Author: Reid C. Thompson
Defining the problem of physician burnout
Something is changing in medicine. Increasingly, physicians are losing their sense of meaning and purpose. The risk factors for this problem are multifactorial and yet the diagnosis is clear: over 50 percent of physicians report symptoms of burnout and disengagement.1 Burnout is a syndrome characterized by a sense of emotional exhaustion, depersonalization, cynicism, a reduced sense of personal accomplishment, and loss of meaning in one's work. Burnout in US physicians has increased during the past decade to epidemic proportions and is dramatically higher than that of US workers in other fields. The rate of burnout among physicians varies by clinical discipline, with many of the specialties at the front line of access to care (emergency medicine, family medicine, and OB-GYN) at highest risk. Neurosurgeons are not immune. There are many dimensions to physician burnout. Work-related stress fuels burnout, which in turn, leads to a loss of meaning in one's work. Physicians cite an ever-increasing excessive clinical and clerical workload, loss of autonomy and flexibility with regard to scheduling, lack of efficiency and resources (do more with less), and an erosion of work-life balance as important drivers of burnout. Important variables that play a role in determining burnout include age, stage of career, gender, and family make up. Women generally report higher rates than men. Younger and mid-career physicians appear particularly vulnerable, with those who are younger than 55 years old demonstrating a 200 percent increased risk of burnout compared with those older than 55. Having a child younger than 21 increases the odds of burnout by 54 percent, and having a spouse/partner who works as a non-physician increases the odds by 23 percent.2
What is the cost of physician burnout?
There is a tremendous cost to the epidemic of physician burnout. Surgeons in particular show a troubling drop in quality of care and patient safety along with an increase in medical errors when burnout is reported. Shanafelt and co-authors studied the relationship between burnout and medical errors among American surgeons and found that for each one-point increase in a surgeon?s self-reported emotional exhaustion, there was a 5 percent increase in reported major medical errors. Each one-point increase in a surgeon's depersonalization score was associated with an 11 percent increase in the likelihood of reporting an error.3 In cross-sectional studies of more than 7,100 US surgeons, burnout was an independent predictor of being involved in a medical malpractice lawsuit.4
Burnout also leads to loss of productivity and turnover.5 This loss of productivity amortized to a national level is estimated to be the equivalent of eliminating the graduating classes of seven medical schools. The cost of replacing a physician who leaves a practice has been estimated to range from $500,000 to $1 million. For a neurosurgeon this is likely an underestimate. Estimates of the cost of physician burnout are difficult to quantify, but a recent publication from the Blue Ridge Group put the cost at a staggering $150 billion per year when taking into account medical errors, medical malpractice costs, loss of productivity, and physician turnover.6
Of course, there are other costs. On a personal and societal level, alcohol and substance abuse, depression, and suicide can stem from burnout. Physicians show an increased risk of suicide compared to the general US population, with rates 40 and 120 percent higher for male and female physicians respectively.7
What can be done about the problem of physician burnout?
Over the past several years, emerging literature on the problem of physician burnout emphasize the importance of identifying organizational and health care system factors that threaten the well-being of physicians. What is becoming clear is that in order for academic medical centers to address physician burnout, strategies must be developed that focus specifically on physician well-being. Such strategies must take into account both organizational (institutional) and individual (personal) variables to enact change. Structural organizational change is of paramount importance. Indeed, it is imperative for organizations to address the problem. The institutions that adapt and change their cultures will be successful in recruiting and retaining the best-and happiest-physicians. The corollary is true, as well. Shanafelt and Noseworthy have defined a series of organizational strategies to promote engagement and reduce burnout.8 Important highlights include:
- Acknowledging and assessing the problem.
- Integrating discussions of well-being into career counseling.
- Developing and harnessing the power of leadership.
- It is evident that institutional leaders-department chairs and practice leaders-should model well-being in addition to promoting an overall culture of well-being.
- Creating and cultivating a community at work-including spaces to congregate, such as a physicians lounge.
- Promoting flexibility and work-life integration.
- Providing resources to promote resilience and self-care: access to a gym in the hospital, access to healthy food, access and ease of scheduling dental and medical appointments for physicians.
Well-being and neurosurgery
Well-being is the opposite of burnout, and is characterized by resilience, vigor, and engagement. Interestingly and importantly, physicians who report less burnout are able to identify at least 20 percent of their time is spent doing something they love. Recently, I was asked to co-lead the Task Force on Physician Well-being and Empowerment at Vanderbilt Medical Center. I have learned that a culture of wellness can best start at a department level. Department leaders have a unique opportunity to set the tone regarding expectations for being well. Promoting faculty well-being as an organizational value gives physicians permission to focus on strategies to promote individual well-being. The high-level demands of neurosurgery are almost unique in medicine. Given the prevalence of burnout in physicians, it is important for leaders in neurosurgery to begin a conversation about well-being. How can we instill it into our residents, faculty, and colleagues? There are role models in our field for building resilience into a career-and we can learn from them. There is robust literature emerging that we should familiarize ourselves with.
My impression of neurosurgeons is that we love what we do. We find joy in our work. The act of doing surgery is, in and of itself, an act of mindfulness. This state of pure focus resembles a state of "flow," and I believe it is one of the reasons we love operating! There are literally no distractions when we are purely focused in the operating room. Most people aspire to achieve a state of mindfulness, and work to develop this practice, but the practice of neurosurgery is mindfulness.
We need to be mindful of the power of well-being as a driver for excellence in caring for our patients, and for ourselves. A career in neurosurgery is a marathon, and "building in" resilience is critically important. How do we do this? We can start by having a national conversation.
- Shanafelt, TD, Lotte DN, West CP. Addressing physician burnout—the way forward. JAMA. 2017; 317(9):901-902.
- Dyrbye, LN, Tait D. Shanafelt, TD, Sinsky, CA, Cipriano, PF Jay Bhatt, J, Ommaya, A, West, CP, Meyers, D. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. National Academy of Medicine Perspectives. Published July 5, 2017.
- Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J. Burnout and medical errors among American surgeons. Ann Surg. 2010; 251(6):995- 1000.
- Balch CM, Osreskovich MR, Dyrbye, LN, et al. Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg. 2011; 213:657-67.
- Dewa CS, Loong D, Bonato S, Thanh NX, Jacobs P. How does burnout affect physician productivity? A systematic literature review. BMC Health Serv Res. 2014; 14:325.
- The Blue Ridge Academic Health Group. The hidden epidemic: the moral imperative for academic health centers to address professionals’ well-being. Published: Winter 2017-2018, Report 22. http://whsc.emory.edu/blueridge/publications/reports.html.
- Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003; 289:3161-6.
- Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clinic Proc. 2017; 92:129-146.