Burnout: Not Pretty, but Important

Dread … rhymes with dead…which is sort of what you feel inside when you are burned out.

Dread … as in, “Do I have to go to work?”

Suspicion/cynicism … as in, “Are my patients/staff trying to make my life miserable?”

These and similar thoughts have little alarm bells tied to them … and may indicate burnout. And yes, it happens to doctors. In fact, the statistics say that it’s burning through doctors. More on that later ….

As in you have no more fuel … nothing more to give. Except maybe some irritation.

Alan Daniels, M.D., an orthopedic spine surgeon at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, published his study, “Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention,” in the April 16, 2018 edition of the Journal of the American Academy of Orthopaedic Surgeons.

Dr. Daniels described his motivation for the study to OTW, “My colleagues and I found that an alarming percentage of orthopedic surgeons showed symptoms of burnout—50%. The highest numbers were amongst residents and chairs. These individuals often feel like they have a lack control over their lives.”

“Residents are told where to go, how long to work, and in general, live according to others’ schedules. Chairs stress over their work with their department, national societies, their educational responsibilities, their practice, and are pulled in so many directions that avoiding burnout seems like a minor miracle.”

Work Hour Restrictions Don’t Lower Stress

The residents … aren’t they working less anyway? Didn’t the work hour restrictions take care of a lot of the stress?

“We found that implementation of work-hour restrictions in the U.S. has not improved the burnout rates in American trainees,” says Dr. Daniels. “It is not simply an issue of numbers of hours worked—80 hours are still a lot of hours to work. These people still lose a great amount of control of their lives and are understandably bothered by not being able to make their own decisions.”

“But we can’t just simply follow the European model where trainees work fewer hours, but the program of study is extended. Some studies show that this is actually more difficult for trainees because training is prolonged and those involved feel like they are not getting enough training.”

And what about the chairs, essentially self-selecting people who are determined to scale every academic mountain? “It is harder to give chairs freedom. They tend to be very ambitious people who are at the top of their game … and they got there for a reason. At some point they hit the ceiling of achievement and have nowhere to go.”

So, get them three assistants!

Dr. Daniels: “These are people who want to do it all … and you can’t makethem delegate every task, and many tasks can’t be delegated.”

But there is something. “Work by Khaled Saleh, M.D. found thatfor orthopedic chairs in particular, strong personal relationships—especially relationships with spouses or children—were among the most powerful protective factors against emotional exhaustion.”

Another interesting finding from Dr. Daniels’ work was that faculty at larger programs are more likely to display symptoms of loneliness and increased irritability. “Perhaps young people who train at a large facility simply get lost in the shuffle. They feel the loss of community and unfortunately have an isolating experience at work.”

So, surgeons feel a loss of control … and perhaps those at the helm feel a loss of control as far as how to handle this worrisome trend.

Enter the Maslach Burnout Inventory Human Services Survey for Medical Personnel, a research-based tool that measures emotional exhaustion, depersonalization, and personal accomplishment.

Dr. Daniels: “It could be possible to implement mass screenings of orthopedic surgeons using this inventory at the hospital level during the credentialing or annual retraining process, although the credentialing process is already so arduous that adding more questions about burnout will only increase the work load on already time-strapped physicians! We could also add the questionnaire to standard residency surveillance activities.”

It’s not surprising, says Dr. Daniels, that physicians are burning out. “Orthopedic surgeons feel burdened by senseless paperwork and seemingly useless meetings and so often do not feel part of any community.”

Controlling the Uncontrollable

Adding to the difficulties is the fact that surgeons are take-control people—not exactly the type to emit a cry for help. “Because surgeons won’t to admit that they need help, it is often too late before anyone realizes they are burned out. For residents, a mentorship model would be helpful, as the person could look up to someone with a healthy work-life balance.”

“At the faculty level, our findings show that decreased burnout was correlated with increased perception of a supportive work environment, having a mentor, getting acceptance into a national specialty organization, and the absence of personal issues in the workplace.”

And little is more personal than your gender. “Because orthopedics is a traditionally male-dominated arena, women may feel that they have to conform to male culture, which is to suppress any feelings of stress or burnout.”

But male or female, there are proven methods that, implemented regularly, will reduce your chance of completing flaming out. “Take the athlete model,” says Dr. Daniels. “They are taught to proactively handle moments when their performance isn’t what they hoped for. These tools involve things such as meditation, deep breathing, and visualization.”

“All of this is very understandable … spending three hours per night charting is not rewarding and is not why someone entered the medical field.”

Sheila K. Collins, Ph.D., a writer, speaker and author of, “Stillpoint: A Self-Care Playbook for Caregivers to Find Ease, and Time to Breathe, and Reclaim Joy” explained to OTWthat “burnout is the natural culmination of overwork, lack of support, and a host of other things that cause a person to spiral into something that mimics—or truly is—depression. Very few people are actually taught selfcare skills—we are taught to just keep going.”

The Signs of Burnout

So, for doctors, what brings on burnout? “There is the pressure of physician groups being purchased, the pressure of seeing a certain number of patients a day, family pressures, etc.” says Dr. Collins. “In a 2011 study of 7,000 physicians the frequency of burnout was 41%; by 2014 it had increased in all specialties. In late 2015 a Mayo Clinic study found that more than half of American doctors had at least one symptom of burnout.”

Signs you may be burned out:

The joy has gone out of what you passionately “signed up for” and cynicism has set it … ’Is this it?” you think.

• Physical and mental exhaustion.
• Compassion fatigue—you just can’t muster the energy to care anymore.
• Alcohol or drug abuse.
• Sense of inefficacy: “My work doesn’t matter.”
• Depersonalization—you are just going through the motions.
• Overeating/obesity—you are “stress eating” or you think that you will get more energy if you eat more.

Dr. Collins says, “People seem to have to fight for family time these days, with even kids having tight, packed schedules. Reconnecting to oneself and to your family requires unplugging electronic devices and being together. When you ask a physician why they work so hard they will usually say, ‘For my family.’ But if you never see them then what is the point?”

What does Dr. Collins recommend to combat burnout? “You take care of other people’s bodies all day, but it is vital to be kinder to your ownbody. Meditative practices that involve moving—such as yoga or Tai chi—can go a long way to rejuvenating your body and spirit.”

And if you say you don’t have time, well, think about how much time you will have if you burnout and lose your job, end up in rehab, etc. Prevention, prevention, prevention!

Dr. Collins advises, “Look for the ‘still point’, i.e., the body as experienced from the inside. Find the quiet in the storm—your center. There isa quiet place inside you if you take the time to find it. Doing breathing exercises for 5 minutes can establish a positive, energetic basis for your day.”

“Some doctors have had success because they have seen the red flags and taken the opportunity to change the way they are doing their work; even a small change can make a big difference. For example, I know of one practice where the doctors encourage each other to leave the office and go golfing every Thursday afternoon. It has done wonders for their mental health andproductivity.”

Gather your inner control freak and take control by reaching out for help.

Dr. Daniels has the last word: “If you find yourself increasingly irritable and withdrawing from those around you, know that these are early warning signs of burnout. Tell someone. Put any possible shame to the side and take control of your life.”

Author’s note: As a psychotherapist, I wholeheartedly support the idea of implementing the Maslach Burnout Inventory. I propose that those in the leadership of the national societies seek out orthopedic surgeons who have almost reached the burnout stage but were able to ask for help and avoid disaster. These individuals could create video presentations that could be shown to medical students, residents, etc.