Preventing Spine Surgeon Burnout and Suicide

North American Spine Society 34th Annual Meeting Highlight

Peer Reviewed

“Psychological disorders [among physicians] have to be destigmatized, and we have to create a safe and a caring culture where people can call out if they need help and be able to provide help for them as well,” Todd Albert, MD told attendees at the North American Spine Society 34th Annual Meeting in Chicago, IL.
Downcast surgeon sitting in a hospital corridor“Burnout is defined as a state of emotional, mental, and physical exhaustion caused by excessive or prolonged stress”. Photo Source: 123RF.com.“Burnout is defined as a state of emotional, mental, and physical exhaustion caused by excessive or prolonged stress,” said Dr. Albert who is Surgeon-in-Chief Emeritus at the Hospital for Spine Surgery (HSS), and Professor in the Department of Orthopaedics at Weill Cornell Medical College in New York, NY. “It is like your energy expenditure is being turned on all the time, and it becomes a little more than you can potentially handle.”

Dr. Albert described the three elements of burnout: 1) emotional exhaustion, 2) depersonalization (a detached and cynical view of patients and colleagues), and a perceived lack of personal accomplishment. Signs and symptoms of burnout are shown in Table 1.
Table 1. Signs and Symptoms of BurnoutMost people entered the medical field with the best intention, Dr. Albert said. “We wanted to take care of others, we were committed to the public good, and were impervious to financial temptation or other self-interests. And, as a result, we were one of the most respected professions.”

However, those same goals “lead you to work 25 hours a day 8 days a week without concern of self-care or for your family or those around you,” Dr. Albert said. “Our role models set that example for us by working all the time.”

The paradigm shift that has occurred in the healthcare field is largely driven by decreased autonomy in work, greater focus on cost and productivity, greater percentage of patients with chronic diseases, and increased patient/family expectations along a decrease in patient trust, Dr. Albert said. In academic centers, decreased research funding and resident work hour limitations also play a role in this shift.

From a professional perspective, physician burnout can lead to decreased quality of care, increased medical errors, decreased patient satisfaction, decreased productivity and professional effort, and high physician turnover. From a personal perspective, burnout can lead to broken relationships, alcohol and substance abuse, depression, and, in the most severe cases, suicide.

High Suicide Rates Found in Physicians

Dr. Albert cited press coverage of recent suicides among high profile surgeons, including Dean G. Lorich, MD, who was Associate Director of the Orthopedic Trauma Service at HSS, as well as two female physicians and a female medical student from Mount Sinai St. Luke’s Hospital.1,2

“There are up to 400 physician suicides a year, which is two times the suicide rate of the general population,” Dr. Albert said.3 “In addition, suicide is the second leading cause of death among residents.”4

Data from physician surveys are disturbing as well, with 54% of doctors reporting being burned out,5 88% being moderately or severely stressed,6 and 59% being unlikely to recommend a career in medicine,7 Dr. Albert said.

A comparison of physician surveys in 2011 and 2014 showed significant increases in the rates of physician burnout (54.4% versus 45.5%; P<0.001) and significant decreases in work/life satisfaction (48.5% versus 40.9%; P<0.001) in nearly every specialty.5 Compared with other specialties, physiatrists and orthopaedic surgeons had relatively high burnout rates and low work/life satisfaction rates.5

The most common contributors to physician burnout cited by physicians in a Medscape survey was too many bureaucratic tasks (eg, charting and paperwork; 59%) followed by spending to many hours at work (34%).8

A Focus on Burnout Among Orthopaedic Surgeons

In an HSS survey, rates on the Maslach Burnout Inventory ranged from 26.3% among orthopaedists to 40.5% among residents/fellows (median, 29.9%). When the same group of HSS participants completed the Areas of Worklife Survey, most of the subgroups showed scores >3 indicating a higher degree of congruence between the worker and workplace on six domains (workload, control, reward, community, fairness, and value).

The burnout issue for orthopaedic surgeons can be seen as early as the second year of medical school and especially when comparing rates of depression before and 1 year into surgical residency (3.9% vs 26.1%).9

In a survey of general surgery residents in the US, the rate of depressive symptoms were 2 times higher than in the general population, suicidal ideation rates were 3 times higher, and alcohol abuse was 5 times higher than in the general population.10 Ultimately, markers of burnout did improve at approximately 10 years into the subjects’ careers, except for those who became department chairs and program directors, Dr. Albert said.10

In a study focusing on orthopaedic leadership, residency program directors had the highest rate of emotional exhaustion (52%), and orthopaedic department chairs the second highest range of emotional exhaustion (38%).11

How Does Physician Burnout Affect Patient Care?

“There is significant evidence that orthopaedic surgeon burnout affects the care we give our patients as it results in decreased empathy, decreased communication, increased medical errors, increased offloading of tests and referrals, and increased wait time for referrals, which cost the system money,” Dr. Albert told NASS attendees.12,13 In fact, physician burnout is estimated to cost $15 to $55 million dollars over 2 years.14

“The biggest problem we have is that physicians aren’t willing to seek help,” Dr. Albert said. “Just like an alcoholic has to admit they have a problem and seek help, physicians have to do the same, and we aren’t particularly good at it.”

Orthopaedists, in particular, are among the least likely physicians to seek professional help (20%) with physiatrists close behind at 29%, he said.4,15

How to Treat Surgeon Burnout

Dr. Albert groups treatment into 2 main categories: 1) physician-directed and 2) organizational-directed interventions (Table 2).16 A meta-analysis of interventions found the strongest evidence of effectiveness for organization-directed interventions.16
Table 2. Treatments for Surgeon Burnout
“The most important thing is creating an environment where we can make the diagnosis of burnout and allow people to talk about it,” Dr. Albert said.

“For trainees, we have to help them foster relationships with colleagues and family, structure time for exercise and hobbies, and implement appropriate coping strategies,” Dr. Albert said. Residency programs should offer structured interventions including mentorship, fostering relationships with external medical institutions, and preparing for early assessment and treatment.

“Exercise has been shown to be extremely important, as has meditation or some meditation-like activities,” Dr. Albert told NASS attendees. “And relationships make a huge difference, as do avocations whether it be art, writing, or music.”

Dr. Albert also noted that resiliency can be enhanced and taught. He also suggested reading The Obstacle Is the Way by Ryan Holiday, which was inspired by Meditations by Marcus Aurelius.

Physician Wellness Departments

Establishing physician wellness departments, as was first done at Stanford University, is another important step in preventing and treating physician burnout. A newly created wellness task force at HSS has introduced a wellness calendar, online journey meditations, mentorship opportunities, health coaching, social events (dinners, book clubs, sporting events), and structured exercise programs. HSS has also invested in increased hiring of the physician assistants and other staff to decrease physician workload.

Conclusion

Dr. Albert concluded by emphasizing that physician burnout has to be destigmatized to allow more physicians to talk about the issue and seek help.

See the second article in this series for a Q&A on physician burnout between Dr. Albert and attendees at the NASS meeting.

Updated on: 12/20/19
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Carving Out Time to Prevent Physician Burnout: Q&A with Todd Albert, MD
Todd J. Albert, MD
Surgeon-in-Chief Emeritus
Professor of Orthopaedic Surgery
Hospital for Special Surgery
Weill Cornell Medical College
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