When Christina Maslach, PhD, started her psychology research career in the early 1970s, she didn’t know her work would lead to the Maslach Burnout Inventory, a measure for professional burnout still being used today. She first published the inventory with coauthor Susan E. Jackson in 1981. Dr. Maslach, who is professor of psychology at the University of California, Berkeley, has researched and published extensively about burnout throughout her career and has helped to define the way we discuss and understand the combination of stress, exhaustion, and powerlessness that endangers the careers—and lives—of many emergency physicians.

ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with Dr. Maslach to discuss the early research that led to her developing the Maslach Burnout Inventory, and what she’s learned from decades of talking to people about burnout. Here is Part 2 of their conversation. Part 1 appeared in the September issue.

KK: I’m noticing people moving away from the term “burnout” and moving toward “resiliency.” What are your thoughts on that?

Dr. Christina Maslach

CM: On the one hand, I think it’s a good strategy to focus on what are the positive goals we could move toward. People are going to be more highly motivated to make things better—let’s improve the situation—rather than simply focusing on the negative. In fact, we did that in our research earlier when we started focusing on what we were calling engagement as the opposite of what we were seeing in terms of burnout.

Where I would disagree a little bit is that resilience is really focusing on individual characteristics such as how well you cope, how well you take care of yourself, etc. The biggest challenge I find right now is that people keep thinking of burnout as a personal problem, and how do we get people to fix themselves? What that means is, we’re not paying attention to all of the causes of the problem.

Years ago, there was a cartoon showing a medical doctor in a white lab coat running on a treadmill really fast, with a huge fire and flames licking at his heels. Resiliency is directed at how to make you run faster, be stronger, last longer, etc., but it’s not doing a thing about the fire. At some point, we really need to make sure that we’re looking at both, but being healthy, getting enough rest, meditating, and doing yoga aren’t going to solve the problem. I’m a believer in what’s happening upstream is causing this problem.

KK: Do you recall either a specific time or a specific individual where you thought your interaction with somebody saved a life?

ABOVE: Image from the cover of the issue of Human Behavior magazine where Dr. Maslach published her first article in 1976.
LEFT: Cover of Burnout: The Cost of Caring, published in 1982.

CM: I will go back to that very first article based on all the interviews I did, where I spoke with people. The reaction that I got to that paper was huge, and people would write or call and say, “I read your article, and now I realize I have a different understanding of what’s happening and what I need to do.”

KK: Do you have any suggestions for emergency physicians to avoid burnout, recognize it, manage it?

CM: Everybody thinks of burnout primarily in terms of workload. The demands are way too high combined with too few resources, etc. That is a predictor of the exhaustion part of burnout. The research is showing us that there are at least five other areas between people and the job that can predict burnout, or greater engagement with work.

1. The workload issue.
2. The extent to which you have some sort of control, autonomy, or discretion over how you do your job.
3. Reward, which is positive feedback, getting positive feedback when you’ve done good work. What we’re finding is that it’s not so much salary or benefits; it’s social reward and recognition.
4. Community, which is the workplace community (eg, your colleagues, bosses, the people you supervise, any­body who you come in contact with on a regular basis). If there is a toxic work environment where people don’t trust each other, don’t feel that everybody has their back and they have theirs, there’s no support. There’s destructive competition—it is deadly.
5. Fairness. Whatever the rules are, there should be a fair way in which they are administered to avoid issues of discrimination and not treating people fairly and well.
6. Values. It’s what is driving you to do that kind of work, your passion. I see that in health care when we get into how many minutes can you spend with each patient, getting the beds turned, the financial pressure that is eating into the quality of care that they’re providing. That can also be a great source of burnout.

KK: Absolutely, and knowing those domains is critically important. Some call it health care reform, but I think it’s really payment reform. Spending less time with patients and providing less value, that sixth component, is putting a lot of pressure on us, which is weakening our resilience, and making burnout worse. Thank you so much for your time and your wonderful work. You truly have benefited emergency medicine.