types were identified as having possible applicability to rheumatology: physician workflow and organizational strategies; peer support and formal communication training; leadership support; and addressing stress, mental health, and mindfulness. Across interventions, mindfulness had the highest quality of evidence to support its effectiveness.
Conclusion Although the quality of evidence for interventions to prevent burnout in physicians is low, promising strategies such as mindfulness have been identified.
Burnout is conceptualized as a combination of emotional exhaustion, depersonalization (ie, increased mental distance or indifference toward work), and a diminished sense of personal accomplishment resulting from chronic workplace stress.1,2 It is included in the International Classification of Diseases, 11th revision (ICD-11) as a syndrome and occupational phenomenon influencing health status, but is not a medical disease or disorder.2 Physician burnout is a significant problem in modern medicine. It affects medical students,3 residents,4 and practicing physicians.5 Internationally, the prevalence of physician burnout has been challenging to determine because of variability in definitions and assessments.5 In a previous systematic review of physician burnout, the prevalence ranged from 0% to 80%.5 In the United States, a trend toward improvement in burnout was seen between 2011 and 2017; however, 1 or more symptoms of burnout continued to be reported by 44% of physicians surveyed in later years.6 In addition, the coronavirus disease 2019 (COVID-19) pandemic contributed substantially to heightened physician burnout globally.7,8
Although the prevalence of burnout among rheumatologists is not well reported, recent investigations suggest it is substantial, at around 50%. In 2019 and prior to the COVID-19 pandemic, a survey of 128 rheumatologists demonstrated that at least 50% had burnout in 1 or more domains of the Maslach Burnout Index (MBI).9 In a national Canadian Rheumatology Association (CRA) survey in 2020, 51% of respondents reported burnout with higher rates observed in women and younger rheumatologists.10 Similarly high burnout prevalence has been reported among rheumatologists in Latin America,11 South Asia,12 and the US.13-15
The factors contributing to rheumatologist burnout have not been well elucidated, and it is unclear if and how much they differ by medical specialty. Electronic health record (EHR) dissatisfaction has been noted as a contributing factor within rheumatology9 and other physician specialties. Factors contributing to EHR-related burnout include insufficient time for documentation, high volume of inbox and/or patient call volumes, and negative physician perceptions of EHRs.16 The increasing feminization of rheumatology17 as a specialty may also be playing a role, with female rheumatologists experiencing higher rates of burnout compared to male colleagues.10 In a Latin American survey, rheumatologists reported additional factors that contributed to their burnout including insufficient income, long working hours, administrative responsibilities, government regulations, lack of respect from staff or patients, EHRs, and lack of autonomy.11 Among pediatric rheumatologists, the use of telemedicine during the COVID-19 pandemic increased burnout; this was attributed to the difficulty in performing the musculoskeletal physical examination virtually.18 In a qualitative evaluation of early career rheumatologists, excessive administrative tasks including documentation, billing, and insurance and pharmaceutical company paperwork were identified as major threats to well-being.19
Although the consequences of rheumatologist burnout have not been reported, to our knowledge, the consequences of physician burnout in general are well described and are not limited to effects on personal well-being. Many studies have shown provider burnout affects patient care as it can be associated with increased medical errors, lower patient satisfaction, decreased professional work effort, and loss of productivity.5,20,21 Given projected workforce shortages in rheumatology nationally10 and internationally,22 high rates of burnout among the workforce may compound challenges in the field and negatively affect access to care for patients. Addressing burnout has been one suggested strategy to retain rheumatologists in the workforce.23
Given the documented high rate of burnout among Canadian rheumatologists, the CRA Human Resources (HR) Committee embarked on a review of organization-level strategies with potential to address rheumatologist burnout. To this end, we conducted an overview of reviews on interventions addressing physician burnout to identify strategies that could be implemented in the rheumatology workforce.
METHODS
The complete study protocol and abstraction tools were developed a priori and are available from the corresponding author upon request. Although a de novo systematic review methodology was considered, preliminary searches did not reveal any rheumatology-specific data. Owing to the high number of existing systematic reviews on interventions to address physician burnout, we determined that an overview of reviews would be most useful to inform discussions about strategies to address physician burnout at an organizational level in rheumatology.
Search strategy. The search strategy was developed by HK and CEHB in consultation with a medical librarian (search strategy in the Supplementary Material, available with the online version of this article). It was adapted for each included database. A search of Cochrane Database of Systematic Reviews, Embase, Medline, and PsycInfo was undertaken on January 25, 2022. Search results were restricted to English language articles published in 2011 and later. Because of lack of team language competencies and funds available for translation services, language restriction was necessary. The publication time frame was selected because the operation of healthcare organizations has evolved rapidly (eg, widespread use of EHRs), and studies published prior to 2011 are unlikely to be relevant to physicians practicing today.
Selection criteria. The review considered studies that included physicians working in primary, secondary, or intensive care settings. Studies that focused on medical students and physicians in training were excluded because of the different responsibilities encountered in these career stages compared to attending physicians. Similarly, other nonphysician healthcare providers and staff members were excluded. Given our focus on organization-level interventions, it was anticipated that some relevant intervention studies may include mixed participant samples. To be included, studies must have contained ≥ 10% of participants who were physicians.
Interventions designed to prevent burnout and implemented at the organization level were eligible. To qualify as an organization-level intervention, the intervention must be organized, financially supported, or made accessible to physicians through their employer. Interventions that were directed at the individual and/or organized outside the workplace were excluded. For example, a community-based mindfulness group would be excluded, but a mindfulness program organized through the workplace at no cost to the employee and with protected time for attendance would be included. All comparators were eligible for inclusion (eg, no comparator, waitlist control).
The outcome of interest was burnout or a related measure of work-related stress. Acute stress, secondary posttraumatic stress disorder, vicarious trauma, and other stress-related outcomes (eg, general stress) were excluded. Other mental health concerns such as anxiety and depression, as well as measures of positive well-being and protective factors (eg, self-compassion) were not eligible. Studies in which burnout was a secondary outcome were included, regardless of whether burnout was the target of the review.
The review considered studies with the following designs: systematic reviews, realist reviews, and umbrella reviews. All reviews were included regardless of heterogeneity among included study designs. The selection criteria were designed to establish a broad scope to identify all interventions that may be relevant to our objective, regardless of the level of evidence. Ineligible articles included conference abstracts, editorials, letters to the editor, gray literature, study protocols, theses and dissertations, observational studies, experimental studies, quasi-experimental studies, and studies for which the full text was not available.
Study selection. All citations identified in the database searches were first uploaded into EndNote, then Covidence,24 and identified duplicates were removed. Three reviewers (CEHB, HK, NMSH) completed screening of titles and abstracts using Covidence.24 Each study was reviewed against the established selection criteria by 2 independent reviewers. The full text articles of potentially relevant studies were retrieved and reviewed by 2 independent reviewers (HK, NMSH). All disagreements were resolved through discussion until consensus was reached.
We followed established methods for conducting a systematic review of reviews, including identifying and managing overlapping systematic reviews as outlined in the Cochrane Handbook for Systematic Reviews of Interventions.25 For the selected reviews, the overlap of primary studies was assessed by producing a citation matrix. This step involved listing each of the primary studies included in the selected reviews and mapping them to the reviews in which they were identified. The resulting matrix was used to inform decision making to avoid double counting outcome data from overlapping reviews and ensure that a primary study’s outcome data were extracted only once. Next, each identified review was assessed against the selection criteria. We also excluded reviews when none of the primary studies met our selection inclusion.
Reviews containing at least 1 unique primary study (ie, not identified in any other review) were selected for data extraction. This decision was justified by our aim to identify all potentially relevant interventions. The cost of losing relevant data was deemed to be greater than that of double counting overlapping primary studies in the context of our objectives. The reviews for which all relevant primary studies overlapped in other reviews were assessed for selection based on recency, comprehensiveness, and quality. Inclusion decisions were made such that all unique primary studies were captured by the fewest number of high-quality reviews. This most often resulted in retention of the most recent and comprehensive reviews and removal of those that were older and narrower in scope. When a review was included as a primary study in a more recent review, the most recent publication was included, and the subsumed review removed.
Quality assessment. Two reviewers (NMSH and CEHB) evaluated each study using A Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 to evaluate the methodological quality of the included systematic reviews.26 Overall, quality assessment was determined using the scheme for interpreting weakness developed by Shea et al using the 7 critical AMSTAR 2 items, and the 9 noncritical items.26
Data extraction. Our a priori analysis plan was to summarize only the results from high-quality studies by AMSTAR 2 criteria.26 However, because of the low number of high-quality studies available, this was not possible; therefore, we decided to review and report on all studies, regardless of quality. Two reviewers (HK, NMSH) extracted data from the included reviews using an extraction tool developed a priori for this study and according to Cochrane guidance on data extraction for this type of review.25 The extracted data included characteristics of the selected reviews including scope, population, method, and limitations. Extraction also included specific details about the interventions and outcomes. Where there was a metaanalysis done, the summary results were extracted; where no metaanalysis was conducted, descriptive findings were noted to facilitate a narrative synthesis of results. Although the objective was organization-directed interventions, some reviews also included physician-directed interventions; a summary of these findings was included as well for comparison. Additionally, many studies pooled the results of organization- and physician-directed interventions, which made data extraction and analysis difficult. Results were extracted and reported separately where possible. Authors were not contacted for missing information, as this was felt unlikely to substantially change the findings of the study.
Rheumatologist review. The results were reviewed first by 1 rheumatologist (CEHB) and 1 rheumatology resident (HK) to ascertain potentially relevant interventions for rheumatologists, excluding interventions applicable only to unrelated specialties (eg, surgery). A narrative review of interventions was then completed.
RESULTS
The search retrieved 3185 records, of which 796 were duplicates. After removal of duplicates, 2389 articles were retained for title and abstract screening. Full-text review was completed for 115 articles and resulted in the identification of 35 reviews. Following assessment of primary study eligibility and overlap, 17 reviews were selected for data extraction.27-43 These selected reviews contained a total of 399 unique primary studies, 50 of which were relevant to our objective. See the Figure for a detailed summary of results from the study selection process.
Flow diagram of inclusion of reviews. * Based on the SR inclusion criteria, it was possible for primary studies to include organization-level burnout interventions with ≥ 10% of participants being physicians, but full-text review of the primary studies revealed that none met these criteria. ** Including primary studies from the 4 SRs captured in another SR. *** Reasons for exclusion are reported in the order of priority that was followed when determining eligibility. HCP: healthcare provider; SR: systematic review.
The characteristics of selected reviews are presented in Table 1. There were 15 systematic reviews,27-34,36,38-43 1 realist review,37 and 1 umbrella review.35 Reviews were published between 2015 and 2021. The number of primary studies in each review ranged from 6 to 81 (median 19 [IQR 13-36]). The number of relevant primary studies ranged from 2 to 24 (median 7 [IQR 5-11]) for each review. There was insufficient information reported in 7/17 reviews to determine the proportion of participants who were physicians. Of those with information, the proportion of physician participants was above 50% in 6/10 reviews. Nonphysician participants most frequently included physicians in training, medical students, and interdisciplinary health professionals such as nurses. No studies were conducted in rheumatology, although rheumatologists may have been included in some of the study samples. Four reviews were specific to physicians practicing in a particular setting (eg, emergency care), whereas 5 were open to any setting (eg, primary, secondary, or intensive care), and 8 did not address setting in the inclusion criteria.
Characteristics of systematic reviews.
A metaanalysis was conducted in 6 of the reviews,27-32 with results summarized in Table 2. Overall, the findings indicate that tested interventions led to small to moderate reductions in burnout. Organization-directed interventions were found to be more effective than physician-directed interventions in 2 comparative analyses,27,28 whereas in a third comparative analysis the results favored physician-directed interventions.32 Table 3 presents a summary of the outcomes from the remaining reviews without metaanalyses.33-43 Review authors highlighted the heterogeneity of the evidence, citing concerns about low quality of evidence, high risk of bias, and high variability in study design, interventions, outcome measures, instruments, and conceptualizations of burnout. Findings were often presented with the caveat that they be interpreted with caution as a result of this heterogeneity. Across all reviews, the strongest evidence appeared to be for mindfulness-based interventions. Yet, even among mindfulness-based interventions, the considerable heterogeneity in intervention protocols has been identified as a weakness of the literature.39
Summary of burnout interventions and metaanalysis results.
Summary of burnout interventions and findings from reviews in which no metaanalysis was conducted.
Quality ratings. Table 4 presents the AMSTAR 2 quality assessment results. The 1 realist review37 and 1 umbrella review35 were not included in the AMSTAR 2 assessment as it was developed specifically for systematic reviews.26 One review was rated as moderate, 5 as low, and 9 as critically low (Table 4). Eight included the components of the PICO model (Patient/Population – Intervention – Comparison/Comparator – Outcome). Only 2 reviews explicitly noted development and registration of the protocol prior to conducting the review. A list of excluded studies and justification for their exclusion was provided in 2 reviews and partially in a third. Ten reviews conducted risk of bias assessments for the primary studies. Of those reviews, 7 accounted for risk of bias in the interpretation of results.
AMSTAR 2 quality assessment.
Contextual review of interventions applicable to rheumatology. Recognizing the heterogeneity of interventions, we reviewed and categorized them based on similarity of content. We identified intervention categories with potential applicability to rheumatology and created a narrative review that was discussed with the CRA HR Committee. Areas determined by the committee to warrant further exploration included physician workflow and organizational strategies, peer support and formal communication training, leadership support, and addressing mental health (eg, stress, mindfulness). Examples of specific interventions in each area and the rationale for potential applicability to rheumatology is explained in Table 5. Since none of the primary studies identified by the reviews were conducted with rheumatologists, we deemed it irrelevant to reextract and reanalyze primary study data owing to concerns about generalizability to rheumatology in addition to the low study quality.
Narrative summary of organization-level interventions to prevent physician burnout and possible applicability to rheumatology.
DISCUSSION
There is a high prevalence of burnout among rheumatologists internationally, and these rates have been increasing over recent years.10-13 The CRA, global rheumatology associations, and broader healthcare systems have an interest in promoting workforce well-being and supporting initiatives to reduce burnout among its members. The healthcare provider experience is also internationally understood as part of the “quadruple aim” of high-value healthcare.45 The aim of this study was to identify organization-level interventions that would be appropriate to meet this goal. In the current overview of reviews, we identified no reviews or even primary studies that were conducted in rheumatology; however, it is possible that some samples included rheumatologists alongside other physicians. Further, the existing reviews were largely of low quality. Nevertheless, upon review of the interventions to reduce burnout, some were identified as potentially relevant to rheumatologists meriting exploration in future studies.
The interventions with the highest quality evidence are mindfulness-based interventions. Traditional mindfulness-based stress reduction programs require 2.5 hours per week of group sessions for 8 consecutive weeks in addition to 45 minutes of independent daily practice.46 Regarding mindfulness outcomes, a dose-response relationship is observed such that increased practice is associated with greater improvement; however, the evidence indicating whether this relationship applies to other psychological outcomes like burnout is limited.47 Brief mindfulness interventions are being explored, but evidence of their effectiveness in reducing burnout is mixed.48 Given the time demands placed on rheumatologists, adapted brief mindfulness-based interventions will be more feasible to implement, especially if delivered during protected time offered through their employer. Most rheumatologists in Canada are considered self-employed, which may pose barriers to protected time for such interventions.
In addition to mindfulness-based strategies, interventions designed to reduce burnout by targeting stress and mental health were identified. These included variations of mental health counseling, psychoeducation, art therapy in a cognitive behavioral framework, and exercise programs. Given that burnout is a significant predictor of depressive symptoms, insomnia, use of psychopharmacological medications, and hospitalization for mental health concerns,49 interventions that address aspects of mental health in combination with burnout may be valuable in the prevention and management of more severe psychological symptoms. Although such interventions may be beneficial for rheumatologists, further study is needed as the current evidence is sparse, low quality, and not tailored to rheumatology.
We also identified physician workflow and organization strategies, as well as peer support and formal communication training strategies that may be uniquely beneficial to rheumatologists. Rheumatology is primarily an outpatient-based specialty. Rheumatologists often follow patients for life as a result of the complex and chronic nature of many rheumatic diseases and their corresponding treatments. This can lead to challenges in managing workflows and access to care. A shortage of rheumatologists regionally may compound access issues and physician burnout. Further, there can be high volumes of administrative work necessary to access medications and monitor complex multisystem diseases. Several interventions identified in our review could be investigated further for their effect on rheumatologist burnout, including offloading tasks where possible to nonphysicians such as medical assistants or scribes. Time spent on tasks which could or should be performed by others was found to be associated with burnout in a sample of hospitalists.50 Indeed, some evidence exists that the use of scribes in rheumatology improved clinic workflow and physician satisfaction, although burnout was not examined as an outcome.51 Although not directly captured in our review, EHR optimization strategies may also decrease burnout. However, a recent scoping review on this topic published after our search was completed found only 2 studies that used team-based interventions to improve burnout symptoms related to electronic medical records, and these studies did not demonstrate significant improvement in burnout scores.52 Further research on ways to reduce EHR-related burnout are urgently needed. Last, because of the complexity of rheumatology care, it may also be reasonable to consider increasing the duration of appointments to reduce time pressure for evaluation. However, hiring scribes or increasing appointment times are associated with costs to the individual physician in most models of community-based rheumatology care, and therefore these strategies do not adequately target organizational or structural factors related to burnout.
Rheumatologists may also encounter rare and complex cases, which can contribute to stress. In a series of interviews, complex patients were identified as a factor that might have a negative emotional effect and contribute to burnout among family physicians.53 Given that rheumatologists are often one of the professionals collaborating on the medical team alongside family physicians for these complex patients, it stands to reason that they may experience similar negative mental health effects. Opportunities for peer support through group discussions and complex care rounds offer a way to mitigate the psychological effects of working with complex cases, poor patient outcomes and deaths, and the burden of individual rheumatologist decision making.
Using the AMSTAR 2 tool,26 the quality of systematic reviews in our study was generally found to be low. Further, metaanalyses were rarely conducted because the heterogeneity of the primary studies was too great. Six of the studies we reviewed included metaanalyses.27-32 Yet, even among those using the same instrument to assess burnout (ie, the MBI), comparison is difficult. This is because some metaanalyses used the overall burnout score,27,28,32 whereas others reported on 1 or more of the subscales27,30,31 (ie, depersonalization, emotional exhaustion, personal accomplishment). Across reviews, the factors contributing to heterogeneity included variability in study designs, populations and inclusion criteria, definitions of burnout, instruments for measuring burnout, and conceptualizations of physician-directed and organization-directed interventions. The lack of consensus for whether a particular type of intervention (eg, mindfulness training) qualified as physician-directed or organization-directed also presented a challenge. Overall, there has been a significant amount of research exploring strategies to reduce burnout among healthcare providers, but the evidence is difficult to synthesize, and the quality is low. In future, the quality of the systematic reviews on this topic could be improved through adherence to AMSTAR 2 reporting criteria. Although not formally addressed in our study, primary studies should also adhere to rigorous standards for design, conduct, and transparency of reporting. We recommend consistent use of well validated burnout measures and powering studies adequately to examine subpopulations of interest.
It is worth noting that the heterogeneity of interventions indicates there are multiple opportunities to influence the factors that contribute to burnout. Diverse avenues exist for future investigations of interventions to reduce burnout in rheumatologists. At present, there are ongoing groups and activities around Canada to support physician wellness. The CRA HR Committee completed a review of resources and found that the onus is typically placed on the physician to seek out and engage in supports as opposed to organizations implementing system-level strategies. For example, Well Doc Alberta (https://www.welldocalberta.org) offers psychoeducation and preventive strategies to support physician mental health. Yet, accessing the website, reviewing the materials, and practicing the interventions takes time and is unlikely to be integrated into a rheumatologist’s typical workday. Engagement in these activities during the workday may negatively affect clinical volume and consequent remuneration in traditional fee-for-service models.
This study has limitations. As previously mentioned, there were inconsistencies between reviews in their categorization of the same interventions as organization-directed or physician-directed. Further, it was difficult to make comparisons between reviews because of heterogeneity. The proportion of physician participants in the reviews was not always clearly reported, and it is possible some study findings were less generalizable to physicians. Our review focused also on the outcome of burnout; other outcomes such as depression or anxiety may be equally important and could be considered in future reviews. The low quality of systematic reviews indicates this body of literature should be interpreted with caution. We had planned to complete a Delphi consensus procedure with the CRA HR Committee to further refine potentially relevant interventions; however, this was not done because of the heterogeneity and low levels of evidence of the studies. Despite these limitations, our study had several strengths. We prioritized breadth in our search, considered overlapping primary studies, and maximized inclusion of any potentially relevant interventions. Thus, we are confident we captured and reviewed all interventions that may have utility at an organizational level. In addition, we adopted a pragmatic lens to consider what might be applicable to rheumatologists across Canada, given the unique demands of this specialty.
To our knowledge, there has been no research investigating organization-directed interventions to prevent burnout or reduce burnout in rheumatologists. The results from our overview of reviews indicate that although there has been a notable number of studies implementing interventions to prevent burnout in broader physician and healthcare provider populations, the quality of evidence is low. This is largely a result of heterogeneity; thus, to grow this body of knowledge, consistency across methodological elements such as operationalization of burnout, assessment methods, and intervention design is critical for future studies to consider. Despite the low quality of the evidence, there have been encouraging findings that indicate several interventions with potential applicability to rheumatologists. Future work should focus on interventions that address physician workflow; organizational strategies; peer support and formal communication training; leadership support; and addressing stress, mental health, and mindfulness.
Footnotes
This study was supported as part of the workplan of the Canadian Rheumatology Association HR Committee. CEHB is funded through the Arthritis Stars Career Development Award from the Canadian Institutes of Health Research, Institute of Musculoskeletal Health and Arthritis (STAR-19-0611.CIHR SI2-169745).
The authors declare no conflicts of interest relevant to this article.
- Accepted for publication July 13, 2023.
- Copyright © 2023 by the Journal of Rheumatology
This is an Open Access article, which permits use, distribution, and reproduction, without modification, provided the original article is correctly cited and is not used for commercial purposes.
REFERENCES
ONLINE SUPPLEMENT
Supplementary material accompanies the online version of this article.
