Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College leadership. The 2018 ACS Governors Survey, conducted in August 2018 by the B/G Survey Workgroup, had a 91 percent (263/289) response rate.
One of the survey’s topics was surgeon burnout, and this article outlines the Governors’ feedback on this issue.
According to the Agency for Healthcare Research and Quality, the health care environment—with its packed work days, demanding pace, time pressures, and emotional intensity—can put physicians and other clinicians at high risk for burnout. Burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment.
In recent years, the rising prevalence of burnout among clinicians (more than 50 percent in some studies) has led to questions regarding its effects on access to care, patient safety, and quality of care. Burned-out physicians are more likely to leave practice, which reduces patient access to and continuity of care. Burnout also can threaten patient safety and care quality, as depersonalization leads to ineffective interactions with patients. Physicians experiencing prolonged fatigue also suffer from impaired attention, memory, and executive function.
This survey revealed many causative factors for burnout, such as the administrative burdens associated with electronic health records (EHRs), liability concerns, regulatory demands, call pressures, diminished work-life balance, decreased compensation, lack of peer support, and exhaustion. Most often, the affected physician is left with a reduced sense of personal accomplishment. The increasing pressures from these factors do not allow physicians the necessary time to recover.
As job dissatisfaction is often a symptom or result of burnout, we specifically surveyed Governors on job satisfaction and factors associated with this state of mind. Although an overwhelming number (87 percent) of Governors reported they were somewhat or completely satisfied with their job (see Figure 1), more than half (52 percent) also reported a common experience of episodic burnout (see Figure 2). In their responses, Governors indicated that liability threats, regulatory burdens, and administrative pressures, combined with call requirements and poor peer support, increased overall emotional exhaustion and eroded time allotted for personal priorities.
Governors ages 55 and younger were less likely to be completely satisfied with their jobs (25 percent), whereas Governors ages 56 and older were more likely to be completely satisfied (57 percent). International Governors also were more likely to be completely satisfied (73 percent) with their jobs than their Canadian counterparts (60 percent), and especially more than Governors in the U.S., only 39 percent of whom reported satisfaction with their job.
Figure 1. How satisfied are you with your current job?
Figure 2. Have you experienced burnout as a surgeon at any time in your career?
Reported experiences of burnout varied greatly between men and women, with 79 percent of women Governors reporting they experienced burnout in their career versus 46 percent of men. Burnout also varied greatly by age, with 77 percent of Governors ages 55 and younger indicating they have experienced burnout. Interestingly, all 12 Governors ages 45 and younger have experienced burnout. In comparison, 70 percent of Governors ages 56 and older have experienced burnout, and most notably, all 10 Governors ages 71 and older indicated they have never experienced burnout. International Governors (26 percent) were less likely to experience burnout than Canadian (70 percent) or U.S. Governors (56 percent).
Practicing medicine can be stressful. Surgeons are inherently hardworking, driven, and self-motivated, but these personality traits also can be detrimental, leading to an increased risk of burnout. Surgeons routinely are ready to take on tough challenges while expecting the best outcomes. These principles are learned and reinforced with an emphasis to always put the patient first and never show weakness. A reluctance to reveal weakness drives many surgeons who are exhibiting signs of burnout to make a conscious choice not to talk about their personal concerns. This tendency was validated in the survey, with 45 percent of Governors reporting they were resistant to talking about their burnout concerns because of the associated stigma (see Figure 3).
Figure 3. Were you resistant to talking about burnout because of the possible stigma?
Although surgeons may recognize the signs of burnout, many do not seek treatment because of the negative connotations associated with asking for assistance. Less than 17 percent of the Governors who reported burnout actually underwent any type of treatment or sought assistance (see Figure 4).
Figure 4. Did you seek treatment for burnout?
Physicians often fail to recognize their personal challenges but can readily identify problems in others. More than 72 percent of Governors responded that they have seen their colleagues experience burnout (see Figure 5).
Figure 5. Have you witnessed a colleague experience burnout?
Surgeons often continue to work even as their energy levels drop. They keep plowing ahead because the work has to be accomplished. When surgeons reach the tipping point, the enjoyment they once experienced in their practice is gone. Instead of relishing the next challenge, they are focused on simply making it through the day. The ultimate sign of burnout is committing suicide, which unfortunately occurs too often. Almost 30 percent of Governors were aware of a resident or staff member who took his or her own life (see Figure 6).
Figure 6. Are you aware of a surgical colleague who has committed suicide?
The good news is that options are available for surgeons and health care systems to treat and prevent burnout. Similar to many medical conditions, the best strategy to avert the consequences of burnout is prevention. Personal wellness activities, a deliberate focus on wellness, and looking after colleagues are excellent first steps. Some causes of burnout, such as regulatory burdens and administrative pressures, are not directly controllable, but much still can be accomplished through self-made decisions. For example, do you get enough sleep? Do you take a sufficient amount of time off? Do you participate in nonmedical activities for fun, such as family excursions?
Figure 7. Is there a program in your facility to deal with burnout?
It is essential that we work on our own resilience. It is our obligation as surgical leaders to simultaneously change surgical culture and create an environment that supports these behaviors. We must challenge the surgical cultural norms that portray and expect surgeons to be superhuman, without acknowledging fundamental needs for self-care and a life outside of medicine. We must be at the table with hospital administrators and policymakers to reduce the burdens that challenge the joys in our careers. Collectively, surgeons can insist departments and hospitals create and support programs to identify and treat physicians at risk.
Other industries have learned that it is less expensive to treat workers well and have systems in place to retain good talent than it is to recruit and train replacements. Unfortunately, only 44 percent of Governors work at a facility that has a program to deal with burnout (see Figure 7), and only 27 percent of Governors reported being aware of resources to assist with burnout.
Interestingly, only 33 percent of Governors thought that mandating a wellness program within their institution would help with burnout, and 29 percent were unsure whether such a program would have successful outcomes. In contrast, almost all hospitals require or strongly urge nurses to participate in wellness programs, and the results have been favorable.
Burnout is a significant challenge and can vary by specialty. Surgeons can do much more to help curb this issue from a system perspective and individually. Although many resources are readily available via medical organizations, such as the College, it is surprising that only 26 percent of Governors said they are aware of them. Improved awareness of these tools is necessary to successfully combat burnout (see sidebar). The need for resources and programs to educate and support the affected individuals cannot be overemphasized.
Burnout is a serious problem in health care, especially for surgeons. Adding to the complexity of this issue, women Governors revealed a higher rate of burnout, and younger Governors noted a lower level of job satisfaction. Most of the Governors (93 percent) agree that it is important for the ACS to continue to address the issue of burnout among surgeons (see Figure 8). Governors overwhelmingly support the College’s continued focus on this problem and efforts to uncover solutions.
Figure 8. The importance of the ACS’ continued focus on burnout for surgeons
Physicians are at risk for burnout because of many factors and any long-term sustainable solutions will require the ongoing collaboration of myriad stakeholders. The College and other health care professional organizations, organized medical staffs, hospitals and hospital systems, medical schools and training centers, insurers, individual physicians, and concerned colleagues will need to collaborate to address this problem and provide practical solutions.
As surgeons and members of an organized medical staff, we should proactively improve wellness efforts by identifying at-risk colleagues and facilitating treatment options for them. We also can insist that facilities and hospital systems develop wellness programs. As a profession, we can work to decrease the stigma associated with asking for assistance. The College can further publicize the resources available to surgeons around the world to aid in the battle against burnout. The ACS is continuing to raise awareness and to develop new resources to meet the challenges associated with burnout.
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