Physician burnout and fatigue: a call to re‐focus on work intensity beyond work duration

Abstract

Burnout is a major problem afflicting one in two physicians, and up to three in five physicians in training.1, 2 To date, most scientific literature and qualitative improvement interventions emphasise the importance of mandatory duty hour restrictions, strengthening of personal resilience or mental wellness and making practical changes to the work environment to make it more conducive.1, 3, 4 However, in my humble opinion, while reduction in working hours, optimization of working conditions/environment and strengthening of physician mental grit/resilience are no doubt important in mitigating physician stress, fatigue and burnout, there appears to be an under-recognised piece of the puzzle that relates to physician work intensity. As Horner et al. writes, ‘(the work of physicians) can be assessed by the time required to complete it and by the intensity of the effort’.5 For a single patient encounter, there are numerous conceivable contributors to high work intensity, ranging from complexity of medical issues, challenging patient–physician interactions, unexpected events/deterioration, clinical uncertainties, physical demands of performing medical procedures, pre-/post-encounter charting/documentation and health system issues pertaining to appointment scheduling, pacing and interruptions.6 Intriguingly, the concept of physician work intensity has by and large been discussed in a cursory manner in burnout literature, and instead has been described mainly in the context of valuation of medical services for medical claims.5, 6 Yet, I postulate that high work intensity is a major contributor to work-related stressors, fatigue and burnout, mediated by cognitive load and emotional/affective overlay. Moreover, high work intensity or poor patient–physician ratios often translates to less quality time spent with individual patients, culminating in unfulfilled desires to establish meaningful therapeutic relationships and provide holistic care. There are generic assessment tools such as the National Aeronautics and Space Administration-Task Load Index (NASA-TLX)7 and Subjective Work Assessment Technique (SWAT),8 Multiple Resource Questionnaire (MRQ)9 and Dundee Stress State (DSS)10 that evaluate the qualitative dimensions of work such as cognitive, physical, temporal and emotional demands, which have been found to be valid for use in clinical settings.10 It is plausible that clinical audits might involve anonymised surveys of work intensity assessments, which can then inform the development and implementation of targeted workplace-based interventions to reduce stress and fatigue. For example, for surgical subspecialties that are more physically demanding,5 technological applications such as robotics surgery and artificial intelligence software can help to reduce operator fatigue, whereas other specialties such as family medicine may experience higher temporal demands (i.e. time pressure),5 in which case regular assessments of patient–doctor ratio with properly calibrated manpower distribution, and artificial intelligence/administrative assistance to reduce clerical burdens might be useful interventions. For hospital physicians who are often subject to multi-layered workflow interruptions and distractions at work that make their job both chaotic and stressful, physician-led and senior management-supported interventions to contain/mitigate inappropriate workflow interruptions/distractions were found to be efficacious.11