Orthopedist Lifestyles -- Linking to Burnout: Medscape Survey

The following slides present the major findings of the 2013 physician lifestyle survey, which focused on the links between work burnout and physicians' lives outside of practice.

A national survey published in the Archives of Internal Medicine in 2012 reported that US physicians suffer more burnout than other American workers.^[1] Some 45.8% of physicians were experiencing at least 1 symptom of burnout: loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment. In Medscape's current survey, when orthopedists were given the same criteria, the response was slightly more encouraging: 40% responded that they were burned out, placing them 10th on the list of most burned-out specialty. The 2 specialties with the highest percentage of burnout were those that dealt with severely ill patients -- emergency medicine and critical care -- while generalists rounded out the top of the list: family physicians, internists, and general surgeons. Surprisingly, pediatricians were among the least burned-out specialists, along with rheumatologists, psychiatrists, and pathologists.

Burnout is serious. According to a 2013 study, job stress, coupled with inadequate treatment for mental illness, may account for the higher-than-average rate of suicide among US physicians.^[2] In the Medscape survey, it was no surprise that physicians in specialties with the highest percentage of burned-out members also reported greater severity in their own burnout. Orthopedists ranked fifth from the bottom in terms of burnout severity, with a mean severity score of 3.6, (1 = does not interfere with my life; 7 = so severe that I am thinking of leaving medicine altogether).

Orthopedists were given a list of stressors and asked to rate how important they were as a cause of burnout on a scale of 1 to 7, where 1 = not at all important and 7 = extremely important. The top-rated stressors were "too many bureaucratic tasks," "the present and future impact of the Affordable Care Act," and "spending too many hours at work." The least important stressors concerned difficult colleagues, staff, or employers and compassion fatigue. It is clear that external stressors play the major role in physician burnout. In a Medscape Primary Care roundtable discussion, Roy Poses, MD, of Brown University said, "Most interventions meant to improve burnout have treated it like a psychiatric illness, not a rational response to a badly led, dysfunctional healthcare system."^[3]

A higher percentage of female orthopedists reported burnout (47% vs 39% of men), which is consistent with the general physician population. Women may have more conflicts between work and home, particularly if they have children. It should be noted that because of the physical requirements needed to perform many orthopedic surgeries, there are far fewer women in this specialty than in most others. Despite this, the burnout discrepancy between the sexes is no greater and, in fact, is less than in many other specialties.

The rate of burnout is lowest in the youngest and oldest orthopedists. It gradually increases with age; 18% of burned-out orthopedists are ages 36-45, increasing to 29% in those 46-55, and reaching its peak at 31% in orthopedists aged 56-65. Burnout rate drops significantly to 15% after age 66, which is still higher than among other burned-out specialists in that age group. The physical stamina required by this surgical profession may play a unique role in age-related stress levels.

It comes as no surprise that when asked to score their happiness at work from 1 (very unhappy) to 7 (very happy), burned-out orthopedists gave a very low score (3.6) compared with their more satisfied counterparts (5.4). They were much happier at home (5.3) than at work but less so than their non-burned-out peers (5.8). In the Archives of Internal Medicine survey,^[1] physicians were asked about work-life balance; those practicing preventive medicine, dermatology, and general pediatrics gave the highest satisfaction ratings, whereas those in general surgery and its subspecialties, as well as obstetrics/gynecology, reported the lowest rates. These ratings generally correlated with the severity ratings in the Medscape survey.

There was very little difference between burned-out orthopedists and their less stressed peers in choosing favorite pastimes. The most popular pastime among orthopedists was spending time with family (92% of burned-out orthopedists and 88% of those who were less stressed). Physical activity and exercise followed closely (85% and 79%, respectively). The orthopedist percentages for this pastime are among the highest, if not the highest, of all the specialty groups surveyed. It is not surprising, considering the physical requirements that the specialty demands. The third favorite was travel (68% vs 64%).

With an average of 13 paid vacation days per year, Americans are far worse off than those in other developed countries (eg, Italy, 42; France, 37; Germany, 35; United Kingdom, 28; Canada, 26; Japan, 25). US physicians don't fare much better than their American patients. And those who are burned out do worse than their peers. About 35% of burned-out orthopedists take only 2 weeks of vacation, if not less, each year compared with only 27% of their happier peers. And 64% of burned-out orthopedists take 2 or more weeks compared with 71% of their peers.

According to a 2009 survey from the US Travel Association, activities with the greatest interest among US adults are, in order of popularity, visiting friends and relatives, sightseeing, going to beaches, visiting museums, going to national or state parks, going on cruises, visiting theme parks, traveling to cities, and visiting mountain regions.^[4] Orthopedists, burned out or not, like the same vacation types, including foreign travel, beach vacations, and vacation homes. However, burned-out orthopedists were less likely to take foreign vacations (42% vs 56%). Of note, winter sports were more popular among orthopedists than nearly all other specialists.

As with pastimes and vacations, in the Medscape survey the proportions of orthopedists who were burned out and not burned out matched up closely in regard to the types of volunteer work they did, with pro-bono clinical work topping the list. However, the burned-out respondents were far less likely to participate in organized religious events than their less stressed colleagues (13% vs 20%). Volunteer rates were high in general, with only about 22% of both groups reporting never volunteering.

Orthopedists were asked to rate their physical health on a scale of 1 to 7, where 1 = in poor health and 7 = extremely healthy. Orthopedist ratings matched those of the overall physician sample: Those who were burned out were less confident about their health (5.5) than their non-burned-out colleagues (5.8).

The most recent CDC statistics report that 26.2% of Americans exercise less than once a month -- essentially not at all. In the Medscape survey, only 2% of non-burned-out orthopedists and 4% of the burned-out group confessed to not exercising at all. The CDC also reported that about 21% of US adults participated in enough aerobic and muscle-strengthening exercises to meet guidelines. Guidelines for muscle strengthening require exercising more than twice per week; for aerobic exercises it's at least 150 minutes per week.^[5] Although more than half of all orthopedists who responded exercise at least twice a week, the percentage is lower among burned-out orthopedists (64% vs 71% of their less stressed peers). In addition, 32% of the burned-out group exercised once a week at most compared with 27% of the less stressed group.

According to a CDC report, 35.8% of US men and women were overweight in 2011 and 27.8% were obese. Only 34.5% were of normal weight and 1.8% were underweight.^[6,7] Orthopedists who reported their BMI in the Medscape survey do only somewhat better than their patients; among the non-burned-out group, 49% claimed to be of normal weight or underweight compared with 60% of their burned-out peers. Those who are burned out also tend to weigh more: 51% reported being overweight or obese compared with 43% of their happier peers.

Although the national quit rate has increased over the past few years, according to recent CDC data, 21% of Americans still smoke.^[8] Smoking is not a problem among the great majority of orthopedists, both those who are burned out and those who are not, with only 1%-2% of orthopedists being smokers.

As reported in a 2010 Gallup poll, 67% of American adults drink alcohol, a rate that has been "remarkably stable" since this began being tracked in 1939.^[9] In the most recent CDC report, 57.1% of US adults had at least 1 drink within the past month, 18.3% of adults are binge drinkers, and 6.6% confess to being heavy drinkers (adult men having more than 2 drinks per day and adult women having more than 1 drink per day).^[10] Medscape orthopedist responders have moderate drinking habits, and little difference was seen between those who are burned out and those who are not, although the burned-out group seems to drink less. Eighteen percent don't drink at all compared with 16% of less stressed physicians, and 61% vs 59% have fewer than 1 drink per day. Finally, 21% of the burned-out sample has 1 or more drinks per day vs 25% of the non-stressed group. These are higher drinking rates than many other specialty groups have reported.

Income seems to play a less significant role in burnout among orthopedists compared with other physicians. In response to this question, 70% of burned-out orthopedists consider themselves to have adequate savings for their age group and professional stage compared with 74% of their less stressed peers, while 28% of burned-out orthopedists vs 23% of their peers claim to have minimal savings to unmanageable debt.

According to a 2008 Pew Report, 88% of Americans believe in God or a universal spirit.^[11] In our Medscape poll, instead of asking for specific religious affiliations, we wanted to know whether orthopedists have a spiritual belief, regardless of active participation. There was little difference in responses from the burnout and non-burnout groups, with 75% of burned-out and 80% of non-burned-out respondents reporting a religious or spiritual belief.

Nearly 60% of both burned-out and non-burned-out orthopedists who reported a spiritual belief actively attend religious services. These findings are similar to those in the overall physician sample.

Instead of asking Medscape orthopedists whether they are Democrat, Republican, or Independent, the survey question focused on whether members considered themselves liberal or conservative in fiscal and social areas. Without clear definitions of these terms, the responses are very subjective; the objective was to get a sense of political biases rather than voting habits. There weren't great differences between the burned-out and non-burned-out groups, although burned-out physicians were slightly more fiscally conservative at 70% compared with 65% of their non-burned-out peers. Forty-seven percent of non-burned-out orthopedists report being socially liberal vs 55% of their more stressed peers.

According to Paul Griner, MD, author of The Power of Patient Stories: Learning Moments in Medicine, "If you are not spending relaxed time with your loved ones, having some fun outside of work, or enjoying interpersonal relationships, you are at a greater risk for burnout." Orthopedists have an extremely high rate of marriage or life with a domestic partner, and there is basically no difference between the burned-out (92%) and non-burned-out (93%) groups.

Orthopedists tend to have more children than other physicians. In the Medscape survey, 15% of burned-out orthopedists have no children compared with 11% of the non-stressed sample; these numbers are lower than those reported in the overall physician population, in which 21% of burned-out respondents and 15% of non-burned-out respondents reported having no children. Furthermore, 81% of non-burned-out orthopedists have 2 or more children, as does 74% of the burned-out group.

According to a 2007 report from the Migration Policy Institute, 26.3% of physicians have come to the United States as adults.^[12] In the Medscape survey, burnout rates were not very different in orthopedists who came to the United States as adults: 37% compared with 41% of those who were born here. This lack of disparity was not seen in many other specialist groups, in which burnout rates are often much higher among physicians born in the United States. It should be noted, however, that only 10% of the orthopedists responding to this survey were foreign-born -- much lower than the percentage reported by the Migration Policy Institute.

This word cloud was created from the write-in responses to a question asking about important stressors. The word "patients" is most prominent, suggesting that this relationship is key in physician burnout. In dealing with this issue, Dr. Griner advises physicians to "participate actively in health reforms that will return a greater level of control to physicians and their patients. These include payment for value and greater patient participation in decision-making about care. Reorganizing primary care practices to allow more time for complex patients and recognition by insurers that excessive hassle is bad for patients and physician are also vital. These changes should lead to more satisfied patients and physicians and less burnout."

In the Archives article,^[1] the authors sum up the very challenging problem of physician burnout: "Collectively, the findings...indicate that (1) the prevalence of burnout among US physicians is at an alarming level, (2) physicians in specialties at the front line of care access (emergency medicine, general internal medicine, and family medicine) are at greatest risk, (3) physicians work longer hours and have greater struggles with work-life integration than other US workers, and (4) after adjusting for hours worked per week, higher levels of education and professional degrees seem to reduce the risk for burnout in fields outside of medicine, whereas a degree in medicine (MD or DO) increases the risk. These results suggest that the experience of burnout among physicians does not simply mirror larger societal trends."