Burnout in Cardiology: A Narrative Review

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The frequency of burnout is rising among cardiologists, affecting not only their well-being but also the quality of patient care. Computerization of practice, bureaucracy, excessive workload, lack of control/autonomy, hostile and hectic work environments, insufficient income, and work life imbalance are the main categories listed as contributing factors to cardiologists’ burnout. Organization- and physician-directed interventions can be impactful; however, the effectiveness and feasibility of these interventions have rarely been assessed in cardiology. This review summarizes recent publications on burnout in cardiology, discusses the contributing factors and implications of burnout on physicians’ health and patient safety, and explores possible interventions.

Physician burnout has been increasing, especially during the COVID-19 pandemic,^1-3 and now affects more than half of physicians.⁴ However, burnout is neither new nor temporary. Linzer et al reported 45% prevalence of burnout among US clinicians in 2019 before the COVID-19 pandemic; that increased to 60% in late 2021.¹ Cardiology is a specialty that often involves treating life-or-death situations in an environment of acute stress and complexity, with a constant demand for precision and rapid decision-making. Addressing burnout is not only pivotal for maintaining the well-being of cardiologists but also for safeguarding the patient care quality and safety.^5-7 This manuscript reviews burnout in the field of cardiology, discusses the contributing factors and implications of burnout on physicians’ health and patient safety, and explores possible interventions.

The prevalence of burnout varies according to definition. Many of the studies that investigate burnout are based on self-reported burnout, while others use validated and widely accepted tools. The most commonly used tools are the Maslach Burnout Inventory (MBI)⁸ and the Mini-Z.⁹ The MBI assesses 3 key dimensions and defines burnout as a combination of these subscales caused by job-related stress; these dimensions are (1) emotional exhaustion, (2) depersonalization (a distant attitude towards work that manifests as negative and cynical behaviors), and (3) reduced sense of personal accomplishment.⁸ However, even among studies that used the MBI, a review identified at least 47 distinct definitions of burnout,¹⁰ using different cut-off scores and criteria. The Mini-Z 2.0 Clinician Worklife Survey is a validated tool that was developed for use by medical providers to assess 3 outcomes (burnout, stress, and satisfaction) and 7 drivers (work control, work chaos, teamwork, values alignment with leadership, documentation time pressure, electronic medical record [EMR] use at home, and EMR proficiency) of burnout.⁹ The Mini-Z is free, while the MBI requires payment.

Table 1 summarizes recent burnout studies in the field of cardiology as well as studies that assess burnout-related symptoms and outcomes.

An international online survey of 5890 cardiologists conducted by the American College of Cardiology in late 2019 and published in 2023 showed that 1 in 4 cardiologists (28%) experienced any self-reported mental health condition (MHC), including psychological distress (76.1% of the above) or other psychiatric disorder.¹¹ Higher rate of MHCs were reported in general (32.8%) and pediatric cardiology (32.6%). Cardiologists that reported MHCs were more likely to feel that they were treated unfairly (22.5% vs 11.2%), were undervalued (17.6% vs 7.5%), and were dissatisfied with financial compensation (29.7% vs 21.0%).

In another study of 2274 cardiologists from the American College of Cardiology regarding burnout, symptoms were reported by approximately 1 in 4 respondents (26.8%), of whom at least 1 symptom of burnout was experienced by 19.2%, chronic burnout by 6.4%, and complete burnout with the possible need of outside intervention by 1.2%.¹² Almost half (49.5%) reported being under stress.

According to the Medscape Cardiologist Lifestyle, Happiness & Burnout Report 2023,¹³ which included 9175 US-based physicians across more than 29 specialties, 43% of 367 cardiologists felt either burned out (29%) or both burned out and depressed (14%). Cardiology (43%) had the third lowest rate of burned-out physicians among all specialties, while emergency medicine (65%), internal medicine (60%), and pediatrics (59%) were at the top of the list. Among all physicians, the prevalence of burnout increased from 42% to 53% during the past 5 years (2018), without clinically significant change among cardiologists (46% then, 43% now).

Other studies targeted more specific populations in the field of cardiology. In the third annual “Cardiovascular Diseases Fellowship Program Directors (PDs)” survey, 21% of 141 PDs reported some symptoms of burnout, and 45% felt a great deal of stress because of their job.¹⁴ In a prospective international survey of 125 cardiac imaging specialists, more than half (58%) reported suffering from burnout, with the majority (64%) reporting worsening features of burnout during the pandemic.¹⁵ Almost 1 in 2 (44%) considered quitting their job.

Few recent studies examined stress and burnout in interventional cardiology. In Simsek et al’s survey of 1159 attending interventional cardiologists (IC) and 192 interventional cardiology fellows, 69% reported being affected by burnout and 41% considered leaving their job during the past year.¹⁶ On a scale of 0 to 10, IC attendings thought they worked too hard (7.5, 5.3-8.5), felt worn out at the end of the day (7.2, 5.2-8.2), were too stressed (7.0, 5.0-8.0), burned out (6.5, 3.9-7.7), and frustrated (6.1, 3.0-7.9). In a study of 111 first-year IC fellows, 84% considered the IC fellowship somewhat (62%) or very stressful (22%).¹⁷ In another study, 65% of 135 IC fellows reported an increase of stress at work and at home as a result of the COVID-19 pandemic.¹⁸

A study of 481 cardiologists (70% of whom were ICs) reported sleep disorders in 25%, with the main factors diminishing sleep being related to work (66%) and burnout (56.5%).¹⁹   A Dutch study of 382 cardiologists, using the Professional Fulfillment Index, reported high scores on professional fulfilment (3.85 out of 5, SD = 0.62) and average scores on work exhaustion (2.25 out of 5, SD = 0.97) and interpersonal disengagement (2.04 out of 5,  SD = 0.80).²⁰

The significant variability of the prevalence of burnout across different studies may be attributed partially to variations in the methodologies employed and differences in the subgroups under assessment. Among the studies that directly assessed burnout, two used the Mini-Z survey and reported similar burnout rates (26.8% and 21%),^12,14 while the rest that did not use a validated tool reported higher burnout rates (58%, 56.5%, 69%, 43%).^13,15,16 Validated tools tend to indicate a lower prevalence of burnout, assessing multiple components of burnout, whereas surveys relying solely on a single yes-or-no question tend to exaggerate its occurrence.²¹ Burnout is likely not a binary trait, but exists in a continuum. Short versions of validated burnout assessment tools are available and provide accurate results for researchers seeking a brief method of evaluation.

Identifying the factors contributing to cardiologists’ burnout is the first step for identifying possible interventions (Table 2). System-level factors are mostly listed as contributing factors. We created a conceptual model of burnout and related symptoms in cardiologists (Figure 1) based on the MEMO (Minimizing Error, Maximizing Outcome) project from Linzer et al.²²

Computerization of practice. Electronic health records (EHRs) are considered an important factor contributing to physician burnout and a barrier to patient care: 72% of cardiologists experiencing burnout reported documentation time pressures and 57% reported increased EHR used at home, according to Mehta et al.¹² Thirty-two percent believe that the computerization of practice (EHRs) contributes most to cardiologists’ burnout, according to Medscape.¹³ Similar findings are documented in other specialties.^23,24

Bureaucracy. Increased bureaucratic tasks, excessive documentation requirements, and lack of administrative support are commonly reported burnout contributing factors in cardiology.^12,13,15,16 According to the most recent Medscape Report, 65% of cardiologists reported having too many bureaucratic tasks as the factor that contributes the most to the cardiologists’ burnout.¹³

Excessive workload. Too many hours at work was reported by 37% of cardiologists in the last Medscape Report as one of the factors that contribute most to burnout.¹³ Prior to the pandemic, 68% of cardiac imaging specialists reported that a heavy workload contributed to their stress.¹⁵ Similar findings are reported in studies that involve physicians of all specialties.^25,26

Lack of control/autonomy. In the Medscape report, 42% of cardiologists reported lack of control/autonomy as one of the factors that contributes the most to burnout.¹³  Lack of control over workload was also one of the factors independently associated with a higher rate of burnout (odds ratio [OR]: 2.03; 95% CI:1.57-2.62; P < .001) among cardiologists in a study by Mehta et al.¹²

Hectic work environment. A hectic work environment was independently associated with higher risk of burnout among cardiologists in the study by Mehta et al (OR: 1.90; 95% CI: 1.45-2.50; P ≤ .001).¹² Workplace chaos has been associated with burnout in multiple physician studies.^22,27 The field of cardiology thrives within a dynamic, fast-paced environment, further compounded by an aging patient population that is progressively growing in complexity.

Hostile work environment. Twenty-four percent of cardiac imaging specialists reported gender discrimination or bullying at work, and 9% reported age discrimination as contributing factors to burnout in a study by Joshi et al.¹⁵ Moreover, 31% of the cardiologists that participated in the 2023 Medscape Report believe that lack of respect from administrators/employers, colleagues, or staff is one of the most important contributing factors to burnout.¹³ In a study by Sharma et al, cardiologists who felt that their work environment was hostile were more likely to have MHCs, including psychological distress or other psychiatric disorder, compared with those who did not (41.7% vs 17.4%; P < .001).¹¹

Insufficient income. IC fellows rated insufficient income as the most significant contributor to burnout.¹⁶ In the study by Sharma et al, dissatisfaction with financial compensation was more likely to be reported by cardiologists who reported MHCs.¹¹ In the 2023 Medscape report, insufficient compensation is reported by 26% of the cardiologist population as one of the factors that most contributes to burnout.¹³ Similar findings have been reported in the trainee physician population.²⁵

Work life imbalance. In the study by Mehta et al, participants with burnout had higher levels of dissatisfaction with family life (30% vs 10%, P ≤ .001) and believed that their job interfered with their family responsibilities (46% vs 29%, P ≤ .001).¹² For Dutch cardiologists, work-home interference was the most important predictor for experiencing burnout symptoms.²⁰ Similar findings are reported in physicians from other specialties.^28-30

Women, younger, unmarried; the vulnerable. Several studies in cardiology show that women, younger, and unmarried cardiologists are more susceptible to burnout.^11,12,14 Mehta et al reported that mid-career cardiologists (8-21 years of practice) had the highest prevalence of burnout (39%) and women cardiologists reported burnout more frequently than men (31% vs 24%, P ≤ .001); additionally, those with burnout were less likely to be married (79% vs 85%, P ≤ .01).¹² In a study by Cullen et al, rates of enjoyment without stress or burnout were lower in women (13% vs 43%), mid-career (46-55 years old), and early career (34-45 years old) cardiologists vs late career (≥ 56 years old) cardiologists (24% vs 31% vs 53%, respectively).¹⁴ According to Sharma et al, cardiologists who were women (33.7% vs 26.3%), younger (< 55 years old), divorced, single, had no children (31.4% vs 26.9%), were of Hispanic origin, were part-time employed, and were in their early career with 5 to 10 years of practice post-training were most likely to have MHCs,.¹¹ In contrast, in the Medscape report, the percentage of burnout was similar in women (43%) and men (45%),¹³ similar to the study by Simsek et al (68% vs 73%, P = .370).¹⁶

The association between burnout and both psychological and physical conditions is well-established. Burnout was associated with multiple ailments, such as hypercholesterolemia, type 2 diabetes, coronary heart disease, musculoskeletal pain, prolonged fatigue, headaches, gastrointestinal issues, and mortality before age 45,³¹ while a hectic and psychologically demanding job was associated with higher risk of developing coronary heart disease symptoms and signs (OR 1.29, P < .025) and premature death (RR 4.0, P < .01).³²

The impact of burnout on patient safety often goes unnoticed. Patient safety can be defined as “the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare”.³³

Multiple studies have assessed the association between physician burnout and patient safety. In a 2022 systematic review and meta-analysis of 170 observational studies of 239 246 physicians, physician burnout was associated with nearly 4-fold less job satisfaction and a more than 3-fold increase in career choice regret and turnover intention.⁵ Physician burnout was associated with higher risk of patient safety incidents (odds ratio [OR] 2.04; 95% CI, 1.69-2.45; k = 35 studies, n = 41 059 physicians]. Most studies included self-reported incidents (31 of 39), whereas the remaining studies reported objectively determined errors.

In a Danish study of 569 776 patients and 409 general practitioners (GPs), patients were more likely to change GPs who had higher occupational distress (burnout and low job satisfaction).⁷ A similar Danish study of 461 376 patients and 392 GPs showed that as GP well-being and job satisfaction decreased, hospitalizations for ambulatory care sensitive conditions increased, even after adjustment for sociodemographic risk factors.³⁴ In a British study of 40 227 patients and 320 GPs, increased emotional exhaustion, depersonalization, job dissatisfaction, and turnover intention were associated with higher opioid and antibiotic prescribing.³⁵

A cross-sectional study of 135 primary care physicians in Israel showed that higher burnout and workload were associated with higher referral rate to board-certified specialists.³⁶ Halbesleben and Rathert, who surveyed 178 matched pairs of physicians and their patients, found that as physician depersonalization (which is a dimension of burnout) and patient post-discharge recovery time increased, patient satisfaction declined (after controlling for severity of illness and other demographic factors).³⁷ These findings are consistent with previous studies,^38-42 although some studies did not find an association between burnout and adverse clinical outcomes.^43,44

Despite an abundance of published studies on the prevalence and consequences of physician burnout, only a few interventions have been developed and assessed, with very few in the field of cardiology (Figure 2).^45,46 A systematic review and metanalysis of 52 studies reported a decrease in burnout from 54% to 44% after implementing individual-focused and structural or organizational strategies.⁴⁷ The outcomes did not show variations between structural or organizational interventions and individual-focused interventions, except for overall burnout, where structural or organizational interventions demonstrated greater effectiveness.

These results are consistent with another systematic review and meta-analysis of 19 studies that found significantly better results with organization-directed vs physician-directed interventions, albeit of small magnitude.⁴⁸

Structural or organization-directed interventions. Organization-level interventions are important since burnout is often associated with system-level factors. Shanafelt and Noseworthy from the Mayo Clinic suggested 9 organizational strategies to reduce burnout:

1. Acknowledge and assess the problem,
2. Harness the power of leadership,
3. Develop and implement targeted interventions,
4. Cultivate community at work,
5. Use rewards and incentives wisely,
6. Align values and strengthen culture,
7. Promote flexibility and work-life integration,
8. Provide resources to promote resilience and self-care, and
9. Facilitate and fund organizational science.⁴⁹

Implementation of these strategies was associated with a 7% decrease in physician burnout after 2 years, despite an 11% rise in the national average. 

Wu et al reviewed 7 studies that developed health information technology-related solutions to mitigate burnout and suggest validation and standardization of health information technology burnout measures, with focus on EHR-based interventions.⁵⁰ Windle et al created a clinician-centered EHR framework, after first understanding clinicians’ needs, which proved to be significantly more useful, usable and satisfying to the clinicians that participated in the evaluation.⁵¹ Moreover, physicians who agree that their organization has done a great job with EHR implementation, training and support are twice as likely to report lower levels of burnout, compared with physicians that disagree (aOR 2.14; 95% CI, 2.01-2.28).52 Among 401 participants with at least one 1-on-1 training session regarding EHR, 32% reported feelings of burnout in the pre-survey compared to 23% in the post-survey, which was taken 4 weeks after the final session (P < .01).⁵³ Alternatively, some EHR-based training studies did not detect a reduction in burnout with re-evaluation 2 weeks after the training.^54,55 Identification of the technological improvements with the greatest impact requires high-quality interventional studies with larger samples and long implementation periods. 

Other interventions focus on reducing physicians’ job demands, such as work hours and the intensity of the workload. A large study with 5276 US physicians reported that physician task load was strongly associated with the risk of burnout; for every 10% decrease in physician task load, the odds of experiencing burnout were 33% lower.⁵⁶ A systematic review of 9 studies that examined the effect of work hour limits on resident burnout found that the reduction of resident hours was associated with a decrease in the mean burnout score.⁵⁷ A systematic review and metanalysis of 9 randomized clinical trials (RCTs) published in 2023 reported that shorter shift length was associated with significantly less emotional exhaustion and dissatisfaction as well as higher overall well-being compared to longer shift length.⁵⁸

Studying the effect of organization-directed interventions on physician burnout, DeChant et al reported that the teamwork interventions that consistently improved physician burnout involved initiatives to incorporate scribes or medical assistants into EHR processes, expanded team responsibilities, and improved communication among physicians.⁵⁹ In a cluster RCT by Linzer et al workflow redesign improved burnout (OR for improvement in burnout 5.9, P = .02) as did targeted quality improvement projects (OR 4.8, P = .02).²⁷ This suggests workflow redesign may decrease the workload for physicians and help them cope with burnout.

Physician-directed interventions. Individual-level interventions play a crucial role in effectively mitigating burnout,⁶⁰ especially when combined with system-level approaches. Individual-level interventions include mindfulness,^61-63 mind-body skills,^64-66 and coaching trainings,^67-70 and are usually low-cost and accessible. A systematic review and meta-analysis of 25 studies found that mindfulness-based interventions were associated with a significant but small reduction in the between-group analysis of registered clinical trials and in the pre-post-analysis of all included burnout studies.⁷¹ A recent systematic review of Positive Psychology Interventions (PPIs), which included 14 studies, documented improvements in burnout, stress, anxiety, and depressive symptoms.⁷² The studies enrolled healthcare workers and used various methods of PPIs, most of them mindfulness-based, with focus on resilience, general positive psychology, and/or gratitude.

A systematic review of 14 studies that involved 1099 physicians undergoing coaching suggests that coaching can improve well-being and reduce distress/burnout.⁷³ Coaching, as defined by the International Coaching Federation, is “a thought-provoking and creative process that inspires [participants] to maximize their personal and professional potential” and is delivered by trained coaches.⁷⁴  However, a randomized clinical trial of 40 cardiologists that included coaching found no differences in burnout,⁷⁵ nor did other studies.^75-78

Can interventions be implemented without significantly increasing the cost of services? Shanafelt et al argue that cost can be neutral, highlighting that interventions must be considered as an investment.⁷⁹ Three cost categories associated with physicians’ burnout to be taken into consideration are (1) the costs associated with turnover, (2) lost revenue associated with decreased productivity, and (3) financial risk to the organization’s long-term viability due to decreased patient satisfaction and problems with patient safety. Han et al did a cost-consequence analysis estimating the cost of physician burnout in the United States, and on a national scale it estimated a cost of approximately $4.6 billion each year;  at an organizational level, the annual economic cost was approximately $7600 per employed physician each year.⁸⁰

A cost assessment could push the implementation of these strategies, as there is a paucity of studies in the present literature. Trockel et al presented a cost assessment related to the IMPACT (Influencing and Modeling Provider Action for Culture Transformation) intervention.⁸¹ Assuming $250 000 as the cost to replace each departing physician, they estimated more than $1 million in cost saving due to lower turnover, while the cost of the intervention was approximately $117 268. Considering projections by the Association of American Medical Colleges that predict a potential shortage of up to 124 000 physicians in the United States by 2034,⁸² the financial implications become even more compelling.

Interventions can be beneficial in the long run, so more research evaluating the effectiveness and the cost-effectiveness of proposed interventions is needed.  It is still unclear which interventions are the most cost-effective, what are specific challenges for each specialty, such as cardiology, and whether the impact of the interventions is maintained over time.

Artificial intelligence (AI) has demonstrated evolutionary advancements in recent years. The prospective integration of AI models in medicine could potentially alleviate the workload burden for physicians and serve as the core of future interventions aimed at mitigating burnout.⁸³ Notably, upon assessment of the potential impact of AI on healthcare spending, Sahni et al estimated that a wider adoption of AI could reduce annual US healthcare spending by $200 to $360 billion.⁸⁴

Burnout is rising among cardiologists and affects not only clinician well-being but also the quality of patient care. Excessive workload, bureaucracy, and computerization of practice all contribute to physician burnout.  Both organization- and physician-directed interventions are important and may be cost-effective.⁸⁵ Additional research is needed to clarify optimal burnout reduction strategies in cardiologists and beyond. Studies should prioritize the implementation of strategies that foster a physician-oriented work environment with a focus on promoting professional satisfaction combined with programs that enhance resilience at the individual level.

From the ¹Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA; ²Department of Medicine, Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA; ³Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA| Institute for Professional Worklife, Hennepin Healthcare, Minneapolis, Minnesota, USA; ⁴Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, UK | Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK; ⁵Department of Cardiology, Athens Naval Hospital, Athens, Greece.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. Email: esbrilakis@gmail.com; X: @esbrilakis, @m1chaella_alex

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