Physician Distress and Burnout: The Neurobiological Perspective

Abstract

Physician burnout and other forms of occupational distress are a significant problem in modern medicine, especially during the coronavirus disease pandemic, yet few doctors are familiar with the neurobiology that contributes to these problems. Burnout has been linked to changes that reduce a physician's sense of control over their own practice, undermine connections with patients and colleagues, interfere with work-life integration, and result in uncontrolled stress. Brain research has revealed that uncontrollable stress, but not controllable stress, impairs the functioning of the prefrontal cortex, a recently evolved brain region that provides top-down regulation over thought, action, and emotion. The prefrontal cortex governs many cognitive operations essential to physicians, including abstract reasoning, higher-order decision making, insight, and the ability to persevere through challenges. However, the prefrontal cortex is remarkably reliant on arousal state and is impaired under conditions of fatigue and/or uncontrollable stress when there are inadequate or excessive levels of the arousal modulators (eg, norepinephrine, dopamine, acetylcholine). With chronic stress exposure, prefrontal gray matter connections are lost, but they can be restored by stress relief. Reduced prefrontal cortex self-regulation may explain several challenges associated with burnout in physicians, including reduced motivation, unprofessional behavior, and suboptimal communication with patients. Understanding this neurobiology may help physicians have a more informed perspective to help relieve or prevent symptoms of burnout and may help administrative leaders to optimize the work environment to create more effective organizations. Efforts to restore a sense of control to physicians may be particularly helpful.

Figure 1-. The higher cognitive functions of the prefrontal cortex are impaired by fatigue or uncontrollable stress: Potential ramifications to clinical practice –

A. The prefrontal cortex (PFC, highlit in green) resides in the brain’s frontal lobe, anterior to the motor cortices. The PFC has extensive connections with cortical and subcortical brain areas that provide top-down control over thought, attention, action, and emotion when we feel rested, interested and in control. B. Under conditions of uncontrollable stress or fatigue, PFC connections are weakened (gray) and there is a loss of top-down control and impaired PFC cognitive functions. Stress also activates more primitive brain circuits (highlit in red) that mediate unconscious responses and habits. Chronic stress exposure causes atrophy of PFC connections, weakening the thoughtful, evaluative responding needed for professional and personal fulfillment. C. Examples of some of the cognitive changes that occur with PFC dysfunction and their potential consequences to physician performance. For a brief summary of these neurobiological mechanisms at the Yale Medical School Youtube Channel, see: www.youtube.com/watch?v=vdDvChLuQsA .

Figure 2-. The effects of arousal on prefrontal cortical function.

Arousal state has an “inverted-U” dose response effect on PFC functioning. PFC synapses require stimulation from the arousal systems (acetylcholine, norepinephrine, dopamine, serotonin) in order to function properly, and inadequate levels e.g. during fatigue, weaken PFC function. Conversely, excessive norepinephrine and dopamine release during uncontrollable stress also weakens PFC function, by rapidly weakening PFC synaptic connections. It is noteworthy that caffeine increases the release of acetylcholine in the PFC, which may explain why it can be helpful to cognitive function in rested individuals.