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According to the U.S. Health Resources and Services Administration (HRSA), a number of places in the United States are considered Health Professional Shortage Areas (HPSAs). HSPSas are defined as geographic regions that have shortages of primary medical care, dental care, and mental-health providers. Additionally, the HRSA classifies medially underserved areas/populations (MUA/Ps) 
as locations that have an insufficient number of primary-care providers, high rates of infant mortality and poverty, and/or a high number of elderly individuals. 

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According to recent data, there are 5,805 primary-care HPSAs in the United States, encompassing 55.3 million residents.1 A total of 15,431 practitioners would be needed in these areas to meet the current demand for primary-care providers, which translates to a population-to-practitioner ratio of 2,000:1.1 Factor this information into the realization that the Affordable Care Act enacted in 2010 promises to extend health coverage to millions of presently uninsured individuals, and the potential to create a breeding ground for stress and burnout among U.S. health-care providers becomes very strong. 

A number of recent studies have established that stress and burnout are on the rise among health-care providers. Research has also shown a strong correlation between the presence of burnout among health-care providers, increased medical errors, poor patient outcomes, and increased health-care costs.

It is critical for providers to be cognizant of the early signs and symptoms of stress and burnout, the most effective ways to prevent and manage these conditions, and the potential negative consequences of unaddressed stress and burnout. 

Review of the literature

The Mayo Clinic and the American Medical Association (AMA) surveyed 7,288 physicians in June 2011 using the Maslach Burnout Inventory (MBI), a 22-item questionnaire designed to measure perceived burnout in human-services professions. The MBI, which was created by Christina Maslach, PhD, a professor of psychology at the University of California, Berkeley, rates burnout as low, moderate, or high.

The Mayo Clinic/AMA survey results revealed that 45.8% of physicians experience at least one symptom related to burnout in the work setting, and 37.9% of physicians had a high level of emotional exhaustion. This same study also found that almost 60% of physicians who practice emergency medicine, internal medicine, and family medicine had high levels of burnout.2 The figures from this study indicated that burnout rates among physicians had nearly doubled when compared with previous studies, which revealed rates ranging from 26.5% to 30%.3-5

A pilot study of 384 orthopedic residents and 264 orthopedic faculty members at two academic training programs was conducted to determine the quality of life and presence of burnout risk factors among the participants. The residents and faculty completed an anonymous survey that was developed based on the MBI, the General Health Questionnaire-12, and the Revised Dyadic Adjustment Scale. The results showed 56% of the orthopedic residents and 28% of the faculty members had high levels of burnout. In addition, 16% of residents and 28% of the faculty reported symptoms pertaining to psychological distress.6

A second part of the pilot study looked at how the spouses of residents and attending physicians are affected by training and academic practice. The respondents included 259 spouses of orthopedic residents and 169 spouses of orthopedic faculty. The findings revealed the presence of psychological distress in 18% of resident spouses and in 10% of faculty spouses. A correlation was noted between decreased satisfaction of the spouses and excessive irritability among their mates.7

Nurses, like physicians, are also at high risk for developing stress and burnout, especially nurses who work in environments in which patients are critically or terminally ill and staffing is insufficient. Because nurses are very often the front-line providers of health care and frequently witness the suffering of their patients, they are more likely to experience emotional distress and physical exhaustion, which are precursors to burnout. 

A descriptive, cross-sectional survey investigated the prevalence of burnout among oncology nurses. A total of 153 nurses completed the survey, with the participant breakdown being 132 registered nurses, 10 medical assistants, six patient-care technicians, and five radiology technicians. Nearly half (44%) of the inpatient staff was found to be at high risk for experiencing burnout, compared with 33% of the outpatient staff.8

Another study investigated job-related burnout among registered nurses and explored whether this problem influences the development of hospital-acquired infections among inpatients. A significant association was found between burnout among registered nurses and the development of surgical-site infections as well as catheter-associated urinary-tract infections. This study also found hospitals that were able to lower the burnout rate of registered nurses by 30% had 6,239 fewer infections, which translated into an annual cost savings of $68 million.9

It has become clear that burnout among registered nurses has a negative impact on patient outcomes, decreases quality of care, and contributes significantly to rising health costs.

Stress and burnout

The terms stress and burnout have very distinct and separate meanings. Stress was defined in 1926 by endocrinologist Hans Selye as “non-specific [biological] response of the body to any demand placed upon it.”10 Nevertheless, stress remains difficult to understand. Is it attributable to specific causes, effects, or a combination of the two? Is it the body’s reaction to stimuli that disturbs the body’s equilibrium, or do the stimuli cause the disturbance? 

The term burnout was coined in the 1970s and referred to a reaction to interpersonal job-related stressors.11,12 Prolonged stressors can lead to burnout.

Eustress vs. distress. Stress can present in two forms: eustress and distress. Eustress is a healthy form of stress and is related to such desirable life events as participating in a challenge, winning a race, receiving a promotion, watching a scary movie, riding a roller coaster, and engaging physical strength training. Eustress leads to feelings of excitement, motivation, contentment, and fulfillment. 

Distress, on the other hand, is an unhealthy form of stress that may include physical and emotional strain or tension or persistent stress that is not resolved through coping and adaptation. Distress may also be a precursor of anxiety, depression, substance abuse, addiction, compassion fatigue, and burnout. 

The human body is designed to give warning signals of stress overload that may include physical and cognitive symptoms. Physical signs and symptoms include insomnia or disturbed sleep, digestive problems, headaches, low energy, chronic tiredness, psychosomatic illnesses, muscle tension, teeth grinding, hypertension, and tachycardia.

The cognitive symptoms of excessive stress may consist of irritability, anger, anxiety, hypervigilance, impaired concentration, and decreased libido. Chronic stress leads to overengagement; over-reactive emotions; hyperactivity; and a sense of urgency, panic, phobias, and anxiety-type disorders. The symptoms of stress overload are often seen by the sufferer as obstacles to performance and success that he or she merely wants to eliminate.

The symptoms seldom slow down the victim, until the final blow is struck and the ulcer, stroke, or heart attack occurs.13 Lack of balance in one’s life can lead to stress overload, depletion of emotional reserves, insufficient coping skills, and ultimately burnout.

Burnout. No standardized system-wide approach or treatment for burnout exists, a condition not included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.14 Herbert J. Freudenberger, a German-born American psychologist most widely known for his contributions to understanding and treating stress, burnout, and substance abuse, was the first to use the term burnout in 1974. Freudenberger defined burnout as a state of mental and physical exhaustion brought on by an individual’s professional life.15

The most widely accepted definition of burnout comes from Maslach, who defines it as emotional exhaustion, depersonalization and reduced sense of personal accomplishment that can occur among individuals who do “people work” of some kind (Table 1).16

Table 1. The burnout triad

Emotional exhaustion
  • Fatigue on arising in the morning
  • Feeling emotionally drained from work
  • Perceiving working with others all day as a strain
  • Perceiving working with others as no longer enjoyable
  • Dehumanized perception of others
  • More callous actions toward others
  • Negative or cynical attitudes toward patients
  • Treatment of patients as impersonal objects
  • Indifference to what happens to patients
Decreased sense of personal accomplishment
  • Feeling of ineffectively dealing with patients’ problems
  • Feeling unable to positively influence the lives of others/li>
  • Not feeling exhilarated after working closely with patients

Among health-care providers, emotional exhaustion is characterized by physical and emotional depletion and fatigue. Signs of emotional exhaustion may include feeling fatigued on arising in the morning, feeling emotionally drained from work, and feeling that working with patients all day is a strain and no longer enjoyable.