How to Comprehend the Influence of Burnout on the PA Career

The physician assistant profession is appealing to many people, at least initially, due to a perception of it being a middle ground — the ability to be a medical provider with a high level of decision making and responsibility without the pressure or time it takes to become a doctor.

But, the stress that so often comes with working in medicine isn't isolated to the highest ranking member of the healthcare team, as any nurse, social worker, physical therapist, or X-ray tech can tell you. Every healthcare role comes with its fair share of work-related challenges.

In recent years, there has been increased interest and exploration into the prevalence of and factors that contribute to "burnout" among healthcare workers.

Burnout is characterized as a long-term, persistent job stress caused by emotional exhaustion, lack of enthusiasm for work, a reduced sense of personal accomplishment or satisfaction, and cynicism.

Beyond the exhaustion and dissatisfaction that can affect an individual provider, burnout also has the potential to impact institutions and patients by decreasing provider productivity, increasing provider shortages, and resulting in provider disengagement and medical errors.

Though most of the information on provider burnout has been collected on physicians, the first report on national trends of burnout among PAs was published in the Journal of the American Academy of Physician Assistants (aka, JAAPA) last fall.

To give you a fuller picture of the trends in provider exhaustion and the contributing factors, we'll go through the highlights of this report along with some additional data from the American Academy of Physician Assistants (AAPA) along with a more extensive report on burnout trends among physicians.

So let's get to it.

What the data reveals

The topic of provider burnout intrigues me not just as a PA, but as someone who has worked in what is often expected to be one of the most emotionally difficult specialties, oncology, since the beginning of my career.

Though working with cancer patients has been, at times, emotionally exhausting, the rewards of working the specialty have far outweighed the negatives.

And I'm not alone in this feeling.

In a recent national survey of PAs in oncology, 34.8% of respondents reported burnout. Interestingly, the same survey showed a career satisfaction level of 86.4% and a specialty satisfaction of 88.8% (Tetzlaff, 2018). (Keep an eye on this relationship between burnout and career satisfaction because it's not the last we'll see of it.)

One-third of PAs in a specialty reporting burnout is significant, but a previous survey of PAs in emergency medicine showed an even more substantial degree with 59% reporting moderate to high levels of burnout (Bell, 2002).

While these single-specialty surveys help to give us a window into the job satisfaction and stress levels of PAs in a particular discipline, a recent JAAPA article, Burnout, job satisfaction, and stress levels of PAs, assessed these issues across the profession by collecting responses from 15,999 PAs as part of the 2016 AAPA Salary Survey (Coplan, 2018).

Unlike the single-specialty surveys, the JAAPA report did not report overall burnout rates and, instead, assessed burnout by three components: enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. Respondents were provided with statements that closely aligned with each of the three categories and rated them on a scale of 1 (not at all) to 7 (extreme).

Understanding Burnout Among Practicing PAslBe a Physician Assistant

Overall, PAs had enthusiasm for their work (62.1% responded 5-7, mean=4.75), 21.4% reported some degree of cynicism (moderate 13.9%, high 5.3%, extreme 2.2%, mean=3.2), and just 10.4% reported a low sense of personal accomplishment (mean=2.22).


All good news!


Practicing PAs were also asked if they had ever left a position due to stress. Of those who responded, 45.4% never had, 12.8% never had but were considering quitting their current position due to stress, burnout or a toxic workplace, and 30% had quit once in the past due to stress. Another 11.7% had left more than one position due to burnout, but this result was not statistically significant.


It may be tempting to use this information as a stand-in for overall burnout levels. However, this question asked PAs to reflect on the entirety of their careers, not only their current stress levels.


And, based on what we've already seen, burnout may be present in individuals who simultaneously really love their jobs and may be unlikely to leave. So we can't substitute here.


The survey also looked at happiness levels of PAs both in an out of work, which I thought was a nice addition. This inclusion helps to acknowledge the "illusion of separation" that we often have between our work and outside-of-work lives and that each has the potential of affecting the satisfaction level of the other.


There's more positive news on this front: PAs are generally pretty happy in both realms.


On a scale of 1 (strongly disagree) to 5 (strongly agree), 75.2% agreed or strongly agreed that they were happy at work, 88.8% were satisfied or very satisfied with their life, 77.2% agreed or strongly agreed that their life was close to ideal (!!), and 93% agreed or strongly agreed they were happy outside of work. Of nearly 160 thousand PAs! These results make me happy.


The survey also assessed factors contributing to job stress. Spending too many hours at work ranked as the most important factor (mean=4.63), This was followed by income not high enough (mean=4.44). (Which I imagine is a more persistent feeling of the "they don't pay me enough for this" moments that most of us PAs have when unexpected disasters land in our laps.)


Another aspect of this survey that I found quite valuable was the comparison of PA responses on factors contributing to stress to those of physicians. To accomplish this, they used the most comprehensive report on physician burnout from the same year, the 2016 Medscape Physician Lifestyle Report.


There is a more recent version of this physician report available (which we'll look at very shortly), but the 2016 survey was used for the best head-to-head comparison against the 2016 PA data.


In looking at the results from each survey, the averages of both PAs and physicians rated most stressors on the "not important" side of the scale of 1 (not at all important) to 7 (extremely important).


PAs ranked 7 of 10 factors contributing to stress higher than physicians did, though physicians ranked too many bureaucratic tasks, increased computerization of practice, and feeling like just a cog in the wheel higher than PAs did.


Though the JAAPA report compared responses between female and male PAs and examined job stressors of PAs versus physicians, further details of burnout or job satisfaction among different practice specialties of PAs were not examined.


However, a 2018 article by AAPA, drawn from the 2017 version of the AAPA PA Salary Survey, looked at overall burnout, professional fulfillment, and exhaustion by broad specialty categories (e.g., pediatric subspecialties, primary care, internal medicine subspecialties, surgical subspecialties, emergency medicine) (Smith, 2018).


Among these groups, PAs working in emergency medicine had the highest rates of burnout (34.5%), followed by internal medicine subspecialties (29.9%), and primary care (29.3%).


PAs in emergency medicine also reported the highest rates of professional fulfillment (72.3%) and exhaustion at work (50.8%), similar to the relationship seen in the single-specialty report on oncology PAs. The reverse trends also seemed to be true — pediatric subspecialty PAs has the lowest rates of burnout as well as the lowest rates of professional fulfillment 50.6%) and exhaustion (39.3%).


Additionally, the updated information from AAPA gave a better sense of overall burnout rates with the highest percentage (32.6%) seen in PAs with 5-9 years of experience, and the lowest rate (24.8%) observed in PAs with 15-19 years of experience. And—you guessed it—the PAs with the highest rate of burnout (those with 5-9 years of experience) also had the highest percentage (72.8%) of professional fulfillment.


Though the AAPA publication gave a bit more detail on burnout across experience levels and different specialty groups, it didn't break down specialties beyond general disciplines to where we could look at the difference between, say, PAs working in nephrology versus cardiology.


However, in the annual Medscape report on physicians, breakdowns by subspecialty (both medicine and surgery) are included. The most recent release, Medscape National Physician Burnout & Depression Report 2018, included 29 subspecialties.


Those with the highest rates of burnout included critical care (48%), neurology (48%), family medicine (47%), ob/gyn (46%), internal medicine (46%), and emergency medicine (45%).


Clinical specialties with the lowest rates of burnout included endocrinology (35%), orthopedics (34%), ophthalmology (33%), dermatology (32%), and plastic surgery (23%).


Though patients with urgent and emergent conditions can be encountered in any practice, notice that the highest rates of burnout were in specialties where high acuity patients are common, and the lowest rates of burnout were noted for providers in specialties that infrequently see urgent conditions.


Though the groups covered in the AAPA report were much broader, emergency medicine PAs reporting the highest rates of burnout among PAs falls in line with this specialty trend.


Incorporating burnout knowledge into early PA career job choice

There’s a lot we don’t yet know about burnout among PAs and how factors like specialty, training, or practice environment may play a role in both persistent stress and job satisfaction.

But, at present, knowing that burnout can be an issue is enough to know it’s something to consider when approaching a job hunt.

When considering a career in medicine, it's important to face that working in healthcare can contribute to stress that impacts both your professional and personal life.


While many aspiring PAs realize this, few go as far as considering what this may look like in their own lives once they are practicing as a provider.


It's human nature to romanticize the future and believe that after you get into PA school, or once the didactic year is over, or once you start working as a PA, or once you land a new position that everything will be smooth sailing.


But as you gain experience, your responsibilities will grow. Stress does not evaporate as you get closer to becoming and PA or as your career advances, but the factors that cause stress will evolve over time.


If we use the information gleaned from physicians as a surrogate for "provider" burnout and stress, the specialty or subspecialty you choose can have a bearing on the likelihood that you'll experience stress or burnout as a PA.


And, as the results suggest, the stress not come primarily from the body system you're focused on but, instead, from the acuity of cases you'll see in your everyday work.


It's also difficult to ignore the relationship that was repeatedly observed in the research between higher levels of job stress and an elevated sense of professional fulfillment.


The key to finding a role that balances stress and fulfillment is to think through the many contributing factors of a position and how those may align with your personality, lifestyle, and career goals.


Most early career PAs start this search by pursuing openings in a particular specialty or several specialties that they grew to like while in PA school.


Though this is a good place to start, once you're a bit deeper into the process and can learn more about a role through an interview, it's important to look at other aspects of a position that might contribute to or help mitigate stress, which, in large part, include work schedule and colleague support.


When weighing the pros and cons of a position, take into account the training time allotted. Ask if they've worked with new grads before. If possible, speak to those providers to learn about their experience.

Understanding Burnout Among Practicing PAslBe a Physician Assistant


Also, think through the proposed work schedule and how much time you'd have to "recover" between your workdays.


As someone who's been through it and mentored many new graduate PAs, I can attest that it takes 4-5x the mental effort to get through a patient case when you're brand new compared to someone with experience. It's mentally exhausting to be a new PA.


A 7-day-on/7-day-off schedule may sound appealing at first, like a full vacation every other week. But it's a challenging schedule for anyone to pull off, and it's especially hard when you're a brand new provider.


Lastly, the support you receive from colleagues and collaborating physicians in any PA role can have a significant influence on both the level of stress you feel and your overall job satisfaction. As a new PA, support is essential in growing both your skills and your confidence as a provider.


Working in medicine is an inherently stressful endeavor, but feeling as if you are supported by your colleagues and secure enough to speak up when you are struggling will help tremendously in keeping your stress in check and move you towards a work life and personal life that are "close to ideal."



REFERENCES

Tetzlaff ED, Hylton HM, DeMora L, et al. National study of burnout and career satisfaction among physician assistants in oncology: implications for team-based care. J Oncol Pract. 2018 Jan;14(1):e11-e22. doi: 10.1200/JOP.2017.025544. Epub 2017 Nov 30.

Bell RB, Davison M, Sefcik D. A first survey. Measuring burnout in emergency medicine physician assistants. JAAPA. 2002 Mar;15(3):40-42, 45-48, 51-52.

Coplan B, McCall TC, Smith N, Gellert VL, Essary AC. Burnout, job satisfaction, and stress levels of PAs. JAAPA. 2018 Sep;31(9):42-46. doi: 10.1097/01.JAA.0000544305.38577.84.

Smith N. Are PAs Burned Out? AAPA. 2018 May. https://www.aapa.org/news-central/2018/05/pas-report-low-burnout/

Peckham C. Medscape National Physician Burnout & Depression Report 2018. 2018 Jan. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235