Section Editors: Nancy Hagerman, MD and Natalie Barnett, MD
With help from: Emad Mossad, MD and Karla Castro-Frenzel, MD
Physician Burnout
Burnout is characterized by emotional exhaustion, depersonalization, and low sense of personal accomplishment and is linked with decreased physician quality of life, quality of care, patient safety, and professionalism. Anesthesiologists and critical care physicians are at a high risk for burnout. This study surveyed anesthesiologists via an emailed survey link distributed by the ASA, with an effective 13.6% response rate. Of the respondents, 59% were at high risk for burnout and 13.8% met criteria for burnout syndrome. There was an increased risk associated with perceived lack of support at work, working > 40 hr/week, perceived staffing shortages, and lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual status.
Survey distributed by the AMA yielding a 17.1% response rate. Burnout was observed in 44.7% of White physicians, 41.7% of Asian physicians, 38.5% of Black physicians, and 37.4% of Hispanic/Latinx physicians. However, all groups reported higher rates of burnout than were observed in aggregate sample of general US population.
This narrative review thoroughly defines and describes burnout and its far-reaching health implications for physicians, patients, and healthcare institutions. The authors point out that a degree in medicine increases the risk of burnout, whereas higher education in other fields correlates with a reduction in burnout [offering protection]. They go on to describe the predictors of burnout within anesthesia practice. They emphasize the relative isolation in anesthesia as a significant contributing factor. The association of burnout with depression and suicide are also extensively explored. Of note, the authors describe the relative risk of suicide in female physicians as 2.3, compared to the general population, and much higher than that of male physicians (1.4 compared to the general population). The culture of medicine and systemic factors in the modern hospital both contribute to burnout by overemphasizing the business aspects of anesthesiology practice. Presenteeism and perfectionism, leading to unrealistic demands, appear to contribute to burnout among anesthesiologists. The article emphasizes institution and system-based strategies to mitigate burnout, including enhancing physician professional development, screening for distress, and institutional support programs for physicians and the care team immediately after encountering traumatizing clinical scenarios. They describe a meta-analysis by the Mayo Clinic of 15 randomized-controlled trials comprised of almost 3,000 physicians which found that institutional efforts [at reducing burnout] were more effective than individual efforts.
Physicians are at significant risk of burnout and poor mental health as shown in numerous population studies. This risk differs across medical specialties with up to three-fold increased odds in acute care physicians especially in anesthetists. It is even more evident in its disproportionate manifestation in women due to many factors like inequities in opportunities, recognition and credibility, bias in job and wage losses and disproportionate care-giving responsibilities. The authors focus on the impact of the COVID-19 pandemic as a stress catalyst that heightened the demonstration of this risk for burn out and the impact of gender. They emphasize the critical need for recognition and acknowledgment of that risk, and identify personal, institutional and governmental interventions that can impact the risk of burn-out for all anesthetists, especially women.
The recognition of burnout syndrome, its signs and symptoms, predisposing factors, and strategies for prevention date to the early 1970’s. However, awareness of the incidence and impact of burnout and its relation to performance and safety has taken a much longer time. The recent addition of burnout syndrome as a diagnosis to the ICD-11 is long-awaited advance. We now have a better recognition and understanding of the discipline specific incidence of burnout, showing physicians as more vulnerable, and anesthesiologists with a range of 10-40% incidence in multiple surveys and studies. Younger female physician anesthesiologists, with children and those in postgraduate training are at the highest risk. Anesthesiology specialty risk factors are related to social isolation, negative coping strategies, personality traits, and exposure to workplace intimidation and bullying. Workplace risk factors include working hours, number of night calls per week, limited support, and conflict between work and home. Interventions to promote wellness have been supported by an ACGME/ASA initiative including individual based as well as system based strategies.
In a mixed methods systematic review of the literature the authors identified 61 pertinent studies that demonstrated a consistently significant association of physician burnout and depression, anxiety and suicidality, and a variable relation with alcohol and substance use disorders. The examined studies showed contributing risk factors as work-environment factors, lack of empathy, and limited time for personal life, lack of collegiality and an unsupportive work-place relationships, and a culture of invulnerability (perception of illness as failure or weakness). They identified interventional targets to include enhancing workplace conditions, work relations (including adequate support and mentorship), addressing stigma to allow a culture of vulnerability and ability to seek help without shame, and individual responsibility for self-care
For generations, the practice of medicine has been both demanding and rewarding. A deeply reciprocal, caring relation with our patients is an obligation and a satisfaction. However, there is clearly a rising epidemic of exhaustion, depression and burnout in the current era, associated with a stigma that precludes appropriate access to mental health. The focus on physician well-being interventions is reasonable and necessary. But the more impactful interventions may be a critical change in our current health-care system that is fragmented, corporatized and costly; a system that prizes efficiency over relationships, profits over common good and volume over value. To restore the caring, rewarding relationship of physicians to their patients, a transformation and reform of health-care from a market service to a common good that is a fundamental feature of a thriving society.
Burnout syndrome has reached epidemic levels among physicians, with a significant prevalence in the most stressful medical disciplines, including anesthesiology. The three main components of burnout syndrome include emotional exhaustion (EE), high depersonalization (DP) and low personal accomplishment (PA). In a systematic review of the burnout literature, the authors identified 15 pertinent surveys or prospective studies related to anesthesia providers. The qualitative analysis identified the incidence of burn out to range from 10-41% among anesthesia providers. There was no relation to hospital characteristics (academic versus community), gender or marital status. Burnout was significantly associated with high workload, low support from work or family, alcohol consumption and younger age or earlier stage of career. Protective effect was noted for job support and mentoring or supervision. Physicians-directed as well as organization-directed intervention can have a critical impact on the incidence of burnout experienced by anesthesia providers
The prevalence of burnout among physicians has been well documented and commonly suggested solutions involve resilience training to support well-being. West et al. conducted a national survey in 2017 to evaluate resilience in physicians to compare physician resilience with other US workers. Information was collected on resilience as well as symptoms of burnout in both populations. Of the 30,456 physicians invited to participate in the survey, 5445 completed the survey. Compared to the population of US workers, physicians scored as having higher resiliency. Among physicians, physician resilience was inversely related to burnout symptoms, although even the most resilient physicians had substantial rates of burnout. The authors conclude that although efforts to strengthen or maintain resilience are appropriate, an equal or greater emphasis should be placed on systems-level interventions to combat burnout.
This editorial focuses on the true cost of burnout and offers a novel role that regulatory agency can play in alleviating this burden. The cost is most explicitly described as both a risk to patient safety and as an economic burden to the U.S. economy. The authors quote one particular study that estimates that the economic cost to be around $2.5-$6.3 billion dollars per year. They go on to compare and contrast individual versus institutional interventions, noting that a meta-analysis on this subject found institutional interventions more effective in reducing burnout. Finally, the article suggests that if the Joint Commission were to require yearly measurement of burnout in order to maintain accreditation, it could well provide the impetus that the human cost of burnout has not. The editorial is well-referenced, with a substantial array of studies and articles evaluating burnout from different angles.
Mindfulness
Emotional exhaustion decreased sense of personal achievement, and depersonalization are characteristic markers of physician burnout. Not only does burnout affect the individual, it also spreads into impacting family, friends & coworkers of the individual. Mindfulness can improve well-being & mental health. The Headspace® app has been well-rated and is a well-being smartphone application. This prospective, self-controlled study investigated the Headspace® app and its utility to improve resident wellness amongst anesthesiology residents. REDCap questionnaires were administered for baseline, and at 1-month and 4-months after starting the app. Components of questionnaire included abbreviated Maslach Burnout Inventory and components for depression, stress, and sleep quality. Participants used the app most commonly for management of anxiety and stress, and general well-being. Mindfulness app use was associated with an increase in feelings of personal achievement and a decrease in depression scores amongst participating residents.
More than half of physicians are suffering from burnout which has detrimental consequences to physicians themselves as well as their patients. Drivers of burnout are typically classified into the three categories of culture of medicine, practice inefficiency, and personal resilience. Only one of these categories can be modified by the individual – personal resilience. Meditation and mindfulness can potential help strengthen resilience. The GAIN method is an acronym for the four pillars of resilience, happiness, and stress reduction: Gratitude, Acceptance, Intention, and Nonjudgement. The GAIN method is portable and a quick technique to incorporate mindfulness meditation into a daily routine.
Stress and distraction in the operating room have been associated with decreased efficiency and closely linked to poorer patient outcomes; just as stress and burnout are also associated with poorer patient outcomes. Participants were trained in a 4-minute mindfulness breath awareness audio recording. After the mindfulness training and implementation, there was observed improvement in operating room flow and perceived stress.
Mindful practice in medicine possesses the key traits of enhanced self-awareness, attentive listening, flexibility, and bias recognition. Mindful practice is associated with improved patient care as well as higher overall patient satisfaction. Mindfulness-based stress reduction can improve physician burnout and associated symptoms, particularly important to anesthesiologists as anesthesiologists have higher than average rates of burnout amongst US physicians. Given the benefits to both patient care and physician burnout, mindful practice could be applied to the practice of anesthesiology.
Physician Well-Being
This narrative essay posits that physicians constitute a distinct, unique, patient population secondary to their education and experience. However, until the publication of this essay, no formal term for physicians who became patients existed in the literature. Without a name for something that exists, it is as if that something does not exist. The lack of a term is akin to denial. Physicians can and do get ill. The author coins the term “physician-as-patient” in order to give this patient population a name. The author shares in her journey from terminal cancer diagnosis to survival within the context of her vocation, staff, and colleagues. She calls attention to the distinct vulnerabilities and strengths that characterize physicians-as-patients.
This article frames the problem of physician burnout within the contexts of (1) a modified Maslow’s hierarchy of physician wellness needs and (2) the 6 areas of worklife model [proposed by Leiter and Maslach]. The authors emphasize that well-being and quality of life are closely related. They redefine well-being as not only the absence of burnout, but a multidimensional concept that refers to a state of happiness and contentment, fulfillment, engagement, and satisfaction with life. They propose a novel process to improve clinician well-being and quality of life by interweaving the principles of human-centered design, quality improvement, and implementation science. The article mentions that psychological safety is a key, foundational component implemented early in the process and essential to the ultimate success of the process. The authors describe how they successfully implemented this creative problem-solving approach at their own institution. They offers concrete examples of each step in the problem-solving process, making the whole approach accessible. The authors maintain that these principles can be adapted to varied clinical setting. They also emphasize the iterative nature of the process given the dynamic fluctuations in surgical volume.
This timely article focuses on the subject of physicians’ overall well-being [health] within the context of significant burnout and staffing shortages. The article effectively argues that 1) clinical burnout has negative consequences for patient care and staffing and 2) that burnout is an occupational phenomenon and, therefore, 3) requires a change in culture rather than individual interventions such as more yoga and meditation. The article recounts the history of “wellness” in medicine and how it failed clinicians. The authors describe how the modern health care infrastructure takes advantage of the altruistic tendencies physicians are known for. The article astutely highlights how this behavior contrasts with the 2017 Revised Declaration of Geneva, “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.” They remind the audience that the NAM and the ACGME, as recently as 2017, have called for a systems approach to address clinician well-being. Despite this call to action, health care organizations have continued to predominantly allocate their attention and resources to individual-focused interventions. The article offers 5 avenues where cultural change can begin: 1) eliminating the glorification of excessive self-sacrifice, 2) liability reform 3) normalizing mental health support 4) pivoting healthcare systems’ focus from recruitment to retention and 5) expanding physician autonomy. Drawing attention to these 5 avenues provides an accessible path for the reader to reflect on how he/she/they can help contribute to the necessary cultural shift toward improved clinician well-being [health].
Anesthesiologists are at high risk for burnout, second victim phenomenon and other mental health issues. Contributing factors include high acuity patients/procedures with significant morbidity and mortality, unpredictable management of adverse events, working extended hours with few breaks. Access to a formalized peer-support program in times of personal stress following adverse clinical events could improve staff psychological well-being while minimizing rates of burnout. The Royal Brisbane and Women’s Hospital Department of Anesthesia & Perioperative Medicine created a program based on 4 objectives: 1) ensure the automatic follow up of all anesthetic staff involved in critical incidents; 2) identify staff members at risk of immediate & ongoing psychological distress & facilitate access to resources & expert assistance; 3) encourage individual staff members who are experiencing difficulty for any reason to seek out & receive peer support; 4) promote a departmental culture of understanding for staff experiencing psychological stress. All members of the peer support group are anesthetists who have been trained in a unique psychological first aid training program. Discussion between staff and responders is always maintained in confidentiality. All responders are equipped with contact information for more in-depth and formal counseling should that be necessary.
The phenomenon of “second victim” in health care professionals has shown the potential positive effects of peer support. Peer support following intraoperative crises and/or emotionally charged situations has recently been recognized as a powerful tool to combat the potentially adverse outcomes in second victims.
Engagement
Analysis of the Safety Attitudes Questionnaire and the Gallup Q (an employee engagement survey) across a large hospital system showed a potential association between unit-level perceptions of safety culture and employee engagement. This could support the assertion that engaging work environments can positively impact patient safety culture.
