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J Gen Intern Med. Dec 2009; 24(12): 1318–1321.
Published online Oct 3, 2009. doi:  10.1007/s11606-009-1129-z
PMCID: PMC2787943
Single Item Measures of Emotional Exhaustion and Depersonalization Are Useful for Assessing Burnout in Medical Professionals
Colin P. West, MD, PhD,corresponding author1,2,5 Liselotte N. Dyrbye, MD,3 Jeff A. Sloan, PhD,2 and Tait D. Shanafelt, MD4
1Division of General Internal Medicine, Mayo Clinic, Rochester, MN USA
2Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN USA
3Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN USA
4Division of Hematology, Mayo Clinic, Rochester, MN USA
5Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 USA
Colin P. West, Phone: +1-507-2842661, Fax: +1-507-2845889, west.colin/at/mayo.edu.
corresponding authorCorresponding author.
Received May 12, 2009; Revised August 21, 2009; Accepted September 9, 2009.
BACKGROUND
Burnout has negative effects on work performance and patient care. The current standard for burnout assessment is the Maslach Burnout Inventory (MBI), a well-validated instrument consisting of 22 items answered on a 7-point Likert scale. However, the length of the MBI can limit its utility in physician surveys.
OBJECTIVE
To evaluate the performance of two questions relative to the full MBI for measuring burnout.
DESIGN AND PARTICIPANTS
Cross-sectional data from 2,248 medical students, 333 internal medicine residents, 465 internal medicine faculty, and 7,905 practicing surgeons.
MEASUREMENTS AND MAIN RESULTS
The single questions with the highest factor loading on the emotional exhaustion (EE) (“I feel burned out from my work”) and depersonalization (DP) (“I have become more callous toward people since I took this job”) domains of burnout were evaluated in four large samples of medical students, internal medicine residents, internal medicine faculty, and practicing surgeons. Spearman correlations between the single EE question and the full EE domain score minus that question ranged from 0.76–0.83. Spearman correlations between the single DP question and the full DP domain score minus that question ranged from 0.61–0.72. Responses to the single item measures of emotional exhaustion and depersonalization stratified risk of high burnout in the relevant domain on the full MBI, with consistent patterns across the four sampled groups.
CONCLUSIONS
Single item measures of emotional exhaustion and depersonalization provide meaningful information on burnout in medical professionals.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-009-1129-z) contains supplementary material, which is available to authorized users.
KEY WORDS: burnout, measurement, graduate medical education, medical practice
Burnout is a syndrome encompassing three domains (depersonalization, emotional exhaustion, and a sense of low personal accomplishment) that is associated with decreased work performance.1 Burnout has been shown to be common in medical professionals at all stages of training and practice.27 Furthermore, burnout has been associated with suboptimal patient care practices,8 medical errors,9 and reduced empathy.10
The most widely used, well-validated instrument for the assessment of burnout is the Maslach Burnout Inventory (MBI).1 Using this 22-item tool, responders rate the frequency with which they experience various feelings or emotions on a 7-point Likert scale with response options ranging from “Never” to “Daily.” Higher values of depersonalization (MBI-DP) and emotional exhaustion (MBI-EE) and lower values of personal accomplishment (MBI-PA) signify burnout. This instrument has been used in numerous previous studies of physicians,2,11,12 and many evaluations of burnout have focused on the presence of high levels of either emotional exhaustion or depersonalization as a cornerstone of burnout among high-achieving medical professionals.2,8,12
Despite the recognized utility of the MBI for measuring burnout, the instrument’s length limits its use for assessing burnout in larger surveys of medical professionals. Across numerous studies, one emotional exhaustion question (“I feel burned out from my work”) and one depersonalization question (“I have become more callous toward people since I took this job”) from the MBI have exhibited the highest factor loading with their respective burnout domains.1,1316 With this in mind, we assessed the performance of these two questions relative to the full MBI for measuring burnout in four groups of medical professionals: medical students, internal medicine residents, internal medicine faculty physicians, and practicing surgeons.
Participants
Participants were from four separate studies of burnout in medical professionals. In 2007 all 4,287 medical students attending the Mayo Medical School, University of Washington School of Medicine, University of Chicago Pritzker School of Medicine, University of Minnesota Medical School, University of Alabama School of Medicine, University of California San Diego School of Medicine, and the Uniformed Services University of the Health Sciences were asked to complete a web-based survey on issues related to student well-being.3 Responses from the 2,248 (52.4%) students providing data on this survey were included in the present analysis. All entering categorical and preliminary internal medicine trainees in academic years 2003 through 2008 at the Mayo Clinic Rochester Internal Medicine Residency program were invited to participate in the Mayo Internal Medicine Well-Being (IMWELL) Study, in which they were surveyed quarterly on issues relating to quality of life, well-being, and distress.9 Initial survey responses for 333 of 432 (77.1%) residents were used for the current report.
In 2007, the Mayo Clinic Department of Medicine surveyed its physician faculty on issues relating to job satisfaction and well-being, including burnout, with 465 of 556 (83.6%) responding.17 Finally, in 2008, the American College of Surgeons surveyed its physician membership on factors contributing to career satisfaction, with 7,905 of 24,922 (31.7%) responding.18 The Mayo Clinic institutional review board approved each of these studies.
Statistical Analyses
Standard univariate statistics were used to characterize the sample. Spearman correlations between the single MBI-EE question and the MBI-EE score with that question excluded, and analogous results for the single MBI-DP question, were generated. For each response sample, mean MBI-EE and MBI-DP scores were compared across levels of the single MBI-EE and MBI-DP questions, respectively. Finally, to compare the single question results with those of the full MBI instrument, likelihood ratios and risks for high emotional exhaustion and high depersonalization were evaluated for each level of the single MBI-EE and MBI-DP questions. Statistical analyses were conducted using SAS version 9.1 (SAS Institute Inc., Cary, NC).
Ages of participants across the four samples differed as expected. The majority of medical students and internal medicine residents were 25–30 years of age, while the most common ages for the practicing internal medicine and surgical physicians were 45–54. Most responders (51.8% of medical students, 61.6% of internal medicine residents, 77.2% of internal medicine faculty, and 86.7% of surgeons) were men. No significant differences in results for men versus women were noted.
Spearman correlations between the single emotional exhaustion question and the MBI-EE score minus this question ranged from 0.76 to 0.83 across the four samples. Spearman correlations between the single depersonalization question and the MBI-DP score minus this question ranged from 0.61 to 0.72 across the four samples. When all items used to measure emotional exhaustion or depersonalization in the full MBI were evaluated, response to these two items showed the highest correlation with overall emotional exhaustion or depersonalization score in all four individual studies.
Mean overall MBI-EE and MBI-DP scores increased as the response to the single item questions increased in frequency, as shown in Tables 1 and and2.2. Mean overall scores for those answering “Never” or “A few times a year or less” to the single item measures were consistent with low average burnout in each domain. Mean overall scores for those answering “Once a week” or more often to the single item measures were associated with high average burnout in each domain. Mean overall scores for each response category on the single item measures were very similar across the four sample groups.
Table 1
Table 1
Mean Overall MBI Score for Emotional Exhaustion (EE) by Response to “I Feel Burned Out From My Work”
Table 2
Table 2
Mean Overall MBI Score for Depersonalization (DP) by Response to “I Have Become More Callous Toward People Since I Took this Job”
Likelihood ratios and risk for high emotional exhaustion and high depersonalization based on response to the single item measures are shown in Tables 3 and and4.4. Likelihood ratios and risk were again very similar across the four sample groups. The summary likelihood ratios for MBI-EE answers “Never” or “A few times a year or less” to the single item measure for emotional exhaustion were ≤0.06. In contrast, the likelihood ratios for MBI-EE answers “Once a week” or more often to the single item measure ranged from 6 to 42. Similarly, the summary likelihood ratios for MBI-DP answers “Never” or “A few times a year or less” to the single item measure for depersonalization were <0.18. The likelihood ratios for MBI-DP answers “Once a week” or more often to the single item measure ranged from 16 to 37. The pooled risk for high emotional exhaustion and high depersonalization increased with increased frequency of each single item measure (Online Figure).
Table 3
Table 3
Likelihood Ratios and Pooled Risk for High Emotional Exhaustion (EE) by Response to “I Feel Burned Out from my Work”
Table 4
Table 4
Likelihood Ratios and Pooled Risk for High Depersonalization (DP) by Response to “I Have Become More Callous Toward People Since I Took this Job”
This study confirms the ability of two single item measures of emotional exhaustion and depersonalization to provide important information on the likelihood of high burnout among physicians and medical students. Among those who answered a “few times a year” or less on the single item measures for emotional exhaustion or depersonalization, less than 7% had a high degree of burnout in that domain on the overall MBI. In contrast, among those who answered “a few times a week” or more on the single item measures, >90% had a high degree of burnout in each domain on the overall MBI. Supposing a baseline prevalence of high emotional exhaustion of 30% and the likelihood ratios found in this study, responding “A few times a year or less” to the question “I feel burned out from my work” indicates a probability of high emotional exhaustion on the full MBI of only 2.5%. Similarly, supposing a baseline prevalence of high depersonalization of 25% and the likelihood ratios found in this study, responding “A few times a week” to the question “I have become more callous toward people since I took this job” indicates a probability of high depersonalization on the full MBI of 92.5%.
Although these results show that response to single item measures of emotional exhaustion and depersonalization meaningfully stratify the risk of high burnout in the relevant domain, these two questions should not be viewed as replacements for the full MBI, which has a robust literature supporting its usefulness, validity, and reliability in assessing burnout in medical professionals. Burnout is a multifaceted construct, and no single item can fully reflect each domain of burnout. Therefore, these items are not meant to provide comprehensive assessment or monitoring of burnout for individual respondents. However, our study indicates that results on these two questions can serve as useful surrogates for the MBI in settings where it is not possible to administer the full 22-item instrument. For example, these two questions may be easily integrated into large surveys of medical workers that can only devote one or two items to a given topic. Thus, workplace “snapshots” of burnout may be obtained with administration of the full MBI where additional clarity is required.
This study’s main strength is its large sample size, inclusion of participants from a variety of practice settings including national samples of physicians and medical students, and the striking consistency of the results across samples. Our aggregate sample of 10,525 physicians and medical students compares favorably with the original MBI validation sample of 1,104 physicians and nurses. However, this study does have limitations. First, response rates in the individual samples ranged from 32–84% and nonresponse bias could occur. Second, it is possible that the results do not generalize to medical workers other than physicians, although the consistency of our findings across the studied groups may argue against this. Third, although the medical student and surgeon cohorts in this study were derived from national multi-center studies, the internal medicine resident and faculty cohorts were from a single academic institution. Finally, it is important to emphasize the present analysis is not intended to develop a new instrument for the assessment of burnout, but rather to evaluate how the characteristics of two questions from the MBI correlate with the full overall MBI domain score.
In summary, response to the single question “I feel burned out from my work” on the 7-point Likert scale developed by Maslach provides meaningful stratification of risk of high burnout in the domain of emotional exhaustion. Similarly, response to the single question “I have become more callous toward people since I took this job” on the 7-point Likert scale developed by Maslach provides meaningful stratification of risk of high burnout in the domain of depersonalization. These two questions may be useful in assessing burnout in medical professionals in settings where the full MBI cannot be practically applied.
Electronic supplementary material
Below is the link to the electronic supplementary material
Figure 1(25K, doc)
a Pooled risk of high emotional exhaustion burnout and 95% confidence intervals by level of response to “I have become more callous toward people since I took this job”. b Pooled risk of high depersonalization burnout and 95% confidence intervals by level of response to “I have become more callous toward other since I took this job.” (DOC 25 KB)
Acknowledgments
This work was supported by a grant from the Saint Marys Hospital Sponsorship Board. The authors wish to acknowledge the participation of the American College of Surgeons, particularly Charles M. Balch, MD, Gerald J. Bechamps, MD, and Thomas R. Russell, MD, and the site leaders for each medical school, Steven J. Durning, MD (Uniformed Services University of the Health Sciences), Anne M. Eacker, MD (University of Washington School of Medicine), William Harper, MD (University of Chicago Pritzker School of Medicine), F. Stanford Massie, MD (University of Alabama School of Medicine), Christine Y. Moutier, MD (University of California, San Diego), David V. Power, MD (University of Minnesota Medical School), and Matthew R. Thomas, MD (Mayo Clinic).
Conflict of Interest None disclosed.
Footnotes
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-009-1129-z) contains supplementary material, which is available to authorized users.
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