Burnout in medicine has reached epidemic proportions. A recent systematic analysis found that the prevalence of burnout was as high as 80.5%. All medical specialties are affected, although prevalence rates of burnout vary widely between specialties.

Classically, burnout is defined as a triad of emotional exhaustion, depersonalization, and inefficacy. Recently, moral distress or moral injury has also been recognized as a potential component of burnout. Physician burnout contributes to workforce turnover, jeopardizes patient safety, and may play a role in the relatively high rate of suicide among physicians in “high-burnout” specialties compared to peers in other professions. For all these reasons, burnout should be considered a public health crisis that demands urgent attention.

Several features, including work-life imbalance, decreased autonomy, and administrative burden are thought to contribute to burnout. Many burnout interventions, therefore, focus on individual interventions (e.g., yoga classes). There is increasing resistance to the “bagels and yoga” approach to resilience, however, and a growing focus on organizational solutions, including well-trained support staff and scribes. We believe there is an as-yet unaddressed but substantial contributor to burnout that is essentially hidden in plain sight: physician compensation.

Discussions of money are often taboo. Among physicians, discussions of compensation can carry even more of a stigma because of the inherent tension between the altruistic associations of patient care and the financial realities of medical practice. But ignoring the role of money in burnout means ignoring the single most common response to the question: “What would reduce your burnout?”

When asked this question, 35% of Medscape survey respondents selected, “increased compensation to reduce financial stress.” This answer was chosen more than reducing patient loads (chosen by 24% of respondents) or increasing physician autonomy (chosen by 23% of respondents), both of which are frequently cited as solutions to burnout.

Therefore, it is imperative that the discussions surrounding burnout include physician compensation.

One of the earliest and largest studies of physician burnout to date asked about work-life balance, but did not directly address physician finances. The largest study of burnout in neurologists(a group known for high rates of burnout) asked about compensation strategy (e.g., salary versus productivity, etc.), but not actual compensation. A review of strategies to reduce burnout mentioned physician finances but found no standardized tools for measurement, benchmarks, or evidence for correlation with particular outcomes highlighting just how little is known about the role of compensation in burnout.

Only the Medscape survey in 2018 asked about money with 24% citing insufficient compensation as a contributor to burnout. The National Academy of Medicine’s well-being and burnout reduction initiative provides six “in-depth case studies” with “actionable solutions to promote clinician well-being and reduce burnout.” None of these addresses physician compensation despite one citing investing $2 million into wellness initiatives.

Compensation can affect burnout in many ways. We discuss here just some of those ways. Our goal is not to provide a comprehensive review of the impact of compensation on burnout, rather to encourage those addressing burnout to include physician compensation in their studies and proposed solutions.

One of the more obvious connections between burnout and compensation is financial stress. For physicians with significant debt, increased compensation can quickly reduce worry about making monthly debt payments. But debt can affect burnout more subtly as well. Debt burden influences both academic performance and specialty choice.

If medical students are choosing higher-paying specialties over lower-paying ones for the purpose of reducing their debt faster instead of for intrinsic interest in the specialty, they might burn out sooner, despite the higher salary. Such individuals may be at the highest risk of burning out if the compensation model changes over the course of their career (e.g., from fee-for-service to capitated payments), and they suddenly find themselves financially strained and professionally unfulfilled. Additionally, while many proposed burnout solutions focus on reducing workload at work, few address workload at home.

A higher salary, though, can help reduce the workload at home by providing the financial resources to hire help with chores (e.g., lawn care, laundry, meal preparation), thereby freeing up more time for leisure activities after work hours.

Another insidious way money could contribute to burnout is through comparisons with other physicians. Could neurologists suffer burnout more frequently than neurosurgeons or radiologists, with whom they work closely, not because they earn inadequate salaries to live comfortably, but because they are paid less than their colleagues despite caring for the same patients?

For some, it might not be an absolute salary, but relative salary that causes distress. This may also explain the relationship between burnout and other markers of organizational inequity. Explicit and implicit racial bias, for instance, is associated with higher rates of burnout for resident physicians. For similar reasons, the gender pay gap could be one factor in why women experience burnout more frequently than men?

Salary differences could also explain some of the previously reported associations with burnout. For instance, burnout in Neurology is lower in the Midwest than in other geographic areas and in rural compared to metropolitan areas. These findings are unexpected, but may reflect, at least partially, a result of a higher salary to cost of living ratio.

Many physicians, even those who are employed and earn a salary, receive productivity bonuses, which seem to provide a financial incentive for additional work.

It is not known, though, how many physicians receive regular raises, even cost of living raises. The psychological impact of raises, merit increases, and bonuses is complex, but the data suggests that pay-for-performance metrics may actually diminish quality of performance. Psychologically, a raise may carry more impact as it shows appreciation, and it is not tied to increased workload, which could counter any potential anti-burnout effects of the bonus.

A raise also has the benefit of being prospective compensation, allowing recipients to budget accordingly, reducing financial stress all year rather than waiting and hoping for a bonus that might not come at the end of a reporting period. The inverse is likely true as well. Decreasing reimbursement from payers, so physicians make less money for the same work could exacerbate burnout.

It’s unlikely that higher salaries will solve all burnout.

Some physicians with no financial concerns still experience burnout. We suspect that there is a minimum amount of compensation needed to remove financial concerns, after which further increases will have limited impact.

However, failing to address these financial concerns could limit the impact of other burnout reduction strategies. In our review of the burnout literature, we found money to be overlooked in surveys and proposed solutions. We encourage those engaged in anti-burnout work to consider personal finances as part of their comprehensive strategies for physician wellness.

Sneha Mantri, Andrew Spector, and Nada El Husseini are neurologists.

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