Burnout Rate and Risk Factors Among Anesthesiologists in the United States

Anoushka M. Afonso, M.D.; Joshua B. Cadwell, M.B.A., M.S.; Steven J. Staffa, M.S.; David Zurakowski, Ph.D.; Amy E. Vinson, M.D.

Disclosures

Anesthesiology. 2021;134(5):683-696. 

In This Article

Discussion

Our findings show that anesthesiologists are at high risk of burnout in the United States. Burnout is linked to decreased quality of care,[26] professionalism,[27] patient safety,[8] and physician quality of life.[28] Shanafelt et al.[1] estimated that 45.8% of physicians are at risk of burnout, a high percentage that persists even after accounting for higher rates of resilience among physicians.[24] That study also found that the prevalence of burnout among anesthesiologists (48%), a small fraction of their sample (n = 309 [4.2%]), was higher than the mean. The higher rate of burnout in our study (59.2%) may be explained by differences in sample size, shifts in social climate, or increasing rates of burnout over time.

We also explored the rate of burnout syndrome, which we defined as the presence of all three dimensions of burnout, in accordance with the World Health Organization.[25] The presence of all three dimensions at once is less presented in the literature than "high risk for burnout." However, given the reported rates of major morbidities in anesthesiology, such as substance use disorder and suicide, we felt it important to report.[29,30] The rate of burnout syndrome was predictably lower than that of burnout (13.8% vs. 59.2%), but burnout syndrome still affected a meaningful proportion of anesthesiologists in our dataset. Similar to the case for high risk for burnout, risk factors for burnout syndrome were strongly associated with workplace factors, especially perceived support of work-life. Age was the only personal factor that was significantly associated with burnout syndrome.

Although studies have analyzed burnout among trainees or attendings in anesthesia internationally,[13–16] they did not capture specific risk factors that are pervasive in the population of anesthesiologists. Sun et al.[12] observed a rate of burnout of 52% among anesthesiology residents and first-year graduates that was unrelated to hours worked or student debt. However, our study suggests that workplace factors, rather than personal factors, are the primary factors associated with being at high risk for burnout among practicing anesthesiologists. In particular, lack of workplace support, working greater than or equal to 40 h/week, staffing shortages, and lack of a workplace confidant were all associated with burnout, which is consistent with recent data.[31] Higher-risk characteristics of burnout in other studies included long work hours, excessive alcohol consumption, female gender identity, not being married, non-Hispanic White race, U.S. medical school graduate, younger age, poor learning environment, inadequate sleep quality, and lower income.[7,17,18,32–34] Although our analysis sample, as compared with ASA members, was slightly older and had a higher percentage of females, we do not feel that this small difference affected our prevalence of burnout. Many other studies did not find sex as an independent predictor of burnout, yet the prevalence of depersonalization and emotional exhaustion is higher among men and women, respectively.[31,34,35] In our study, contrary to previous investigations[36] but in line with the National Academy of Medicine consensus study,[18] personal factors seemed to be of lower importance than workplace factors. These results hold true in sensitivity analyses within each of the individual subscales (emotional exhaustion, depersonalization, and personal accomplishment; Supplemental Digital Content 3 [http://links.lww.com/ALN/C562], 4 [http://links.lww.com/ALN/C563], and 5 [http://links.lww.com/ALN/C564]).

To date, groups that are underrepresented in medicine have not been as regularly measured in physician burnout studies. In their initial report on the Maslach Burnout Inventory Human Services Survey, Maslach and Jackson[37] noted that respondents who identified as being part of a racial minority did not have higher rates of burnout, and our results confirm this. Interestingly, we also found that anesthesiologists with English as a second language tended to have a lower risk of burnout, which echoes previous findings that international medical students had lower rates of burnout than U.S. medical graduates.[33] These findings highlight the importance of workplace factors, although it remains unclear why these populations have lower rates of burnout.

Among personal factors, lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual status had the strongest association with burnout in underrepresented participants. Because lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual people represent an increasing proportion of medical students and future physicians,[38] this finding warrants further investigation. Identifying as a sexual minority has been associated with greater psychologic distress in the workplace[39] and higher burnout.[40] In fact, Przedworski et al.[41] investigated 4,673 medical students with self-reported sexual orientation data in a national longitudinal cohort study. Compared with heterosexual students, first-year sexual minority medical students (who identified as nonheterosexual) experience significantly greater risk of depression, anxiety, and low self-rated health. Another cohort study of 27,504 U.S. medical students showed that lesbian, gay, or bisexual students reported mistreatment and discrimination based on sexual orientation.[42] Members of this community may lack inherent familial support because they do not necessarily share their sexual or gender identity with their family of origin. Additionally, members of the lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual population may not be fully protected from workplace discrimination; this lack of protection may lead individuals to hide their lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual status, potentially amplifying the effect of workplace factors on burnout.

Actionable Interventions to Ameliorate Burnout

Our results suggest that feelings of support (in mentorship, at work, and at home) are the most critical factors in anesthesiologist well-being. Our results substantiate that lack of support in work-life contributed to anesthesiologist burnout and can provide a baseline assessment of anesthesiologist well-being and burnout. After quantifying the magnitude of different risk factors that contribute to burnout, we can intervene most effectively from the perspective of how to make anesthesiologists feel more support at work. Indeed, not feeling supported in work-life was strongly associated with high risk for burnout and even more strongly with burnout syndrome.

There are a number of effective strategies to reduce burnout, as demonstrated in a 2016 systematic review and meta-analysis of burnout reduction strategies, showing a burnout reduction from 54% to 44% in the intervention groups.[43] A recent publication describes interventions for well-being with descriptions of policy-level, institutional, and personal strategies to ameliorate burnout and improve physician well-being. With actionable recommendations that can be adopted by policy-makers (systematic destigmatizing of mental health care, educational debt reform, limiting discoverability of peer support), institutions (peer support programs, electronic health optimization, emphasis on mentorship), and physicians (mindfulness, stress reduction training, optimum nutrition, and physical activity), we can take practical steps toward decreasing burnout and improving overall well-being.[44]

Workplace culture is directly linked to leadership,[45] in particular executive leadership.[46] However, all physicians assume leadership roles, whether in the operating room or at the department level, and therefore have an opportunity to foster a culture of support. We have shown that a culture of support is associated with a lower risk of burnout, and data suggest that burnout may have a negative effect on patient satisfaction and safety.[8,47] Put simply, leadership drives culture, culture drives burnout, and burnout affects patient care. Solutions focused on leadership skills, self-care, balance between demands and resources, and alignment in the working environment are likely to have downstream effects, multiplying investments made.[29]

Multiple models of supportive cultures exist,[46,48] but, in essence, a culture of support must reach all aspects of life and practice, integrating principles of healthy well-being and care into each. The creation of such a culture should follow an iterative path, requiring repeated feedback from people at every organizational level. Care must be taken to ensure that giving feedback is safe, without fear of reprisal. After any changes, assessments must be made to ensure that the changes are effective—these assessments can be in the form of formal survey instruments, focus groups, or surrogate markers of engagement, such as employee retention or involvement in voluntary organizational activities. Mentorship meetings should incorporate both work and life factors into goal setting, taking care to strategize ways in which balance can be attained on an individual basis.

Finally, given the continued burden of depression, suicide, and substance use disorders in medicine and anesthesiology,[29,30] a goal of any well-being initiative should be to create a culture in which anyone who needs help, gets help, with no barriers attributable to stigma, fear of career impact, time constraints, or ability to pay. Institutions and leadership should ensure access to mental health resources. Seeking help must be seen as a laudable act of professionalism and the expected course when in need.

Potential Limitations

Our survey was disseminated in March 2020, just before the escalation of the COVID-19 pandemic in the United States. This pandemic has disproportionately affected anesthesiologists on the front line.[49] However, because of the timing of our responses, the pandemic likely had a minimal effect on the data. The pandemic began to escalate in the last week of March 2020 and did not initially peak in the United States until April 2020.[50] As noted, 83.3% and 99.5% of the responses to our surveys occurred before March 20 and 24, respectively. Therefore, the responses represent rates of burnout just before the pandemic and may not represent levels of burnout and stress currently. Our effective response rate was low at 13.6%, likely because of the increased email burden and the truncated schedule of email reminders. Given the volume of email communication experienced throughout March 2020 regarding the emerging COVID-19 pandemic, cognitive bandwidth to participate in extraneous tasks like voluntary survey studies was likely impacted. Even so, the response rate in this study is not much lower than those in recent large-scale studies of burnout, which were slightly more than 17%.[4,24] Other factors possibly contributed to the low response rate, such as survey fatigue or burnout itself. Furthermore, our sample being similar to the overall population of ASA member anesthesiologists suggests that our results are generalizable to the larger population. Finally, we used the complete Maslach Burnout Inventory Human Services Survey questionnaire, which contains 22 items; although use of a well-validated survey instrument is certainly not a limitation, the length limited the number of additional questions feasible to ask. Therefore, only select personal and practice factors could be queried, and additional risk factors, such as geographic location, were not collected.

Conclusions

Given the inherent stress of anesthesiology, burnout is not an unexpected occupational hazard. No clear trend of burnout rates over time has been established among anesthesiologists, although the landscape continues to evolve dynamically. In this large, national, survey-based study of anesthesiologists, the prevalence of high risk for burnout and burnout syndrome were high (59.2% and 13.8%, respectively). Burnout was primarily associated with workplace factors, particularly the lack of feeling supported in work-life. The high rates of high risk for burnout and burnout syndrome identified here demand attention in the form of well-designed interventions that factor in the drivers of burnout in this population. These factors include lack of support at work and home, long work hours, staffing shortages, and issues related to sexual and gender identity. These risk factors can be used to identify anesthesiologists at risk for burnout and to design initiatives to reduce the risk of burnout and manage existing burnout among anesthesiologists.

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