Rethinking the Canary in the Coal Mine: The Social Determinants of Health (SDOH) and Burnout

The term “burnout” was popularized by the psychologist, Herbert Freudenberger, in the 1970’s to capture a phenomenon he personally experienced while putting in long hours caring for patients in his practice and at a free clinic. He subsequently dedicated his professional life to developing the research around burnout particularly in individuals in helping professions¹.  Christina Maslach, author of the Maslach Burnout Inventory, defines burnout as “a psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that can occur among individuals who work with other people in some capacity. ²“

With at least 50% of practicing physicians exhibiting at least one sign of burnout, physician burnout has been called a public health crisis³. Rates of burnout are continuing to increase, resulting in physician reduced workload, early retirement and existing of the profession⁴. With an ongoing national physician shortage and an aging population, the balance is tipped even further off kilter.

Though much of the literature on physician burnout has focused on interventions such as mindfulness, yoga, meditation and techniques at the individual physician level, fewer data exist on changing the structure of the environment itself.  Systems level changes are much needed and recognized as a part of the solution to burnout though appear much more complex than gym memberships and yoga retreats³. However, perhaps there is another dimension to burnout we may be missing.

A recent article in the Journal of the American Board of Family Medicine surveyed 1298 family medicine physicians practicing in outpatient ambulatory settings. De Marchis and colleagues at the University of California San Francisco reported physicians were more likely to report lower rates of burnout who had improved clinic capacity to address their patients’ social determinants of health with access to a social worker, pharmacist or working within an interprofessional patient-centered medical home.  The reported association was statistically significant and appeared to be irrespective of the percentage of vulnerable populations the clinic served⁵.

Though multiple validated screening tools have been developed to assess individual social determinants of health ranging from food insecurity to housing in clinical settings, screening for SDOH is more complicated than screening for diabetes or hypertension. Dr. Garg and colleagues in a 2016 Journal of the American Medical Association opinion article cautioned about the ethical implications of screening for SDOH without adequate capability to address those needs⁶. As the field of SDOH continues to evolve, we must commit to create and share validated, evidence-based interventions in the clinical and community realm.

As a physician, if our mission is truly to improve the health and lives of our patients, addressing the SDOH is the best “bang for our buck.” But what if it turns out that it also gives us the ability to gain back our lost emotional reserve by seeing our patients actually get better? What if it allows us to rid ourselves of depersonalization and to see them again as precarious humans doing the best that they can do without judgement? What if it gives us renewed enthusiasm for our calling and a sense of personal accomplishment again? Could part of the solution to physician burnout lie in addressing the SDOH? As the shifting landscape of medicine takes us away from patients, perhaps coming back to them through SDOH is part of the answer for both of us.

-Premal Patel, MD Community of Practice Member

Dr. Premal Patel is a board-certified Physician and an Associate Professor in the Department of Internal Medicine. She also serves as the Associate Director of the Global Health Education Program at UTMB and is co-coordinator of the Global Health Inter-Professional Core Course.

References:

1. Freudenberger HJ. Staff burn-out. J Soc Issues 1974;30:159-65.
2. Maslach, Christina, et al. Maslach burnout inventory. Vol. 21. Palo Alto, CA: Consulting Psychologists Press, 1986.
3. CP West et al. Physician burnout: contributors, consequences and solutions. Journal of Internal Medicine 2018; 283:6: 516-529.
4. Jha AK, et al. A Crisis in Health Care: A Call to Action on Physician Burnout.https://cdn1.sph.harvard.edu/wpcontent/uploads/sites/21/2019/01/PhysicianBurnoutReport2018FINAL.pdf. Accessed on June. 12, 2019.
5. De Marchis et al Physician burnout and higher clinic capacity to address patient’s social needs. J Am Board Fam Med 2019;32:69-79.
6. Garg A, Boynton-Jarret R, Dworkin P. Avoiding the Unintended Consequences of Screening for Social Determinants of Health. JAMA 2016;316:8: 813-814.