How would you diagnose a physician experiencing burnout? The classic definition includes a combination of emotional exhaustion, depersonalization (often manifesting as cynicism), and a sense of inefficacy (reduced personal accomplishment). If he/she presented to you as a patient, and as a result of your workup your treatment recommendation included reduced work hours to time off from work, what diagnosis would you enter into the patient’s chart?
No diagnosis for burnout exists in DSM-5 (the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders). In the 10th edition of the International Classification of Diseases (ICD-10) – burnout has been identified as a factor influencing health status and contact with health services, is coded Z73.0, and defined as a state of vital exhaustion. Z73.0 cannot be used as the actual diagnostic code.
Why is there no diagnosis for a condition that, according to Dr. Tait Shanafelt as published in the Mayo Clinic Proceedings, impacts 54% of physicians?
The Argument against a Burnout Diagnosis
According to a 2015 posting in “Frontiers in Public Health”:
- The burnout construct is “fragile” with methodological flaws in its definition
- Burnout overlaps with depression, yet many other DSM-5 coded disorders overlap with depression
- The structure of the burnout syndrome is “Incoherent”, with the definition lacking enough attention to depression
- Defining Burnout as a job-related syndrome is not nosologically discriminant, because the most common test for burnout is the Maslach Burnout Inventory (MBI) and is self-fulling by design, while job-related depression is still considered depression.
There is an analogy here to Post Traumatic Stress Disorder (PTSD) which did not receive recognition as a diagnosis for many years despite clear evidence that it merited that status. While no one would argue that experiencing combat is more intense than working in healthcare settings, there are many parallels. In both, healthy people enter an environment filled with chaos, uncertainty, risk, and exposure to life and death. They come out the other end negatively impacted. It is only a matter of the degree of the impact. Considering the number of physicians reducing their workload or leaving practice altogether, and the rate of physician suicide, that impact differential may not be as significant as some think.
The Argument for a Burnout Diagnosis
Dror Dolfin, MD, in a presentation at the 2nd International Meeting on Wellbeing and Performance in Clinical Practice held in Greece last month, asked the question, “Why is it that psychiatry, the medical field entrusted with the diagnosis and treatment of disorders of thought, emotion and behavior, fails to recognize or even show an interest in the burnout syndrome, a disorder exaction an enormous toll on the lives of working men and women, on their thoughts, emotions, and behavior?” (Note: Dr. Dolfin is a psychiatrist himself.)
He postulates that including a diagnosis of burnout would ensure:
- accountability for certain working conditions causing injury to the patient’s brain, and employer responsibility to provide safe working conditions
- responsibility to pursue an effective intervention
- better focus research
- offer compensation for the injury
Aside from concerns of diagnostic purity, there is the socio-economic concern that if burnout was considered a distinct diagnosis, a flood of job-related disability claims would be released, not only in health care, but in many occupations. This could be devastating to corporations and public entities, and damaging to the economy as a whole.
Modeling the Cause of Burnout
In preparing for our upcoming book on effective approaches to prevent burnout, my co-author, Diane Shannon, MD, and I have developed a model of the drivers of burnout, which are viewed as concentric rings.
- At the core is the physician, who by nature is at high risk for burnout due to the personality traits required to be accepted into medical school and advance through training programs
- The physician is surrounded by the workplace, which presents a constant stream of barriers and frustrations to the physician who is highly motivated and driven to provide quality care to patients, no matter how challenging
- The workplace is surrounded by the external environment with its changing regulations, billing requirements, and technological challenges that make it very difficult to design efficient work processes.
The regulators in the external environment will not provide a diagnosis that recognizes the impact of the work environment on the physician. This makes it even more challenging to identify the root causes of the problem, and to develop and implement effective solutions.
What do you think should be done about diagnosing burnout?
How would you enter the diagnosis in the progress note for a physician requesting medical help for an occupational stress disorder?
I look forward to your comments below.