Editor’s note: As noted in the American College of Surgeons Board of Governors’ (B/G) Committee on Physician Competency and Health report published in the May issue, the Bulletin will be publishing excerpts from the Committee’s guidebook titled Being Well and Staying Competent: Challenges for the Surgeon, which is posted on the members-only web portal at www.efacs.org. The following is the first article in that series.
The practice of medicine is rapidly changing and causing significant stress for American physicians—particularly for practicing surgeons. Examples of these stressors include: the loss of autonomy associated with hospital-based practice, the restrictions on practice associated with managed care, the ongoing escalation of liability lawsuits, and the maintenance of competency in a rapidly changing specialty.
These stressors can interact with preexisting psychological characteristics typical of surgeons to pose certain occupational hazards.1 Surgeons are trained to never make mistakes, so when they do occur, the surgeon may be tormented by his or her own sense of perfectionism, resulting in self-incrimination and even self-loathing. An exaggerated sense of responsibility coupled with guilt and self-doubt adds stress to an already difficult situation. Unfortunately, some surgeons are unable to differentiate perfectionism from the aspiration to excel. Numerous authors have demonstrated that perfectionism is a vulnerability factor for depression, anxiety, burnout, and suicide.2,3 As perfectionists, surgeons often suffer from numerous cognitive distortions: that they are valued only for their performance; that the better they do, the better they are expected to do; and that, if they lose the “edge,” they will lose their colleagues’ support. The consequences of this perfectionism include only short-lived satisfaction with achievements; a sense that awards and accolades are unmerited; and striving to excel not for personal and professional satisfaction or pleasure, but rather to relieve the tormented psyche.1
Perfectionism is one of the major precursors for burnout because it is often accompanied by an exaggerated sense of responsibility that leads to self-doubt and guilt, which then lead to rigidity, stubbornness, and the inability to delegate. These behaviors, in turn, may result in a devotion to, and identification with, work to the exclusion of relationships and self-care.
Perfectionism is also one of the predisposing factors for suicide because fear of failure provokes the need for complete control of everything in a physician’s professional and personal lives, which can leave us feeling empty, disconnected, and cynical.
Burnout is characterized by the following:4
- Overwhelming physical and emotional exhaustion
- Feelings of cynicism and detachment from the job
- A sense of ineffectiveness and lack of accomplishment
- Over-identification with work to the exclusion of other activities
- Irritability and hyper-vigilance
As a consequence of burnout, individuals suffering from burnout often experience sleep problems, including nightmares; withdraw socially; display poor judgment; may violate professional and personal boundaries; engage in interpersonal conflicts; develop feelings of numbness and detachment; and have difficulty concentrating.
The B/G Committee on Physician Competency and Health has conducted two surveys of the Fellows of the American College of Surgeons, one in 2008 and one in 2010, leading to multiple publications that have demonstrated a very strong association between burnout and diminished quality of life and practice, depression, suicidal ideation, medical errors, and alcohol abuse.
Specific findings from the 2008 and 2010 surveys include the following:
- 40 percent of responding surgeons met diagnostic criteria for burnout
- 30 percent screened positive for depression
- Only 36 percent of surgeons felt that their work schedule left enough time for personal and family life
- Only 51 percent of respondents felt their children should pursue a career in surgery
- Three factors independently associated with burnout were hours worked per week, nights on call per week, and compensation determined entirely by billing
- Surgeons who placed greater emphasis on finding meaning in work and focused on what is important in life, maintained a positive outlook, and embraced a philosophy that stresses work-life balance were less likely to experience burnout
Fortunately, a number of strategies are available to both decrease and reverse burnout:
- Promote a culture of medicine that values work-life balance
- Provide access to online self-assessment tools to identify levels of stress and burnout
- Promote the “just culture” paradigm during training and make clear that shaming and humiliating of colleagues are unacceptable behaviors
- Define a psycho-social-spiritual support system and access it frequently
- Identify power versus powerlessness over people, places, things, and situations (that is to say, if physicians stop trying to control everything, they will find more joy in their lives)
- Identify the differences between self-knowledge and self-awareness (Self-knowledge is what we believe to be true about ourselves; self-awareness is seeing ourselves as others see us. These insights are rarely the same, yet are equally important.)
- Develop educational programs that promote supportive environments. For example, the B/G Committee on Physician Competency and Health presented three programs as panels at the Clinical Congress meetings in 2009, 2010, and 2011—Stress and Burnout Among Surgeons: Understanding and Managing the Syndrome; Surgeon Burnout: Putting Out the Flames; and Light at the End of the Tunnel: Prognosis for Recovery of Surgeons with Potentially Impairing Conditions.
- Most importantly, physicians should give themselves permission to be sick and to accept good medical care
Speaker and author Lee Lipsenthal, MD, offers the following concepts for achieving a balanced life, guidelines which may also function as tools for avoiding burnout:5
- Take care of ourselves so that we can take care of others
- Remember that our state of well-being affects our patient outcomes, our personalities contribute greatly to our well-being, and our perception creates the world we live in
- We have the power to change these things, we must want to
- Developing gratitude and healthy boundaries and releasing a need for control are the best weapons against burnout
The B/G Committee on Physician Competency and Health recommends surgeons consider the following self-assessment statements to determine if a surgeon is vulnerable to burnout:
- I find meaning in my work
- I protect time away from work with my spouse, family, and friends
- I focus on what is most important to me in life
- I try to take a positive outlook on things
- I take vacations
- I participate in recreation/hobbies/exercise
- I talk with family, significant other, or friends about how I am feeling
- I have developed an approach/philosophy to dealing with patients’ suffering and death
- I seek to strike a balance between my personal and professional life
- I look forward to retirement
- I discuss stressful aspects of work with colleagues
- I nurture the religious/spiritual aspects of myself
- I am involved in non-patient care activities (for example, research, education, and administration)
- I engage in contemplative practices or other mindfulness activities, such as meditation or narrative medicine
- I engage in reflective writing or other journaling technique
The more positive the responses, the less likely surgeons are to suffer from burnout, depression, suicidal ideation, decreased professional and personal quality of life, and abuse of alcohol or other drugs.
- Myers MF, Gabbard GO. The Physician As Patient: A Clinical Handbook for Mental Health Professionals. Arlington, VA: American Psychiatric Publishing, Inc; 2008.
- Beevers CG, Miller IW. Perfectionism, cognitive bias, and hopelessness as prospective predictors of suicidal ideation. Suicide Life Threat Behav. 2004;34(2):126-137.
- Hamilton TK, Schweitzer RD. The cost of being perfect: Perfectionism and suicidal ideation in university students. Aust NZ J Psychiatry. 2004;34(5):829-835.
- Balch CM, Freischlag JA, Shanafelt TD. Stress and burnout among surgeons: Understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg. 2009;144(4):371-376.
- Lipsenthal L. Finding Balance in a Medical Life. Publisher: Lee Lipsenthal; 2007.