One day when Dr. Steve Gabbe was taking a break while attending a science conference, he wasn't terribly surprised to hear a half dozen colleagues sharing their frustrations about work, but he was deeply concerned to hear them sound so pessimistic about the future. "I realized I was observing people who were burned out," said Gabbe, dean of the Vanderbilt University School of Medicine, who specializes in obstetrics/gynecology and subspecializes in maternal fetal medicine. "I thought, here are people that are leaders in their field, members of society who have really accomplished something significant … and if this is how they feel, then clearly this message is getting out to faculty and students." So Gabbe, along with Vanderbilt's Dr. Anderson Spickard Jr., a nationally recognized expert on physician health issues, and John F. Christensen, PhD, of Legacy Health System in Portland, Ore., began to research mid-career physician burnout in generalist and specialist physicians. "It's extremely important to understand that burnout actually happens early in a new position," explained Gabbe. "Burnout is perceived to happen over a long time, but in fact, that's not how it happens. It's related to the workplace — the demand of the position, the control one has over his work, and the amount of support one receives — not the person." Burnout is characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment. "The first thing that usually happens is emotional exhaustion," reported Gabbe. "The individual is working long hours, and feels he can't do more. One of the most important questions we can ask is: Are you at the end of your rope?" An unhealthy dose of cynicism signals the next step, where every additional demand appears overwhelming. "It's the 'one more thing I have to do' syndrome," said Gabbe. "We see this particularly in emergency medical physicians, where they were at the end of a shift, yet the demand was uncontrollable. You'll hear physicians referring to the number of patients as 'hits.' That's not a very personal term." By the time physicians perceive a lack of personal accomplishment, they tend to believe nothing they are doing is worthwhile, said Gabbe. "When you have that triad, you're in trouble," he said. "Burnout isn't the same as depression, but it can lead to depression." Doctors need to be sensitive to how colleagues are faring, said Gabbe, adding, "We need to be able to reach out and help them if we see they're having a difficult time." Healthcare organizations have a responsibility to keep healthcare providers happy, Gabbe said, who pointed out the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires hospitals to have wellness programs. "But that alone won't help," said Gabbe. "We're often guilty of not taking our own advice. However, we're seeing more doctors enroll themselves in wellness programs rather than having others suggest it for them." Feedback from annual health questionnaires, like ones dispatched to faculty and staff at Vanderbilt University, is a proactive measure to prevent burnout, said Gabbe. "It tells us how we're doing, suggests recommendations and tells us where to get help," he said. "The stimulus to do it is that by filling out the questionnaire, you lower your healthcare premium. It's a terrific system." Gabbe noted that women were at much greater risk than men to report burnout, primarily because of the stress related to balancing responsibility of the workplace with home. Vanderbilt addressed this trend through the national ELAM (Executive Leadership in Academic Medicine) program, in which Vanderbilt senior faculty member Julia Lewis found a way to help faculty and staff, particularly females, better manage home and work chores. The school contracted with a Chicago-based company to provide a series of valet services. For a fee, a valet will mail holiday presents, get stamps, pick up laundry, acquire theater tickets, take a car to the shop, and run other errands. "You pay for the service, but it's all set up here in the hospital," said Gabbe. "This is the sort of creative approach that can really make a difference for everybody." Not surprisingly, Gabbe also discovered that burnout particularly affects obstetricians and gynecologists, specialists who work longer-than-usual hours and struggle the most with medical malpractice issues, especially those practicing in states without significant tort reform. "For a number of years, we saw not only a decline in the number of new ob/gyn students in the system, especially men," explained Gabbe. "In residencies today, the number of men remains relatively small. But in the last two years, we've seen an increased number of students interested in ob/gyn. I think this reflects a better understanding that, with practices in place, hours can be managed more effectively. We're cautiously optimistic that we'll see some relief for the medical malpractice (insurance) problem. The American College of Obstetricians and Gynecologists deserves a lot of credit for helping medical students better understand how wonderful a field this is." To prevent burnout, Gabbe said physicians must be guided from the earliest years of training to cultivate methods of personal renewal, emotional self-awareness, connection with social support systems, and a sense of mastery and meaning in their work. "Maintaining these values is the work of a lifetime," Gabbe said. "It's not incidental to medicine, but is at the core of the deepest values of the profession to first, do no harm. Doing no harm begins with oneself."