February 2021 | ISE Magazine 29
National studies have shown that almost 50% of
physicians experience some manifestations of burn-
out. Specialties at the front line of healthcare ac-
cess, including internal medicine, emergency, and
primary medicine, show rates higher than national
averages (“Changes in Burnout and Satisfaction
With Work-Life Integration in Physicians and the General
U.S. Working Population Between 2011 and 2017,” Tait D.
Shanafelt, Colin P. West, Christine Sinsky, Mickey Trockel,
Michael Tutty, Daniel V. Satele, Lindsey E. Carlasare and Lotte
N. Dyrbye, Mayo Clinic Proceedings, 2019).
Providers with extensive direct patient care, like hospitalists,
have been shown to have the greatest risk for burnout. Hospi-
talists perform a central role in the delivery of patient care in
the inpatient setting. While responsible for the general inter-
nal medicine care of admitted patients, they attend to a broad
spectrum of increasingly complex, higher acuity patients who
often have a number of comorbidities. The nature of the care
they provide requires working with a broad range of provider-
specialists and support staff across the healthcare facility.
This complexity and interdependence with numerous other
groups exposes the importance of the sociotechnical systems
operating within the inpatient setting. Breakdowns within
these systems have a negative impact on hospitalists’ ability to
deliver efficient, high quality patient care and potentially in-
crease the risk of burnout.
Recent work has focused on work processes associated with
health information technology, such as electronic health re-
cords (EHRs), as a primary source of providers’ burnout.
However, to get a complete picture of all the systemic factors
contributing to burnout, a broader sociotechnical approach is
required to capture the complexity of the interconnected sys-
tems. Therefore, the objective of this study was to assess the
levels of burnout among hospitalists and the differences in per-
ceived sociotechnical factors contributing to such burnout.
Methods, participants and data collection
This research was reviewed and approved for exemption by
the institutional review board committee at the participating
institutions. Hospitalists at two healthcare facilities within a
large integrated healthcare system – one an academic medical
center, the other a large community hospital – were the target
population of this study.
A survey was administered to all hospitalists at the two
participating hospitals. The survey instrument was created to
gather responses to three components: 1. demographic items,
such as sex, age, length of tenure in current position and hos-
pital type; 2. healthcare workplace burnout measures, includ-
ing the full 22-item Maslach Burnout Inventory (MBI-HSS;
see related article at right); and 3. 27 items based on various
sociotechnical workplace factors, such as issues related to work
processes, organizational culture, efficiency and usability of
EHR and other technologies, communications and relation-
ships within and outside groups and role clarity.
This survey was administered to all hospitalists at the two
participating hospitals. Participants were asked to rate the ex-
tent to which they felt the specific workplace factor contrib-
uted to their stress, with higher values representing stronger
agreement that the factor did contribute to distress.
Data analysis of burnout rates and factors
To understand the extent of hospitalist burnout, we employed
three dichotomous definitions of burnout – low, moderate
N
Defining and measuring burnout
The Maslach Burnout Inventory (MBI) is a 22-item measure
of perceived burnout in the human services profession and
was developed by Christina Maslach, a pioneer in the study
of burnout. Maslach is credited with the formation of one of
the most widely used definitions of burnout as “a syndrome of
emotional exhaustion, depersonalization and reduced personal
accomplishment that can occur among individuals who do
people-work of some kind.”
The MBI is divided into sub-scales that independently
measure levels of burnout in three main areas: emotional
exhaustion (nine items), feelings of being emotionally
overextended and exhausted by one’s work; depersonalization
(five items), an unfeeling and impersonal response toward
recipients of one’s service, care treatment or instruction; and
personal accomplishment (eight items), feelings of competence
and successful achievement in one’s work.
Burnout is included in the World Health Organization’s
(WHO) 11th Revision of the International Classification of
Diseases as an occupational phenomenon, and is not classified
as a medical condition. It is described as: “Factors influencing
health status or contact with health services.” That includes
reasons for which people contact health services but that are
not classed as illnesses or health conditions.
Burnout is defined by the WHO as “a syndrome conceptualized
as resulting from chronic workplace stress that has not been
successfully managed. It is characterized by three dimensions:
• Feelings of energy depletion or exhaustion;
• Increased mental distance from one’s job, or feelings of
negativism or cynicism related to one’s job; and
• Reduced professional efficacy.
Burnout refers specifically to phenomena in the occupational
context and should not be applied to describe experiences in
other areas of life.”
To read more, visit the WHO site at link.iise.org/who_burnout.
30 ISE Magazine | www.iise.org/ISEmagazine
and highly restrictive. Least
restrictive is burnout defined
by the experience of high
levels of at least one manifes-
tation of burnout: emotional
exhaustion (EE) >= 27; de-
personalization (DP) >= 10;
and personal accomplishment
(PA) <= 33. Moderately re-
strictive was burnout defined
as experiencing high levels on
two manifestations of burn-
out. And most restrictive is
burnout defined as experienc-
ing all three manifestations of
burnout: high on EE and DP,
low on PA.
To explore the associa-
tion between burnout and
the perception of socio-tech-
nical factors, we used inde-
pendent two-sample T-test
(two-tailed) to identify fac-
tors differing significantly as a
function of burnout level. Sig-
nificance level was set at 0.05.
The moderately restrictive
dichotomous definition was
used to perform this analysis as
it yielded appropriate sample
size within each group: N =
26 with burnout (45%) vs. N = 34 (55%) without burnout.
The overall survey participation rate was 68%, 58 of 85
eligible hospitalists at the academic medical center (67%) and
community hospital (71%). Of those responding, 41% were
male and 59% female. Their ages: 28% were younger than 35,
45% were ages 35 to 44, 21% were ages 45 to 54, 7% were ages
55 to 64. There were 59% of respondents from the academ-
ic medical center, 41% from the community hospital. Their
length of tenure in position was 43% with four or fewer years,
35% with five to nine years, 16% with 10 to 14 years and 5%
with 15 years or more.
Figure 1 presents the overall and demographic results for
hospitalists experiencing high vs. low burnout. The less re-
strictive definition of burnout (experience one manifestation
– i.e., sub-scale, of burnout) yielded burnout rates of 69%. The
moderately restrictive definition of burnout (two manifesta-
tions of burnout) yielded burnout rates of 45% and most re-
strictive (all three manifestations of burnout) yielded burnout
rates of 24%.
Figure 2 presents the overall results including factors differ-
ing significantly as a function of burnout level. The follow-
ing factors were found to differ between hospitalists with and
without burnout: time spent on tasks that could or should be
performed by others (p < 0.05); suboptimal relationships with
other groups (p < 0.05); and frequent interruptions and pro-
cess-breakdowns were rated as contributing most to hospitalist
distress (p < 0.05).
The objective of the study was to understand the extent and
nature of burnout among hospitalists providing patient care
at a large healthcare system. An additional goal was to assess
the differences in perceived sociotechnical factors contributing
to burnout in hospitalist with vs. without burnout. Applying
the definition of burnout used in the large national physician
study, namely the experience of either one or both emotional
exhaustion (EE) or depersonalization (DP) as measured by the
MBI, 69% of the hospitalists in the current study population
fit this definition of burnout, markedly higher than the ap-
proximately 50% among general internal medicine providers
reported in the most recent national study (hospitalists were
not specifically reported), and 52% of hospitalists in the 2014
national study.
Using a somewhat more restrictive definition of burnout as
Hospitalist burnout and sociotechnical factors contributing to workplace stress
FIGURE 1
Burnout levels
The classification of burnout levels across demographics and professional factors.
Low burnout
‡
High burnout
‡
N (%)
N (%)
Overall 32 (55.2%) 26 (44.8%)
Characteristic
Sex
Male
15 (62.5%)
9 (37.5%)
Female
17 (50.0%)
17 (50.0%)
Age,
in years
<35
10 (62.5%)
6 (37.5%)
35-44
15 (57.7%)
11 (42.3%)
45-54
5 (41.7%)
7 (58.3%)
>=55
2 (50.0%)
2 (50.0%)
Location
Academic Medical Center
21 (61.8%)
13 (38.2%)
Community Hospital
11 (45.8%)
13 (54.2%)
Tenure,
in years
0-4
17 (68.0%)
8 (32.0%)
5-9
11 (55.0%)
9 (45.0%)
10-14
4 (44.4%)
5 (55.6%)
15-19
0 (00.0%)
3 (100.0%)
>=20
0 (00.0%)
1 (100.0%)
‡
Burnout level classification of
low burnout
and
high burnout
is
based on the following definition of
high burnout
: Scoring “high” on
two or more symptoms of burnout as measured by the 22-item MBI.
February 2021 | ISE Magazine 31
FIGURE 2
Burnout factors
The sociotechnical factors associated with burnout. Note that except for two statements noted by asterisks (**), all statements in the survey
asked participants to rate their level of agreement as to whether a given stressor contributed to their burnout. The two exceptional statements
were worded in the opposite valency.
Socio-technical factors associated with burnout
Low
burnout
‡
(N = 32)
High
burnout
‡
(N = 26)
Difference
in
means
T-
test
Sig.
mean
†
(SD)
mean
†
(SD)
Frequent pages or interruptions for non-emergent issues 5.2 (1.57) 6.3 (0.97) 1.1
0.003
Lack of time to exercise, take care of oneself, and/or engage in
enjoyable activities outside of work
3.2 (1.32) 4.4 (2.01) 1.2
0.008
Difficult interactions with patients or their families 4.2 (1.71) 5.5 (1.59) 1.3
0.008
Time spent on tasks that are not reflective of working at the top
of my license
4.7 (1.52) 5.7 (1.39) 1.0
0.011
Lack of voice regarding decisions that affect my group/practice 4.0 (2.03) 5.4 (1.51) 1.3
0.014
Hospital leadership is responsive to my concerns and those of
my colleagues**
3.9 (1.86) 2.7 (1.54) -1.2
0.015
Time spent in EHR on documentation or reading notes 4.2 (1.63) 5.2 (1.71) 1.1
0.021
Lack of respect from outside groups 4.4 (1.83) 5.5 (1.70) 1.1
0.025
Time spent on tasks related to case management or tasks
below my practice
4.8 (1.69) 5.8 (1.52) 1.0
0.027
The leadership of my division/department is responsive to my
concerns and those of my colleagues**
5.4 (1.32) 4.5 (1.67) -0.9
0.033
Lack of collaborative patient care with outside groups 4.2 (1.87) 5.2 (1.44) 1.0
0.036
Admissions from the ED 4.5 (1.72) 5.4 (1.56) 1.0
0.036
Communication with colleagues in my group 1.8 (1.11) 2.6 (1.45) 0.8
0.047
Difficulty with staff/peers in other departments 2.9 (1.66) 3.8 (2.00) 0.9
0.056
Performing duties that should be completed by other personnel
(i.e.: entering orders for consultants)
4.1 (1.84) 5.1 (1.87) 0.9
0.063
My group's compensation plan 3.5 (1.78) 4.3 (1.73) 0.8
0.085
Feeling under-appreciated 4.4 (2.19) 5.2 (1.68) 0.8
0.125
Lack of communication with outside groups surrounding
patient care
4.2 (1.85) 4.8 (1.57) 0.7
0.158
Difficulty with staff/peers in my department 1.7 (1.08) 2.2 (1.62) 0.5
0.171
Time spent on electronic medical records and documentation 4.7 (1.42) 5.1 (1.58) 0.5
0.23
Inability to reach outside departments in a timely manner 3.8 (1.65) 4.2 (1.75) 0.3
0.452
Scheduling conflicts/challenges 3.6 (1.66) 3.8 (1.65) 0.3
0.554
Worries about childcare 3.3 (1.98) 2.9 (2.00) -0.3
0.563
Time spent in EHR on orders 3.8 (1.54) 4.0 (1.65) 0.3
0.568
Conflicting responsibilities between work, home, and family 4.3 (2.00) 4.4 (2.00) 0.1
0.883
†
Scores were assigned on a 7-point Likert Scale ranging from 1 (strongly disagree) to 7 (strongly agree), with 4
being the score for a neutral response.
‡
Burnout Level classification of Low Burnout and High Burnout is based on the following definition of High
Burnout: Scoring “High” on 2 or more symptoms of burnout as measured by the 22-item MBI
32 ISE Magazine | www.iise.org/ISEmagazine
Hospitalist burnout and sociotechnical factors contributing to workplace stress
How COVID-19 increases hospital burnout
The heavy burden the COVID-19 pandemic has placed
upon healthcare professionals has a profound effect on
stress and burnout levels, according to published reports.
A May 2020 Forbes article noted physician burnout
already was a problem before the pandemic. A 2018 study
by New Health Guide (newhealthguide.org) showed that
400 physicians die by suicide each year, double that of the
general population; doctors have the highest suicide rate
of any profession in the U.S including combat veterans
(Annals of Internal Medicine, www.acpjournals.org).
Economically, studies estimate that physician burnout
costs the U.S. healthcare system approximately $4.6 billion
per year.
“The stress of long hours, no sleep, poor eating,
inadequate protection, the fear of contaminating loved
ones, the fear of dying and seeing patients die no matter
what you do, the disrespect by hospital administrators and
the fear of being fired, all remain the reality for those who
are in the thick of things,” anesthesiologist and speaker
Lynette Charity, M.D., said.
“For many physicians, COVID-19 may be the proverbial
straw that breaks the camel’s back as they isolate themselves
physically from their family and friends while encountering
a surge of sickness and death,” said Nisha Mehta, M.D., a
radiologist, physician advocate and keynote speaker.
Experts recommend tackling the issue at its root cause with these steps: reduce administrative burdens; flexibility over schedules;
mental health support; reduce gender bias that increases burnout rates among female physicians, according to The National Academy
of Medicine; diversify doctor voices; and speak out to get help.
Rasu Shrestha, executive vice president and chief strategy and transformation officer at Atrium Health, told Healthcare IT News
(healthcareitnews.com) “I am a firm believer that you cannot yoga your way out of burnout. While it is critical to focus on clinician
wellness, I spend a good bit of my energy trying to address the factors that contribute to the burnout in the first place. These include
optimizing workflow challenges, reducing administrative burden and formulating creative care models that emphasize care team
coordination and person-centered care.”
An article appearing in MDEdge (mdedge.com) and The Hospitalist (the-hospitalist.org) included responses from several hospital
caregivers across the United States on the pandemic’s affects and response by their staffs.
“We are social distancing at work, wearing masks, not eating together with our colleagues – with less camaraderie and social
support than we used to have,” said Clarissa Barnes, M.D., a hospitalist at Avera McKennan Hospital in Sioux Falls, South Dakota. “I
feel exhausted and there’s no question that my colleagues and I have sacrificed a lot to deal with the pandemic.”
“One of the most common stressors we’ve heard from doctors is the challenge of caring for patients who are lonely and isolated
in their hospital rooms, suffering and dying in new ways,” said Sarah Richards, M.D., assistant professor of internal medicine at the
University of Nebraska, Omaha. “In low-incidence areas, doctors are expressing guilt because they aren’t under as much stress as their
colleagues. In high-incidence areas, doctors are already experiencing post-traumatic stress disorder.”
“We recognize that we’re all in the same foxhole. That’s been a helpful attitude – recognizing that it’s OK to be upset in a crisis
and to have trouble dealing with what’s going on,” said Joshua Case, M.D., hospitalist medical director for Northwell Health serving
metropolitan New York. “We need to acknowledge that some of us are suffering and try to encourage people to face it head on.”
February 2021 | ISE Magazine 33
defined by high scores in both EE and DP reduces the percent-
age of hospitalists experiencing burnout to 45%, more consis-
tent with the national study. This is worrisome and suggests
that rates of burnout are possibly increasing, with 24% of hos-
pitalists experiencing all symptoms of burnout which can lead
to adverse events like increased likelihood of medical errors
and decreases in quality of care.
Regarding the sociotechnical factors relating to burnout,
the factors that had the greatest discrepancy between hospital-
ists experiencing high vs. low burnout were predominantly
characterized as suboptimally implemented roles, such as ex-
tensive time spent on tasks that could or should be performed
by others, on documentation and extensive/frequent inter-
ruptions on non-emergent issues; difficulties in work culture
and relationships, such as difficulties with staff/peers in other
groups, lack of respect from outside groups or lack of collab-
orative patient care with outside groups; and lack of support
regarding difficult patient/family interactions, responsiveness
from group and hospital leadership.
These findings are in line with research reported in the Na-
tional Academy of Sciences’ recent report on clinician burn-
out, expanding on the impact that sociotechnical factors such
as professional relationships and social support, organizational
culture, excessive workload and suboptimal workflows, inter-
ruptions and distractions have on physician well-being. How-
ever, these findings are contrary to recent findings by Her-
bert L. Fred and Mark S. Scheid (“Physician Burnout: Causes,
Consequences and (?) Cures,” Texas Heart Institute Journal.
2018) and Mark A. Micek, Brian Arndt, Wen-Jan Tuan and
Elizabeth Trowbridge (“Physician Burnout and Timing of
Electronic Health Record Use,” ACI open, 2020) indicating
that perceptions of work processes associated with health in-
formation technology differed significantly based on level of
burnout experienced.
Overall, our findings suggest that hospitalists’ burnout is
mostly related to workplace roles, relationships and communi-
cation with outside groups, and extraordinarily high levels of
interruptions and distractions, requiring long-term organiza-
tional interventions focused on building trust and collegiality.
There are several limitations of our study limiting the gen-
eralizability of our findings. First, we administrated our survey
to hospitalists from two institutions with relatively small sam-
ple sizes. Another limitation is the construction of the survey
relied on the sociotechnical factors identified during town hall
meetings with hospitalists articulating workplace factors they
were currently struggling with, and therefore may not be com-
prehensive. Additionally, the response scales employed within
the survey varied from section to section. One section of items
was on a 4-point scale; others were on a 10-point scale.
Our analyses regarding the sociotechnical factors were
limited to differences between groups (low burnout vs. high
burnout) within items rather than across items, which would
lend much richer analyses of the relationships among the so-
ciotechnical factors. We also tried to address this limitation
by computing a transformation of the data to standardize all
sociotechnical factors to the same scale; however, issues of scale
variability contribute to error in our assessment.
Overall, this study shows that hospitalists are experiencing
high levels of burnout, above recent national averages. More-
over, sociotechnical factors associated with their experience of
burnout tend toward issues with the complexity of their role,
their relationships with colleagues in other groups and exces-
sive workloads, interruptions and distractions.
Note: This study was supported by funding from the Wellbeing
Program at the University of North Carolina Health Care System.
Sara Baker Stokes, Ph.D., is a research project manager in the Division
of Healthcare Engineering at the UNC School of Medicine with exper-
tise in survey research, social and organizational psychology, measure-
ment and improvement in healthcare. Her current research focuses on
provider and staff well-being, engagement and burnout, as well as the
implementation of quality improvement and patient safety programs.
Richa Kanwar holds a master’s degree in information science from the
University of North Carolina at Chapel Hill. She is a research assis-
tant at the Division of Healthcare Engineering in the UNC School of
Medicine. Her research interests include health informatics, user experi-
ence, human factors engineering and systems analysis.
Saumya Jain completed his master’s degree in information science from
the University of North Carolina Chapel Hill. He is a former research
assistant at the Division of Healthcare Engineering in the UNC School
of Medicine. He works as a technical project manager in the IT sector.
His research interests include systems analysis, informatics and data sci-
ence.
Karthik Adapa is a Ph.D. candidate in the Carolina Health Informat-
ics Program at UNC-Chapel Hill. He is a physician by training and
has a master’s degree in public health and public policy.
Samantha Meltzer-Brody, M.D., MPH, is the Assad Meymandi
Distinguished Professor and Chair of the Department of Psychiatry
at the University of North Carolina at Chapel Hill. She also directs
the UNC Center for Women’s Mood Disorders and leads the UNC
SOM and UNC Health Well-Being initiative.
Lukasz Mazur earned his bachelor’s and master’s degrees and Ph.D.
in industrial and management engineering from Montana State Uni-
versity. He is an associate professor and a director of a Division of
Healthcare Engineering in the UNC School of Medicine. His research
interests include engineering management as it pertains to continuous
quality and patient safety efforts in healthcare and human factor engi-
neering. He is an IISE member.
