Burnout is a clinical syndrome that is characterized by emotional exhaustion, depersonalization, and a decreased sense of personal accomplishment, according to a 2009 article on the subject that appeared in what is now the Journal of the American Medical Association (JAMA) Surgery.* The article’s authors state that burnout affects people whose work involves constant demands and intense interactions with individuals with great physical and emotional needs. As this definition includes surgeons, several of the College’s Fellows spoke about their own experiences with burnout, or how they have avoided it, and offered strategies to help counteract its effects.
The Board of Governors’ Physician Competency and Health Workgroup has been studying burnout for more than a decade, according to its current Chair, Roger R. Perry, MD, FACS. Results of surveys that the Workgroup (then an ACS Governors’ committee) conducted in 2008 and 2010 indicate that 40 percent of responding ACS Fellows met diagnostic criteria for burnout. Additionally, 30 percent screened positive for depression. Other characteristics of burnout mentioned in the workgroup’s report included feelings of cynicism and detachment from the job, irritability, and over-identification with work to the exclusion of other activities.†
“It’s a major, major issue,” Dr. Perry said. “Unfortunately, there is not a well-defined strategy of what to do” if you find yourself suffering from burnout, he said.
Learning to ask for help
Most surgeons interviewed for this article, as well as the workgroup report, mentioned the tendency of surgeons to be perfectionists as a general rule, making it difficult for them to ask for help or take time off when they need it.
“It’s a badge of honor for surgeons to say, ‘I’m so busy, I’m doing everything,’” said Erika R. Ketteler, MD, FACS, a vascular surgeon who has been in practice for approximately nine years. Dr. Ketteler is associate program director, general surgery residency program, University of New Mexico and is in practice at the New Mexico VA (Veterans Affairs) Health Care System, Albuquerque.
Dr. Ketteler said her training in palliative care enabled her to recognize when she needed to make improvements to her own quality of life. She realized that as she had taken on a new supervisory role, had a couple of very challenging patients at work, and was dealing with some ill family members at home, she was feeling very stressed.
“The problem with burnout is that people don’t realize it until they are finally over that edge,” Dr. Ketteler said.
To improve her situation, Dr. Ketteler said she made a concerted effort to find time to do things she enjoys. She reinvested in activities such as spinning and yoga and dedicated time to being with her family. She involved her supervisor in what she was experiencing and realized that she didn’t have to say yes to everything that came her way. Dr. Ketteler also found support in social media communities by looking at palliative care blogs, a topic with which she became familiar while in training.
“I gained a lot from sharing and listening and reading about other colleagues who are going through something similar,” Dr. Ketteler said.
At last year’s Clinical Congress, Dr. Ketteler spoke on a panel called My Cup Runneth Over: Surgeon Suffering and Burnout. In feedback from the panel, many surgeons shared that the topic of burnout is often seen as an end-of-career event, Dr. Ketteler said. However, surgeons actually felt that burnout and near-burnout occurs throughout surgical residency, fellowship, and surgical practice. Surgeons on the panel emphasized the importance of changing the culture of surgery to prevent burnout before it occurs.
Using technology to help surgeons connect has been a goal of Philip R. Caropreso, MD, FACS, Communications Chair, ACS Advisory Council for Rural Surgery. Dr. Caropreso is a general surgeon and clinical professor of surgery, University of Iowa Carver College of Medicine (UICCM), Iowa City.
Now retired from active practice, Dr. Caropreso previously maintained solo surgical practices in Keokuk, IA, and Carthage, IL, for 37 years. He wanted to find a way to address the surgeon shortage in rural areas, so he started the College’s rural surgery e-mail listserv almost three years ago. Dr. Caropreso described this effort in the “Dispatches from rural surgeons” that appeared in the July 2014 issue of the Bulletin.‡ This electronic forum offers surgeons who may sometimes feel professionally isolated due to their practice location a space to discuss cases in an objective, non-confrontational way, he said.
Dr. Caropreso added that he was fortunate during his career to develop positive relationships and maintain contact with other surgeons at UICCM—about 100 miles from Keokuk—where he still teaches two trauma courses. His connection with the university helped to ensure his techniques stayed current and his knowledge was sufficient, despite his isolation, Dr. Caropreso said.
In his own experience, Dr. Caropreso said, he has felt support from the community of Keokuk, and that sense of belonging has kept him from feeling burned out. His involvement around town, including serving as president of Friends of the Animal Shelter and on his church council, has earned him respect from the people who live in the area. Even in the case of a complication or a death, Dr. Caropreso said, most people understand that humans make mistakes.
Staying enthusiastic about surgery
For some surgeons, variety at work helps ward off burnout. Dr. Ketteler said the mix of operating, working with residents, and teaching courses makes for a better environment than doing the same thing every day. Carol-anne Moulton, MB, BS, FRACS, MEd, PhD, agreed that variety has been helpful in maintaining her enthusiasm for her work. For Dr. Moulton, that has meant following her interest in surgical qualitative research.
“I think I’ve kept moving. I’m somebody who’s always looking out for something new,” Dr. Moulton said. Dr. Moulton is staff surgeon and associate professor of surgery, University of Toronto, ON, and scientist, University of Toronto Donald R. Wilson Centre for Research in Education. She joined Dr. Ketteler and Gregory R. D. Evans, MD, FACS, at last year’s Clinical Congress to speak on the panel on burnout. Dr. Moulton has researched and studied burnout extensively, which she thinks has helped her to avoid succumbing to the syndrome so far.
“We can’t be brave and all-knowing all the time,” Dr. Moulton said. “Because I study [burnout], I’m very aware of that pressure within me to fit into that stereotype.” Dr. Moulton said she has developed a group practice so that the workload is distributed among several surgeons, and everyone can have some time off without carrying a pager. She added that finding challenges in her work has helped her maintain an enthusiastic attitude.
Changes in health care
One factor that contributes to burnout, according to Dr. Perry, is the unpredictability of how our health care system will evolve. Dr. Perry said that the implementation of electronic health records and administrative requirements, as well as the changing rules of insurance companies, add to the pressures surgeons are already under, which is very unsettling.
Dr. Caropreso agreed that the environment outside clinical practice was a big source of stress during his career, and external influences still affect surgeons today, because nonphysicians are telling doctors what to do.
“I’ve recognized that so much of it is outside of our control, and I try not to get upset about things that are out of my control,” Dr. Perry said.
Taking time for family and hobbies
It has taken Dr. Perry time to learn and implement the strategies that can be useful in avoiding burnout. Earlier in his career, if he had the opportunity to leave work early, he used to feel guilty. If he had time to read, he would only read things related to surgery, he said. “We are so focused on our patients; we will do whatever it takes,” Dr. Perry observed. “Sometimes that comes at the cost of ignoring our own health.” Now, Dr. Perry said, he tries to spend more time at home and not feel guilty about it. He exercises two or three times each week, and he reads material that is not always related to surgery.
Dr. Caropreso said his supportive family, including his children and grandchildren, were factors that helped mitigate his stress. He also took up running, and has since competed in half and full marathons.
According to Dr. Evans, when he started practicing surgery more than 20 years ago, burnout was not a term he heard very often. “It wasn’t something you talked about. You got your work done, and if you were in the hospital 100 hours a week, that’s how it was,” said Dr. Evans, chair, department of plastic surgery, University of California, Irvine, and member of the panel on burnout at last year’s Clinical Congress.
Today, according to Dr. Evans, residents are required to participate in webinars and lectures on the dangers of fatigue and substance abuse. He added that residents are more aware of the importance of abiding by work-hour limits.
Dr. Evans said the traveling he does once or twice a month for his job helps prevent feelings of burnout. He tries to go running, biking, out to the movies, or spend time with his wife and kids when he can. Dr. Evans added, “If I can organize my time and be very efficient at it, that helps me with the stress,” he said.
Raymond R. Price, MD, FACS, a general surgeon at Intermountain Medical Center in Murray, UT, said his faith, family, and work are the foundations in his life, and the key for him is not to get pushed too far in any one direction.
In addition to practicing surgery for approximately 22 years, Dr. Price is the associate director of the Center for Global Surgery at the University of Utah, Salt Lake City. He earned an ACS International Volunteer Award in 2012 for his efforts to improve surgical care in resource-poor countries. This work has “kept me pretty well-grounded,” Dr. Price said. “I can provide the care that I wanted to provide when I went into medicine,” which sometimes can be obstructed in the U.S. because of all the necessary documentation and regulations, he added. “There are people that you see that are very grateful for what they get. It gives you a real sense of accomplishment,” he said of his work with patients in countries like Mongolia, Nigeria, and Indonesia. When he practices surgery in Utah, Dr. Price limits himself to no more than four nights of call per month. He said he learned how to keep a work-life balance from his father, who is also a surgeon and will tell him if he’s doing too much.
Despite the stresses that are typically associated with the profession, the surgeons interviewed for this article said that they are able to stay involved and excited about their role as physicians because of their patients. Dr. Caropreso said that not feeling burned out was a mindset. “For me, it’s been a privilege to be a doctor and a surgeon. People trust me enough to put their lives in my hands, and I’ve always kept that in focus. That has helped a lot.”
*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.
†Perry RR. Governors’ Committee on Physician Competency and Health. Bull Am Coll Surg. 2013;98(5):44-47.
‡Caropreso P. Dispatches from rural surgeons: ACS rural listserv: An “underdog” success story. Bull Am Coll Surg. 2014;99(7):48-51.