How a focus on fortitude can reduce physician burnout

Burnout among physicians and other healthcare staff remains a severe concern for hospitals and health systems. Despite efforts to reduce burnout, the problem continues.

Yet clear steps for comprehensively addressing this condition remain elusive because its causes are complex and vary from individual to individual. While much focus has been on improving the work environment, our research shows that individual differences can play an important role.

We have found that health-system leaders can best address the problem of burnout by adopting a multifaceted framework to better understand it. Such a framework can inform leaders’ efforts to foster fortitude among staff against burnout and to develop more effective intervention strategies.

However, leaders must first understand the nature of fortitude. And leaders can benefit from learning how our recent research has shown that fortitude can help healthcare workers endure work-related stressors that make them more susceptible to experiencing burnout. 

The impacts of burnout in healthcare

It is estimated that physician burnout costs the U.S. healthcare system more than $4.6 billion annually due to turnover and reduced work hours.^a Burnout also is associated with reduced work effort, decreased quality of care, increased malpractice litigation and reduced patient satisfaction, which adds to the cost.

Further, a recent study by the American Medical Association (AMA) showed that 48.2% of physicians are burned out, which, while it is improved from the incidence during the COVID-19 pandemic, remains problematic.^b Another study found that 24% of physicians are considering leaving their current position over the next two years, which has the potential to add to our current physician shortage.^c

Causes of burnout in healthcare

The World Health Organization refers to burnout as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.”^d Aligned with this perspective, much of the current work has been focused on improving the work environment. Related workplace contributors include:

• Burden of electronic health records (EHRs)
• Call burden
• Staffing shortages
• Excessive administrative burden
• Long work hours
• Loss of autonomy
• Work-home conflict

Remedies remain elusive

While these factors are recognized as contributing to burnout, efforts to address them have been slow and too often fall short. Moreover, efforts focused on increasing individual resilience — defined as the ability to bounce back after a setback — have not been widely successful.

For example, two recent meta-analyses of randomized controlled interventions designed to mitigate burnout in physicians failed to show meaningful improvements.^e Coaching showed some promise, and there were some transient improvements using mindfulness training and art therapy. But it is clear that additional factors beyond these workplace characteristics are important antecedents to burnout and need to be identified and addressed.

Understanding fortitude

The external challenges physicians and staff face clearly are important contributors to burnout. That makes it difficult to draw meaningful conclusions from looking at the large population of physicians who are suffering from burnout at any one time. But what if we focused on the many other physicians in similar work-related circumstances who do not burn out? What can we learn from them?

This approach acknowledges the possible existence of unique individual attributes that account for these differences in response to workplace stressors. Research shows that individuals respond to such stressors in different ways.^f Some of this response is shaped by fixed individual demographics such as age, gender and specific personality attributes. But research has also identified characteristics that are more malleable and can be cultivated over time, such as grit, self-efficacy, hardiness, resilience, hope and optimism, which can also influence how individuals experience stress.^g

Based on our research, therefore, rather than looking at these characteristics individually, we have integrated these concepts into a single measure we call fortitude, which refers to the strength of mind that enables a person to encounter stress or adversity with courage.

Specifically, fortitude can be defined as a multidimensional construct that significantly contributes to our understanding of burnout-related phenomena.

The good news is that evidence suggests fortitude is not a fixed trait and that a person can improve and strengthen their level of fortitude. This perspective creates the opportunity to develop more effective strategies for helping to improve the well-being of physicians and other staff who are susceptible to burnout.

Characteristics of fortitude, and their impact on burnout and turnover

Understanding fortitude is critical in understanding the systemic issues and dynamics associated with burnout and turnover. For this purpose, we developed a statistically reliable and valid measure for fortitude in healthcare based on a three-study design examining physicians, advance practice providers (APPs) and healthcare leaders.^h

This research yielded three key takeaways.

1 Fortitude is independently related to burnout and turnover intent. Fortitude helps explain more variance in burnout and turnover intent than any previously developed measure. Furthermore, fortitude explains more than four times the variance in burnout than resilience alone.

2 Fortitude mediates the relationship between burnout and turnover intent. Thus, physicians and APPs who report a higher level of fortitude are less likely to leave.

3 Fortitude moderates the relationship between the extrinsic work-related factors and emotional exhaustion. Our research found that increasing organizational support reduced burnout only in those with high fortitude. In other words, increasing organizational support would have no significant impact in preventing burnout among those with low fortitude.

In addition, our research showed that employee frustration was significantly correlated with burnout. However, this effect of frustration was mitigated in individuals who exhibited fortitude.

These results suggest that a focus on improving fortitude among healthcare practitioners, staff and even leaders is desirable to prevent burnout, increase engagement and decrease turnover intent. Moreover, improvements in fortitude may contribute to success in broader efforts to improve the external work environment.

A new perspective on burnout

Research supports the view that burnout should not be regarded as being solely the result of the work environment and that it is not limited to each individual’s characteristics or personality. Rather, a more nuanced understanding of the antecedents of burnout results from looking at the individual’s degree of fortitude, which shapes how they respond to their work environment. In short, our research indicates it’s not a question of work environment or individual attributes; it’s a product of the work environment and the individual.

The correlation between frustration and burnout is important. Our survey of physicians, APPs and healthcare leaders found that the causes of burnout are widely varied. In sum, we gleaned two key insights from the research:

• A one-size-fits-all approach to improving well-being is likely to have limited impact.
• An opportunity exists to empower individuals to look beyond external organizational factors to focus on their individual opportunities to build fortitude.

Mitigating burnout starts with understanding fortitude

Much effort has been made to reduce burnout and reduce turnover. Unfortunately, the problem continues. By changing perspectives — focusing on the work environment and the individual attribute of fortitude — we can change the conversation to develop more comprehensive and effective intervention strategies. 

footnotes

a. Han, S., Shanafelt, T.D., Sinsky, C.A., et al., “Estimating the attributable cost of physician burnout in the United States.” Annals of Internal Medicine, June 4, 2019.
b. Berg, S., “Physician burnout rate drops below 50% for first time in 4 years,” AMA News Wire, July 2, 2024.
c. Abbasi, J., “Pushed to their limits, 1 in 5 physicians intends to leave practice,” JAMA Network, March 30, 2022.
d. World Health Organization, International Classification of Diseases 11th Revision, February 2024.
e. Haslam, A., Tuia, J., Miller, S.L., et al., “Systematic review and meta-analysis of randomized trials testing interventions to reduce physician burnout,” The American Journal of Medicine, Oct. 25, 2023; and Catapano, P., Cipolla, S., Sampogna, G., et al., “Organizational and individual interventions for managing work-related stress in healthcare professionals: A systematic review,” Medicina, Oct. 20, 2023.
f. McManus, I.C., Keeling, A., and Paice, E., “Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: A twelve year longitudinal study of UK medical graduates,” BMC Medicine, Aug. 18, 2004.
g. Roslan, N.S., Yusoff, M.S.B., Morgan, K., et al., “Evolution of resilience construct, its distinction with hardiness, mental toughness, work engagement and grit, and implications to future healthcare research,” Education in Medicine Journal, March 2022.
h. Weinzimmer, L., and Hippler, S., “New insights into physician burnout and turnover intent: A validated measure of physician fortitude,” BMC Health Services Research, June 18, 2024.

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Actions healthcare leaders can take to promote physician and staff well-being

Although there is no single “recipe” for preventing burnout among a health system’s physicians and other staff, healthcare leaders can take some specific actions to create an environment that fosters well-being and fortitude.

1 Maintain ongoing commitment to mitigating the factors that continue to cause frustration. Unfortunately, much of the work on systemic issues that lead to burnout is out of the control of healthcare leaders and health systems, and there are limits to how much can be easily changed. Fostering a good culture, building good leaders and prioritizing honest communication will be critical in establishing an effective foundation.

Much of this work may currently be underway and includes things such as:

• Intentional training and development of all leadership, including front-line leaders
• Reduction of administrative burden where possible
• Optimization of the EHR burden

2 Leaders should consider an organizational approach to empower individuals to focus on building fortitude. It is paramount for leaders to foster an environment that allows individuals to develop their own unique plans.

Things to consider include:

• Offering burnout mitigation and stress management education along with fortitude and resilience training
• Encouraging servant leadership to establish a culture of support
• Supporting meaningful rounding to identify frustrations, opportunities for improvement and social support
• Providing certified coaches for individuals to work through their current dilemmas and provide an accountability partner to encourage action

3 Individuals should be encouraged to take a more active role in their own well-being. Every person should have an action plan to overcome their frustrations and barriers. Physicians cannot optimally care for their patients and leaders cannot take care of their people if they are burned out themselves.

Consider, for example, if you are in an airplane cabin that suddenly loses pressure, you should put on your own oxygen mask first to be able to take care of those around you. You simply cannot help others if you do not do that first.