Acknowledging the multiple challenges surgeons currently face, the Board of Governors’ Committee on Physician Competency and Health has continued its efforts to both delineate these issues and provide educational programs and support services aimed at promoting physician well-being. The previous chairs and members of the committee have laid a solid groundwork upon which the present committee has expanded.
The Committee on Physician Competency and Health’s responsibilities include developing recommendations on the maintenance of physical and mental wellness in the Fellows as well as addressing issues related to surgical competency with an emphasis on credentialing and practice within expected community standards.
Most physicians are aware that wellness encompasses the physical, emotional, and spiritual aspects of life. Input from Fellows of the College indicates that many surgeons are either personally or professionally coping with significant stressors that have the potential to negatively affect not only their individual well-being, but also their ability to provide optimal patient care.
Surgical education and training are intensely rigorous, and the transition to practice may be even more stressful. Contemporary surgical practice is replete with challenges, including providing patient care to an enlarging population of increasing medical complexity, and coping with declining resources and reimbursement, yet with increasing administrative burdens.
Adding to these stresses are the demands associated with maintaining work-home balance, functioning as an effective part of a health care team, meeting the professional requirements for certification, while functioning in a litigious environment.
The subsequent transition from active practice to retirement is one that many surgeons approach with trepidation and denial, and has been shown to be a difficult phase for practicing surgeons.
Although abundant anecdotal information regarding surgeon stress and stressors existed, no studies had been performed that examined how these problems affected large numbers of surgeons.
Using an anonymous electronic tool developed by Gerald J. Bechamps, MD, FACS, and members of the Physician Competency and Health Committee, the College conducted a study of the Fellows in 2008. Nearly 8,000 Fellows responded to the survey, which asked questions related to both personal characteristics and professional obligations. Also included were questions designed to measure burnout and depression, career satisfaction, perception of quality of life, and issues related to the occurrence of medical error. Significant findings from this survey included a high prevalence of burnout and depression, as well as a considerable occurrence of suicidal ideation. Nonetheless, most surgeons said they enjoyed a good quality of life and level of career satisfaction.1-5
With the College’s support, another anonymous electronic survey of the Fellows was completed in 2010, with questions addressing interpersonal relationships, work-life balance, coping mechanisms, and substance abuse. Of the nearly 7,200 respondents, nearly one-quarter reported involvement in a medical liability lawsuit in the past two years.6
Surgeons involved in these lawsuits tended to be younger, worked more hours, took more night call, and were more often in private practice. Depression and burnout were independently associated with a recent malpractice suit; however, because of the nature of the survey, no causality can be identified. Not surprisingly, surgeons involved in recent legal action reported less career satisfaction.
The data showed that alcohol was by far the most widely used or abused substance. Using the Alcohol Use Disorders Identification Test, Version C, to evaluate for the presence of alcohol abuse or dependence, 15 percent of surgeons had scores consistent with alcohol-use disorders, which exceeds rates quoted for the general population.7 The rate for male surgeons was 14 percent, and the reported rate for female surgeons was 25 percent. A correlation was also found between surgeons reporting alcohol abuse or dependence and the occurrence of a major medical mistake within the previous three months. A strong association with burnout, particularly in the areas of emotional exhaustion and depersonalization, also was noted.
Other studies have indicated that a surgeon who is struggling with impairment often will avoid assistance until forced to do so. Additionally, probably because of the achievement-driven, highly responsible surgeon personality, work performance and attendance will be maintained, although the surgeon may be struggling significantly in all other aspects of life. It is also clear that, likely due to this commitment to patient care, direct harm to patients as a result of surgeon impairment is exceedingly rare.
A literature review also indicates that the prognosis for successful outcomes when alcohol abuse and dependence are treated is very good, with most surgeons being able to return to active practice.8,9 Participation in an established program, with ongoing support from the hospital or academic department and colleagues, as well as long-term, supervised monitoring are also essential to a successful recovery.10
Additional areas of assessment from the 2010 survey have looked at the role of personal health care practices and strategies in avoiding burnout in surgeons. According to the study, surgeons who had seen their primary care provider within the past year were found to have better overall quality of life scores and to be current with recommended health screenings. Making a deliberate effort to maintain a perspective on work-life balance as well as identifying personal values and priorities in life and gaining a sense of meaning from work were found to counteract burnout.11,12 Although stress and intense demands are inherent to the surgical lifestyle, it is essential to identify and develop successful tactics to address them.
Although recognition and acknowledgement of these issues is critically important, further steps must be taken to properly aid our colleagues. These actions include: (1) assuring the individual who is struggling with these issues that they are not alone and need not continue in isolation; (2) encouraging group practices and surgery departments to put into place support mechanisms for prevention, recognition, and assistance; (3) identifying and sharing available resources; and (4) educating the surgeon that the prognosis is good for recovery and that there is a strong likelihood of continuing to function competently.
The Governors’ Committee on Physician Competency and Health has been engaged in an extensive effort to produce a resource document for both the surgeon and departments of surgery that addresses surgeon well-being. We anticipate that this document will be available electronically in the near future.
The challenges mentioned here are certainly not limited to surgeons practicing in North America; studies in other parts of the world show similar findings. The committee welcomes the input and participation of international colleagues.
A large number of manuscripts have already been published from the survey data; several more are under way.
Additionally, we anticipate another survey of ACS Fellows. With significant recent changes in employment patterns as well as recognition of the stresses of career transitions and important differences between the genders, it is imperative that we broaden our understanding and then use this knowledge to guide our progress. The issues confronting surgeons are wide-ranging and have crucial implications for the individual surgeon—and the profession.
The author would like to acknowledge the previous Chairs of the Governors’ Committee on Physician Competency and Health: Kenneth W. Sharp, MD, FACS; Gerald J. Bechamps, MD, FACS; and John B. Hanks, MD, FACS, who have provided exemplary leadership in developing the scope of the committee’s work. Additionally, Tait Shanafelt, MD, and his colleagues at the Mayo Clinic have continued to provide outstanding technical and data analysis support.
- Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag JA. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
- Balch CM, Shanafelt TD, Dyrbye L, Sloan JA, Russell TR, Bechamps GJ, Freischlag JA. Surgeon distress as calibrated by hours worked and nights on call. J Am Coll Surg. 2010;211(5):609-619.
- Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, Rummans T, Swartz K, Novotny PJ, Sloan J, Oreskovich MR. Special report: Suicidal ideation among American surgeons. Arch Surg. 2011;146(1);54-62.
- Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan J, Freischlag J. Relationship between work-home conflicts and burnout among American surgeons: A comparison by sex. Arch Surg. 2011;146(2):211-217.
- Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558-568.
- Balch CM, Oreskovich MR, Dyrbye LN, Calaiano JM, Satele DV, Sloan JA, Shanafelt TD. Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg. 2011;213(5):657-67.
- Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, Meredith C, Buhl A, Dyrbye LN, Shanafelt TD. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147(2):168-174.
- Baldisseri MR. Impaired healthcare professional. Crit Care Med. 2007;35:S106-S116.
- Domino KB, Horbein TF, Polissar NL, Renner G, Johnson J, Alberti S, Hankes L. Risk factors for relapse in health care professionals with substance use disorders. JAMA. 2005;293:1453-1460.
- Buhl A, Oreskovich MR, Meredith CW. Prognosis for the recovery of surgeons from chemical dependency: A 5-year outcome study. Arch Surg. 2011;146(11):1286-1291.
- Shanafelt TD, Oreskovich MR, Dyrbye LN, Satele DV, Hanks JB, Sloan JA, Balch CM. Avoiding burnout: The personal health habits and wellness practices of U.S. surgeons. Ann Surg. 2012;255(4):625-633.
- Bittner JG, Khan Z, Babu M, Hamed O. Stress, burnout and maladaptive coping: Strategies for surgeon well-being. Bull Am Coll Surg. 2011;96(8):17-22.