Keywords
burnout - wellness - well-being - practice improvement - surgeon
There is an alarmingly high rate of burnout among surgeons, which, in turn, carries
an enormous personal and professional toll and strains the social and financial resources
of the U.S. health care system. Available data suggest that more than 50% of practicing
surgeons and nearly 70% of general surgery residents meet the posited criteria for
burnout.[1]
[2]
[3] The notion of burnout and its effects on individuals, institutions, and communities
on a larger scale is not new.[4] The specter of burnout for the practicing surgeon, however, is particularly poignant:
surgeons are unique in their professional task of treating patients across multiple
settings and phases of care, from office, to operating room, to bedside. Patients
expect their surgeons to be lifelong learners and to remain at the forefront of the
scientific and technical foundation of their practice. Thus, with its negative influence
on personal well-being and career satisfaction, burnout threatens both the longevity
of surgeons' careers and the safety of those patients to whom they provide care.
In this study, we focus on the history of burnout, the evolution of its definition,
and its risk factors, with particular emphasis on the relevance of burnout to the
practice of surgery. We offer a summary of reported personal and professional consequences
of this increasingly common problem and review contemporary efforts that have helped
to identify and potentially mitigate burnout risk factors. This study should by no
means be considered exhaustive of the substantial literature that has emerged on this
topic. We further direct the interested reader to several excellent reviews on physician
burnout[5]
[6]
[7]
[8] to complement this study.
Defining “Burnout”: A History
Defining “Burnout”: A History
The first written descriptions of what is commonly understood by “burnout” may date
back as far as the Old Testament, in which Moses' father-in-law rebukes, “You will
only wear yourselves out. The work is too heavy for you; you cannot handle it alone”
(Exodus 18:17–18).[9] The first instance of the verb form “to burn out,” however, may be found in William
Shakespeare's The Passionate Pilgrim, written in the 16th century, in which the object of the speaker's affection has
“Burned out love, as soon as straw outburneth.”[10] Graham Greene's 1961 novel A Burnt-Out Case tells the story of “a spiritually tormented and disillusioned architect [who] quits
his job and withdraws into the African jungle.”[4]
“Burnout syndrome” made its first appearance in social psychology during the 1960s
and 1970s, initially in the description of probation officers, volunteer staff employed
in urban clinics for drug addicts, and lawyers in the service of vulnerable populations.[11]
[12]
[13]
[14] At the turn of the millennium, researchers shifted the focus of burnout away from
individuals who seemed to have “unrealistically high altruistic goals” to larger populations
not employed in human services or education.[9] Maslach et al described the following three key dimensions of burnout: (1) overwhelming
emotional exhaustion (EE), (2) feelings of cynicism and detachment from the job (“depersonalization,”
DP), and (3) a sense of ineffectiveness and lack of personal accomplishment (PA).[4] Balch and Shanafelt identified two common burnout symptoms specific to health care:
“Treating patients and colleagues as objects rather than human beings, and feeling
emotionally depleted.”[15]
The Maslach Burnout Inventory (MBI), a 22-item self-administered questionnaire divided
into three subscales, emerged in the 1980s as a measure to assess each of the aforementioned
dimensions.[16]
[17] Although other tools such as the Copenhagen Burnout Inventory and Oldenburg Burnout
Inventory have been published, the MBI has been the leading methodological component
of burnout research.[4]
[18]
[19] Criticisms of these tools include a preponderance of negative phrasing, a lack of
sufficient dimensionality to address each component of burnout, and a limited ability
to assess changes in burnout response to different interventions.[6]
[20] The Personal Fulfillment Index is one example of a newer assessment that specifically
addresses disengagement from patient care and allows reassessment of burnout in individuals
across time and circumstance.[20] Nevertheless, nearly three decades since the MBI was conceived and in the midst
of a surge in burnout research, Kaschka et al called to attention the dangers of the
profligate use of the term “burnout,” the need for the field to develop standardized
diagnostic instruments (as opposed to self-evaluation), and the urgency of greater
study into the prevalence, incidence, and consequences of this burgeoning epidemic.[9]
In the past several years, while much work has contributed to a better understanding
of the prevalence of burnout, still there remains an absence of uniform criteria and
a standardized, validated diagnostic tool for burnout. A recent editorial on burnout
among neurosurgeons described identifying burnout in oneself and among colleagues
as similar to finding “the edge of a cliff in the dark.”[21] The relationship between burnout and depression, for example, continues to evolve:
some groups argue in favor of a model in which burnout is separate from but may contribute
to depression, whereas others insist that burnout and depression are distinguished
only by attribution of the former to a specific domain (i.e., the workplace).[5]
[22]
[23]
[24]
[25] Methodologically, a large and influential study of burnout among U.S. general surgery
residents has received criticism for identifying burnout based on individual MBI subscale
scores rather than a composite one.[2]
[26] Thus quantifying and contextualizing burnout remains a challenge.
Burnout and the “Second Victim”
Burnout and the “Second Victim”
The delivery of health care in the 21st century has been marked by heightened public
attention to medical errors, ushered in by an oft-cited report of the Institute of
Medicine (IOM) in 2000.[27] Increased public scrutiny, however, has done little to quell the frequently profound
effect that adverse patient outcomes have on most physicians and surgeons. In the
same year as the IOM report, Wu offered the concept of the physician as the “second
victim” of medical errors and untoward outcomes. “Although it is often said that ‘doctors
are only human,’” Wu writes, “technological wonders, the apparent precision of laboratory
tests, and innovations that present tangible images of illness have in fact created
an expectation of perfection.”[28] Scott et al later described a postevent, six-stage trajectory of the second victim
comprising[1] chaos and accident response,[2] intrusive reflections,[3] restoring personal integrity,[4] enduring the inquisition,[5] obtaining emotional first aid, and[6] moving on.[29]
Second victims are marked by a sense of personal responsibility for the adverse outcome
in a given patient, from which there emerges a deep sense of guilt and self-doubt
surrounding their knowledge, clinical skills, and career.[29] The consequences of this self-doubt creep into both the personal and professional
lives of physicians; a decrease in job satisfaction, collapse in confidence, and heightened
concerns over professional reputation become increasingly dominant, as do feelings
of anger, embarrassment, and humiliation.[30] Investigations into the incidence of this phenomenon have concluded that anywhere
from 10 to 75% of health care professionals will experience second victim syndrome
(SVS).[31] We direct the interested reader to recent excellent reviews on this topic.[30]
[31]
The relationship between burnout and SVS deserves attention. Surgeons who experience
burnout have reported an increase in the rate of errors committed.[32] As such, burnout has effectively become a risk factor for subsequent SVS and may
contribute to a vicious, feed-forward process marked by a turbulent, often unpredictable
emotional state that further increases medical errors.[30] For surgeons, the perception of having made a major medical error is associated
with a threefold increased risk of suicidal ideation (SI), compounding an otherwise
independent association between burnout and SI.[32]
[33]
To manage SVS, it is imperative to address the possibility of underlying burnout.
A recent study surveyed 126 surgeons across three teaching hospitals of the same university
and identified intraoperative adverse events as occurring anywhere from one (32%)
to more than six (9%) times in a given year.[34] In the wake of these events, 84% of respondents reported emotions on a spectrum
consistent with SVS and affirmed both a fear of litigation and concern for lack of
a standardized reporting system.[34] Given these data and the troubling relationship between burnout and SVS, it is important
to appreciate that administrative support following medical errors may not address
burnout per se, thereby leaving open the potential for ongoing negative effects on
patient outcomes and cost of care.
The Scope of the Problem
In 2001, Campbell et al used the MBI and a study-specific questionnaire to survey
a total of 582 actively practicing surgeons, with 32% reporting high levels of EE,
13% reporting DP, and 4% reporting low LP.[35] Building on these findings a decade later, Shanafelt et al produced a landmark cross-sectional
study of the American College of Surgeons (ACS), in which nearly 8,000 surgeons responded
to surveys comprising the MBI, a depression-screening questionnaire, and a quality
of life (QOL) assessment.[36] Forty percent of these respondents met the study criteria for burnout, defined as
a high score on either the EE or DP subscales. Furthermore, 30% of respondents screened
positive for depression, and 28 and 11% had a significant decrement in the mental
and physical QOL scores, respectively, compared with the mean score for the U.S. population.
Among smaller reports, a study examining burnout among colorectal surgeons in the
United Kingdom National Health Service (NHS) surveyed a total of 253 respondents and,
using the MBI, identified 27% with low PA and 17% with high EE.[37] An MBI-based survey of 259 responding members of the American Society of Transplant
Surgeons found 38% of respondents with high EE, 27% with high DP, and 16% with low
PA scores.[38] A similar MBI-based survey of 549 members of the Society of Surgical Oncology identified
a total of 28% meeting burnout criteria, consistent with a separately reported 36%
prevalence on subset analysis of surgical oncologists from the ACS study.[39]
[40] McCain et al used the Professional Quality of Life Scale V (ProQOL-V) to identify
a 37.2% prevalence of burnout in a survey of 168 responding NHS physicians, of whom
nearly one-quarter were surgeons.[41] A cross-sectional study of nearly 1,000 U.S. practicing surgeons across multiple
specialties responding to a questionnaire identified 26% of respondents at “high risk
of physician burnout” based on a Primary Care Posttraumatic Stress Disorder Screen.[42]
Data collection by way of self-reporting is inherently vulnerable to selection bias.
The respondents to the surveys disseminated in these studies range from 14 to 44%;
clearly, there is a large swathe of the surgeon workforce being missed. It would be
a mistake to equate the decision to not respond to these questionnaires with the absence
of burnout, as published reports have suggested that burnout is associated with a
tendency toward introversion and isolation.[37]
[43]
The implications of these data, notwithstanding the methodological weaknesses and
biases that attend them, are daunting. Recent data from pioneers in the field suggest
that this trend is worsening with time, with one study reporting an overall mean rate
of physician burnout as rising from 46 to 54% between 2011 and 2014.[44] By 2025, a projected deficit of between 45,000 to 90,000 physicians will place added
burden onto an already strained health care system, and general surgery is among those
disciplines that is expected to suffer disproportionately.[45]
[46]
[47] Aside from the myriad personal and professional consequences that befall the practicing
surgeon, which we will review in greater detail in the sections to follow, neither
the medical community nor society on a larger scale can afford the trend toward early
retirement or transition away from clinical practice that has been observed among
those surgeons reporting burnout.[35]
[48]
Workplace Risk Factors
Workplace risk factors for burnout are remarkably consistent across professions. A
recent systematic review and meta-analysis of studies examining the associations between
burnout and work environment across a spectrum of jobs and workplaces concluded that
high demands, low job control, high workload, low reward, and job insecurity increased
the risk of developing EE.[49] Not surprisingly, these associations mirror those that Linzer et al highlighted
in their pioneering work on burnout in primary care physicians: workplace emphasis
on quality, a sense of cohesiveness, trust among staff, alignment of values between
physicians and executives, and a sense of control over the work environment were associated
with lower rates of burnout and higher work satisfaction.[50]
Campbell et al reported that caseload, practice setting, or percent of patients insured
by a health maintenance organization were not associated with burnout in their study;
conversely, the perception that the career was unrewarding and there was a lack of
autonomy or involvement in decision-making were strongly associated.[35] The ACS study reported that area of surgical specialization (specifically trauma
surgeons, urologists, ENT (ear–nose–throat) specialists, vascular surgeons, and general
surgeons), greater number of nights on call per week, greater number of hours worked
per week, greater number of years in practice, and incentive-based pay were associated
with burnout.[36]
[40] Regardless of subspecialty, those surgeons who worked more than 80 hours a week
or had greater than two nights per week on call had the highest reported rates of
burnout.[15] The authors further identified an association between a private practice environment
and burnout, but they pointed out that common risk factors for burnout within either
a private or academic setting included increasing number of hours worked and number
of nights on call per week.[40]
Substantial data exist to implicate the technologies, administrative requirements,
and workplace interactions of the present-day surgical practice in contributing to
burnout. In the recent study of NHS physicians described earlier, 82% of respondents
attributed burnout not only to a combination of excess workload, poor outcomes, and
mistakes, but also to factors such as “constant access to ‘work’” and “the need to
bring clinical administrative work home.”[41] These observations have been validated by other groups. Sinsky et al examined the
office-day time allocation patterns of 57 physicians in four specialties in four states
and identified a 2:1 relationship between time spent on the electronic health record
(EHR) (49.2%) and time spent with a patient (27%); physicians spent up to two additional
hours postclinic for additional EHR or administrative work.[51] In a separate study of similar design, the authors assessed 142 family medicine
physicians and also concluded that time spent on administration and documentation
greatly exceeded that spent with patients.[52] A survey-based study of more than 6,000 responding physicians across all specialties
in the United States reported that the use of computerized physician order entry systems
was associated with a higher risk of burnout.[53]
Personal Risk Factors
The reported risk factors for burnout are not only confined to the workplace but also
include personal and demographic characteristics of the surgeon. Campbell et al identified
younger age and a perceived imbalance between career, family, and personal growth
as individual risk factors.[35] Authors of the 2008 ACS study identified younger age, having a spouse employed outside
the home as a nonphysician health care professional, and youngest child at home of
age <21 years as additional factors (although having children was itself associated
with a lower overall risk).[36]
Perhaps most strikingly, the very character of those who would become physicians may
itself represent a risk factor for the development of burnout. Selflessness, perfectionism,
discipline, perseverance, responsibility, and resilience are coveted qualities among
medical school admissions committees and residency program directors. Meaningful and
longitudinal experiences that speak to an applicants' lifelong commitment to these
ideals are essential. An unforeseen, unfortunate, and likely all-too-common outcome,
however, is an unhealthy sense of self-sacrifice. In a review on the subject, Balch
and Shanafelt write:
Long hours and a lack of control over one's schedule during medical school, residency,
and fellowship may also inculcate surgeons (and physicians from other medical specialties)
with a set of habits that are counterproductive to achieving a balanced and full life
once training is completed … Many physicians seem to believe that they cannot simultaneously
have a fulfilling personal and professional life, and may maintain a strategy that
puts their personal life on hold until they retire or leave the practice of medicine.[15]
As time and energy is poured into the foundation of a surgical career, the same values
that drive excellence in medical school and residency can distract surgeons in training
and practice from their own individual needs. That we often fail to appreciate the
unique relationship between physicians' personal and professional lives is very much
the source of our consternation when we hear the age-old adage, “Physician, heal thyself.”
Personal Consequences of Burnout
Personal Consequences of Burnout
The studies presented have associated burnout with poor dietary choices, lack of physical
activity, and substance abuse, including alcohol, tobacco, and self-prescribed or
illicit drugs.[33]
[37]
[43] The myriad effects of burnout on physical and mental health are summarized in [Fig. 1]. A follow-up report on the 2008 ACS study reported a significant adverse relationship
between all three domains of burnout and symptoms of depression and further identified
an independent association between burnout and SI that was separate from that of depression
and SI.[54] The authors reported a 6.4% rate of SI among surgeons; 60% of those reporting SI
expressed reluctance to seek out mental health resources. These findings are in keeping
with work from other groups that has suggested that nearly half of physicians may
fail to both disclose and seek treatment for mental illness, particularly in the context
of maintaining medical licensure.[55]
[56] A study of SI among surgeons in Italy and Sweden identified a prevalence of 18 and
12%, respectively, and although the authors did not specifically address burnout,
they noted a close association between reported SI and endorsement of recent exhaustion,
disengagement, and adversarial workplace environments.[57]
Fig. 1 Personal and professional consequences of burnout. (Reproduced with permission of
Shanafelt and Noseworthy.[64])
Data examining the longitudinal effects of burnout on friendships, marriages, and
support networks are sparse and often anecdotal. Nevertheless, damage to a surgeon's
personal relationships can further contribute to the aforementioned maladaptive behaviors.
Data support an association between burnout and increasingly tumultuous family lives.[32] An analysis of self-reported behaviors among surgeons with positive burnout scores
suggests a tendency to either keep to oneself or, conversely, lash out at family and
friends.[37] Work–home conflicts, defined as the need to perform both work and personal responsibilities
simultaneously, not only contribute to burnout but also are also likely to be exacerbated
by it.[58]
[59] Additional work is needed to both corroborate and expand on these findings.
Professional Consequences of Burnout
Professional Consequences of Burnout
Surgeon burnout is associated with increased frequency of medical errors and, by extension,
can have detrimental effects on the safety and quality of care provided.[32] Though few studies have examined the impact of career distress and job dissatisfaction
on surgeons' practices in particular, studies of physicians in nonsurgical specialties
have identified associations between these qualities, and medical errors, prescribing
practices, malpractice suits, and poor patient satisfaction scores.[42]
[60]
[61]
[62]
[63] As we have discussed elsewhere, the double impact of burnout in the surgeon who
becomes the “second victim” to these errors can create a scenario in which continued
practice becomes a liability to both the surgeon and workplace. The professional consequences
of burnout are presented in [Fig. 1].
Physicians and surgeons are more likely to seek an exit from clinical practice when
they are burned out, be it in the form of early retirement or transition to an entirely
nonclinical career.[8]
[33]
[35]
[48] Physician turnover is a costly process, with recent estimates placing the price
tag of such an undertaking at more than double a physician's annual salary.[64] It is sobering to consider that those physicians who do not exit practice but continue
to work while shouldering burnout are likely to see their productivity suffer. Aside
from medical errors, one study identified a dose–response relationship between burnout
and decline in full-time work equivalents across 2,000 physicians within the same
organization who were surveyed over a 24-month period.[44] Taken together, the costs associated with medical errors, physician and institutional
liability, physician turnover, and decreased productivity craft a strong economic
argument that should bolster the moral and ethical responsibility to address burnout.
Lessons from the Front Line: Strategies to Reduce Burnout
Lessons from the Front Line: Strategies to Reduce Burnout
The data presented hitherto on surgeon burnout can only beg the question: what now?
With high stakes for both the individual and institution, the past few years have
been witness to a rise in tactics to address and prevent burnout. Collectively, such
strategies begin with awareness. The leadership of multiple societies and professional
bodies, including the National Academy of Medicine, ACS, and Society for Surgery of
the Alimentary Tract, have called attention to the new reality and charged their members
to do the same.[65]
[66]
[67]
While these calls have not gone unanswered, much work remains.
A systematic review and meta-analysis of 15 randomized controlled trials and 37 observational
studies identified several individual and organizational interventions that may provide
meaningful benefit in preventing and reducing physician burnout.[68] These included mindfulness, self-care, or stress-management programs; duty hour
and rotation length restrictions; small group curricula; and communication skills
training. While nearly all studies showed a positive effect on reduction of overall
burnout and, in particular, EE, the authors highlighted the need to further explore
the benefits within individual subgroups of physicians across different specialties
and career stages.
Several studies have identified key interventions that deserve mention, as they are
likely to provide the groundwork upon which additional measures may be developed and
propagated. The opportunity to devote a minimum of 20% of protected time and effort
toward an activity that physicians felt was individually meaningful in light of their
professional goals had a protective effect against burnout among academic faculty
at a single institution.[69] Fassiotto et al recently published encouraging results of a pilot program of career
coaching and time-banking, which acknowledges previously undervalued activities of
academic medical faculty and strives to minimize work–life conflict.[70]
With an eye toward clerical and EHR-related burdens, a small study examined the role
of full-time support staff trained and hired to enter orders and conduct previsit
planning, and identified a nearly 21% increase in work relative value units, self-reported
improvement in focus on patient care, decrease in stress, and decrease in fatigue
among internists.[71] A recent study across 11 outpatient surgical clinics demonstrated improved job satisfaction,
higher work engagement, and less burnout when “relational coordination” was championed
in the workplace.[72] Relational coordination, described as a measure of teamwork in health care, emphasizes
shared goals, accountability, mutual respect, teamwork, and open communication, and
has been associated with heightened work quality and workplace well-being across diverse
professions.[73] Investigators at the Mayo Clinic have embraced a multipronged organizational strategy
that focuses on acknowledging and assessing burnout; developing, implementing, and
measuring the impact of interventions; cultivating a sense of community built on the
principles of relational coordination; and both promoting and enabling work–life balance
and self-care.[64]
Closing Remarks
Tantamount to the noble efforts of the surgical profession to remain at the forefront
of science and service to society is the need to ensure the fitness of surgeons throughout
their professional lives. Research into burnout, its causes, and its detrimental effects
on patients and physicians alike has breathed new life into the importance of this
responsibility, which we cannot ignore any longer. As a group, we must embrace the
“quadruple aim,” sharing an obligation to one another's well-being while remaining
steadfast in our commitment to quality, safety, and the patient experience.[74]
[75]
Those who embark on a career in surgery do not do so with the expectation that the
personal and professional life they inherit will be easy.[76] If anything should be obvious from the literature presented in this study, it is
that the solution to surgeon burnout is more complex than to simply have surgeons
work less. In any profession, master craftsmanship requires constant exposure. To
simply place limits a surgeon's work is not only to take a one-size-fits-all approach
to the issue of burnout but also to risk blunting the skill of the surgical workforce.
Surgery is a unique profession, with unique challenges and unique relationships. We
propose that surgeons take active roles in tailoring solutions that take into account
our unique needs as individuals, and the nuances of our profession. Inasmuch as we
are responsible to our patients, so too must we be responsible to ourselves and to
one another. We must be mindful of factors at the individual, work group, organizational,
and national levels that contribute to burnout and not narrow our focus on time or
remuneration alone. An iteration of this interplay is provided in [Table 1].
Table 1
Drivers of burnout with examples of individual, work unit, organization, and national
factors that influence each driver
|
Drivers of burnout
|
Examples of influential factors across different levels
|
|
Individual
|
Work unit
|
Organizational
|
National
|
|
Workload and job demands
|
Specialty
Practice Location
Practice type
Work–income relationship
|
Expectations
Team structure
Efficiency
Allied health staff
|
Productivity targets
Pattern of compensation
Payer Mix
|
Reimbursement structure
Medicare/Medicaid
Fee-for-service
Bundled payments
Documentation requirements
|
|
Efficiency and resources
|
Experience
Personal efficiency
Organizational skills
Willingness to delegate
Ability to say “no”
|
Support staff
Scribes
Team huddles
Allied health staff
|
EHR
Computerized ordering system
Interpretation and application of state/federal regulations
|
E-prescribing
Medication reconciliation requirements
Federal mandates for EHR
Certification agencies
Precertification requirements
|
|
Meaning in work
|
Knowing what is personally meaningful
Doing what is personally meaningful
Shaping career to match interests
Doctor-patient relationships
Recognizing positive events
|
Matching talents and interests
Education
Research
Leadership
|
Organizational culture
Practice environment
Professional development opportunities
|
Supervisory role of physicians and potential for less contact with patients
Declining funds for education and research
Clerical work burden
|
|
Culture and values
|
Altruism
Moral compass
Commitment to an organization
|
Behavior of leadership
Availability space, rooms
Equity/fairness
|
Organizational mission
Organization values
Communication
Just culture
|
Coverage for uninsured
Remuneration structure: what is rewarded?
Regulations
|
|
Control and flexibility
|
Personality
Assertiveness
Intentionality
|
Control of physician calendars
Clinic hours
Vacation time
Call schedules
|
Scheduling systems
Referral pattern oversight and restrictions
Role and implementation of “practice guidelines”
|
Precertification requirements
Restrictive insurance networks
Practice guidelines
|
|
Social support
|
Personality
Length of service
Relationship-building skills
|
Collegiality
Physical configuration
Social gatherings
|
Collegiality
Physicians' lounge
Community-building strategies, events
|
Role of medical specialty societies in building community, championing members
|
|
Work–life balance
|
Priorities and values
Spouse/partners
Children/
dependents
Health issues
|
Call schedule, including vacations and weekends
Expectations
Role models
|
Vacation policies
Sick/medical leave
Short-term disability
Part-time work
Flexible scheduling
Role models
|
Maintenance of certification
Licensure
Clerical work burden
|
Abbreviation: EHR, electronic health record.
Source: adapted with permission of Shanafelt and Noseworthy.[64]
Progress is being made to improve on the status quo within this generation and for
the next, not in the least by way of elevating burnout research from a science in
its infancy to a fundamental tool with which to continually evaluate and improve the
dynamic between the worker and the workplace. As this field develops, longitudinal
measures of efforts to address and mitigate the risk factors for burnout will help
usher in a period of improved satisfaction and productivity. Above all else, surgery
must remain, in the best sense of the word, a human endeavor.
