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==Measurement==
==Measurement==
Several burnout inventories are available including the Maslach, Copenhagen, and Oldenburg<ref>Dyrbye L et al (2018). [https://nam.edu/a-pragmatic-approach-for-organizations-to-measure-health-care-professional-well-being/ A Pragmatic Approach for Organizations to Measure Health Care Professional Well-Being]. National Academy of Medicine</ref><ref name="nam">{{Citation | vauthors=((Anonymous)) | title=Valid and Reliable Survey Instruments to Measure Burnout, Well-Being, and Other Work-Related Dimensions | url=https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/ | access-date=3 October 2021}}</ref>.
Several burnout inventories are available including the Maslach, Copenhagen, and Oldenburg<ref>Dyrbye L et al (2018). [https://nam.edu/a-pragmatic-approach-for-organizations-to-measure-health-care-professional-well-being/ A Pragmatic Approach for Organizations to Measure Health Care Professional Well-Being]. National Academy of Medicine</ref><ref name="nam">{{Citation | vauthors=((Anonymous)) | title=Valid and Reliable Survey Instruments to Measure Burnout, Well-Being, and Other Work-Related Dimensions | url=https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/ | access-date=3 October 2021}}</ref>.
A serum S100B level has also been correlated with emotional exhaustion.<ref name="pmid27018399">{{cite journal |vauthors=Gulen B, Serinken M, Eken C, Karcıoglu Ö, Kucukdagli OT, Kilic E, Akpinar G, Nogay S, Kuh M |title=Serum S100B as a Surrogate Biomarker in the Diagnoses of Burnout and Depression in Emergency Medicine Residents |journal=Acad Emerg Med |volume=23 |issue=7 |pages=786–9 |date=July 2016 |pmid=27018399 |doi=10.1111/acem.12973 |url=}}</ref>
A [[systematic review]] comparing the quality of burnout scales has been published and found the CBI to have the strongest validity, followed by the Oldenburg Burnout Inventory.<ref name="pmid33436137">{{cite journal |vauthors=Shoman Y, Marca SC, Bianchi R, Godderis L, van der Molen HF, Guseva Canu I |title=Psychometric properties of burnout measures: a systematic review |journal=Epidemiol Psychiatr Sci |volume=30 |issue= |pages=e8 |date=January 2021 |pmid=33436137 |pmc=8057391 |doi=10.1017/S2045796020001134 |url=}}</ref>


===Maslach Burnout Inventory===
===Maslach Burnout Inventory===
Line 226: Line 230:
* client-related burnout
* client-related burnout


Regarding comparison to the Maslach Burnout Inventory, a [[systematic review]] has been published<ref name="pmid33436137">{{cite journal |vauthors=Shoman Y, Marca SC, Bianchi R, Godderis L, van der Molen HF, Guseva Canu I |title=Psychometric properties of burnout measures: a systematic review |journal=Epidemiol Psychiatr Sci |volume=30 |issue= |pages=e8 |date=January 2021 |pmid=33436137 |pmc=8057391 |doi=10.1017/S2045796020001134 |url=}}</ref>, and a more recent study that compared to one-item versions of the MBI scales<ref name="pmid39082466">{{cite journal |vauthors=Li H, Dance E, Poonja Z, Aguilar LS, Colmers-Gray I |title=Agreement between the Maslach Burnout Inventory and the Copenhagen Burnout Inventory among emergency physicians and trainees |journal=Acad Emerg Med |volume= |issue= |pages= |date=July 2024 |pmid=39082466 |doi=10.1111/acem.14994 |url=}}</ref>. Neither study reported correlations between scales.
A [[systematic review]] comparing the quality of burnout scales has been published and found the CBI to have validity.<ref name="pmid33436137">{{cite journal |vauthors=Shoman Y, Marca SC, Bianchi R, Godderis L, van der Molen HF, Guseva Canu I |title=Psychometric properties of burnout measures: a systematic review |journal=Epidemiol Psychiatr Sci |volume=30 |issue= |pages=e8 |date=January 2021 |pmid=33436137 |pmc=8057391 |doi=10.1017/S2045796020001134 |url=}}</ref> However, this review did not measure correlations between scales.
 
More recently, and a cross-sectional study that compared the Copenhagen to one-item versions of the MBI scales and found very similar rates of burnout.<ref name="pmid39082466">{{cite journal |vauthors=Li H, Dance E, Poonja Z, Aguilar LS, Colmers-Gray I |title=Agreement between the Maslach Burnout Inventory and the Copenhagen Burnout Inventory among emergency physicians and trainees |journal=Acad Emerg Med |volume= |issue= |pages= |date=July 2024 |pmid=39082466 |doi=10.1111/acem.14994 |url=}}</ref> A [[systematic review]] found that the Copenhagen reported an absolute 18% higher rate of burnout than did the MBI report.<ref name="pmid36536586">{{cite journal |vauthors=Alahmari MA, Al Moaleem MM, Hamdi BA, Hamzi MA, Aljadaani AT, Khormi FA, Darraj MA, Shrwani RJ, AlOmar AA, Tahhah MK, Alyousefy MA, Al Sanabani FA |title=Prevalence of Burnout in Healthcare Specialties: A Systematic Review Using Copenhagen and Maslach Burnout Inventories |journal=Med Sci Monit |volume=28 |issue= |pages=e938798 |date=December 2022 |pmid=36536586 |pmc=9789675 |doi=10.12659/MSM.938798 |url=}}</ref>
 
None of these three studies reported correlations between scales.


===Oldenburg Burnout Inventory===
===Oldenburg Burnout Inventory===
The Oldenburg Burnout Inventory has 16 items and was developed by Demerouti and others and has two scales<ref name="DemeroutiBakker2003">{{cite journal | last1 = Demerouti | first1 = E| last2 = Bakker | first2 = AB | last3 = Vardakou | first3 = I| last4 = Kantas | first4 = A| title = The Convergent Validity of Two Burnout Instruments | journal = European Journal of Psychological Assessment | date = March 2003 | volume = 19 | issue = 1 | pages = 12–23 | issn = 1015-5759 | eissn = 2151-2426 | doi = 10.1027//1015-5759.19.1.12 | pmid = | url = }}</ref><ref name="Oldenburg2010">{{cite journal | vauthors=((Demerouti, E.)), ((Mostert, K.)), ((Bakker, A. B.)) | journal=Journal of Occupational Health Psychology | title=Burnout and work engagement: A thorough investigation of the independency of both constructs. | volume=15 | issue=3 | pages=209–222 | date= July 2010 | url=http://doi.apa.org/getdoi.cfm?doi=10.1037/a0019408 | issn=1939-1307, 1076-8998 | doi=10.1037/a0019408 | access-date=18 September 2022}}</ref>:
The Oldenburg Burnout Inventory has 16 items and was developed by Demerouti and others and has two scales with Likert anchors that as subjective severity but not frequency:<ref name="DemeroutiBakker2003">{{cite journal | last1 = Demerouti | first1 = E| last2 = Bakker | first2 = AB | last3 = Vardakou | first3 = I| last4 = Kantas | first4 = A| title = The Convergent Validity of Two Burnout Instruments | journal = European Journal of Psychological Assessment | date = March 2003 | volume = 19 | issue = 1 | pages = 12–23 | issn = 1015-5759 | eissn = 2151-2426 | doi = 10.1027//1015-5759.19.1.12 | pmid = | url = }}</ref><ref name="Oldenburg2010">{{cite journal | vauthors=((Demerouti, E.)), ((Mostert, K.)), ((Bakker, A. B.)) | journal=Journal of Occupational Health Psychology | title=Burnout and work engagement: A thorough investigation of the independency of both constructs. | volume=15 | issue=3 | pages=209–222 | date= July 2010 | url=http://doi.apa.org/getdoi.cfm?doi=10.1037/a0019408 | issn=1939-1307, 1076-8998 | doi=10.1037/a0019408 | access-date=18 September 2022}}</ref>:
* Disengagement scale. The highest loading item is "I find my work to be a positive challenge" and the second highest loading item is "I always find new and interesting aspects in my work"<ref name="Oldenburg2008">Demerouti E, Bakker AB. The Oldenburg Burnout Inventory: A good alternative to measure burnout and engagement. Handbook of stress and burnout in health care. 2008 Jan;65(7). https://www.isonderhouden.nl/doc/pdf/arnoldbakker/articles/articles_arnold_bakker_173.pdf</ref>.
* Disengagement scale. The highest loading item is "I find my work to be a positive challenge" and the second highest loading item is "I always find new and interesting aspects in my work"<ref name="Oldenburg2008">Demerouti E, Bakker AB. The Oldenburg Burnout Inventory: A good alternative to measure burnout and engagement. Handbook of stress and burnout in health care. 2008 Jan;65(7). https://www.isonderhouden.nl/doc/pdf/arnoldbakker/articles/articles_arnold_bakker_173.pdf</ref>.
* Exhaustion scale. The highest loading item is "After my work, I usually feel worn out and weary"<ref name="Oldenburg2008"/>.
* Exhaustion scale. The highest loading item is "After my work, I usually feel worn out and weary"<ref name="Oldenburg2008"/>.

Latest revision as of 23:14, 6 November 2024

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Burnout is a concept in industrial and organizational psychology for "an excessive stress reaction to one's occupational or professional environment. It is manifested by feelings of emotional and physical exhaustion coupled with a sense of frustration and failure".[1] Burnout has three dimensions[2]:

  • Emotional exhaustion
  • Depersonalization (cynicism)
  • Diminished personal accomplishment (inefficacy)

Subsequent research suggests the third dimension, personal accomplishment, better fits with the concept of professional engagement rather than with burnout.[3]

Workaholism more closely correlates with burnout than with engagement, although workaholism correlated with both (weakly negatively with engagement [via absorption])[4].

Engagement may not simply be the opposite of burnout[5]. Engagement and burnout may be related more specifically[6]:

  • Emotional exhaustion may be the opposite of vigor
  • Cynicism may be the opposite of dedication

OR

"Vigor and dedication are the direct positive opposites of exhaustion and cynicism, respectively."[5]

According to Schaufeli[5] , the "Energetic Process" is based on Hockey's model of compensatory control and when "perceived demands are too high to be met by the usual working effort, two options are open:

  • Strain coping mode leading to fatigue and irritability
  • Passive coping mode leading to disengagement


The distinction between burnout and depression is not clear[7].

Prevalence

The prevalence of burnout in the general, employed population of the United States, aged is (measured by MBI except where noted)[8][9][10]:

  • General, employed U.S. population
    • (2010): aged 31-47 30%[8], aged 29-65 29%[9]
    • (2014): aged 31-65 28%[10]
    • (2017): aged 29-65 28%[11]
    • (2021): during COVID epidemic in Japan: 31% (measured by Mini-Z)[12]
  • College graduates 2010: aged 31-47 36%[8]

Health care workers

As of 2017, 44% of physicians have have burnout[11] Previously, in 2014, as many as 50% of physicians in practice may have burnout.[10] General practitioners seem to have low job control and the highest proportion of burnout cases[13].

For physicians in training, rates of burnout (emotional exhaustion) for students, residents and fellows is about 50% while the rate is 36% in similarly aged college graduates.[8]

Causes

Burnout is due to loss of control at work, and also "burnout is mainly predicted by job demands but also by lack of job resources"[14].

Curiously, a study of physicians found, "High levels of personal accomplishment increased stress levels (beta=0 080), whereas depersonalisation lowered stress levels (beta=-0 105)"[15] The study also found that

Different underlying factors may lead to varying phenotypes of burnout[16][17] One study found[16]:

  • Burnout (high on all three dimensions)
  • Engagement (low on all three)
  • Overextended (high on exhaustion only)
  • Disengaged (high on cynicism only). Also called depersonalization by Leiter[16] which may be the same as mental distance used by the World Health Organization[18].
  • Ineffective (high on inefficacy only)

Regarding the possible connection of burnout with autonomy, burnout is more common in[19]:

  • chaotic practices[19]
  • larger practices[19]
  • accountable care organizations[19]

Burnout in physicians in training is associated with perceived harassment[20]. In one survey of 24 American medical schools, harassment occurring at least one time was reported by 83% of students[20]. In this study, harassment was more commonly reported being perpetrated by residents[20]. The rates of burnout among students responding to the survey were[20]:

  • All students 34%
  • Those reporting recurrent harassment by faculty 57%
  • Those not reporting recurrent harassment by faculty 32%

Job demands-resources model of burnout

Several items, specifically workload, are reflected in the job demands-resources model of burnout[21].

These findings are reflected in the Demand-Control theory of job stress. [22]

Areas of Worklife Survey (AWS)

Leiter and Maslach found the following antecedents from the Areas of Worklife Survey (AWS) using factor analysis:[23]

  • Workload
  • Fairness
  • Control
  • Community
  • Values
  • Rewards

Of these causes, workload is the strongest correlate of emotional exhaustion[23] but loss of control may be the initial factor. Perceived control or autonomy and fairness correlate with cynicism.[23][24]

  • 16% of burnout is attributed to perceived control at the worksite.[25]

Leiter et al found that workload relates more to exhaustion while values incongruency relates more to cynicism[26].

Leadership quality

Leadership affects both burnout and work fulfillment. A study at the Mayo Clinic found that the "average leadership behaviour score of physicians’ work unit supervisor explained 11% of the variation in burnout and 47% of the variation in workplace satisfaction"[27].

In a second study across 11 healthcare organizations, the rates of burnout by tercile of leadership ratings of effectiveness by their direct reports[28]:

  • 18%
  • 35%
  • 47%

According to the yearly survey of recent medical school graduates by the Association of American Medical Colleges, the following are reported [29]:

  • Occasional public embarrassment 20%
  • Occasional public humiliation 8%

Burnout is now being studied in its reported antitheses, job satisfaction, job engagement and thriving. Thriving may protect against burnout[30][31]. Engagement is both negatively associated with burnout, but also unhealthy engagement may lead to burnout.[32]

Measurement

Several burnout inventories are available including the Maslach, Copenhagen, and Oldenburg[33][34].

A serum S100B level has also been correlated with emotional exhaustion.[35]

A systematic review comparing the quality of burnout scales has been published and found the CBI to have the strongest validity, followed by the Oldenburg Burnout Inventory.[36]

Maslach Burnout Inventory

The Maslach Burnout Inventory is a well-studied measurement of burnout that was first published in 1981. Maslach and her colleague Jackson first identified the construct "burnout" in the 1970s, and developed a measure that weighs the effects of on three scales[2]:

  • Emotional exhaustion (nine items)
  • Depersonalization (five items)
  • Personal accomplishment (eight items)

The Maslach Burnout Inventory (MBI) has several versions:

  • Human Services Survey (MBI-HSS) is 22-tems and for jobs such as 'clergy, police, therapists, social workers, medical'[37]
    • MBI-HSS without the Personal Accomplishment subscale is 14 items.
  • General Survey (MBI-GS) a 16-items for more general, non-social jobs as well[38]
    • MBI-GS without the Professional Efficacy subscale is 10 items.

Eckleberry-Hunt in 2017 raised the question that burnout is being over-reported by deeming burnout present if either emotional exhaustion or depersonalization are present.[39]

2-item Maslach Burnout Inventory

In this short survey, abnormal is defined as symptoms weekly or more on either item by West[40][41][42] and other[43][44] researchers.

1. I feel burned out from my work[42] or How often do you feel burned out from your work?[41]

  • Never
  • A few times a year or less
  • Once a month
  • A few times a month
  • Once a week
  • A few times a week
  • Every day

This item correlates with emotional exhaustion subscale of the Maslach Burnout Inventory (minus the single item being tested)[40]:

  • 0.76 to 0.83 across the four samples[40]

2. I have become more callous toward people since I took this job[42] or How often do you feel you’ve become more callous toward people since you started your residency?[41]

  • Never
  • A few times a year or less
  • Once a month
  • A few times a month
  • Once a week
  • A few times a week
  • Every day

This item correlates with depersonalization subscale of the Maslach Burnout Inventory (minus the single item being tested)[40]:

  • 0.61 to 0.72 across the four samples[40]

The two-item score correlates with the overall MBI with a correlation of 0.65[45] which is under the threshold recommended for group crrelations[46]

The two-item format has been used in national surveys in 2011[9] and its follow-up survey in 2014[10].

Single item burnout question (SIBOQ) or Mini Z

Single item burnout question (SIBOQ) variations[47][47][48]
Schmoldt, 1994[47] AMA / STEPSforward[48]
Most studies do not report the stem. Veninga using a 1 to 10 scale used for the stem,
"On the following scale, indicate by circling a number where you feel you are."[49] 		"Using your own definition of “burnout,” please circle one of the answers below"
or
“Overall, based on your definition of burnout, how would you rate your level of burnout?”[50]
I enjoy my work. I have no symptoms of burnout. I enjoy my work. I have no symptoms of burnout.
Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.
I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.
The symptoms of burnout that I’m experiencing won’t go away. I think about frustration at work a lot. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot.
I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help. I feel completely burned out. I am at the point where I may need to seek help.

The 10‑item Zero Burnout Program survey, or called the Mini Z[51], was adapted from the earlier Northwest Permanente (NWP) and Ohio Permanente Medical Group (OPMG) by Freeborn[52] and Schmoldt[47] which based this single question on earlier work by Veninga[49]. The SIBOQ was then used by later version of the Physician Worklife Survey[53]. The SIBOQ was first validated against the MBI by Rohland in 2004[54]. The SIBOQ was later used by the Minimizing Error, Maximizing Outcomes (MEMO)[55] studies used the self-definition format.

The Mini Z is a single item (burnout is defined as answers c, d, or e) that correlates with the emotional exhaustion scale of the Maslach[54]:

  • The Northwest Permanente (NWP) and Ohio Permanente Medical Group (OPMG) by Schmoldt, Freeborn and Klevit[52][47] stated[47] that the NWP also used the self-diagnosis item of Veninga that started in 1991 used the format:
    • The tedium index of Pines[56]
    • The self-diagnosis of burnout item of Veninga where the respondent chooses a number between 1 ("Not burned out") and 10 ("completely burned out").[49]

Structure

1. Using your own definition of “burnout,” please circle one of the answers below: a. I enjoy my work. I have no symptoms of burnout. b. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out. c. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion. d. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot. e. I feel completely burned out. I am at the point where I may need to seek help.

2. The Mini-Z also contains the relevant dimensions:

  • Workload
    • My control over my workload is...
    • Sufficiency of time for documentation is...
    • The amount of time I spend on the electronic health record (EHR) at home is...
  • Cynicism:
    • My professional values are well aligned with those of my department leaders...

The Mini Z is promoted by the American Medical Association's Steps Forward campaign.[48]

The Mini Z may report lower prevalence of burnout than when measured by the full Maslach Burnout Inventory (MBI).[57][58][59]

Burnout Assessment Tool

A newer survey is the Burnout Assessment Tool (BAT)[60] developed by Schaufeli and others[61]. The BAT has four subscales:

  • Exhaustion
  • Mental distance
  • Emotional impairment
  • Cognitive impairment

The BAT versions are:

  • Full version with 23 items
  • Short version with 12 items[62]

Copenhagen Burnout Inventory

The Copenhagen Burnout Inventory has 19 items and was developed in 2005.[63] It has three scales with Likert anchors that as subjective severity but not frequency:

  • personal burnout
  • work burnout
  • client-related burnout

A systematic review comparing the quality of burnout scales has been published and found the CBI to have validity.[36] However, this review did not measure correlations between scales.

More recently, and a cross-sectional study that compared the Copenhagen to one-item versions of the MBI scales and found very similar rates of burnout.[64] A systematic review found that the Copenhagen reported an absolute 18% higher rate of burnout than did the MBI report.[65]

None of these three studies reported correlations between scales.

Oldenburg Burnout Inventory

The Oldenburg Burnout Inventory has 16 items and was developed by Demerouti and others and has two scales with Likert anchors that as subjective severity but not frequency:[66][67]:

  • Disengagement scale. The highest loading item is "I find my work to be a positive challenge" and the second highest loading item is "I always find new and interesting aspects in my work"[68].
  • Exhaustion scale. The highest loading item is "After my work, I usually feel worn out and weary"[68].

Professional Fulfillment Index (PFI) (Stanford)

The PFI contains relevant dimensions including interpersonal disengagement[69]:

  • "Less empathetic with my patients"
  • "Less empathetic with my colleagues"

Physician Well-Being Index (PWBI)

The PWBI contains 7 items, one of which queries burnout in a yes/no response format. Its development[70] and application[71] have been reported.

Scales include disengagement:

  • "Have you worried that your work is hardening you emotionally?"

Professional Quality of Life (ProQOL)

The ProQOL has 30 items over three scales[72]:

  • Compassion satisfaction (CS)
  • Burnout (BO)
  • Compassion fatigue (CF)

The ProQOL does not include depersonalization.

The ProQO moderately correlates with the single-item burnout question from the Mini-Z[73].

The ProQOL is available at https://proqol.org/.

Prevention

Thriving[30][31] and engagement[74][3] are negatively correlated with, and thus may be protective, against burnout. However, unhealthy engagement may lead to burnout.[32]

Perceived control or autonomy and fairness correlate with cynicism.[23][24]

Successful teamwork may be important[75][76].

Religion, spirituality

Spirituality may be projective against burnout in medical students[77][78], medical residents/faculty[79][80], nurses[81] UK general practioners[82], and emergency medicine physicians[83].

Consequences

Clinical symptoms

Schaufeli found, consistent with Hockley’s State Regulation Model of Compensatory Control[84] that burnout can lead to somatic symptoms and that "burnout fully mediates the relationship between job demands and health problems."[85]


Clinical care

Burnout is associated with many clinical outcomes and personnel outcomes, but the relationships have much statistical heterogeneity[86].

Finances of an organization

Burnout may be associated with operating margins[87].

Treatment

Institutional and individual strategies to reduce burnout have been reviewed[88]. Of 15 studies, 12 were "individual-focused" and only 3 addressed " structural interventions within the work environment"ref name="pmid27692469"/>.

Physicians may not be aware that they are burned out and providing awareness may increase engagement with addressing burnout[89].

Meditation and Dhyana

Trauma-informed yoga may help[90].


Transcendental Meditation may help[91].

Art therapy

Randomized controlled trials of art therapy yield mixed and heterogeneous results[92][93].

See also

References

  1. ↑ Anonymous (2024), Professional Burnout (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ 2.0 2.1 Maslach, Christina; Jackson, Susan E. (1981). "The measurement of experienced burnout". Journal of Organizational Behavior. Wiley-Blackwell. 2 (2): 99–113. doi:10.1002/job.4030020205. ISSN 0894-3796.
  3. ↑ 3.0 3.1 Schaufeli, Wilmar B.; Bakker, Arnold B.; Salanova, Marisa (2016). "The Measurement of Work Engagement With a Short Questionnaire". Educational and Psychological Measurement. 66 (4): 701–716. doi:10.1177/0013164405282471. ISSN 0013-1644.
  4. ↑ Schaufeli, Wilmar B.; Taris, Toon W.; van Rhenen, Willem (April 2008). "Workaholism, Burnout, and Work Engagement: Three of a Kind or Three Different Kinds of Employee Well-being?". Applied Psychology. 57 (2): 173–203. doi:10.1111/j.1464-0597.2007.00285.x. eISSN 1464-0597. ISSN 0269-994X.
  5. ↑ 5.0 5.1 5.2 Schaufeli, W.B. and Bakker, A.B. (2004), Job demands, job resources, and their relationship with burnout and engagement: a multi‐sample study. J. Organiz. Behav., 25: 293-315. doi:10.1002/job.248
  6. ↑ González-Romá, Vicente; Schaufeli, Wilmar B.; Bakker, Arnold B.; Lloret, Susana (February 2006). "Burnout and work engagement: Independent factors or opposite poles?". Journal of Vocational Behavior. 68 (1): 165–174. doi:10.1016/j.jvb.2005.01.003. ISSN 0001-8791.
  7. ↑ Sen S (2022). "Is It Burnout or Depression? Expanding Efforts to Improve Physician Well-Being". N Engl J Med. 387 (18): 1629–1630. doi:10.1056/NEJMp2209540. PMID 36317749 Check |pmid= value (help).
  8. ↑ 8.0 8.1 8.2 8.3 Dyrbye LN, West CP, Satele D, Boone S, Tan L, Sloan J; et al. (2014). "Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population". Acad Med. 89 (3): 443–51. doi:10.1097/ACM.0000000000000134. PMID 24448053.
  9. ↑ 9.0 9.1 9.2 Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D; et al. (2012). "Burnout and satisfaction with work-life balance among US physicians relative to the general US population". Arch Intern Med. 172 (18): 1377–85. doi:10.1001/archinternmed.2012.3199. PMID 22911330.
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