Letter to the Editor regarding ‘Is burnout simply a stress reaction?’ Further to the call for a nosological identity;the impact of burnout within the medical profession

To the Editor

Burnout is a syndrome of major societal significance, characterised by exhaustion, cynicism and reduced professional efficacy as a result of a person’s employment. Parker and Tavella (2022) examined the biological relationship between stress and burnout, concluding that ‘burnout is likely a nuanced stress reaction’. Despite appearing in medical literature for several decades, there has been only modest progress in its nosological status. While recently having been included in the International Classification of Diseases, 11th Revision, burnout as a recognised diagnostic entity has remained absent in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Parker and Tavella prompted us to briefly explore the recent literature pertaining to the impact and treatment of burnout. We narrowed our examination to look within our own profession, in lieu of the relevance of burnout within medical professionals and trainees working within systems that are often under major stress. We highlight how the lack of definition can cause diagnostic confusion with depressive illness and how each carries unique challenges for the individuals afflicted. We also highlight the role of intervention in burnout and demonstrate how this could have potential upstream effect in preventing more severe depressive illness and suicidality.

To argue that burnout deserves a nosological identity, we must first establish that it has distinct clinical features and can cause significant dysfunction. Menon et al. (2020) examined the association between burnout and depression by comparing the clinical outcomes of suicidal ideation and medical error, occurring in 1354 American trainees and attending physicians. There was an incidence of suicidal ideation occurring in 5.5% of physicians within the study.

When utilising a logistic regression model, Menon et al. (2020) found that there was an 85% increase in odds of suicidal ideation (odds ratio [OR] = 1.85; 95% confidence interval [CI] = [1.47, 2.31]) for each standard deviation increase in the Standard Professional Fulfilment Index score. However, while suicidal ideation appeared attributed to the degree of burnout, when this was adjusted for depression, there was no significant association between burnout and suicidal ideation (OR = 0.85; 95% CI = [0.63, 1.17]). In a clinical context, this study highlights the clinical overlap between burnout and depression, raising the risk of misattribution and subsequent undertreatment.

Menon et al. (2020) also found that for every standard deviation increase in burnout score, there was an increase in odds of self-reported medical error (OR = 1.48; 95% CI = [1.28, 1.71]). However, contrary to the findings for suicidality, the symptom could not be attributed to depression, with no association found when adjusted for this (OR = 1.01; 95% CI = [0.88, 1.16]).

Burnout may therefore be unique to depression in that burnt-out clinicians may be prone to making medical errors. The ramification of making medical errors could have bearing on the potential quality and safety of patient care, safety towards other staff members and the wellbeing of the physicians who could be at risk medicolegally and to their psychological wellbeing.

We further examined the literature to look at the effectiveness of targeted interventions for burnout. West et al. (2016) conducted a systematic review of 15 randomised trials and 37 cohort studies looking at the efficacy of individual-focused and organisational strategies to manage burnout in medical professionals. Overall, burnout decreased from 54% to 44% (10% difference, 95% CI = [5, 14]; p < 0.0001) with a relative risk reduction of 18%. Within specific domains, there were reductions compared to control in emotional exhaustion with mean differences in Maslach Burnout Index of −2.06 (95% CI = [−3.86, −0.27]) and −2.71 (95% CI = [−3.83, −1.59]) across randomised controlled trials (RCTs) and cohort studies, respectively. For depersonalisation scores, there was a pooled reduction of −0.64 (95% CI = [−1.14, −0.15]). Structural or organisational interventions appeared more effective than individual-focused interventions (p = 0.03). Mindfulness or stress management–focussed interventions were found to have a non-significant reduction in overall burnout of 34% to 28% (95% CI = [−2, 14]; p = 0.14). The authors concluded that both organisation and individual-focused interventions are likely necessary in the treatment of burnout (West et al., 2016).

Given the existing clinical overlap, the literature still seems unclear whether burnout could indeed be a prodromal depressive state, a subtype of depression or a discrete construct. However, regardless of this overlap in symptom experience, the evidence suggests that depression and burnout have distinct clinical outcomes, in suicidal ideation and medical errors, respectively (West et al., 2016). We therefore argue that there is an occupational benefit for further establishing burnout as a nosological entity, as identifying and using established targeted burnout interventions will reduce the impact of its own unique and serious clinical outcomes. In agreement with Parker and Tavella, we conclude that burnout deserves nosological recognition that would improve its accurate identification and encourage further well-designed studies focussing on improving the delivery of targeted intervention.