Cuyamaca College downstream effects of burnout on patient care summary

An example of a situation or time in which you have felt burnt out with work or school.

  • A discussion on what we can do to address burnout or an example of burnout reduction strategies you have seen in your experience that have worked well.
  • A summary of the downstream effects of burnout on patient care.
  • Reproduced with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
    Burnout Among Health Care Professionals
    A Call to Explore and Address This
    Underrecognized Threat to Safe, High-Quality
    Lotte N. Dyrbye, MD, MHPE, Mayo Clinic; Tait D. Shanafelt, MD, Mayo Clinic;
    Christine A. Sinsky, MD, American Medical Association; Pamela F. Cipriano, PhD,
    RN, NEA-BC, FAAN, American Nurses Association; Jay Bhatt, DO, MPH, MPA,
    American Hospital Association; Alexander Ommaya, DSc, Association of American
    Medical Colleges; Colin P. West, MD, PhD, Mayo Clinic; David Meyers, MD, Agency
    for Healthcare Research and Quality
    July 5, 2017
    The US health care system is rapidly changing in an effort to deliver better
    care, improve health, and lower costs while providing care for an aging population with high rates of chronic disease and co-morbidities. Among the changes affecting clinical practice are new payment and delivery approaches, electronic
    health records, patient portals, and publicly reported quality metrics—all of which
    change the landscape of how care is provided, documented, and reimbursed. Navigating these changes are health care professionals (HCPs), whose daily work is critical to the success of health care improvement. Unfortunately, as a result of these
    changes and resulting added pressures, many HCPs are burned out, a syndrome
    characterized by a high degree of emotional exhaustion and high depersonalization
    (i.e., cynicism), and a low sense of personal accomplishment from work [1,2].
    What Is the Extent of Burnout Among Health
    Care Professionals?
    More than half of US physicians are experiencing substantial symptoms of burnout. Physicians working in
    the specialties at the front lines of care (e.g., emergency medicine, family medicine, general internal
    medicine, neurology) are among the highest risk of
    burnout. Burnout is nearly twice as prevalent among
    physicians as US workers in other fields after controlling for work hours and other factors [1,2]. Between
    2011 and 2014, the prevalence of burnout increased
    by 9 percent among physicians while remaining stable
    in other US workers. Several studies have also found
    Perspectives | Expert Voices in Health & Health Care
    a high prevalence of burnout and depression among
    medical students and residents, with rates higher than
    those of age-similar individuals pursuing other careers
    Nurses and Other Health Care Professionals
    Studies of nurses report a similarly high prevalence
    of burnout and depression. In a 1999 study of more
    than 10,000 registered inpatient nurses, 43 percent
    had high degree of emotional exhaustion [10]. A subsequent study of approximately 68,000 registered
    nurses in 2007 reported that 35 percent, 37 percent,
    and 22 percent of hospital nurses, nursing home
    nurses, and nurses working in other settings had high
    degree of emotional exhaustion [11]. The prevalence
    Reproduced with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
    of depression may also be higher among nurses than
    other US workers. In a study of 1,171 registered inpatient nurses, 18 percent had depression versus a
    national prevalence of approximately 9 percent [12].
    Less is known about other members of the health care
    team, although existing data suggest a similar prevalence of burnout among nurse practitioners and physician assistants [13].
    Why Should We Be Concerned About Burnout
    Among Health Care Professionals?
    Quality and Safety
    There are cross-sectional studies of physicians that
    suggest a significant effect on quality and risk of medical malpractice suits. In cross-sectional studies of more
    than 7,100 US surgeons, burnout was an independent
    predictor of reporting a recent major medical error
    [14] and being involved in a medical malpractice suit
    [15] on multivariate analysis that is controlled for other personal and professional factors. The relationship
    between burnout and medical error is likely bidirectional. In a longitudinal study of internal medicine residents, higher levels of burnout were associated with
    increased odds of reporting an error in the subsequent
    3 months. Self-perceived medical errors were also associated with worsening burnout, depressive symptoms, and decrease in quality of life, suggesting a cyclical relationship between medical errors and distress
    [16,17]. Mean stress levels of hospital employees have
    also been shown to correlate with the number of hospital malpractice suits [18], and mean burnout levels
    among hospital nurses are an independent predictor
    of health care–associated infection [19]. Other studies have found that as mean emotional exhaustion
    levels of physicians and nurses working in intensive
    care units rose, so did standardized patient mortality
    ratios [20], while perceived quality of interpersonal
    teamwork deteriorated [21].
    Patient Satisfaction
    Cross-sectional studies with modest sample sizes have
    reported significant correlations between a physician’s
    degree of depersonalization and patient satisfaction
    with their hospital care [22] and between a physician’s
    job satisfaction and patient satisfaction with their
    health care [23] and patient-reported adherence to
    medical advice [24]. Additional studies have reported
    an inverse relationship between nurse job satisfaction
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    and emotional exhaustion and patient satisfaction ratings across a variety of domains [11,25,26].
    Turnover and Reduction of Work Effort
    Cross-sectional studies of physicians have found burnout to be independently associated with job dissatisfaction [27] and more than 200 percent increased
    odds of intent to leave [28,29] the current practice for
    reasons other than retirement. Similarly, in studies of
    nurses, burnout and job dissatisfaction were associated with plans to leave the current job or nursing field
    [30-32]. This dissatisfaction and intent often translates
    into action. A longitudinal study of physicians reported
    that each 1-point increase in emotional exhaustion
    or 1-point decrease in job satisfaction between 2011
    and 2013 was associated with a 28 percent and 67
    percent greater likelihood, respectively, of reduction
    in professional effort (i.e., reduction in work hours
    according to payroll records) over the following year
    [33], resulting in a loss of productivity at the national
    level estimated to equate to eliminating the graduating
    classes of seven medical schools [34]. Other studies
    support this relationship between burnout and leaving
    the clinical practice [27,35,36]. Although leaving one’s
    current job or reducing work hours may provide individual relief [34], these tactics further strain a health
    care system already struggling to meet access needs
    Health Care Costs
    HCP turnover has financial implications for health care
    organizations. The cost of turnover among RNs is estimated at 1.2 to 1.3 times their salary (estimated total costs of $82,000–$88,000 per RN in 2007) [38,39].
    Costs to replace one physician depend on specialty,
    location, and length of vacancy, with estimated costs
    ranging from hundreds of thousands to more than
    $1 million [40,41]. Several small studies point to the
    possibility of physicians experiencing burnout or high
    workloads making more referrals and ordering more
    tests [42,43]. Burnout may also increase health care
    expenditures indirectly via higher rates of medical errors [14,16,17] and malpractice claims [14,15], absenteeism, and lower job productivity [12,44-47].
    Personal Consequences
    HCP burnout represents real suffering among people
    dedicated to preventing and relieving the suffering
    Published July 5, 2017
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    Burnout Among Health Care Professionals
    of others. Cross-sectional studies of physicians have
    found burnout to be independently associated with
    25 percent increased odds of alcohol abuse/dependence and 200 percent increased odds of suicidal ideation among physicians [48,49]. In a longitudinal study
    of medical students, burnout predicted development
    of suicidal thoughts over the ensuing year, independent of symptoms of depression [7]. Physicians are at
    increased risk of suicide compared with the US general
    population [50], with the suicide rate among male physicians 40 percent higher than that of other males in
    the population and the suicide rate among female physicians 130 percent higher than that of other females
    in the population [50].
    What Is Driving Burnout Among Health Care
    Work-Related Factors
    A large number of studies suggest that work-related
    stress fuels burnout [51] and job dissatisfaction among
    HCPs [52,53]. Work process inefficiencies (e.g., computerized order entry and documentation), excessive
    workloads (e.g., work hours, overnight call frequency,
    nurse-patient ratios), work-home conflicts, organizational climate factors (e.g., management culture;
    lack of physician-nurse collaboration, value congruence, opportunities for advancement, and social support), and deterioration in control, autonomy, and
    meaning at work have been associated with burnout
    among physicians and nurses [1,10,11,27,30,31,45,5465]. For example, multivariate analyses of data from
    cross-sectional studies of physicians have reported independent relationships between burnout and work
    hours (3 percent increased odds for each additional
    hour/week), night or weekend call (3–9 percent increased odds for each additional night or weekend
    on call), time spent at home on work-related tasks
    (2 percent increased odds for each additional hour/
    week), and work-home conflict (200–250 percent
    increased odds). In a study of inpatient nurses, each
    increase of one patient per nursing staff ratio (selfreported staffing levels) increased odds of high degree
    of emotional exhaustion by 23 percent and job dissatisfaction by 15 percent [10]. Moral distress, stemming from factors such as perceived powerlessness,
    unnecessary/futile care, inadequate informed consent,
    and false hope [66], is also a significant predictor of
    burnout among nurses [65]. Registered nurses who
    worked in nursing homes may also be at higher risk for
    burnout and lower job satisfaction than nurses who
    work in other settings [11].
    Cross-sectional studies have consistently found
    physician specialty to be an independent predictor
    of burnout, with some specialties associated with 40
    percent lower odds of burnout (e.g., dermatology) and
    others associated with up to 300 percent increased
    odds of burnout (e.g., emergency medicine, general internal medicine, neurology) in comparison with other
    specialties [1,2,27,35,55,57,58,67], suggesting there is
    something unique to the work lives in these specialties
    that contributes to increased risk. There may also be
    distinct work-related drivers for physicians in private
    practice, as several studies have found them at approximately 20 percent higher odds for burnout independent of specialty, work hours, incentive pay, and a
    variety of other factors [2,35,55,58]. Multivariate analyses of data from cross-sectional studies of physicians
    have reported independent relationships between
    burnout and incentive pay (130 percent increased
    odds versus other salary models), career stage (25
    percent more likely among midcareer physicians than
    early or late career), career fit (275 percent more likely
    among physicians who spend less than 20 percent of
    their work effort on the activity they find most personally meaningful), and use of computerized physician
    order entry (29 percent more likely among physicians
    who enter orders into a computer) [35,57,58]. Other
    aspects within the work environment that drive clerical burden likely also contribute [58,68,69]. Additionally, leadership behaviors matter [70]. How well leaders seek input from, inform, mentor, and recognize
    individuals for their contributions relates to burnout
    and the career satisfaction of the physicians they lead
    [70]. Large national studies of physicians also suggest
    that organizations that provide physicians with control over workplace issues are more likely to employ
    physicians with higher career satisfaction and lower
    reported stress [36,52].
    Demographic Profiles of Those at Higher Risk
    Cross-sectional studies of physicians have found independent relationships between burnout and physician sex, age, relationship status, age of children, and
    spousal/partner occupation [2,27,57,71]. Although
    gender is not consistently an independent predictor of
    burnout after adjusting for age and other factors, some
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    Reproduced with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
    studies have found female physicians to have 30–60
    percent increased odds of burnout [2,58,67]. Female
    physicians are more likely to experience depressive
    symptoms than male physicians; however, depression
    is not more common among female physicians than
    other females in the general population [50]. Younger
    physicians are also at increased odds of burnout, with
    those who are less than 55 years old at 200 percent increased risk compared with those older than 55. Having a child younger than 21 years old increases the
    odds of burnout by 54 percent, and having a spouse/
    partner who works as a nonphysician HCP increases
    the odds by 23 percent. We are unaware of any studies
    that have explored ethnic or racial differences in the
    prevalence of burnout among practicing physicians, although some work has been done in medical students
    [72]. Among other helping professionals, the prevalence of burnout among African Americans has been
    shown to be lower than among Caucasians [51,73].
    Individual characteristics, such as personality and interpersonal skills, and experiences may influence how
    HCPs deal with stress and adjust to rapidly changing work environments [74-77]. Research, however,
    suggests that individuals who choose to become physicians are not inherently more vulnerable to stress and
    burnout [78].
    What Research Is Needed?
    Despite decades of publications documenting the
    problem and some of its causes and potential
    consequences, many questions remain, and information on effective interventions remains limited [2,7981]. A major limitation of the existing research is that
    the vast majority of studies have been cross-sectional,
    hampering our ability to understand causality. Many
    studies lack the multivariate analyses needed to elucidate the extent to which hypothesized variables are
    independent predictors or interacting or confounding correlates. Only a limited number of the complex
    array of factors (e.g., workplace conditions and personal characteristics) that may contribute to burnout
    and poor job dissatisfaction among HCPs have been
    studied. There is a scarcity of research studies exploring differences by work setting (e.g., inpatient, outpatient, skilled nursing home) and the work experience
    of other members of the health care team, including
    nurse practitioners, physician assistants, pharmacists,
    medical assistants, and nonclinical staff. Terminology
    and measurement tools used vary substantially across
    studies, limiting comparisons across HCP populations, hampering efforts to quantitatively summarize
    outcomes (for example through meta-analyses), and
    slowing the rate of advancement in the field. Most intervention studies have used convenience sampling,
    lacked appropriate comparison groups, were short
    in duration, involved only a single discipline or organization, and focused primarily on individual interventions, such as mindfulness-based stress reduction,
    despite problems within the health care system being a much greater contributing factor to burnout and
    Box 1 | High-Priority Research Principles
    All Studies

    Build on existing models and conceptual frameworks

    Use robust study design (e.g., prospective cohort, case control, randomized)

    Use valid and reliable metrics

    Employ multivariate analysis consistent with conceptual framework
    To Explore Causation

    Use longitudinal study design
    Intervention Studies

    Use randomized controlled or cohort study designs with crossover or appropriate comparison group

    Include appropriate follow-up (e.g., 6–12 months after the end of intervention)

    Include multidisciplinary team or consider, when appropriate, effect of intervention on other members
    of health care team

    Should be feasible for scaling and implementation

    Report on cost
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    Published July 5, 2017
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    Burnout Among Health Care Professionals
    Box 2 | Research to Identify Organizational and Health Care System Factors That Contribute to
    Distress and Threaten Well-Being for Health Care Professionals
    Organizational environment

    What structural, functional (including clinical), financial, and operational features are associated with
    risk of burnout, depression, and suicidality among HCPs, and which features are associated with higher
    levels of well-being?

    What factors most strongly differentiate higher-performing from lower-performing systems with respect
    to HCP well-being?

    What models of health care delivery system (forms of economic integration and employment models)
    optimize HCP performance, well-being, and satisfaction?

    How do different types of delivery system organizational structures compare with respect to workforce
    efficiency, autonomy, and meaning in work?

    How do nonfinancial performance incentives, such as price transparency, public performance reporting
    for consumers, and private performance feedback reports to physicians, affect HCP distress and wellbeing?
    Practice environment

    What is the relationship between practice-level factors (e.g., delivery model, team composition, employment status, hours of operation) and HCP distress and well-being?

    Which care team design facilitates high-quality care, meaning in work, work efficiency, job satisfaction,
    and well-being among all care team members?

    What is the relationship between panel characteristics (e.g., panel size, complexity of patients seen,
    changing patient expectations/engagement) and HCP distress and well-being?

    What is the effect of health IT systems and changes on HCP distress and well-being?

    What are optimal workloads for HCPs that promote quality of care, prevent burnout, and achieve patient safety?

    What effect does case complexity have on HCP distress and well-being?

    To what extent does lack of continuity of care contribute to HCP burnout, especially in primary care?

    What is the relationship between implementation of safety interventions (e.g., reporting of patient
    safety events, prevention and control of health care–associated infections, improving diagnostic error,
    the safe use of medical devices and medications, and transitions of care and handoffs between health
    care providers) and HCP distress and well-being?
    Financial environment

    How do different payment models (e.g., bundled payment) and financial incentives affect HCP distress
    and well-being?

    Which changes done at a system level to better align financial incentives have improved HCP well-being,
    and which ones have negatively affected HCP well-being?

    Does measuring cost of care affect HCP well-being?
    Regulatory and liability environment

    Do medical licensing requirements discourage HCPs from accessing mental health care?

    What is the effect of malpractice liability and tort reform on HCP distress and well-being?
    dissatisfaction [82]. These shortcomings should be addressed.
    Future research should adhere to core research
    principles (Box 1). Methodologically rigorous research
    should build on existing models and conceptual frameworks [53,83-87] and use instruments to measure domains of HCPs’ work-lives, experiences, burnout, and
    well-being (i.e., emotional, psychological, and social
    well-being) that have acceptable levels of reliability
    and validity. Despite the widespread use of study-specific and often single-item approaches to explore these
    dimensions, instruments with established reliability
    and validity to measure burnout, stress, engagement,
    quality of life, fatigue, and other dimensions of mental health exist, and their use should be encouraged
    [87]. The Maslach Burnout Inventory (MBI) is the gold
    standard for measuring burnout, with the MBI-Human
    Services Survey version most suitable for measuring
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    Box 3 | Research to Gain Further Understanding of the Implications of Health Care Professional
    Distress and Well-Being for Health Care Outcomes

    What is the relationship between HCP distress and well-being and quality of care and patient health
    What is the relationship between HCP distress and well-being and patient safety?
    What is the relationship between HCP distress and well-being and patient experience, patient engagement, and patient adherence to treatment? What are the short- and long-term economic costs of HCP
    What role does HCP distress and well-being have in turnover and reduced work effort?
    What is the relationship between HCP distress and well-being and referral patterns, test ordering, and
    prescribing practices in relation to health care costs and overuse of health care?
    What role does HCP mental health play in attitudes toward cost-conscious care?
    What is the effect of HCP distress and well-being on overuse of health care overutilization?
    burnout among HCPs (e.g., nurses, physicians, health
    aides, social workers, counselors, therapists) and the
    MBI-General Survey version for others working in jobs
    such as customer service, management, and most other professions. Instruments designed to measure multiple dimensions of well-being (burnout, stress, worklife integration, meaning/purpose in work) specifically
    for physicians have also been developed [88-93] and
    validated [87]. These instruments have also proved
    useful for workers in other fields [88], and studies to
    establish national benchmarks for nurses, nurse practitioners, and physician assistants are ongoing. Those
    instruments with published national benchmarks for
    HCPs and demonstrated to have predictive validity for
    relevant outcomes are particularly useful [87-91]. Development of additional instruments to measure new
    constructs need to apply established rigorous scientific
    processes of instrument development and validation,
    including particular attention to concurrent and predictive validity.
    To move the field forward, methodologically rigorous research should be conducted within the following
    three major areas:
    1) Research to identify organizational and health
    care system factors that increase risk of distress for
    health care professionals
    Research is needed that creates new knowledge by
    identifying the organizational and health care system
    factors that are placing HCPs at increased risk for burnout. In particular, longitudinal studies are needed to
    better identify individual, work-unit, health care organization/employer, and health care system factors that
    Page 6
    contribute to poor well-being among HCPs. Research
    priorities within this domain are listed in Box 2. It is critical that researchers consider how factors may differentially affect different members of the health care team.
    For example, the incorporation of computer order entry may affect physicians, pharmacists, and nurses in
    different ways, increasing workload or stress for some
    while lessening it for others.
    2) Research to gain further understanding of the
    implications of health care professional distress
    and well-being for health care outcomes
    Longitudinal study designs and measured (rather than
    self-reported) health care outcomes are needed to advance our understanding of the professional consequences of HCP burnout and other forms of distress
    (Box 3). Given the effect of HCPs’ decisions on health
    care outcomes and costs, research should also focus
    on exploring relationships between HCPs’ distress, wellbeing, and referral patterns, test ordering, prescribing
    practices, and other decisions that affect health care
    quality, safety, and costs. Economic models that estimate the costs of poor HCP well-being are also needed.
    Efforts in this regard have begun, and additional studies are needed to maximize precision and generalizability [19,94].
    3) Intervention research to improve the work-lives
    and well-being of health care professionals
    Relatively few methodologically robust intervention
    studies have been conducted [81,95]. Intervention research should be a high priority. A recent systematic
    review and meta-analysis evaluating interventions to
    Published July 5, 2017
    Reproduced with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
    Burnout Among Health Care Professionals
    reduce physician burnout identified only 15 randomized
    controlled trials and 37 cohort studies [81]. The analysis concluded that a broad range of interventions are
    mildly to modestly effective in reducing physician burnout and that both organizational/structural- and individual-focused interventions are effective [81]. A second,
    subsequent meta-analysis resulted in similar findings
    [95]. Targets for intervention research are listed in Box 4
    and will be further informed by the research proposed
    in area 1 above. Both interventions that include diverse
    groups of HCPs and others that target the unique needs
    of each type of HCP (e.g., physicians, nurses, nurse practitioners, physician assistants, pharmacists) are needed.
    It is also vital to determine the work conditions and HCP
    individual factors necessary for successfully implementing interventions that improve performance and wellbeing. Furthermore, studies assessing the degree to
    which interventions that improve HCP well-being also
    improve patient outcomes, access to care, and cost of
    care could have a transformative effect. Implementation-science principles should be used to promote the
    uptake of research findings into common health care
    Overcoming Barriers to Research
    To date, research funding for studies designed to advance these three aims has been limited. Given the potentially serious ramifications of poor well-being and low
    job satisfaction among HCPs on the success of efforts
    to advance the patient experience of care, improve the
    health of populations, and reduce cost of health care,
    this should be remedied. Implementation of health care
    legislation and associated regulations should include
    appropriately scaled resources that can be allocated to
    study the effects of regulatory requirements associated
    with health care legislation on population health, patient satisfaction, cost, and HCP well-being and job satisfaction. Only with such effort will viable and sustainable
    solutions be realized.
    The high prevalence of burnout among HCPs is cause
    for concern because it appears to be affecting quality,
    safety, and health care system performance. Efforts are
    needed to address this growing problem. Progress will
    require methodologically sound studies, adequate funding, and collaborative efforts. Formation of the National
    Academy of Medicine Action Collaborative (for a full list
    of participants, please see
    clinician-resilience-and-well-being) is an important
    step. Many organizations have initiated steps to address aspects of the problem, but as indicated in this
    article, many important questions remain. The authors
    hope that research sponsors, institutions, clinician organizations, researchers, clinicians, and patients join in
    supporting enhanced research efforts focused on these
    Box 4 | Intervention Research to Improve the Work-Lives and Well-Being of Health Care Professionals

    What organizational interventions in the practice environment reduce distress and cultivate well-being
    among HCPs?
    What work conditions and HCP individual factors are necessary for successfully implementing interventions
    that improve performance and well-being?
    What are the optimal approaches to designing and implementing individual and organizational interventions to reduce HCP distress and promote HCP well-being?
    What system-level factors are necessary for implementing interventions that improve performance and
    HCP well-being?
    How do health care organizations optimally incorporate regular assessment of HCP well-being and act on
    What is needed for delivery systems to implement best practices known to create positive work environments that support high-performing teams and individual well-being?
    What practice environment factors optimize implementation of interventions aimed at increasing efficiency
    and controlling and improving affordability without increasing HCP distress?
    What interventions to improve HCP well-being also improve patient outcomes?
    How should organizations evaluate and improve the work environment, help individuals promote their
    well-being, and support those who experience distress?
    What is an effective way to screen for distress, reduce barriers to care, and treat distress?
    What personal strategies are essential to facilitating recovery from burnout?
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    Reproduced with permission from the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
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    Author Information
    Lotte N. Dyrbye, MD, MHPE, is Professor of Medicine
    and Associate Director, Program on Physician WellBeing at Mayo Clinic. Tait D. Shanafelt, MD, is Professor of Medicine, Director, Program on Physician WellBeing, and Medcal Director, Office of Staff Services, at
    Mayo Clinic. Christine A. Sinsky, MD, is Vice President,
    Professional Satisfaction, at American Medical Association. Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, is
    President at American Nurses Association. Jay Bhatt,
    DO, MPH, MPA, is Chief Medical Officer at American
    Hospital Association. Alexander Ommaya, DSc, is Senior Director, Clinical and Translational Research and
    Policy, at Association of American Medical Colleges.
    Colin P. West, MD, PhD is Professor of Medicine and
    Associate Director, Program on Physician Well-Being at
    Mayo Clinic. David Meyers, MD, is Chief Medical Officer at Agency for Healthcare Research and Quality.
    Lotte N. Dyrbye, MD, MHPE, 200 First Street SW, Rochester, MN 55905; Telephone: (507) 284-2511; E-mail:
    The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations,
    the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to
    help inform and stimulate discussion. It is not a report
    of the NAM or the National Academies. Copyright by
    the National Academy of Sciences. All rights reserved.
    Suggested Citation
    Dyrbye, L.N., T.D. Shanafelt, C.A. Sinsky, P.F. Cipriano,
    J. Bhatt, A. Ommaya, C.P. West, and D. Meyers. 2017.
    Burnout among health care professionals: A call to
    explore and address this underrecognized threat to
    safe, high-quality care. NAM Perspectives. Discussion
    Paper, National Academy of Medicine, Washington,
    Page 11

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