Physician Burnout: Historical Context, Psychosomatic Division, Evolution, Results, Solutions, and Recommendations

Definition

Physician burnout is a psychosomatic syndrome that arises from feeling overwhelmed with confronting issues in those with dedication or commitment to their job. It presents with emotional, mental, and physical fatigue that negatively influences patient treatment decisions and care, representing a primary occupational hazard affecting a significant number of these healthcare providers at some point in their career such that there is an urgency to the need for improvement.

1. Historical Context

Physician burnout has garnered significant attention. In a PubMed search from 2020 to April 2022, more than 7000 articles were returned on it [1]. As physician burnout remains a timely topic, investigating its history, evolution, results, and solutions is relevant.

1.1. Burnout Is Defined

Physician burnout researchers introduce burnout as a concept simultaneously and independently recognized by Freudenberger and Maslach in the 1970s [2,3,4]. Yet Fredenberger coined the term with his 1974 publication [5] regarding his observations of volunteer service providers of alternative organizations, and Maslach states the primacy of this work in her 1976 publication [6]—the first of hers on this topic—that includes reports on physicians among other professionals. Both publications are narratives. Frendenberger references only three publications—his own—and Maslach cites none. It is unusual in academic assessments that recognition is given to narrative researchers as the founders of a topic of study [7]—making the scale and impact of their contribution all the more remarkable. An author on physician burnout who has recognized the priority of Fredenberger’s publication over that of Maslach presents the subsequent research of Maslach with Jackson for developing the most widely accepted standard for burnout assessment—the 1981 Maslach Burnout Inventory (MBI) [8]—including a Human Services Survey applicable to healthcare professionals [9]. The 2005-created [10] Copenhagen Burnout Inventory (CBI) now represents an additional esteemed method for burnout assessment [11]. With his death in 1999 [12], publications by Fredenberger on burnout did not continue into the 21st century, and the most recent work on burnout by Maslach is from 2009, written in Spanish [13]. In the last publication by Freudenberger on burnout in 1989, he notes his astonishment regarding the speed of adoption of the concept; however, physician burnout per se was still not a focus of his research. One researcher who has published significantly on all aspects of burnout in the current decade—particularly for physicians—is Rotenstein [14,15,16,17,18,19]. Her most cited work remains the 2018 systematic review on the topic [20], which continues to stress the importance of the work of Freudenberger and Maslach in developing the concept of physician burnout.

1.2. Historical Circumstances Precipitating Physician Burnout

Physician burnout is deemed a historical constant [21]; however, circumstances particular to the 1960s and early 1970s were such that physician burnout became obvious, widespread, and particularly detrimental by the mid-1970s when it was first described [6]. The ability of physicians to help patients recover from illnesses resulting from a focus on microbiological factors regarding disease following World War II, one not previously available to physicians before this focus [22,23], was the basis for complete patient trust in physicians [24]. This faith in physicians by patients precipitated physician self-confidence, often evolving into arrogance by the beginning of the 1960s [25]. Concomitantly, the baby boom following World War II until the mid-1960s [26] increased the proportion of young people in society, making their demographic increasingly influential in decision-making by the end of the 1960s [27]. A focus on democratic decision-making by these young people began the questioning of physician authority [25]. With this questioning came the promotion of patient-centered care [28] through the new field of bioethics, holding the physician responsible for—and demanding patients share in—their treatment decision-making [29]. The result was increasing malpractice suits against physicians, raising their insurance rates [30], and creating the evolving view that physicians should be public servants rather than small business owners [31], leading to the proletarianization of the medical profession [32]. A new view of who was appropriate as a physician came with a “brain drain” [33] and an increase in the number of women [34] and minorities [35] who gained admission to medical schools. As such, although the ability of physicians during this period to heal patients was more than ever before [36], the status of the physician became significantly reduced [37], as was the ability of the physician to gain the type of remuneration previously expected [38]. These were systematic problems [39] unsolvable by individual physicians that, by the mid-1970s, came to an apex, making physician burnout widespread and seemingly insurmountable [40].

2. Psychosomatic Division

The definition of physician burnout recognizes it as a psychosomatic syndrome. Psychosomatic disorders include physical dysfunctions lacking a sufficient organic explanatory source and organic illnesses where psychosocial factors play a significant role [41]. As such, they include a psychological and a corporal component. Understanding these two components concerning physician burnout depends on the theories interpreting them.

2.1. Psychological Theories

Various psychological theories are relevant to understanding physician burnout. These theories originate from different perspectives, but each has been fruitful in understanding burnout from psychological considerations.

Maslach’s Three Dimensions relate to the Maslach Burnout Inventory (MBI), developed in 1981 to measure burnout, recognizing it as evident with negative scores in all three factors of exhaustion, cynicism, and professional efficacy [42]. Thus, although the MBI equated each of these three as on a continuum, burnout is only identifiable with the presence of all three. The Maslach Burnout Inventory for Medical Personnel (MBI-HSS-MP), a widely used instrument assessing burnout designed for health professionals specifically, was determined to have good psychometric properties in nurses and physicians in 2022 [43]. A 2024 systematic review and meta-analysis of the MBI provided some support for the adequacy of its measurement properties as a research tool measuring exhaustion, cynicism, and professional efficacy while identifying research challenges [44].

Job Demands–Resources Theory (JD-R) explains how the organizational environment impacts employee well-being and performance with the central proposition that the two categories of job demands and job resources classify job characteristics [45]. Job demands require sustained effort associated with physiological and psychological costs. Job resources refer to job aspects that help reach work-related goals, reduce job demands and the associated costs, and stimulate personal growth and development [46]. Four innovations of the past decade are (a) the person × situation approach of JD-R, (b) multilevel JD-R theory, (c) proactive approaches in JD-R theory, and (d) the work–home resources model [47]. For (a), the personality is stable, but work events and job characteristics (e.g., workload, social support) may fluctuate—even day to day. With the person × situation approach, a comprehensive model includes personal stability and situation variability. Then, (b) acknowledges that employees function within teams, which, in turn, are situated in organizations, and recognizes the importance of selecting leaders who can influence job demands and resources. The proactive approaches to JD-R of (c) propose that employees are motivated to acquire resources to cope with their job demands, including job crafting, proactive vitality management, and playful work design [48]. Lastly, (d) identifies that job demands and resources may influence home outcomes regarding personal resources (e.g., time, mood, energy), and home demands and resources may simultaneously and similarly influence work outcomes [49].

Self-determination theory (SDT) by Deci and Ryan maintains that human motivation depends on innate psychological needs for competence, autonomy, and relatedness [50]. Accordingly, psychological needs, self-direction, well-being, and performance are either facilitated or thwarted by the context of personal, social, and cultural considerations [51]. When physicians are more self-determined in their motivation, they tend to experience better occupational health mediated by physicians’ need satisfaction and autonomous work motivation [52]. To this extent, the association of burnout is negative with an autonomy causality orientation [53].

2.2. Somatic Theories

In 1999, it was proposed and demonstrated that burnout is identified with more sleep disturbances, waking up exhausted, and higher cortisol levels during the workday, suggesting that chronic burnout is associated with heightened somatic arousal and elevated salivary cortisol levels [54]. Several recent studies focus on the relationship between sleep and burnout [55,56,57]. However, whether poor sleep causes burnout, burnout causes poor sleep, or both has not been determined [58]. Similarly, there has been significant recent research on the role of decreased cortisol levels regarding burnout in physicians [59,60] with heightened cortisol reactivity in male physicians with burnout [61]. Moreover, relevant changes are not isolated to cortisol in burnout. Changes in the levels of cortisol, prolactin, adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH), and thyroid hormones, as well as plasma brain-derived neurotrophic factor (BDNF), are evident. In addition and at the same time [62], sleep disorders can disrupt hormonal equilibrium, impacting the balance of cortisol, thyroid hormones, testosterone, insulin, and hormones responsible for regulating hunger sensations [63]. What remains unclear is whether there can be an aversion to burnout from the medical treatment of sleep disorders with treatments to improve hormonal equilibrium.

3. Evolution

Several factors have arisen since the 1970s, causing additional escalation of physician burnout. Their arrangement is in three levels: macro, meso, and micro (

Table 1. Levels of physician burnout and their associated factors evolving physician burnout.

Level	Factor Evolving Physician Burnout
Macro	Corporate structure Electronic recordkeeping COVID-19
Meso	Doctor-patient communication Increase in women and minorities
Micro	Professionalism Psychological traits

).

3.1. Macro Factors Evolving Physician Burnout

The factors describable as macro are historically situated and systematic [64] for which policies are created and negotiated [65]. They are factors dependent on cohort responses rather than those of specific relationships or individuals [66]. However, they shape these relationships and individuals in ways they cannot control directly—although there is increasing interest in value co-creation in healthcare [67]. Otherwise, control over these factors must originate from the attitude assumed by each physician, demonstrating resilience [68].

3.1.1. Corporate Structure

The increasing corporate culture of hospitals conflicts with the value of medicine as a calling that promotes pride in professional achievement [69]. Regarding the role of hospitals in mitigating physician burnout, in developing countries, improved internal corporate social responsibility (ICSR) significantly impacts the level of physician burnout through the promotion of physician resilience training [70]. However, administrative changes to counteract physician burnout are most effective at a departmental level rather than in the larger institution, as physician pride resides within the department more so than the hospital [71]. Senior management can aid in this regard by maintaining equality between departments and giving lower-status departments capacity-building support based on the understanding that all departments are vital to the hospital in promoting a shared identity [72].

3.1.2. Electronic Recordkeeping

For all physicians, the shift to electronic recordkeeping, placing its responsibility on the physician, has been an additional strain that has been a significant contributing factor to increasing physician burnout [73,74] by taking away time from patient care and categorizing this care in ways that are not self-evident [75]. A recent scoping review of electronic health records and physician burnout identified six main causes leading to physician burnout related to electronic recordkeeping: their documentation and related tasks, poor design, the increased workload attending to them, overtime work they create, inbox alerts requiring immediate attention, and alert fatigue from information regarding medication refills and test results [76]. Patient portals and electronic health record messaging create a separate source of often non-reimbursable patient care, producing a previously unknown source of physician burnout [77].

3.1.3. COVID-19

The most substantial reason for burnout in recent years has been the effect of the COVID-19 pandemic on physicians [78]. Beyond the redeployment of appointment-based physicians to emergency care [79], physicians by necessity switched to telemedicine [80]—often with results that were detrimental to the doctor–patient relationship [81,82]. Physicians were fearful of infecting their families with the virus [83,84], predicted substantial malpractice suits [85], and there was an increase in their mistakes [86], with mass resignations in certain specialties [87]. Women and younger physicians were most affected by burnout from pandemic-related causes [88,89]. Post-COVID-19, physicians experienced increased stress, anxiety, and depression regarding their workload, autonomy, role conflicts, social interaction inequities, and work–family balance [90].

3.2. Meso Factors Evolving Physician Burnout

Meso-level considerations regard the social context in which individuals are situated [91]. As such, they affect physician burnout concerning interpersonal relationships regarding communication [92]. Primary relationships regarding burnout for physicians are those with their patients and physician colleagues—both necessitate trust for burnout aversion [93,94,95,96].

3.2.1. Doctor–Patient Communication

Telehealth became pervasive in doctor–patient communication worldwide due to COVID-19 limitations [79], with positive results for burnout in psychiatrists [97] but detrimental ones regarding burnout in cardiology [98], dermatology [82], and oncology [99]. For psychiatrists, this improvement in their burnout from the necessary adoption of telehealth came from its ease of promoting dialog and patient preference for this method of communication [97]. However, neither cardiologists nor dermatologists considered telehealth effective for promoting appropriate patient care for their specialty [82,98]. Burnout in oncologists regarding the necessity of adopting telehealth during COVID-19 was particularly nuanced compared with other specialties as it extended to the empathetic concern oncologists showed towards their patients—especially concerning communicating serious news [100]. A slight increase in the positive perception of telehealth is evident post-COVID-19. However, the ease of use and eHealth literacy remain concerns [101]. Regarding the effects of telehealth after the pandemic, there are two situations noted as increasing burnout: low feelings of personal accomplishment and managing challenging patient cases. In contrast, similarly to the experience of psychiatrists during the pandemic, the primary mediating factor to provider burnout regarding telehealth was improved patient experience [102].

3.2.2. Increase in Women and Minority Physicians

Although disparity remains, there has been a dedicated increase in the percentage of women [103] and minorities [104] who are physicians. Yet, with this increase, there has been little perceived change in the “white supremacy culture” of medicine [105], representing a leading cause of burnout for these underrepresented groups [106,107] as this culture maintains the inadequate representation of minorities as physicians [108]. A recent systematic review and meta-analysis identified that, although female and male physicians each experience burnout, women may do so to a greater degree. They may benefit from institutional talent management approaches that recognize their greater tendency to burnout compared with men [109], which seems to arise from lower rates of professional fulfillment, contrasted to men [110]. In developing countries, such as South Africa, burnout is the overwhelming experience of female physicians [111].

3.3. Micro Factors Evolving Physician Burnout

Single individual-level variations affecting physician burnout represent the micro-level factors [112]. These variations extend to their views on professionalism and their psychological traits.

3.3.1. Professionalism

Four behavioral domains divide physician professionalism: respect, integrity, excellence, and responsibility [113]. Respect by physicians regards having compassion for others [114]. Those physicians with greater compassion are more likely to experience burnout from compassion fatigue [115]. In contrast, self-compassion from personal respect reduces physician burnout [116]. Integrity concerns a commitment to ethical practice, with those physicians who feel forced to make decisions contrary to their ethical sense suffering moral distress [117]. An exaggerated sense of personal responsibility to perform at a level of excellence combined with perfectionism affects physician burnout [118]. The physician must be less committed to perfection in the care provided to work effectively in what has become the corporate culture of medicine, as perfectionism is one of the primary predictors of physician burnout [119]. In developing countries, perfectionistic tendencies, difficulty setting boundaries, a strong sense of responsibility, and a lack of self-care practices can increase vulnerability to burnout resulting from challenging work environments, resource limitations, and systemic factors [120]. Identified in Israeli physicians was maladaptive perfectionism as a profound risk factor for suicidality [121]. In India, a study of physicians revealed a mediating effect on the relationship between perfectionism and physician burnout from psychological capital [122].

3.3.2. Psychological Traits

The psychological traits of physicians affect their experience of burnout. The finding is that the personality traits of emotional intelligence and self-efficacy prevent the occurrence of burnout, where emotional intelligence is understanding and coping with individual emotions and feelings regarding job performance and demands, and self-efficacy is the ability of a physician to control their work environment with the aim of better performance [123]. One of the most well-known and relevant approaches to personality traits—the Big Five—is the five-factor model proposed by McCrae & Costa [124] and validated in 1987 [125]. In a 2023 systematic review of these traits concerning burnout, those physicians with higher levels of neuroticism, lower agreeableness, greater conscientiousness, less extraversion, and reduced openness demonstrate higher levels of burnout [126]. Together, these negative traits are representative of the Type D (distressed) personality type linked to physician burnout—particularly those in emergency care [127]. Type D personality, defined as a combination of high negative affect and high social isolation, has been associated with poor health outcomes [128], including self-medication in physicians that may lead to substance misuse [129].

4. Resulting Factors Affecting Physician Burnout

Similarly to the factors evolving physician burnout, the arrangement of resulting factors affecting physician burnout can be in three levels—macro, meso, and micro (

Table 2. Levels of physician burnout and their associated factors promoting improvement.

Level	Factor Promoting Burnout Improvement
Macro	Fundamental physician rights Adequate working conditions Increased salaries Career and professional development Improvements to physical and social environment Clear professional guidelines and protocols Increased staffing
Meso	Career re-engagement Increased years of experience Better treatment by patients, their families, and visitors
Micro	Identification of biological risk factors Heart variability testing Hair cortisol testing

).

4.1. Macro Factors Promoting Improvement

One result of this continuing increase in physician burnout is the call for recognizing physicians as healthcare workers who deserve fundamental rights and adequate conditions to respond to systemic issues [2]. Such calls for equity became increasingly vocal because of physician experiences regarding COVID-19 [130]. Job morale of physicians in low-income and middle-income countries is primarily affected by negative institutional experiences with the following positively influencing a decrease in burnout: increasing salaries, offering career and professional development opportunities, physical and social working environment improvements, clear professional guidelines and protocols, and increasing healthcare staff [131].

4.2. Meso Factors Promoting Improvement

A meso-defined result for physician burnout concerns equating burnout with career disengagement and focusing on physician dissatisfaction with their job, as those with burnout are four times more likely to be dissatisfied with being a physician and three times as likely to intend to either leave their practice or regret their choice [132]. On the other hand, a large longitudinal study reports that although physician burnout is increasing, its increase is not homogeneous—it is women and those with less than ten years of practice who experience the most burnout [133]—something evident during COVID-19 in various specialties [88,89]. In all, physician burnout regarding meso issues undermines the safe delivery of healthcare, putting physicians and their patients at risk [134] and leading to mistreatment of physicians by patients, families, and visitors—especially for female and racial and ethnic minority physicians [135].

4.3. Micro Factors Promoting Improvement

In contrast to the macro- or meso-identified results of burnout, a micro-directed result regards seeking to understand and control burnout through its biological markers related to stress and immunity, with results indicating that early detection of biological risk factors is a way to prevent burnout in physicians by designing appropriate psychosocial strategies [60]. Understanding how the brain changes in response to uncontrollable stress can help physicians recognize the symptoms of burnout and serve to direct organizational interventions [136]. For physicians in sub-Saharan Africa, data on heart rate variability and hair cortisol levels assessing stress-related physiologic responses to acute and chronic stress found that greater life satisfaction related to decreased stress and motivation to work excessively was associated with increased stress and burnout—particularly for women physicians [137].

5. Solutions

Similarly to the diagnosis of physician burnout, solving physician burnout is described as overwhelming [69]. To a certain extent, the solutions to physician burnout are no different from the ten points proposed by Freudenberger with the introduction of the term in his 1975 work [138].

5.1. Solutions to Burnout According to Freudenberger

Freudenberger provides an outline of ten points regarding alleviating burnout in volunteers. Restated for physicians in particular, they are as follows: (1) Ensure that the training period is adequate so that any medical students likely to get burned out recognize they are ill suited for the profession. (2) Train medical educators to identify the difference between realistic dedication and unrealistic commitment by engaging the medical student using self-reflecting questions in a series. (3) At the institutional level, avoid sending the same physician repetitively into the same situation—rotate functions. (4) Limit the number of hours a physician works—the suggestion is nine hours as the maximum—staggering hours worked so that no individual always works the night shift. (5) If working in a physician collective, after four weeks of work, take off the fifth week—the suggestion is even that after three months of work, take off the fourth month. (6) Working as a team, physicians have backup when feeling burned out. (7) Physicians should be encouraged to share their experiences—to talk when they feel burned out and listen when others do. (8) Attending workshops promotes learning and gives the physician a stimulating and inspirational experience. (9) Ensure that there are sufficient physicians for the population. (10) Encourage physicians to get adequate physical exercise. These ten points are divisible into macro, meso, and micro in their effects (

Table 3. Stages of burnout regarding levels of prevention and their relationship to Freudenberger’s ten points with the point number in round brackets.

Level	Freudenberger’s Ten Points
Macro	Adequate the physician training period (1) Train medical educators to differentiate realistic dedication from unrealistic commitment (2) Provide significant vacation time (5) Ensure sufficient physicians for the population (9)
Meso	Rotate functions (3) Limit the number of working hours (4) Provide backup to burned-out physicians (6)
Micro	Encourage physicians to share their experiences (7) Attend workshops (8) Encourage physicians to get adequate physical exercise (10)

).

5.1.1. Macro Level

Concerning macro considerations, for Freudenberger, appropriate training was the focus. To this effect, the recommendation to mitigate burnout is to educate medical students who can and choose to work within the systemic limitations of healthcare delivery, demonstrating the appropriate resilience [139]. One study suggests that resilience-based interventions by medical schools may be a promising buffer to the type of burnout specific to medical students [140]. The responsibility of medical training regarding reducing physician burnout extends to ensuring a sufficient number of these appropriately educated physicians for the population, as burnout results from too many patients under the care of one physician [141]. From this perspective, to avoid burnout, macro challenges are best accepted by the physician through a demonstration of resilience [142]. At the institutional level, the recommendation promoted by Freudenberger is to ensure sufficient vacation time—a primary component of a well-functioning system in his view of reducing burnout supported by recent research [143].

5.1.2. Meso Level

In the view of Freudenberger, institutions have a role in reducing burnout by promoting harmonious relationships among colleagues—a point supported by current research [144]. From his point of view, there are three ways to accomplish this, all of which relate to appropriate and effective scheduling—representing the foundation of strategies to reduce burnout suggested by the Mayo Clinic [145] of viewing physicians as a predictably limited institutional resource that is non-renewable [146]. As such, advanced and appropriate institutional planning is necessary so physicians can perform effectively, as most physicians believe poor institutional organization drives their burnout [147]. This planning can reduce burnout by rotating physician functions, limiting work hours, and ensuring that if they display the signs of burnout, there is backup available [148,149].

5.1.3. Micro Level

When Freudenberger advised that a way to avert burnout was sharing personal experiences, it was before the finding that reduced openness is a predictor of burnout in physicians. General advice is available that states physicians should be encouraged to be more open [150]. Freudenberger is unique in proposing the importance of attending workshops in promoting openness. In this regard, post-COVID-19, the advice is that less is more as physicians have become overwhelmed by the options available from webinars [151]. Similarly, Freudenberger was advanced in his view of the importance of physical exercise in overcoming burnout. There are few studies on the value of physical exercise in decreasing burnout in physicians [152,153]. One recent study recounted that physicians cite a lack of time and energy to exercise; however, of those who exercise, the chosen activities are cycling, running, and working out at the gym. The advice is that physicians will only engage in physical activities—and better nutrition to sustain the effort—if their healthcare institutions provide better opportunities [152].

5.2. Freudenberger on Meditation Regarding Burnout

Interestingly, what Freudenberger did not recommend was meditation. “Engage in any activity that will make you physically tired. Many times the exhaustion of the burn-out is an emotional and mental one. It is this type of exhaustion that will not let you sleep. That is why it is not always a good idea, in my opinion, to shift to meditation or yoga, which cause a mental dropping inward. Introspection is not what the burnt-out person requires. He requires physical exhaustion, not further mental strain and fatigue” [138]. The recent support for this advice to focus on physical exhaustion was addressed in a study of 11,500 medical students across 13 countries that found a negative association of physical activity with burnout and a positive association with quality of life, with higher intensities and frequencies precipitating more substantial improvements in outcomes [153]. In contrast, although Freudenberger did not support meditation for reducing burnout, various studies have found meditation to shield physicians against stress, permitting them to maintain empathy and compassion for patients [154,155,156,157]. The drawback to these programs for physicians is the level of commitment necessary for noticeable improvement in their burnout, which may be impossible to achieve [158].

Mindfulness Techniques Potentially Effective in Reducing Physician Burnout

Beyond the advice of Freudenberger against meditation for physician burnout, the focus of meditation as a mindfulness technique is a nonjudgmental present awareness of physical, emotional, and mental states. What it is that mindfulness techniques do not necessitate is an adapted response as the purpose [159]. Instead, mindfulness practices focus on attentional control of internal conditions [160]. This lack of mindfulness interventions having the added dimension of creating adaptive responses is why Freudenberger did not think they were effective. Corresponding to point 2 of the advice offered by Freudenberger to reduce burnout—a method that does involve an adaptive response—is an author-created question-asking method of self-reflection to reduce burnout in healthcare researchers available to physicians in both a group [161] and individual form [162]. Freudenberger advises offering this type of self-reflection during training in contrast to meditation. Yet, the identification is that medical students are the least likely to engage in this type of self-directed reflective process in comparison to physicians because of less experience in such self-direction and their perceived overload with learning commitments [163]. Nevertheless, a recent scoping review on the impact of mindfulness practice on physician burnout has found that the interpretation of Freudenberg on this matter is questionable, as mindfulness alone has shown links to improvement in well-being and positive psychology [164]. What is relevant regarding mindfulness techniques applicable to medical students is cultivating awareness and nonjudgmental acceptance of inner experiences, as this cultivation provides a self-regulation resource that can sustain well-being [165].

5.3. Burnout Prevention Levels Concerning Freudenberger’s List

Implied in the list produced by Freudenberger is that the type of intervention for physician burnout depends on the extent of burnout that the physician experiences. This point is made clear in a 2021 publication [150] that outlines the various levels of burnout and the types of interventions that are most effective for any particular stage of burnout experienced—each conceptualized as a form of prevention (see

Table 4. Burnout prevention levels and their relationship to Freudenberger’s ten points with the point number in round brackets.

Level	Freudenberger’s Ten Points
Primordial prevention	Ensure adequacy of the physician training period (1) Train medical educators to differentiate realistic dedication from unrealistic commitment (2) Encouraged physicians to share their experiences (7) Attend workshops (8) Encourage physicians to get adequate physical exercise (10)
Systems-based primary prevention	Rotate functions (3) Limit the number of working hours (4) Provide significant vacation time (5) Provide backup to burned-out physicians (6) Ensure sufficient physicians for the population (9)
Secondary prevention	Meditation (not recommended by Freudenberger)
Tertiary prevention	Freudenberger provides no advice, but AI may help

). The first is primordial prevention—a strategy to avoid risk factors before they develop. Referring back to the list by Freudenberger, these would include individual-directed methods—points (1), (2), (7), (8), and (10). Second is systems-based primary prevention, promoting organizational change. In the list, these would be points (3), (4), (5), (6), and (9). Secondary prevention interventions are those that are reactive and do not seek to address the source of the problem. Meditation as a mindfulness-based practice is this type of intervention—one not recommended by Freudenberger. Finally, tertiary prevention is regarding an established ongoing burnout condition. The authors of the 2021 publication have no advice on how to improve this level of burnout—neither does Freudenberger. Instead, the acceptance is that “it is inevitable that some physicians will slip through the cracks” [150]. Yet, one of the most significant reasons for burnout in physicians today is physician administration of their electronic recordkeeping [73,74]. One type of intervention that has shown promise in tertiary prevention is the effect of utilizing ambient artificial intelligence notes [166,167], demonstrating that the use of AI in this manner is beginning to reduce the level of burnout in physicians.

6. Recommendations

In 2025, research on physician burnout finds its prevalence fluctuates between 25% and surpasses 80%, depending on the medical specialty and geographical location [168]. Physician burnout appears to be an ever-increasing and unmanageable syndrome that has the potential to cause significant harm to physicians, their patients, and the healthcare system in general. What is evident is that solving physician burnout requires a multi-tiered approach to prevention.

The recommendation for reducing physician burnout is to consider the advice of Freudenberger—the researcher who first identified burnout—but in a more structured manner than he envisioned regarding different levels of prevention. In addition to following the advice of Freudenberger, mindfulness techniques show promise in the secondary prevention of physician burnout, and new uses of AI in reducing physician administrative burdens are notably beneficial in tertiary prevention. Ambient artificial intelligence notes should be researched and tested on physicians overburdened with electronic recordkeeping to improve the prospects of those physicians who experience overwhelming burnout requiring immediate intervention.

In conclusion, there must be a dedicated and comprehensive solution to physician burnout for healthcare delivery to remain safe and effective for all involved.