Among the 221 survey starts, 171 respondents (77.4%) completed one or more of the substance use questions (Table 6). Only 3.5% chose the option “prefer not to answer,” and about 18% reported no nonmedical drug use during their lifetime. When asked about lifetime use, nearly one-quarter admitted to using tobacco and more than three-quarters admitted to using alcohol. We also asked about the frequency, within the last year, of substance use for stress management. Possible answers were “never,” “occasionally,” “frequently (once or twice a week),” and “daily.” To this question, 6% of respondents admitted daily substance use, 10% described frequent use, and almost 25% reported occasional use.
The adjusted associations between burnout constructs (MBI-HSS) and components of the SF-12, SSPC-14, substance use, and participant demographics are summarized in Table 1. Males had higher levels of DP, LPA, and total burnout and, relative to attending physicians, residents had higher DP. The MCS of the SF-12 was significantly associated with all 3 aspects of burnout, as well as with the total burnout score. The SF-12’s PCS was associated with EE, LPA, and total burnout score but not with DP (P = .08). In each case, unfavorable SF-12 scores were associated with unfavorable burnout scores.
Stronger personal and professional support scores from the SSPC-14 were associated with decreased levels of EE (Table 1), but work satisfaction was not associated with decreased levels of DP. Personal support, professional support, and work satisfaction were each associated with perceived LPA, but not in a consistent direction. The association of overall burnout score with work satisfaction (P = .06) and professional support (P = .08) failed to reach statistical significance. The association of alcohol use with decreased LPA was likewise near the threshold for statistical significance. Thus, there was no significant evidence of associations between burnout and alcohol, tobacco, or cannabis use.
We compared the results of the SSPC-14 questions in this study to the same 14 questions from our previous study (Figure 2). The differences in mean responses between studies (mean values from the current study minus previous study mean values) were small (<1 point) for 11 of the questions. In 3 questions, however, the difference was greater than 1 point in either direction. Compared with the prior cohort, the ASA webinar-associated respondents were more likely to feel that their job satisfied them economically but also that they had less control at work, and they were more likely to report that their work kept them from friends and family.
Five hundred twenty-eight people answered the Honesty Survey. Most respondents (97.1%) said they would not be offended by such questions, and 73% said they would not be concerned about what would be done with the information. When asked about what safeguards would increase the likelihood of honest answers, anonymity was the most common answer. Similarly, most people said they would answer honestly if anonymity were assured. There was a nearly even split as to whether an opt-out feature would improve participation and a nearly even split as to whether paper or electronic forms assured anonymity more effectively.
We studied 170 people participating in a webinar on the topic of burnout. Subjects were predominantly physicians, 74% male, 83% over 40 years old, and 71% in nonteaching practices. Twenty-six to 59% of the respondents had a Maslach score—EE, DP, or LPA—suggestive of burnout, but only 15% had all 3. All burnout scores were independently associated with the SF-12 MCS, while only EE and LPA were associated with the SF-12 PCS. Burnout scores were associated with some elements of the SSPC-14, but there was no evidence of association between burnout scores and alcohol, cannabis, or tobacco use.
Each person has the required elements to develop burnout since, to some degree, we all have a certain amount of EE, DP, and LPA. Most people have occasional imbalance from either personal or situational characteristics (or both) but are still able to cope. For the remainder, if these situational and personal characteristics get out of balance with their life and work, they are unable to cope, they become disengaged, and burnout results (Figure 3). Certain people at increased risk for burnout include those who are younger, highly educated, unmarried, with high expectations and low self-esteem.7,8,17,26 Previously, we found that residents had more risk characteristics than did attending physicians or nurses,7,8,17 but even mature physicians12 and department chairs10,27,28 are not immune. In addition, not all specialists have the same risk of burnout; interspecialty variation in the incidence of burnout is common among physicians.17
The gender effect on burnout has been reported but is not firmly established. Balch et al9 reported male surgeons were at lower risk for burnout than their female colleagues. However, not all studies have found females to be at higher risk. We previously reported no gender association with burnout in a cross-section of perioperative providers.17 Completely different results were found by Merlani et al,29 who found that being male was associated with a high risk of burnout in intensive care unit providers. Our present results are most like Merlani’s in that males had a greater risk for DP, LPA, and total burnout score, but not for EE. Each of these studies has a good distribution of men and women, but each study is looking at a different set of influences on its specific cohort. Perhaps gender alone is not an independent risk factor for the development of burnout. Perhaps there is some other confounding interaction. Until future studies examine and clarify these questions, it would be prudent not to make any generalizations about gender effects on burnout.
Some have suggested30–32 that illness-related absences are common in burned out employees. A review by Kuhn and Flanagan,33 looking at literature back to 1986 dealing with the topic of burnout, depression, and suicide, suggests that the incidence of all these findings is on the rise. The number of publications dealing with physician mental health topics, in either the lay or the professional press, would seem to confirm that observation. We know of no previous studies that directly measure the associations between burnout indices and the MCS or PCS of the SF-12. With the exception of DP, we found that poor MCS and PCS health were independently associated with greater burnout risk in each MBI-HSS category. While these data do not establish whether the incidence is changing or which came first, they do suggest that burnout, physical problems, and mental health problems likely coexist and could affect overall health-related quality of life. Although it is reasonable to expect that certain aspects of burnout (particularly EE) would overlap with depression, further work is necessary to confirm these findings. In Maslach et al’s8 words, “…there are important distinctions between ‘burnout’ and ‘depression.’ Depression is a clinical syndrome, whereas, burnout describes a crisis in one’s relationship with work.”
There were few overarching trends associating SSPC with individual burnout elements (EE, DP, LPA), but we did observe a relationship with total burnout score. To tease more information from our results, we compared them with those of our 2011 study,17 where we utilized SSPC and MBI-HSS to evaluate providers from a single surgical unit. Compared to that study, more respondents felt economically satisfied, but at the same time, they felt less in control of their daily work. They also felt their jobs kept them from family and friends, that is, work-life imbalance.
In this light, it is strange that the same group felt less in control and had a less favorable work–life balance. Demographics again help explain this finding. There are only 2 nurses in the current study, whereas 63 (43%) of respondents in the prior study were nurses or nurse anesthetists. Nurses generally were better off in the areas of burnout, social support, and personal coping than were physicians.17 In most hospitals, whether teaching or community-based, nurses are for the most part removed from the stressful business aspects of patient care. Physicians, particularly in community settings, are often faced with nonpatient-related administrative duties and workforce demands33 and are thus susceptible to the uncertainties and lack of control that cause stress.12 While many anesthesia groups have been acquired by large management companies, many remain independent. The leaders of these independent groups remain responsible for the fiscal well-being of these practices. We cannot say with certainty whether being in a teaching or community hospital would change the incidence of burnout and stress for anesthesiologists, but it has been shown that private practice surgeons have more burnout than do academic surgeons.9
Substance use in physicians is not new,35 but identifying precipitating factors can help with understanding the problem and creating interventions. O’Connor and Spickard36 think it reasonable that substance use habits of practicing physicians are based on “behaviors during and before medical training.” In 1988, Juntunen et al16 studied alcohol consumption habits of Finnish doctors and reported that they drank more than the general population and that their drinking was associated with burnout. Unfortunately, they did not use a specific burnout measuring tool to reach this conclusion. Studies of physician substance abuse are fraught with problems of bias, and underreporting maybe more common than overreporting. Brooke et al15 point out that the stigma associated with addiction “forms a barrier” that prevents physicians from getting necessary help, as well as potentially biasing study results. We were unable to detect a relationship between substance use (tobacco, cannabis, alcohol) and any element of burnout after adjusting for other factors, although the association between alcohol use and LPA was near the threshold of statistical significance (P = .06; see Table 1). However, there is substantial statistical uncertainty regarding substance use, and our findings do not exclude the possibility of association with burnout (eg, the upper 95% confidence limit for the effect of tobacco use on total burnout is larger than the estimated effect of gender).
As with all survey-based studies, the results are biased. Participants were initially recruited because of an a priori interest in burnout and the burnout webinar, but we do not know why they were interested in the topic. Regardless of participants’ reasons for opting in or out of the survey, the final cohort is demographically similar to ASA-attending members, albeit somewhat older (see Table 2).
We also tried to maximize response to potentially “more sensitive” questions (ie, questions on substance usage), primarily by placing them at the end of the survey and providing assurances of anonymity.19,37 The percentage of participants completing all survey questions was nearly 77%, more than twice the response rate of some other studies.9 Although 96.5% of respondents answered the substance use questions, we wondered whether they answered them with the same honesty as with the remainder. In our short Honesty Survey, we found that most people would answer honestly if anonymity were assured. There was a nearly even split as to whether a “prefer not to answer” option improved participation or whether paper or electronic forms more effectively assured anonymity. We feel confident that people answered all questions honestly.
Studies on effectively identifying burned out individuals remain necessary; however, studies describing effective treatment options are also needed.33 A Cochrane database review, published in 2014, looked at controlled trials up to November 2013 on the subject of treating job-related stress in health care professionals.38 Of thousands of studies, only 58 studies met the inclusion criteria for the review, and even in these, the evidence was of low quality at best. Future studies will need to confirm the salutary effects of such things as personal and professional support and coping so that special treatments with measurable outcomes can be developed.
Despite the critical need for research on therapy, there is still a need for studies of burnout itself. For example, how does burnout compare across practice types (eg, fee-for-service versus salaried, academic practice versus private practice)? Are there regional and national trends in burnout incidence? Does a fellowship or a subspecialty practice change the risk of burnout? How does burnout in anesthesia providers compare with burnout in other health care providers (including both physician and nursing specialties)? What is the definitive answer on the effects of gender on burnout? These studies are necessary to identify groups most in need of help so that necessary resources are utilized in the best places to do the most good.
Because burnout tends to affect younger people more,7,8 and residents were underrepresented compared to the ASA-attending membership, the actual risk of burnout may be higher. Even though a large number still exhibit one or more high-risk characteristics, anesthesiologists as a group may have a lower risk of burnout than some other medical specialists.17 The burned-out individual is likely to have physical or mental health issues or both. Although mostly economically satisfied, these participants felt less in control at work and felt work kept them away from friends or family. We were unable to detect a relationship between burnout and substance abuse with the questions we asked. However, the continued inclusion of questions of this type—perhaps a different questionnaire—may be of importance in identifying potential at-risk groups.
Name: Steve Alan Hyman, MD.
Contribution: This author helped in literature search, design the study, collect the data, analyze and interpret the data, and write and edit the manuscript.
Name: Matthew S. Shotwell, PhD.
Contribution: This author helped design the study, analyze and interpret the data and figures, and write and edit the manuscript.
Name: Damon R. Michaels, MMHC, BS.
Contribution: This author helped design the study, collect the data, and edit the manuscript.
Name: Xue Han, MPH, MS.
Contribution: This author helped analyze and interpret the data and figures.
Name: Elizabeth Borg Card, MSN, APN, FNP-BC, CPAN, CCRP.
Contribution: This author helped design the study, collect and interpret the data, and write and edit the manuscript.
Name: Jennifer L. Morse, MS.
Contribution: This author helped collect and analyze the data.
Name: Matthew B. Weinger, MD.
Contribution: This author helped design the study and edit the manuscript.
This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.
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