Occupational burnout is a syndrome consisting of three elements: emotional exhaustion, depersonalization (ie, a detached, cynical view of patients and colleagues), and a perceived lack of personal accomplishment.1,2 The term has been used since the early 1970s, when researchers began examining the effects of emotional stress on behavior and professionalism among caregivers and human services workers.2 During these early investigations, burnout negatively affected clients and colleagues, decreased productivity, and impeded personal fulfillment.2 Workshops at individual and organizational levels were instituted to reduce the occurrence of burnout, although interventions at the individual level yielded mixed results.2
The medical field produces some of the most stressful and demanding human service occupations; therefore, a substantial amount of burnout research has focused on physicians. Extensive studies of surgeons3,4 and nonsurgeons5 have been performed. In a recent national study of 7,288 physicians in the United States, Shanafelt et al5 found that physicians experienced a significantly higher incidence of burnout symptoms than did workers from the general population (37.9% versus 27.8%, respectively). In addition, the authors noted that 45.8% of physicians reported at least one symptom of burnout. Because these symptoms are so common3,6,7 and because burnout has been shown to decrease the quality of patient care through increased medical errors8 and depersonalization,9,10 it is clear that prevention and treatment measures would be valuable to physicians and the US healthcare system.
Burnout in Orthopaedic Surgeons
Shanafelt et al5 found that nearly half of orthopaedic surgeons experienced symptoms of burnout—slightly less than physicians in emergency medicine, general internal medicine, and family medicine subspecialties. This finding is consistent with several studies in the orthopaedic literature that have examined burnout symptoms in practicing surgeons, academic leaders, and trainees around the world.11-13 These studies have reported burnout rates of 40% to 60%.11-13
In a study of burnout in orthopaedic surgeons and general practitioners in Belgrade, Lesić et al14 found no difference in the rates of emotional exhaustion (70%). These results suggest that orthopaedic surgeons and primary care physicians have similar rates of burnout in some practice environments. The study also found higher rates of depersonalization in orthopaedic surgeons than in general practitioners, although general practitioners had lower rates of personal accomplishment.
Several studies have noted that surgeons, faculty leaders, and trainees suffer different types of burnout at various rates; therefore, those roles must be investigated independently12,15,16 (Table 1). Among practicing surgeons and faculty members, burnout is marked by high levels of emotional exhaustion and depersonalization, whereas feelings of personal achievement are often preserved. This pattern is consistent in several studies in the literature.12,14,17 Orthopaedic faculty leaders, such as department chairpersons and chiefs, also exhibit this pattern of burnout, but they experience higher rates of emotional exhaustion. Saleh et al13 found that 38% of orthopaedic department chairs scored in the highest range of emotional exhaustion, and Sargent et al12 reported high levels of burnout in 28% of orthopaedic faculty. In an earlier study of 195 academic orthopaedic department leaders, Saleh et al16 found that residency program directors suffered the highest rates of exhaustion, with 52% of respondents scoring in the highest range.
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Table 1: Summary of Burnout Studies Specific to Orthopaedic Surgeons
Sargent et al12 analyzed burnout rates in orthopaedic faculty and found that the rates vary depending on surgeon and program status. Young academic surgeons practicing <10 years reported notably higher rates of emotional exhaustion and depersonalization than did those who had been practicing longer. These results are consistent with findings in an earlier study of practicing surgeons in all specialties.19 It is possible that younger orthopaedic surgeons in private practice are similarly affected. Although the reason for higher rates of burnout in younger surgeons remains unclear, it is likely that older surgeons have broader perspectives and superior coping mechanisms. Sargent et al12 hypothesized that attrition in the field may play a role, as well. The authors found that faculty who work in larger programs are more likely to display symptoms of loneliness and increased irritability, which may reflect increased stress in high-volume tertiary referral centers.
In contrast to practicing surgeons, faculty, and faculty leaders, orthopaedic trainees report high levels of emotional exhaustion, very high levels of depersonalization, and feelings of low personal accomplishment. Using the Maslach Burnout Inventory (MBI), the 12-Item General Health Questionnaire, and the Revised Dyadic Adjustment Scale, Sargent et al12 surveyed 384 US orthopaedic trainees and 264 faculty members and found that 56% of residents scored at the highest level of detachment compared with only 24.8% of faculty. These findings are similar to those reported by Barrack et al20 in a study on burnout before and after resident work-hour restrictions were implemented. The authors noted that resident scores for emotional exhaustion and depersonalization were elevated prior to implementation of work-hour restrictions, with associated low scores for perceived personal achievement. The work-hour restrictions improved emotional exhaustion and personal achievement scores but had limited impact on depersonalization scores.20
Trainees abroad work fewer hours; thus, it is unsurprising that the reported burnout rates are lower than those in the United States. A recent study of burnout in Dutch trainees working 48 hours per week found that 16.2% reported emotional exhaustion and 11.4% reported depersonalization.15 Another recent study investigating burnout symptoms in 51 Australian residents found that 26% of residents reported emotional exhaustion, 10% reported depersonalization, and 37% reported low scores in personal accomplishment.18 In both of these studies, lower rates of burnout were reported overall in trainees abroad.
It is notable that these studies found lower rates of depersonalization, yet the implementation of work-hour restrictions in the United States has not improved these rates in American trainees. The failure to improve depersonalization in the United States is consistent across specialties. Hutter et al21 found the same result in American general surgery residents. It is possible that the lower depersonalization scores in the Dutch and Australian studies can be explained by reasons unrelated to work hours, such as cultural influence.
Effects of Burnout
Burnout can result in negative outcomes for surgeons and trainees. The symptoms alone reduce quality of life; emotional exhaustion is associated with physical exhaustion and poor judgment, depersonalization results in cynicism and impaired relationships with patients and colleagues, and feelings of low personal achievement lead to decreased effectiveness and productivity.11 The syndrome can also lead to depression,4 alcohol and drug abuse,19 and physical illness, such as male infertility, diabetes mellitus, and heart disease.12 Burnout has been associated with increased risk of metabolic syndrome, dysregulation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, and myocardial infarction.22,23
Surgeon burnout can have negative effects on personal and institutional levels, potentially resulting in a negative attitude, poor performance, absenteeism, and increased employee turnover.19 It can also lead to medical errors. Shanafelt et al8 found that each point increase in the depersonalization score (based on the MBI) was associated with an 11% increase in the likelihood of reporting a medical error. In contrast, a one point increase in the emotional exhaustion score was associated with a 5% increased likelihood of reporting an error. Even in the absence of medical errors, burnout results in decreased quality of medical care because both practicing physicians and residents with burnout symptoms report decreased compassion at work, terse conversations with patients, and other suboptimal patient care experiences.9,24
Risk Factors
Rigorous work is needed to maintain a professional orthopaedic surgical practice and gain financial and job security. However, rigorous work is also a factor that may lead to burnout. Identifying surgeons who are at higher risk of burnout can facilitate earlier diagnosis and intervention. Sargent et al25 used a survey to assess the risk factors for each element of burnout in orthopaedic faculty and trainees. The authors found that emotional exhaustion in faculty members correlated with anxiety regarding clinical competence, concern about the growing number of orthopaedic surgeons, difficult relationships with other faculty members, financial concerns, increased stress at work, and increased conflict between work and home life.25 Among residents, emotional exhaustion was also associated with anxiety regarding clinical competence, stressful relationships with senior residents and faculty, increased stress at work, and increased conflict between life at work and at home.
Sargent et al25 also found that depersonalization in faculty members was associated with a greater number of work hours, increased alcohol use, and stress in relationships with nursing staff. Depersonalization in residents was associated with longer work hours, increase in anticipated debt, and stress in relationships with nursing staff. For both faculty and residents, perceived personal achievement scores correlated with quality of life at home, including marriage and parenthood.25 Burnout should be considered when surgeons experience difficulty in relationships with colleagues, staff, or family members.
The risk factors identified by Sargent et al25 are similar to those described by Saleh et al13 in their study of burnout in orthopaedic leaders. The authors administered a modified MBI-Human Services Survey (HSS) to 110 chairpersons of academic orthopaedic departments and reported that emotional exhaustion was associated with stress in relationships with spouses and other family members, perception of spousal encouragement to take advantage of new professional opportunities, and a lack of balance between one's personal and professional lives.13 Increased irritability and social withdrawal were found to be early warning signs that heralded burnout and could facilitate early diagnosis.13
It is important to note that some of these risk factors are similar to the effects of burnout. Thus, it is often difficult to determine whether associated problems, such as difficulty in relationships with family, are the cause or effect of burnout.
Diagnosis
The MBI-HSS, a 22-question validated instrument, facilitates an objective diagnosis of burnout. Three domains of burnout are assessed: emotional exhaustion, depersonalization, and sense of personal accomplishment.1 Nearly all of the recent studies on burnout in medicine have used this survey, although there are adaptations with additional questions developed by Gabbe et al.7 Some studies use additional instruments, such as the 12-Item General Health Questionnaire that is used for mental disorder screening, and the Revised Dyadic Adjustment Scale that is used to assess work-life balance.12 Mass screening of orthopaedic surgeons with the MBI-HSS could be implemented at the hospital level during the credentialing or annual retraining process. Adding the questionnaire to standard residency surveillance activities would be even easier. Mass screening has not yet been performed; therefore, other strategies for diagnosing physician burnout, such as focusing on physicians with multiple risk factors or identifying physicians with symptoms of burnout, should be used.
Treatment
Treatment and prevention of burnout continue to present a considerable challenge to the medical community. Minimal evidence-based literature has described effective interventions to treat the condition (Table 2). However, several recent studies provide a starting point for treatment of persons affected by burnout and prevention at the institutional level.
Table 2: Summary of Strategies for the Treatment and Prevention of Burnout
In 2012, Goodman and Schorling26 published a study on the effects of mindfulness-based stress reduction on all three domains of the MBI-HSS in 93 healthcare providers, including 51 physicians of different specialties. Mindfulness-based interventions train participants to achieve increased physical and emotional self-awareness, which reduces reactivity to stressful or emotionally challenging experiences. These interventions involve didactic sessions as well as practice sessions that focus on breathing and Hatha yoga. The authors noted that, compared with other healthcare providers, physicians showed the highest baseline scores for emotional exhaustion and depersonalization. Furthermore, 55.3% of physicians scored in the high range of emotional exhaustion and 21.3% of physicians scored in the high range of depersonalization compared with other healthcare providers (35.9% and 7.7%, respectively). The study found that emotional exhaustion scores for physicians improved from 28.1 to 21.3 points, depersonalization scores decreased from 9.2 to 6.7 points, and feelings of personal accomplishment rose from 37.7 to 41.0 points after an eight-session course (P < 0.001 for all three categories). There was a significant difference in improvement in emotional exhaustion between physicians and other healthcare providers (P = 0.016).
In a similar study, Krasner et al27 developed an 8-week educational program focused on mindful communication and studied its effectiveness. Sixty-eight primary care physicians participated in the program, which included didactic sessions on raising self-awareness, managing conflict, and understanding burnout. Mindfulness exercises also involved breathing and yoga-like movements. The authors found that all three subscales of the MBI-HSS improved significantly for course participants, and the improvements persisted for the duration of the follow-up period of 15 months. Emotional exhaustion scores decreased from 26.8 to 20.0 points, depersonalization scores decreased from 8.4 to 5.9 points, and personal accomplishment scores increased from 40.2 to 42.6 points (P < 0.001 for all three categories). However, the interventions in the studies by Krasner et al27 and Goodman and Schorling26 lacked control groups, and the participants were self-selecting. Nevertheless, these studies and a recent meta-analysis suggest that mindfulness-based training may be an effective intervention for physician burnout.32
Two studies evaluated the efficacy of counseling sessions and workshops for treatment of burnout. A randomized controlled trial conducted by Martins et al28 compared 37 pediatric residents who participated in self-care workshops for 2 months with 37 pediatric residents in the control group. The authors reported that the workshops led to improvement only in the depersonalization domain; there were no other significant differences between the groups. In contrast, a study in Norway by Isaksson Ro et al29 examined 184 physicians who completed a short course (1 to 5 days) that focused on coping strategies and stress management. The study found considerable postcourse improvement in emotional exhaustion, which was maintained for >3 years. It is possible that workshop effectiveness is dependent on the content or the methods by which the material is presented and tailored to the course participants. Further research is warranted to investigate this treatment modality.
Prevention
In addition to individualized treatment, prevention is crucial to limiting the effects of burnout on surgeons and institutions. Optimizing protective factors at both the individual and institutional/residency program levels may help reduce the prevalence of burnout. In a study of 264 full-time orthopaedic faculty members and 384 orthopaedic residents, Sargent et al12 identified multiple protective factors for the groups. For faculty, decreased burnout was correlated with increased perception of a supportive work environment, the presence of a mentor, acceptance into a national specialty organization, and the absence of personal issues in the workplace. Meditation, making time for exercise/hobbies, limiting alcohol use, and spending quality time with a spouse also decreased burnout.12 For residents, several factors were found to be protective, including perceived support from other medical institutions, working with an in-program mentor, leaving personal concerns outside work, personal time focused on exercise and hobbies, taking vacations, limiting alcohol use, and drawing on religion or faith.12
In a another study by Sargent et al,25 the authors found that an increase in hours worked by spouses correlated with an increase in perceived personal achievement scores. The second control group showed that residents with a parent who is a physician correlated with reduced emotional exhaustion and depersonalization. However, the study has limitations that affect the interpretation of these findings. The response rate was only 25%, which likely indicates a selection bias. The authors also used univariate analysis to determine which of the factors were protective. Thus, many of the factors could actually be covariates instead of independent protective factors. A multivariate analysis would be required to distinguish between the two possibilities.
In their study of burnout in orthopaedic chairpersons, Saleh et al13 also found that strong personal relationships, most notably relationships with spouses or children, were among the most powerful protective factors against emotional exhaustion. Establishing effective time and energy management skills or attending stress and marriage workshops can strengthen marital and family bonds. The authors recommended that orthopaedic surgeons use strategies for stress management and performance that work with, not against, autonomic nervous system responses. Compared with avoidance strategies, these preventative measures are similar to the coping mechanisms used by elite athletes. Athletes are taught to handle unmet performance expectations and other stressors by responding proactively and demonstrating problem-solving skills.13
Maslach et al2 found that implementation of changes at the organizational or institutional level was the most effective means of reducing the burden of burnout. Several authors in the medical27 and orthopaedic literature30 have called for institutional adjustments. Dunn et al31 evaluated the effects of practice management changes designed to increase physician control. Factors involved customizing work and scheduling options, creating group meetings regarding concerns and case discussions, and increasing efficiency and satisfaction with medical practice. The study involved creating a medical assistant training program at a clinic to reduce staff turnover and emphasizing clinical versus administrative concerns at physician meetings. After 5 years, the changes resulted in substantially lower emotional exhaustion scores among physicians, whereas the average local physician burnout rates increased. However, controlling environmental factors may be difficult in many areas of the current healthcare system because weak measures to increase physician control could increase cynicism.
To minimize burnout, Choong30 recommends that institutions ensure that the expectations of both the practicing surgeon and institution be understood and mutually agreed on at the outset. Institutions should also optimize infrastructure and support for surgeons, outline a system of rewards for surgeon contributions, clarify guidelines for promotion, and create mentorship opportunities for younger surgeons. Critical elements that reduce burnout include increasing physician autonomy, work efficiency, and satisfaction; encouraging participation in leadership opportunities; improving fairness; and streamlining workflow.30
Summary
Orthopaedic surgeons with burnout are at increased risk for cynicism, depression, and physical illnesses, such as heart disease. Burnout also decreases the quality of patient care, increases medical errors, and increases staff turnover. Although validated measures exist for diagnosing burnout, colleagues and family members must be aware of early warning signs and risk factors, such as irritability, withdrawal, and failing relationships at work and at home. Emerging evidence indicates that mindfulness-based interventions or educational programs combined with meditation may be effective treatments for burnout. Prevention of burnout on personal and institutional/residency program levels may be the most effective means of mitigating burnout in orthopaedic surgeons. Programs can emphasize prevention by fostering resident relationships with colleagues and family, allowing structured time for exercise and hobbies, and implementing appropriate coping strategies. Residency programs can introduce structured interventions, such as providing mentorships, blocking time for exercise and hobbies, fostering relationships with external medical institutions, and preparing for early assessment and treatment. At the institutional level, burnout can be prevented by improving physician management over the practice, streamlining workflow, and creating ways for physicians to share meaningful experiences, such as participating in clinically focused meetings.
References
Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 22 and 28 are level II studies. References 10, 20, 21, 26, 27, 29, and 31 are level III studies. References 3-9, 11-19, 24, and 25 are level IV studies. References 1, 2, 23, and 30 are level V expert opinion.
References printed in bold type are those published within the past 5 years.
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