Burnout In Surgery
By Jacob Moalem, MD, FACS
Originally published by The American College of Surgeons (facs.org)
The term “burnout” is commonly used in our everyday lexicon and in the medical literature. Although definitions vary,1 the affected individual will manifest high rates of emotional exhaustion, depersonalization, and a low sense of personal accomplishment in association with chronic occupational stress. Each of these three elements may be measured using the Maslach Burnout Inventory,2 and higher scores indicate greater severity of symptoms. Burnout and depression are closely linked, and authors have theorized that each condition might predispose the other. A recent review has suggested that the heterogeneity of both constructs preclude any definite conclusions regarding the distinction or overlap between burnout and a type of depression.3
Burnout manifests with a wide variety of physical and cognitive symptoms that have profound effects on both the personal and professional lives of affected individuals. These include changes in appetite, insomnia, disengagement, hostility, diminished attention and dedication, depression, anxiety, and worse physical health. These outcomes of burnout may lead to alcohol or substance abuse, broken relationships or divorce, or even suicide.4
A recent landmark study of members of the American College of Surgeons revealed that 40 percent of responding surgeons screened positively for burnout, and 30 percent screened positively for symptoms of depression.5 In that study, multivariable regression identified six factors that were independently associated with increased burnout. These included having children younger than 21, purely incentive-based pay, having a spouse who works as a healthcare professional, as well as increasing nights on call, years in practice, and number of hours worked per week. Conversely, having children, increased age, and importantly, having more than 50 percent of time protected for research or administrative work was protective against burnout.5
Several studies have investigated the impact of subspecialty choice on the risk of burnout, with some studies showing that those in front-line surgical specialties, such as trauma and general surgery, are at higher risk.6,7 Alarmingly, a recent study found that the incidence of burnout rose in all medical specialties from 2011-2014, and that among surgery specialties it increased from 42 percent to 52 percent.8 These findings were later validated by a large-scale Medscape study that showed extremely high ( greater than 40 percent) rates of burnout in all specialties, and 51 percent in surgery.9
Several recent, large studies have demonstrated that the widespread implementation of electronic medical record (EMR) systems are a major contributor to burnout among American physicians.10 Physicians have noted a number of negative features of the EMR, including poor usability, time-consuming data entry requirements, interference with face-to-face patient care, lack of interoperability, and perceived degradation of quality of clinical documentation. Another large study revealed that the increasing bureaucratic tasks associated with clinical practice were the most significant cause of burnout, closely followed by spending too many hours at work, the computerization of practice, income concerns, feeling “like a cog in a wheel,” and maintenance of certification requirements.9
The evolution of burnout amongst surgeons can be tracked by examining studies of groups in the training continuum. Medical students enter medical school with similar mental health profiles to their age-matched peers.11,12 The incidence of burnout appears to increase as they progress through medical school,13 with one study suggesting that over the course of their medical school career, half of medical students experience burnout, with as many as 10 percent reporting suicidal ideation.14
Studies of burnout in residency also reveal a troubling trend of rising incidence. One study, done over a decade ago, suggested that 40 percent of surgical residents suffered from burnout.15 A more recent study of 665 surgical residents revealed that 69 percent of respondents tested positive for burnout on at least one subscale.16 A systematic review17 found that several studies compared residents and faculty (in ENT, OB-GYN and orthopedics). All of the studies revealed that quality of life was lower for residents, and, when measured, burnout was higher for residents.
Beyond the negative effect that burnout has on individual physicians, their families, and their colleagues, burnout also has severe effects on the quality of care provided to patients, and on the healthcare system as a whole. A large study by the American College of Surgeons revealed a direct association between burnout scores, particularly in emotional exhaustion and depersonalization, and the likelihood of committing a major medical error.18 Burned out surgeons are then more likely to ruminate on their mistakes, to assign a disproportionate amount of blame to themselves, and to be unable to consider other, which are systemic causes for a bad outcome. Thus, burned out surgeons are able to process and handle adverse outcomes poorly, worsening their symptoms, and also further increasing the risk of additional complications.19
Burnout has also been very closely associated with low career satisfaction.5 As a result, it is not surprising that burnout is associated with a tendency towards early retirement or reductions in work effort.20 Extrapolated to the U.S. physician workforce, these impacts would be the equivalent of an annual loss of more than 1,000 physicians.21 The effect of disengagement and decreased productivity likely increase the overall impact of burnout amongst physicians.
While rates of burnout are on the rise, several techniques and strategies have been found to significantly lower the risk. Individual physicians should work hard to combat burnout by actively nurturing their personal and professional lives and stressing work/life balance, placing greater emphasis on finding meaning in their daily work, focusing on what is important in life, and maintaining a positive outlook.22 In addition, strategies such as employing mindfulness techniques,23consciously expressing gratitude,24 and celebrating small victories25 have all been shown to be effective in reducing burnout. Moreover, there is a burgeoning literature base to support the assertion that resilience is a skill that may be learned and cultivated, is instrumental in preventing burnout,26 and that emotional intelligence, another learned skill, is a strong predictor of resident wellbeing.27
The available literature clearly demonstrates the threat posed by physician burnout on the entire healthcare system today. As financial and productivity pressures continue to mount, and as our surgeons and physicians are required to comply with more and more regulatory requirements, the conditions are ripe for continued worsening in the prevalence and severity of burnout in all career stages in medicine. As surgeons, we all have a responsibility towards one another to look for signs of burnout or depression in our colleagues and to offer support. Surgical leaders, such as division chiefs and department chairs, have an obligation to actively promote the wellbeing of their faculty, residents, and staff as a critical factor in the overall success of their mission.28 Formalized peer support programs such as was instituted at Brigham and Women’s Hospital are highly valued and effective resources for faculty and staff in dealing with adverse events and preventing further trauma.29 In addition, our institution recently incorporated mindfulness training into the medical school curriculum, a program that has been shown to decrease distress and increase quality of life of participating students.30 Finally, purposeful attention to improving resident and faculty wellbeing by providing mentorship and guidance, and optimizing the work environment by ensuring adequate staffing to prevent overwork, maintaining adequate facilities, and limiting or providing assistance with administrative, nonclinical requirements can go a long way to improving morale and work satisfaction.
Recent evidence suggests that surgeons who completed a Physician Well-Being Index and received objective, individualized feedback about their well-being relative to national physician norms were likely to contemplate behavioral changes to improve personal well-being.31 Such resources, and a wide array of related materials and publications, are available for use on the American College of Surgeons Physician Wellbeing webpage. There, a free, confidential, and personalized well-being measuring tool is available. Readers are highly encouraged to participate in this activity, and to promote its use among colleagues.