Burnout in Orthopaedics
Dr. KS Dhillon
Introduction
Occupational burnout is a syndrome composed of emotional exhaustion (EE), depersonalization (DP), and a low sense of personal accomplishment (PA), that is secondary to chronic occupational stress [1]. The Maslach Burnout Inventory (MBI) scale is a scoring system that has been validated in multiple physician [2, 3] and non-physician [4] populations. It is considered as the gold standard for burnout assessment. This scale consists of 22 seven-point Likert scale questions, that measure EE, and PA separately [1].
In clinical practice and research studies, clinically significant burnout is defined as the presence of either high-level DP or high-level EE [2,5].
In recent times, burnout in doctors has been a topic of increasing research interest and has been extensively studied in doctors from various medical specialties [2, 6, 7].
Burnout in doctors is associated with medical errors [8-10], unprofessional conduct [11], as well as reduced quality of patient care [8]. On a personal level, burnout is associated with poorer quality of life [12], alcohol abuse [12], and reduced career satisfaction [13, 14]. Burnout poses a major impact on the medical profession and negatively affects both the personal lives and professional performance of the doctors.
Orthopaedic surgery is a challenging specialty that covers complex
pathologies, major trauma cases, and a wide range of procedures [15]. Orthopaedic surgeons usually have a heavy workload and often work long hours [16]. The postgraduate orthopaedic training program is also very difficult [17]. In the present medical environment, reduced independent surgical practice and exposure has made it more difficult to achieve surgical skills [17], further steepening the learning curve and putting more pressure on the already high expectation and demands of orthopaedics [18].
Given the challenges in practicing orthopedics, the data on burnout in other medical specialties may not be applicable to orthopaedic surgeons.
Definition
Professional burnout is a condition where physical, emotional, and mental exhaustion results from prolonged involvement in work that has high emotional demands. It is usually characterized by the progressive degradation of work relationships. In practical terms, when faced with such situations of chronic professional stress, the doctor in burnout can no longer cope with these situations.
The concept of burnout was first introduced by Greene in 1961 in his book “A burn out case” [19]. Psychoanalyst Freudenberger [20] revived it in the 1970s. Burnout was excellently defined by Maslach, Schaufeli, and Leiter [21]. They defined it as a dislocation between what a person is and what he/she has to do.
In the process, the individual's values, dignity, spirit, and will become eroded. This syndrome has three dimensions:
emotional exhaustion.
depersonalization of the work i.e dehumanization, indifference.
reduction in personal professional effectiveness and accomplishment or fulfillment at work.
Cole and Carlin [22] believe that this is an identity crisis for physicians who entered their profession with certain values. Their distress arises from the feeling that these values are scoffed at.
The work commitments are based on three criteria:
Personal values and motivation attached to carrying out the commitment.
Pleasure or fulfillment that it provides.
The stress that it generates.
When the stress becomes intolerable, the pleasure disappears and the values are compromised, burnout sets in. Values and the feeling of accomplishment are located higher up on the needs pyramid, according to Maslow [23] (fig 1).
Fig 1. The Maslow hierarchy of needs
The instant when the feelings of personal accomplishment are blunted and disrupted, all the other levels of the pyramid can be disrupted including, self-recognition, the social need to belong, and even personal safety and physiological needs. This is why some cases of burnout manifest themselves by a complete physical breakdown.
Three components of burnout
Emotional exhaustion corresponds to fatigue or progressive wearing out, both mental and physical, due to excessive emotional stress. The work schedule, work conditions, and personal affect relative to emotional demands are key factors contributing to the exhaustion. The poor working conditions cause stress to the doctors and nurses. The outsized impact of hospital administration, large clinical practice groups, and the fear of being sued contributes to the emotional exhaustion.
Depersonalization occurs because of exhaustion. All the emotional processes are disrupted, which results in the person becoming indifferent to what may occur. This indifference is a protective mechanism to prevent further decline. The indifference secondary to depersonalization leads to the loss of decision-making capacity and reduced ability to act.
The loss of personal accomplishment is the third component of burnout. The person feels he/she is no longer in a state to do good work. The person perceives and experiences a loss of professional capacity, which further increases their emotional distress. The person enters into a vicious circle that can lead to physical, psychological, and/or emotional breakdown. Christina Maslach [1], by means of the Maslach burnout inventory test, allowed us to get a better grasp on these three components. This simple test has 22 questions that provide an easy and accurate diagnosis of burnout with three sub-scores i.e emotional exhaustion, depersonalization, and personal accomplishment.
What are the clinical manifestations of burnout?
Burnout always has clinical signs [7] of progressive and insidious installation that mark a break with the previous state. These signs can be:
Emotional-- anxiety, sadness, lack of drive, irritability, hypersensitivity, lack of emotion, etc.
Cognitive-- memory, attention, concentration problems.
Behavioral-- withdrawal, isolation, aggressive behavior, reduced empathy, resentment and hostility, cynicism, addictive behaviors, etc.
Motivational-- progressive disengagement, reduced motivation and morale, erosion of values associated with work, devaluation, etc.
Physical signs often occur simultaneously, such as asthenia, trouble sleeping, musculoskeletal disorders (low back pain, neck pain, muscle tension, cramping, etc.), headaches, vertigo, anorexia, and gastrointestinal problems.
There is a correlation between the level of burnout and the following signs: sleep disturbances, back pain, and headaches, the feeling of exhaustion, anxiety about workload, being unable to disconnect after work, and forgetting the difficult moments experienced during the workday. These appear to be the best warning signs of a pre-burnout state or of established burnout.
Psychosocial, regulatory, and occupational risks
There are six categories of psychosocial risk factors:
Intensity and complexity of the work including constraints of scheduling, adequacy of means, and objectives.
Significant emotional requirements including tension with the public and sometimes difficult relationship with patients, being face-to-face with suffering, and difficulty with controlling emotions.
Loss of autonomy at work for the task itself, the management of work time, and in the skills made available. The main culprit is the relationship with administrative functions, because of the stress it induces.
Deteriorated social relationships at work including lack of support from colleagues and superiors, internal violence, and lack of recognition at work.
Conflict in values
Job insecurity.
What is the frequency of burnout and the risk factors in the medical field?
Frequency of burnout
Several studies highlight the seriousness of the burnout situation in the medical world. A survey involving 7905 respondents, carried out by the American College of Surgeons [24], found a 40% burnout rate and that 30% of surgeons had symptoms of depression. The suicide rate among surgeons was 6.3 per 10,000 versus 3.3 per 10,000 in the general population. The rate of depression increased when both members of a couple were surgeons [25], with a higher frequency in women [26].
Campbell et al [27] analyzed the responses of 582 surgeons and they found that 4% had lost the feeling of personal accomplishment, 32% had emotional distress, and 13% had depersonalization. The emotional distress is the origin of depersonalization and is an adaptation to protect oneself. The surgeon then resorts to cynicism to avoid suffering [28].
Burnout is also seen among medical students [29]. In France, the problem is particularly alarming among residents [30]. A national survey with 4050 responses, or 64% of the general medicine residents in France, found that 34% of residents saw themselves in one of the three components of burnout. Thirty-nine percent felt a loss of personal accomplishment and 34% depersonalized their patients. Nearly half of the residents said they were worried, 16.5% were going to quit their medical career and 37% regretted having chosen this career path.
Risk factors for burnout
In the medical population, there are a certain number of factors that negatively affect the perception of quality of life in professional practice. These include, growing bureaucracy [24], higher productivity expectations with the consequence of having less time to spend with each patient [24], an increase in the number of hours worked [31], an imbalance between professional and personal life, which gets worse [24], increasingly rapid change in medical knowledge justifying a constant need for training [24,31], increase in the number of malpractice lawsuits [24], and change in the doctor–patient relationship and the doctor's image in the eyes of the patient [24].
All these factors are responsible for an increase in the stress level and burnout cases. The stress level and burnout cases continue to increase as the doctor's practice becomes more established [24].
Campbell et al [27] have found a clear gradient between the number of hours worked and on-call nights and the level of burnout. The rate was nearly 40% in surgeons working more than 80 hours per week. Emotional distress and depersonalization were also very prominent in surgeons who were on-call for more than two nights per week. The rate of major errors was also directly related to these two criteria. The error rate was 10.7% when working more than 80 hours per week as compared to 6.9% when not working more than 80 hours per week. Family conflicts also seemed to be more common.
Kuerer, Eberlein and Pollock [32] also highlighted the relationship between alcoholism and burnout particularly in surgical oncologists (12.4%). This observation has been made around the world including in the United States [33], Europe, Australia [34], South America [35], and Japan [36].
How does burnout impact orthopedic and trauma surgery?
In orthopaedic surgery, the burnout rate is about 32.3% [37]. A Swiss study [38] found high burnout levels with 23% emotional exhaustion, 27% depersonalization, and 42% loss of personal accomplishment. Saleh et al [39] found a 38% burnout rate among orthopedic surgeons. Sargent et al [40] reported that 56% of orthopedic residents had burnout, and 27% of those who had completed their training had burnout.
Cunningham et al [41] from the US showed that in 67% of orthopedic surgeons, the stress at work significantly impacted their personal life.
Ames et al [42] found a mean burnout rate of 45.8% in the US.
A recent study performed in France among orthopedic residents [43] found that 40% of residents were in a severe burnout state according to the Maslach Burnout Inventory (MBI), with 63% experiencing depersonalization. The rate of loss of personal accomplishment was lower at 33%.
For some doctors, each patient is a potential plaintiff, which contributes to depersonalization of human interactions and of the patient. There are an increasing number of malpractice lawsuits, especially the very high rate of non-justified cases. This high number of cases is poorly tolerated and considered as a major factor contributing to depersonalization and to emotional exhaustion.
In organizations, difficult relationships with the administration, surgeons not being consulted when making decisions, and financial charges that are deemed too high can be a source of stress for the surgeons. The administrative meddling can be very high and least acceptable in the hospital setting.
Apprehension about the workload and patient contact, along with anxiety over financial requirements are the negative factors before the workday.
Being unable to disconnect from the professional world, smoking, drinking alcohol, or taking tranquilizers, and physical problems such as back pain and headaches are the negative factors after the work day.
It is the imbalance between pleasure and stress that leads to burnout and suicide. As high as 40% of orthopedic surgeons deem their stress level to be unacceptable.
Prevention and treatment of burnout
Prevention
To prevent burnout the symptoms have to be detected first. The French National Authority for Health (HAS) has published a burnout evaluation form. According to HAS, the occupational and environmental medicine (OEM) physician and the family doctor are best positioned to pinpoint burnout. The family doctor will focus on family and personal history such as depression, as well as events that could contribute to the appearance of burnout such as the death of a family member, divorce, or financial difficulties. The nurses and OEM physician will focus on the psychosocial risks, and on the quality of social support and work relationships.
The evaluation form is not well-suited to daily medical practice. Here are some of its components:
Individual detection of burnout is based on a range of arguments resting on a systematic analysis of clinical signs, work conditions, and potential individual susceptibility factors.
Group detection of burnout is done by the occupational health team led by the OEM physician using data on the operating room's performance including absenteeism, high turnover, quality of the activity and social relationships, etc. The health and/or the safety of workers and the surgeon are taken into consideration. Work-related accidents, occupational disease, spontaneous medical visits, and ineptitude are looked at.
The following elements must be taken into consideration for preventing burnout:
Workload and schedule: the mean work week for an orthopedic surgeon was 52 hours in one study [44]. The first essential step is to reduce the work time and make time for recreational activities. This can be difficult, especially in private practice. The financial requirements and pressure from the administrators and management can have negative consequences. The work schedule must be adapted to each person's pace.
Management of difficult patients and personal development: Only about 10% of patients are difficult [44]. Difficult patients must be analyzed and we have to know how to adapt our behaviors and approach them differently.
Place malpractice lawsuits into perspective: There are many lawsuits in orthopedics, and they have a direct influence on emotive power and depersonalization. We have to place these into perspective and implement every means to reduce them.
How to adapt to different administrations: The administrative pressure is usually significant and can be an on-going source of stress and conflict. We must know how to manage it. It is necessary to step back and optimize the management of these administrative stressors in order to free up more time to practice medicine. We have to regroup and prepare by defining negotiation boundaries. We need to know how to find a win-win solution.
How to recapture the purpose and values of the profession: Many orthopedic surgeons participate in humanitarian missions. This allows them to detach themselves from material requirements and to freely practice medicine. This helps the surgeons to rediscover their purpose.
How to analyze the share of our professional activity in our life: There is a need to know how to anchor ourselves on our personal values.
How to communicate and express ourselves: There is a need to know how to debrief and share information with the office staff and other doctors. These exchanges with others allow the negative energy to dissipate.
Recognize what is not going well and find a way to fix it: There is a need to manage stress. Surgeons should be allowed to talk about their anxiety and realize that it is shared by others. These discussions lead to solutions and preventative measures being discovered. There are many other self-help solutions such as meditation, and relaxation therapy. Time should be spent on non-work-related activity. This will allow us to disconnect [45].
Treatment
When burnout is diagnosed the doctor is given immediate medical leave and treatment is started by the family doctor, which consists of combined psychiatric and psychological care.
The medical leave allows the doctor to take a break from work and disconnect from professional situations. It allows him/her to rediscover his/her values, and select a work mode and context that is more appropriate.
The family doctor coordinates the treatment. The treatment consists of nonpharmaceutical treatment based on psychotherapy or mind-body therapy that is performed by a health professional or psychologist trained in these methods. The workplace analysis is carried out. It is done by a multidisciplinary team that is coordinated by the OEM physician. Preventative actions, either individual and/or collective, are recommended based on the findings. After discussions with the practitioner, who is the patient here, it is essential that the family doctor reaches out to the OEM physician or the occupational health office to inform them of the workplace conditions.
Conclusion
Burnout is very prevalent among orthopaedic surgeons. Trainees suffer from higher levels of burnout as compared with departmental heads and faculty members. High burnout rates among orthopaedic surgeons need to be addressed through the implementation of preventative strategies. At the surgeon level by voluntary reduction in work hours, and at the institutional level by increasing the number of orthopaedic surgeons to decrease the surgeons' workload. There has to be government policy to help the orthopaedic surgeons deal with burnout and its effects. Workshops such as the Royal Australasian College of Surgeons (RACS) ‘Beating Burnout’ workshop can be useful.
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