What Causes Burnout? It Could be Your Hospital

You have likely heard the alarm bells—the percentage of orthopedic surgeons experiencing burnout at some point in their career are at 40% to 60% rates.^1-3 And while you may have heard advice such as, “Take a yoga class,” a new study points at what may well be a more powerful solution and that is how systemic hospital or clinic strategies can more effectively reduce the incidence rates of burnout than such individual efforts.

The seven-center study, “System-Level Interventions for Addressing Burnout and Improving Professional Wellness for Orthopedic Surgeons,” appears in the February 1, 2023, edition of The Journal of the Pediatric Orthopaedic Society of North America.

The study took a careful look at the role of such systemic issues as burdensome workloads, administrative encumbrances, inadequate job resources, and lack of work-life balance and their role in individual surgeon burnout. Furthermore, the authors discuss existing evidence-based organizational strategies for tackling the problem—strategies, incidentally, that emanate from such well known and regarded institutions as the World Health Organization and the National Academy of Medicine.

A Treatment Plan for Burnout

The study authors identified seven key themes for tackling burnout, specifically:

1. recognizing the presence of burnout and investing in strategies to measure and address it;
2. harnessing leadership support and commitment;
3. establishing and sustaining a culture of wellness and support;
4. promoting diversity and inclusion in the workplace;
5. securing access to mental health care and promoting individual resilience;
6. reducing workplace inefficiencies; and
7. enhancing orthopedic surgeons’ autonomy and control.

Focus on System-Wide Solutions

Study co-author Alfred Atanda, M.D., a pediatric orthopedic surgeon and chief of sports medicine at Nemours Children’s Health, Delaware Valley, has made it his mission to lessen his colleagues’ work-related distress and burnout. For the last three years, Dr. Atanda, director of clinician well-being at Nemours, has devoted 20% of his time to ensuring that doctors have every opportunity to enhance and maintain their psychological health.

“This study was striking in its finding that compared to system-level interventions, it’s the individual-level interventions that are not very effective. In previous decades well-being was promoted by putting the onus on the individual, i.e., ‘You work in a terrible environment, and you need to figure out a way to deal with that. Go meditate or something.’ This research demonstrates that it’s time to flip this model on its head.”

While yoga, mindfulness and the like are part of the picture, says Dr. Atanda, they alone will not move the needle on the epidemic of burnout.

But other things will. “It is vital to introduce a culture of wellness. Traditionally, we have thought about wellness as being separate from our jobs. But what is needed is to cultivate ideas that support people in becoming better team members. The fact is that many people who are put in leadership positions are chosen because they have worked somewhere the longest … but they are never taught how to lead. Just because you are a doctor doesn’t automatically mean you know how to lead others. There are 12-15 types of leadership models that must be employed at different times and circumstances, so there is substantial room for education.”

“We also found that enhancing efficiency is critical and is largely composed of two things: optimizing electronic health records and workplace efficiency. We must eliminate barriers that prevent people from doing their jobs well. There are so many external regulatory pressures and barriers—legal regulations, nursing guidelines, compliance issues—that physicians are even more burdened.”

$500,000 – $1 Million to Replace a Doctor

There are significant personal and professional ramifications associated with surgeon burnout. And while a hospital administration doesn’t always get deeply involved when doctors are using substances, undergoing a divorce, or engaging in suicide ideation, in the event of medical errors, decreased patient satisfaction, and higher physician turnover due to burnout … they listen. Research has shown, that depending on the specialty, it takes between $500,000 and $1 million to replace a doctor.⁴

Blaming the Surgeon for Their Own Stress

“About five years ago I began noticing that trainees were not receiving any instruction on the soft skills needed in order to be successful as an attending surgeon,” said Dr. Atanda to OTW. “They weren’t learning how to communicate, work as a team, or resolve conflict. These are critical skills … and frankly, there are just so many situations where being an orthopedic surgeon doesn’t help. I began lecturing on these subjects at Nemours and then gradually began to do the same at various hospitals around the U.S.”

“During my own training the ethos was that if you were struggling, there was something wrong with you and you just couldn’t handle the rigors of being a physician. Now, we are realizing that burnout is the manifestation of stressors put on people in the workplace—it is an occupational hazard just as if you were to cut yourself with a saw during surgery.”

“The traditional setup is that hospital systems expect doctors to make them money and then everything else is up to us. However, the system needs to empower physicians and other clinicians with the skills they need to work at their maximum potential.”

Stress Is a Systemic Problem

At a 2021 symposium on physician well-being, Dr. Atanda met people who would become his coauthors on two related academic papers. “It was the pandemic and we wanted to strike while the iron is hot.”

“We are finally moving to a place of recognizing that burnout is a systemic problem that results from excessive workloads, administrative burdens, inadequate job resources, and lack of work-life balance. Although primary care and other areas of medicine have done a good job of addressing these issues, orthopedics has lagged behind—until now. Fortunately, we are seeing a groundswell of support among clinicians, researchers, national medical associations, and community organizations to develop system-level strategies to address burnout.”

Workarounds, Don’t Work

“Sometimes we doctors are our own worst enemies. Because we are trained to be ‘MacGyver’s,’ we are masters at the workaround and do whatever it takes to get the job done, meaning that we help to promote a culture of workplace inefficiency. For example, during my residency, I saw patients who needed casts … but there was no casting material because it was a non-orthopedic floor. So, my fellow residents and I would take a bucket, go to the supply closet, get plaster and carry it around with us. It would have been much more efficient in the long run to talk to the people in central supply and figure out how to have a baseline amount of orthopedic supplies on every ward. These workarounds circumnavigate our actual jobs and then we have no incentive to fix the root problem.”

Huge Cause of Burnout: Lack of Autonomy

Gone are the days when doctors were genuinely in charge, says Dr. Atanda. “Many physicians have zero autonomy over their days and that has emerged as a huge risk factor for burnout. As surgeons our time is very valuable, and our presence equates to money for the hospital. We are told, ‘You need to be in clinic 3.5 days/week, and this is your admin time.’ Ideally, we would be told, ‘You have five days this week for 60 patients.’ Then I could take it upon myself to do the work when it’s most convenient for me. I could go on a field trip with my son on a Thursday and stack my procedures on the other days. The traditionally rigid way of scheduling surgeons causes problems in the long run and needs to be loosened up.”

One Vulnerable Orthopedic Group: Residents

In another study, Dr. Atanda and his colleagues examined burnout rates among orthopedic surgeons. The research, “A Comprehensive Umbrella Review for Understanding Burnout in Orthopedic Surgery,” appears in the February 1, 2023, edition of The Journal of the Pediatric Orthopaedic Society of North America.

In their paper, which included eight systematic reviews and eight narrative reviews, Dr. Atanda and his colleagues took a deep dive into the rates, prevention, and management of burnout in the field.

Dr. Atanda and his team determined that orthopedic residents were particularly at risk of experiencing burnout, with estimates of one in two being affected. “We found that burnout was highly associated with being a female or a racial minority, experiencing work-life imbalances, and not having spousal support. The work-related factors included long hours, stressful work relationships, and anxiety about one’s clinical competence.”

And what of family factors?

“Training can be so stressful, so we might think that having a spouse adds to that … but this work showed that overall, having someone in your life is probably better than being alone. Children were also found to be helpful in warding off burnout.”

“When people are exhausted from the demands of their job, it can lead to depersonalization. For example, if a burned-out doctor has 20 patients on the clinic schedule for the day, but 5 drop off, his or her initial reaction isn’t, ‘Oh, that’s too bad I don’t get to help those other five people.’ No, the fact is that you are elated because it’s less work and, critically, less documentation. While theoretically medicine is a calling, the fact remains that it is also a job. That’s fine if the physician has enough support, but if not it’s a recipe for eventual burnout.”

Expert’s Recommendations? Start Small

“Preventing burnout can be daunting, so I always advise that you start with you and your group and really listen to people on the front lines. Sometimes administrators and/or doctors come up with solutions to problems that they think are meaningful … but they aren’t so meaningful to those who will do the work. Just listen—to lead the people you must walk among them. What’s happening with the folks at the check-in desk? What issues are they having in patient transport? You should aim for things that are easy to implement and have a high impact.”

Momentum and Autonomy

“Don’t set out saying, ‘I am going to change the culture here.’ Start with, ‘I will ensure the medication room has the right syringes to deliver the meds.’ This is small and tangible and does a couple of things. First, it gives you some momentum. Second, it gives you the notion that you can actually do something to improve the situation. Often, burnout leaves one feeling hopeless but taking it slowly can help begin to recapture feelings of hope and autonomy.”

Dr. Atanda, a member of the American Medical Association’s Practice Sustainability and Professional Satisfaction Committee, adds, “Just as burnout is contagious, positivity is also contagious … aim for the latter and gain some momentum.”

And while a good attitude will go a long way, ultimately, it can’t “right” the system. That is the system’s responsibility.

When OTW asked about what he hopes for going forward, Dr. Atanda noted, “I imagine a world where doctors are able to work in a way that doesn’t interfere with who they are as people. It’s terrible to see this slow chipping away at our values and erosion of why we went into medicine, I call it my pearl. If I gave you an oyster and said, ‘Take your pearl’ it’s no problem. If I threw that same oyster into the ocean, then you have to dive for it and it would be impossible to find your pearl. That’s what it’s like for a lot of doctors. I was 17 when I went into medicine and now at the age of 44, I feel like those reasons are at the bottom of the ocean. I want a healthcare system where doctors can look at their pearl every day and find the joy they used to experience.”

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