Burnout and quality of interpersonal care Ronald Epstein, University of Rochester 15 October 2009 To the editors, We take a different interpretation of the findings reported by Zantinge, et al.1 in their recent article documenting a positive cross-sectional association between greater psychosocial orientation observed during clinical interviews and higher levels on two of the three facets of burnout. Their study and analyses were designed with a model of implicit causality, suggesting that burnout would reduce physicians’ psychological availability to patients. Instead, they found that more psychosocially-oriented physicians were also more burned out. An unfortunate conclusion of their negative findings might be that physician burnout increases physicians’ sensitivity to patients’ needs and that attempts to reduce burnout might compromise the quality of interpersonal care. However, as the authors imply briefly, by reversing dependent and independent variables, a different conclusion would be reached – physicians who are more sensitive to and willing to engage with patients’ emotional concerns (by training or by temperament) might be more vulnerable to burnout, perhaps because they try to achieve more for their patients. A corollary to this alternative theory is that such physicians would need to develop psychological resilience to allow them to tolerate the additional “emotional labor”2 of empathic engagement with patients and benefit from the interpersonal richness of knowing their patients more intimately.3 Some evidence for the alternative hypothesis comes from our recently-published trial of an educational program in “mindful communication” in a group of primary care physicians with high baseline levels of burnout.4 With an intensive intervention to improve self-awareness, communication and resilience, we noted improvements in burnout, which were associated with improvements in empathy and psychosocial orientation to care. These changes were mediated by increased mindfulness, providing further rationale that psychological resilience to support a more biopsychosocial approach to care is not only desirable but also possible to achieve. We also have become aware of a factor that may confound the interpretation of “psychosocial talk.” This category can sometimes include physician self-disclosures that have little relevance to patients’ concerns.5 The authors’ (and our) concern that distressed physicians might need to self-disclose information about themselves to patients at the expense of time spent on patients’ worries could be easily explored through content-oriented sequential analyses. These further analyses might help explain the lack of association of increased psychosocial talk with improved depression care. Sincerely yours, Ronald M. Epstein, MD Michael S. Krasner, MD Howard Beckman, MD Benjamin Chapman, PhD Anthony L. Suchman, MD, MA Christopher J. Mooney, MA Timothy E. Quill, MD Kevin Fiscella, MD, MPH Reference List 1. Zantinge E, Verhaak P, de Bakker D, van der Meer K, Bensing J. Does burnout among doctors affect their involvement in patients' mental health problems? A study of videotaped consultations. BMC Family Practice 2009;10(1):60. 2. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. Jama 2005;293(9):1100-1106. 3. Horowitz CR, Suchman AL, Branch WT, Jr., Frankel RM. What do doctors find meaningful about their work? Ann Intern Med 2003;138(9):772-775. 4. Krasner MS, Epstein RM, Beckman H et al. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. JAMA: The Journal of the American Medical Association 2009;302(12):1284-1293. 5. McDaniel SH, Beckman HB, Morse DS, Silberman J, Seaburn DB, Epstein RM. Physician self-disclosure in primary care visits: enough about you, what about me? Archives of Internal Medicine 2007;167(12):1321-1326. Competing interests None.