Burnout and Career Satisfaction Among American Surgeons

Authors and Disclosures

Tait D. Shanafelt, MD,* Charles M. Balch, MD,^‡  Gerald J. Bechamps, MD,^§  Thomas Russell, MD,^†  Lotte Dyrbye, MD,* Daniel Satele, BA,* Paul Collicott, MD,^†  Paul J. Novotny, MS,* Jeff Sloan, PhD,* Julie A. Freischlag, MD ^‡

*Mayo Clinic
^† American College of Surgeons, Johns Hopkins Medical Institutions, Johns Hopkins University, Baltimore, Maryland
^‡ Department of Surgery, Johns Hopkins Medical Institutions, Johns Hopkins University, Baltimore, Maryland
^§ Winchester Surgical Clinic

Discussions

Dr. Carlos A. Pellegrini (Seattle, Washington): As the authors appropriately pointed out, burnout and depression not only negatively effect the surgeon's and his family's personal lives, but also the quality of care provided by those affected. Indeed, substance abuse and suicide are more common among physicians altogether, not just surgeons, who suffer from emotional exhaustion, and those so affected are more likely to commit medical errors and provide inferior medical care to their patients. I have three questions with regard to the interpretation of the numbers you presented and two that relate to strategies to solve the problem. With respect to interpretation, you measured quality of life in two dimensions, the mental and the physical, and you stated that you found that the mental dimension was abnormal but just below the norm in 30% of the individuals, whereas it was only 10% of the physical domain. Can you elaborate on the reasons for these contrasting findings? Second, while you mentioned that three-quarters of the surgeons said they would choose surgery again, I was surprised to see that only half of them would recommend surgery as a career for their offspring. Why is that? Third, you found age to be a risk factor in the development of burnout, with the risk falling on the younger population. Knowing that members of Generation X, that is, those born between '62 and '82 who value their free time to a greater extent than those of us in the baby boomer generation, is it possible that their expectations rather than their youth may be the risk factor? Can you comment on this potential confounding effect? With regards to the strategy, my first question relates to the specificity with which emotional exhaustion and depression affects surgeons. As you noted, and you showed with those 1,300 individuals in European family practice, similar rates of this problem have also been reported among critical care physicians in this country and abroad - Canada, with a 41% burnout rate and family care physicians in Europe. Do you think this is a problem that relates to medicine at-large and not just surgery? And if so, why not unite and use our combined strength to develop more universal solutions rather than solutions applicable to surgeons? Lastly, I was confused by the finding that work hours did not appear to bear any weight on the issue of burnout. As you know, the American Council of Graduate Medical Education at the turn of the century convened the workforce that led to the 80-hour-week development. Paul Friedman, who was the chair, Tim Flynn and I were the three surgeon members of this organization who were on that workforce. I was and I remain convinced that this initiative was necessary, was appropriate, and in fact was healthy as it promotes wellness and the ability to pursue personal interest. In your discussion you mentioned Dr. Whittemore's address yesterday, and placed importance on the pursuit of personal interests as an element in preventing the development of the burnout syndrome. Yet most surgeons in this country continue to oppose the 80 hour per week work limit either overtly or covertly. Can you tell us what your position is? What can you infer from your study? I take it as a given that if, as you and the president have expressed, pursuing your personal interests is important, you need to allocate time for that. Where do you get that time if you have no limit on your work hours?

Dr. Charles M. Balch (Baltimore, Maryland): Quality of life (QOL) questions involve very specific issues that have to do with physical limitations versus issues relating to mental quality of life, and we compared each of these to population-based norms in the United States. Of the two, surgeons address their physical QOL issues, or do not perceive that their physical quality of life is much different than that perceived by other people in the country. On the other hand, the fact that mental quality of life answers deviated form the norm by three-fold does mean this is an issue that we should address more both as a profession within our departments and personally. Your point iswell taken whether there is a cause and effect relationship, which we do not know yet. Age is a very important influence on burnout.Iin this and almost all studies that were done before, age is an important factor and younger people are at greater risk. Addressing these issues proactively is going to be important for our younger colleagues, whether it is because of their expectations, or other stressors, real or perceived. We should be proactive about preventing and mitigating this in the first half of their careers so that they might not experience the adverse consequences of burnout in the last half of their careers. How the incidence of burnout for surgeons compares to other medical specialties is important and again, we do not have direct comparative data. One of the conclusions we made in the paper is the internal medicine, anesthesia and other specialties should conduct more of these studies, so that we would be able to sort out whether these are unique to our role as physicians or whether certain aspects are unique to our role as surgeons. We do not have thisdata. Regarding work hours, I intuitively thought there would be more of a relationship between hours worked and burnout incidence. Survey results indicate that it is not as simple as limiting work hours, for there are other features that cause stress, such as nights on call, that may need to be addressed.. It is not to say that we shouldn't use common sense in what we do. I think the difference between residents and those in practice is that the residents are very directed in their work with other physicians, whereas those of us who work long hours do so for the most part because we choose to.

Dr. Murray F. Brennan (New York, New York): The problem is the association with burnout of your subspecialty choice, your billing compensation proportional to billing, your teenage children at home, your working wife and years in practice. There is very little I can do about that. The teenage children leave, but they might come back, so that does not solve anything. Your spouse can leave, but that creates a serious different set of problems. I must retreat to the satisfaction index, but again, there is not much I can do about it. I cannot change my rank. I cannot change my subspecialty. My age is inextricably moving onwards. The only thing I can do is change my time in the O.R. and I am working on that. This is not about the causes of burnout; the associations with burnout. It is how we cope with them. I would have liked to have seen some questions that asked what allows us to cope, the privilege of looking after a seriously ill patient, the joy of watching a resident or a fellow or a faculty member mature. Those kinds of issues would be wonderful if we could bring those out in your next survey. I hope you will follow it up. I hope you will allow the fact that just identifying associations does not mean they are causative, it is the way in which we cope with them that is important.

Dr. Charles M. Balch (Baltimore, Maryland): A primary purpose of this study is to define baseline incidence and to raise awareness about the potential impact of burnout on our professional career. We were actually surprised at the 40% incidence. We all go through stresses and strains throughout the seasons of our surgical career. If there is any one message here, it is that we should be proactive to avoid the small but meaningful percentage of surgeons who get into real trouble with addictive behavior, with early retirement, with suicide, and with adverse patient events. Overall, the statistics would indicate that about 10% to 15% of physicians actually opt out of their career early because of some of these consequences I described. It does not mean that each and every one of us do not go through stresses and strains during our career... , it is how we adapt to them that will influence our emotional health, our productivity and the quality of our patient care. And those who exhibit maladaptive behavior can find themselves with serious problems that could affect them personally and professionally, such as addictive behavior that could affect their license and credentialing, or their patient care.

Dr. Leigh Anne Neumayer (Salt Lake City): I have two questions: Did you look at interactions between any of the significant variables and gender? Also, did you look for any interaction between type of income (salaried positions versus compensation) and the number of cases done?

Dr. Charles M. Balch (Baltimore, Maryland): Dr. Freischlag and I and several other people will be leading an analysis that was just recently completed by the Mayo Clinic Survey Center on 1043 women surgeons, which is the largest that has ever been conducted. There will be a series of sub-analyses among these specific groups including analyses according to specialties, which I think will help us more specifically target the uniqueness of each of these factors, especially those unique to women surgeons.

Dr. Christopher C. Baker (New Orleans, Louisiana): My question relates to the population. I heard you say associates. Did you have members of the candidate group, i.e., residents or people who are not fellows, in this study?

Dr. Charles M. Balch (Baltimore, Maryland): Yes, those are associates. Those were young people who were candidates. They constituted 10% of this study.

Dr. Christopher C. Baker (New Orleans, (Louisiana): Did you notice any differences in your analysis?

Dr. Charles M. Balch (Baltimore, Maryland): We have not done that analysis yet, but we will.

Dr. Darrell A. Campbell, Jr. (Ann Arbor, Michigan): I have a comment and a question. My comment is that when Drs. Eckhauser and Greenfield and I wrote about this a few years ago, we found that the emotional exhaustion rate was exactly the same as what you described, 32%. That was seven or eight years ago. We are not getting worse but we are not getting better either.

On a different subject, we surveyed the members of the Michigan State Medical Society, not just surgeons but everybody in the group, to ask about burnout, using the Maslach Burnout Inventory. I very surprised to find that surgeons were sort of average with an emotional exhaustion level of 32%, but the group with the highest burnout, and it was very high, and this was what was so surprising, was radiologists. I subsequently spoke at the Michigan State Radiological Society meeting, and they give a lot of validity to that finding. I asked them why, and they said that nobody ever gives them any feedback, they do not tell them if they made the right diagnosis, they never know who the patients are, and it is downright depressing. Therefore, I wonder if in your survey you got any sense of this issue of positive feedback as an antidote to burnout. This has been written about in the family medicine literature, and I was just wondering if you have any sense about this subject.

Dr. Charles M. Balch (Baltimore, Maryland): There will hopefully be a great deal of follow-up on this subject by the Governor's Committee on Physician Health and Competence. One of the outcomes I hope we will see is that other major specialties, such as anesthesiology and internal medicine, who will also conduct similar surveys of their members so that we can begin to understand the various causes of extreme burnout and calibrate those to specific career circumstances.