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Editor’s Spotlight/Take 5: What Is the Prevalence of Burnout, Depression, and Substance Use Among Orthopaedic Surgery Residents and What Are the Risk Factors? A Collaborative Orthopaedic Educational Research Group Survey Study

Leopold, Seth S. MD

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Clinical Orthopaedics and Related Research: August 2020 - Volume 478 - Issue 8 - p 1706-1708
doi: 10.1097/CORR.0000000000001366

As the editor of a large journal, sometimes I wonder if readers have reached saturation on the topic of burnout; we have covered it extensively here at Clinical Orthopaedics and Related Research®, including on the editorial page both explicitly [7] and implicitly [9], as well as in columns [6], and in the original research papers we’ve published [4]. Other professional media have done likewise [10] as has the lay press [5]. An article on burnout even was the required reading for this year’s American Board of Orthopaedic Surgery web-based recertification exam [1].

For these reasons and others, and as important as the topic is, I’m sensitive when our reviewers and even some readers have suggested that they’re “burned out on burnout.”

And then a paper comes along that shakes even the most jaded reader (or editor) to attention. This month’s Editor’s Spotlight/Take 5 features a survey study from The Collaborative Orthopaedic Educational Research group [8], which found that more than half of orthopaedic residents meet validated criteria for burnout, and more than one in eight screens positive for depression.

Perhaps like you, I am skeptical of survey data, since not everyone responds to surveys, and those who do may be motivated to tell a particular story. But in this paper, the response percentage was so high that even if all of the survey’s nonresponders sprung out of bed and hurried to work at the hospital every morning sporting an ear-to-ear grin, the proportion of burned-out residents would still approach one in three.

Even more troublingly, more than six in 10 residents in this large survey reported hazardous alcohol use on a validated survey instrument [2, 3].

Burned out on survey statistics, are you? That’s OK, as long as you don’t ignore perhaps the most-important finding of all: Many of the factors associated with burnout, alcohol abuse, or depression that the authors identified in this study are potentially modifiable by our training programs, including the inability for residents to attend health maintenance appointments, lack of exercise, lack of sleep, and lack of support from the program and other trainees. For that reason, this study is a must-read for trainees, faculty, and anyone who cares about the future of our specialty or the people who practice it.

Please join me as I go behind the discovery with lead author Paul Lichstein MD on topics like association versus causation in surveys like this, what to do about the shocking finding frequency of alcohol abuse the authors identified, and some real-world-practical approaches that programs can use to mitigate some very-resistant problems.

Take 5 Interview with Paul Lichstein MD, lead author of “What Is the Prevalence of Burnout, Depression, and Substance Use Among Orthopaedic Surgery Residents and What Are the Risk Factors? A Collaborative Orthopaedic Educational Research Group Survey Study”

Seth S. Leopold MD:Your study’s message is important because it is actionable. Your study group includes leaders at dozens of programs. What specific steps have members of your study group taken to make their programs more humane based on what you learned in this paper, and how will you know if they worked?

Paul Lichstein MD: I think members of the study group and other orthopaedic surgeons and educators who have reviewed the data are all still taking in the troubling findings. They are overwhelming. Not only are burnout and compromised well-being extremely common, but alcohol use also is staggering, and resources to maintain wellness are not being fully utilized. All the same, there is some reason to be encouraged both at the national and at the individual-program level. The study’s results have elevated the visibility and urgency of these problems within the large, collaborative group of program leaders that organized it, and they have started a follow-up study on alcohol use among orthopaedic residents. At the program level, many program directors have had meaningful discussions with their residents about what we found, and have asked residents what they feel would help meet their needs. One of the more salient findings was a potential disconnect between educators and trainees. The training paradigm of today is so different from that in previous generations, especially with the incorporation of technology and ever-evolving specialized treatments. However, I hope that what we learned is that the most readily available and reliable resource in combatting these issues may be the residents themselves, and that we need only listen to them.

Dr. Leopold:Perhaps the greatest immediate threat to resident (and patient) health were your findings about alcohol abuse, which I found frankly alarming. Apart from vigilance, what, specifically do our training programs need to do about this?

Dr. Lichstein: This was the most-alarming and perhaps the most-surprising finding from our study. What also was surprising was the lack of an apparent association between alcohol use and burnout, indicating perhaps an even more insidious issue. Given the immediacy of the problem, vigilance alone is insufficient. Again, this is something that needs to be addressed at the program-specific level. There need to be some honest and open conversations about alcohol use and its implications for programs, trainees, and patients. Anecdotally, programs have begun shifting away from alcohol at social events, journal clubs, and other gatherings. An example of a program-specific intervention would be the creation of a Wellness Committee at Stanford Medical School, to help assess, guide, and advocate for individuals facing issues with wellness.

Dr. Leopold:I was struck by how often residents cited “lack of co-resident support” in association with burnout. It seems to me that this is as likely to be a symptom as a cause; as importantly, I wondered whether a program really can influence how residents treat one another. How did you interpret that finding, and what do you think we should do with it?

Dr. Lichstein: You make a shrewd observation regarding the dynamic of “co-resident support” and I think it opens up one of the more-nuanced aspects of our study. It needs more investigation. We interpreted this finding from the perspective of a mentoring relationship. While the traditional mentorship model—that of experienced physician and trainee—gets most of the attention, an important bond forms amongst trainees journeying through a shared experience and maturing over the course of their education. While this bond can be nurturing, it also can be destructive, so we tried to incorporate some mention of this into our study. Certainly, programs cannot demand that all residents practice universal altruism and be best friends. However, I think your question may underestimate the influence that strong educational leaders can have upon trainees in cultivating an environment of peer support. Trainees look to their mentors as guides in their own mentoring amongst themselves. We can choose to encourage trainees to support one another through challenges, or model indifference and disinterest.

Dr. Leopold:It seems crass to ask the cost question, but you know that readers are thinking about it. Sure, we might be able to improve resident wellness by making programs much, much gentler; we also could decrease freeway deaths by placing a governor on every car engine that keeps vehicles from driving faster than 30 miles per hour. We don’t do either because of the costs. With resident education, those costs are measured in many ways—dollars, to be sure, is one—but some interventions of this sort would even be protested by trainees (for example, fewer hours/year but more years). Humanity versus cost: Where is the balance point?

Dr. Lichstein: This is a timely question indeed. I believe by the time CORR® publishes both our study and this interview, we still will be amidst what might be the largest healthcare crisis of the modern era. I think analogies sometimes can be slippery slopes, but I’ll venture to discuss the issue of cost/benefit within this context. We have been faced with the gut-wrenching decision to close economies and borders at an unimaginable scale and financial cost to avoid a likewise-unimaginable cost to life. In keeping with the analogy, this has not been met with universal acceptance. It is painful, inequitable, and sometimes intolerable. However, what appears undeniable is that sweeping actions do generate sweeping results. Residents are plagued by burnout and it has been shown this permeates from the training years well into practice. The most-worrisome endpoint is the shockingly high rate of physician suicide and suicidal ideation. The problem has clearly surpassed the balance point, reaching an unacceptable boiling point, which necessitates we collectively resolve to flatten the curve so to speak.

Dr. Leopold:Among the major factors that you identified as modifiable, which ones surprised you the most and why?

Dr. Lichstein: The lack of program support and education on burnout, and the inability to attend health-maintenance appointments were two of the more-surprising findings. We did not anticipate these being such universal factors contributing to the burnout domains given current Accreditation Council for Graduate Medical Education curriculum mandates. This finding may reflect sentiments of resentment on behalf of the survey responders, or, a more-concerning neglect at the level of residency programs. If more than 50% of patients experienced a potentially life-threatening complication, immediate scrutiny would ensue. Panels of experts would convene to review all aspects of care to determine what factors might be modified to guard against this complication. Our valued trainees are experiencing a similar complication and it was surprising to find training programs appear to be failing in their support.

Paul Lichstein MD

References

1. The American Board of Orthoapedic Surgery. Web-based longitudinal assessment (ABOS WLA) 2020 knowledge sources. Available at: https://www.abos.org/wp-content/uploads/2020/03/ABOS-WLA-Final-Knowledge-Sources-2020-FINALv2020_3_31.pdf. Accessed April 21, 2020.
2. Bradley KA, Boyd-Wickizer J, Powell SH, Burman ML. Alcohol screening questionnaires in women: a critical review. JAMA. 1998;280:166-171.
3. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. Ambulatory Care Quality Improvement Project (ACQUIP). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158:1789-1795.
4. Dandu N, Zmistowski B, Chen AF, Chapman T, Howley M. How are electronic health records associated with provider productivity and billing in orthopaedic surgery? Clin Orthop Relat Res. 2019;477:2443-2451.
5. Grant A. Burnout isn’t just in your head. it’s in your circumstances. Available at:https://www.nytimes.com/2020/03/19/smarter-living/coronavirus-emotional-support.html. Accessed April 21, 2020.
6. Kelly JD IV. Your Best Life: What motivates you? Clin Orthop Relat Res. 2019;477:509-511.
7. Leopold SS. Editorial: What do you say when a patient says thank you? Clin Orthop Relat Res. 2019;477:1763-1764.
8. Lichstein PM, He JK, Estok D, Prather JC, Dyer GS, Ponce BA, and the Collaborative Orthopaedic Educational Research Group. What is the prevalence of burnout, depression, and substance use among orthopaedic surgery residents and what are the risk factors? A Collaborative Orthopaedic Educational Research Group survey study. Clin Orthop Relat Res. [Published online ahead of print]. DOI: 10.1097/CORR.0000000000001310.
9. Ring D, Leopold SS. Editorial: The sacredness of surgery. Clin Orthop Relat Res. 2019;477:1257-1261.
10. Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. StatNews. July 26, 2018. Available at: https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed April 21, 2020.
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