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Do No Harm, Except Unto Thyself

Meese, Katherine A. MPH; Borkowski, Nancy M. DBA

doi: 10.1213/ANE.0000000000002517
Editorials: Editorial
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From the University of Alabama at Birmingham, Birmingham, Alabama.

Accepted for publication August 29, 2017.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Katherine A. Meese, MPH, University of Alabama at Birmingham, School of Health Professions, Department of Health Services Administration, 1705 University Blvd, SHP 5 Birmingham, AL 35294. Address e-mail to kameese@uab.edu.

We applaud the authors of “A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, And Social Support of Anesthesiologists”1 for advancing the empirical research on physician burnout specifically related to the practice of anesthesiology. In a follow-up to a previous study,2 Hyman et al1 examine the variants of burnout as well as its relationship with reported substance use among clinicians in the field of anesthesiology. The study included 221 respondents to a survey offered to participants after viewing an online webinar regarding burnout. Since voluntary participation with survey-based studies may lend itself to potential selection bias, readers should take this into consideration when reviewing the researchers’ findings. The researchers did report that this study’s participants were demographically similar to the American Society of Anesthesiologists membership.

The study examined associations among burnout, substance use, physical and mental health, and external factors such as work satisfaction, workload and control, professional support, and personal support. The investigators found higher levels of depersonalization, emotional exhaustion, and depression as compared to published controls. The relationship between burnout and substance abuse failed to reach significance. The authors’ narrow definition of substance abuse, including only tobacco, cannabis, and alcohol, may have contributed to the lack of significance in this relationship. While previous studies have shown similar rates of recreational substance abuse among anesthesiologists relative to other specialties,3 rates of opiate use have been found to be higher.3,4

Although the survey was conducted in 2011, the results resemble those of recent studies conducted by NEJM Catalyst5 and Shanafelt et al.6 Bottom-line, physician burnout is a serious issue across the health care industry and in the field of anesthesiology specifically.

Though the problem of burnout has received growing attention in recent years, many opportunities remain to better understand the phenomenon and to implement changes throughout the industry to better support clinicians. The health care community cannot ignore the problems of physician burnout, depression, anxiety, and suicide. Suicide rates have been found to be 1.4–2.27 times higher among physicians compared to the general population for men and women, respectively.7 This has resulted in estimates of more than 300 suicides per year,8 which equates to roughly 2 full medical school classes!9 More specifically, anesthesiologists have been found to be at increased risk for suicide and drug-related deaths compared to internists.10

Hyman et al1 identified numerous factors contributing to burnout, including both intrinsic and environmental factors. The authors’ findings highlight that burnout is a problem across all levels and ages of physicians.1 However, they also note that residents had higher rates of depersonalization than attending anesthesiologists. This observation is consistent with an earlier study that showed that burnout is highest among resident physicians.2 Evidence of burnout in the early stages of a physician’s career may be related to continued and/or accelerated burnout through the physician’s various career stages. An extension of early work on burnout noted that the condition typically occurs in phases, with emotional exhaustion occurring in later phases.11,12 The authors noted in the current article that residents had higher rates of depersonalization relative to attending physicians.1 This phased model suggests that intervention in the early stage of depersonalization represents an important opportunity to reduce the likelihood of progression to the more advanced stage of emotional exhaustion.

The data suggest that early signs of burnout begin in residency, which may have negative repercussions throughout the various stages of a physician’s career. For example, 28% of residents experience a major depressive episode during their medical training, which far supersedes the 7%–8% incidence noted in the general population for the same age group.13 A large multisite study of 740 residents found that individuals meeting the criteria for depression increased from 3.9% before internship to 25.7% during internship.14 A similar study of 47 interns before the start of internship and at the end of the year found that the prevalence of chronic sleep deprivation, depression, and burnout had increased drastically over the course of the year. Interns experiencing moderate depression increased from 4.3% to 29.8% over the course of the year, and the rates of high-level burnout increased from 4.3% before intern year to 55.3%.15

While some residents may be predisposed to depression (an intrinsic factor), the roles of the work environment and stresses of medical training (extrinsic factors) cannot be ignored when studying burnout.

The working environment of residents includes grueling hours, little consideration of personal needs, and pressure to work despite being physically ill, even when that work entails caring for compromised patients (such as those in the intensive care unit). It is rare to find organizational policies that support even minimal family leave for the birth or sickness of children or other family emergencies, and scheduling often requires nights, weekends, and major holidays to be missed. Residents are often managed by one or several “chief residents” who often have never held a management position, are not compensated for their additional duties, have no formal management training, and may be unfamiliar with the organization’s human resource practices and policies.

Hyman et al1 have drawn attention to the role the work environment plays in burnout. Their observations reinforce decades of management and leadership research that suggests that poor supervision and working conditions can lead to dissatisfaction and high employee turnover.16–19 If an employee is dissatisfied in their current job situation, they generally consider alternatives and eventually leave for a different position, employer, or industry, if those alternatives are viable.18 Both real and perceived barriers exist for residents identifying viable alternatives and leaving their current jobs. Sixty percent of residents have medical school debt burdens over $100,000 and 40% have accrued over $200,000 in medical school debt.20 Finding career opportunities outside of medicine to service this debt in a reasonable timeframe could be challenging. Relative to their peers, residents and early career physicians often have less experience with searching and interviewing for jobs, negotiating salaries, or selling their skillsets to potential employers in different industries and roles. Thus, they may be hindered in their abilities to think creatively about how their medical training could be used in a career beyond clinical medicine. These real and perceived barriers may lead to increased burnout if leaving the profession is not an option.

Additionally, turnover is worsened by perceptions of inequity among workers whose jobs or responsibilities may be similar.21,22 Consider the case of anesthesiology residents and nurse anesthetists. Residents often have similar or greater training and experience than a midlevel provider and perform similar job functions, yet experience a large discrepancy in pay and benefits. This can increase job dissatisfaction, as reflected in a quote from a recent national resident survey: “We’re better trained than NPs and PA’s, yet we make half their salaries.”20 This inequality is magnified when residents are ineligible for many of the benefits offered to other full-time hospital employees. Residents are often excluded from programs and benefits aimed at employee recruitment, retention, and satisfaction, which may be a result of moral hazard. Moral hazard occurs when one party makes a decision to take on risk, but another party bears the cost of that decision.23 The hospital has invested scarce resources in recruiting, training, developing, and retaining its other employees. However, for residents, the majority of a resident’s salary and fringe benefits are funded by the federal government.24 Therefore, the hospital does not bear the full cost of this “employee,” and thus may economically value their time and well-being less. The same type of comparisons may be made outside the field of medicine among a residents’ peers who chose jobs in other fields such as engineering or finance. One surveyed resident remarked, “People in other professions with comparable education and experience make significantly more [money].”20

With these work-related challenges along with extensive debt20 coupled with the daily mental and emotional stressors of dealing with human suffering, critical decisions, and death, it is not difficult to imagine many who would not struggle with anxiety or depression, especially if trying to juggle a marriage, family, sick parent, or any other stressors in their personal lives. So why do residents and practicing physicians fail to get the help they need to properly treat and address their mental health? One of the main reasons cited is stigma and fear of professional repercussions.25 We suspect that it is this same fear of repercussion that might also potentially lead to underreporting and treatment of substance use. This may have also contributed to the lack of significant findings by Hyman et al1 regarding the relationship between burnout and substance use. Therefore, these findings should be interpreted with caution. There very well may be an association between burnout and substance use but that the relationship may be undetectable due to inaccurate self-reporting.

In 40 states, the reporting of treatment or diagnosis of anxiety, depression, or impairment due to mental illness is required during the medical licensure process. Additionally, in some states, questions are asked regarding any past diagnoses or treatment of mental illness throughout the course of their lifetime, whether or not the physician is currently affected by the illness.26 The purpose of these disclosures is intended to protect the public by preventing people in high-risk occupations from operating while impaired. Yet, what is more impaired? Getting proper counseling and medical treatment for managing the condition, or avoiding help to continue practicing medicine without fear of losing his/her license? We ask those who vow to do no harm, to do harm unto themselves by forgoing proper treatment, or to their integrity by lying to avoid repercussions.

What can be done to alleviate these problems? First, we echo the suggestion of the American Medical Association by urging state licensure bodies to reduce the risk to physicians for seeking diagnosis and treatment by eliminating questions about past mental illness.27 Second, major changes are needed in the work environments we create for medical providers at each stage of their careers. Researchers have called for interventions including mindfulness training, cognitive behavioral therapy, and exercise programs to reduce burnout among anesthesiologists.28 However, asking clinicians to take personal responsibility for improving or avoiding their own burnout through personal resilience or coping strategies without accompanying environmental changes does a disservice by shifting blame from the organization to the individual. The role of the environment should not be underestimated. Hyman et al1 found that lower burnout scores were associated with both work satisfaction and professional support. This supports prior research that suggests that changes in the work environment hold promise for reducing the problem of burnout. Supportive human resource practices and perceived organizational support have been shown to reduce turnover.29 Improvements in the work environment have been found to significantly reduce burnout among clinicians.30 Similarly, a review of 25 burnout prevention programs found that 80% of programs resulted in a reduction in reported levels of burnout after the intervention. Interventions that included both organization- and person-directed efforts had more enduring effects on burnout.31 It is incumbent on clinical leaders and health administrators to create a supportive environment that has been shown to reduce burnout by acknowledging weaknesses in their current environment and implementing such programs and practices.

There is a physician shortage in the United States, which is expected to worsen in future years. Total shortfalls are expected to reach between roughly 60,000 and 90,000 physicians by 2025, and current shortfalls are estimated in the tens of thousands.32 Physicians are highly trained, highly skilled, and valuable resources for society that cannot be easily replaced. Attrition of 1 US-trained physician from the field takes 12 years or more to develop considering required education and residency. Even the strategy of replacing a US-trained physician with a foreign-trained physician will often take 3 or more years for completing an additional US-based residency. We need to view physicians as rare and precious resources, starting in residency, and give them the skilled management, effective leadership, and working conditions they deserve.

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DISCLOSURES

Name: Katherine A. Meese, MPH.

Contribution: This author helped create the initial draft, conduct the background research, and revise the manuscript.

Name: Nancy M. Borkowski, DBA.

Contribution: This author helped with the original article concept and major manuscript revisions.

This manuscript was handled by: Thomas R. Vetter, MD, MPH.

Acting EIC on final acceptance: Thomas R. Vetter, MD, MPH.

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