By Victoria Stern

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General surgeons and gastroenterologists experience high levels of burnout, due in large part to an overabundance of bureaucratic tasks and overwhelming work hours, according to findings from Medscape’s 2013 physician lifestyle survey.

The online survey collected responses from 24,216 U.S. physicians in 25 specialties, 2% of whom were gastroenterologists (GIs) and 2% of whom were general surgeons. Of the survey respondents, 83% of general surgeons and GIs were men; 60% or more were 45 years and older; and the majority were board certified (84% of general surgeons and 94% of GIs).

According to the survey, 42% of general surgeons and 37% of GIs reported being burned out, which Medscape defined as feeling any or all of the following: cynicism, loss of enthusiasm for work or low sense of personal accomplishment. These findings match well with a 2012 national survey on physician burnout, which found that about 45.8% of physicians experienced at least one symptom of burnout (Arch Intern Med 2012;172:1377-1385).

General surgeons were among 10 specialties that reported the highest rate of burnout, with emergency medicine (52%) and critical care (50%) taking the top two spots. Gastroenterologists were among 10 specialties that experienced the lowest percentage of burnout, which included pediatricians (35%), psychiatrists (33%) and pathologists (32%).

“Surgeons are at particular risk for burnout as we are taught early on that exhaustion is perceived as a status symbol and to base our self-worth on being productive,” said Henry Kuerer, MD, PhD, FACS, professor of surgery at the University of Texas MD Anderson Cancer Center, Houston. “I worry that the burnout rate may be higher, as the survey might not capture even more harried physicians or those who have left their profession.”

In terms of severity of burnout, general surgeons ranked highly, with a mean score of 3.9 (1 being “does not interfere with my life” and 7 being “so severe that I am thinking of leaving medicine altogether”). Only two specialties reported more severe levels of burnout: OB/GYN at 4.1 and pathologists at 4. Gastroenterologists had slightly less severe burnout than general surgeons, with a mean score of 3.6.

For both general surgeons and GIs, too many bureaucratic tasks and hours at work as well as the impact of the Affordable Care Act topped the list of main stressors leading to burnout, garnering scores above 4.5 (1 meaning “not at all important” and 7 meaning “extremely important”). The least important stressors for both specialties were problems with employers, compassion fatigue and difficult colleagues or staff (Figure).

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Figure. Causes of physician burnout.
Source: Medscape.com

“The introduction of EMR [electronic medical records] has contributed to the problem of physician burnout to the extent that some of my colleagues have quit because of it,” said Robert J. fitzgibbons, MD, Harry E. Stuckenhoff Professor of Surgery, Creighton University School of Medicine, Omaha, Neb. “EMR has increased the amount of paperwork tremendously, and what’s particularly disturbing, EMR is a poor way of keeping records.”

Dr. fitzgibbons noted that the electronic forms often provide choices that do not adequately reflect patient information and each form takes about 30 minutes to fill out. After seeing 25 patients a day, Dr. fitzgibbons has hours of paperwork to complete at home. “I spend a lot of time inputting patient information, yet I get a worse record, whereas in the past it took five minutes to dictate a summary of the patient visit,” he said.

Although long hours likely contribute to career dissatisfaction, John Maa, MD, FACS, noted that another reason for burnout may be perceived diminished rewards (financial and societal prestige) for certain surgeons.

“After long years of arduous training, some older general surgeons in practice have become concerned about the sustainability of the current residency training paradigm, the future practice of general surgery, and feel that the years of investment they made are not returning the rewards they had anticipated.” Dr. Maa is assistant professor, University of California, San Francisco Division of General Surgery, and director of the UCSF Surgical Hospitalist Program.

Dhruv Khullar, a student and class president at the Yale School of Medicine and a student at Harvard University’s Kennedy School, agreed that many factors contribute to burnout—namely high workloads, long hours, loss of autonomy and an increasing amount of administrative work—but believes these are symptoms of a greater problem.

“I think what’s at the heart of the problem is that these challenges make it difficult for trainees and physicians to continue to focus on the reasons they got into the profession,” he said. “In the midst of the day-to-day grind, it can be easy to lose one’s enthusiasm and drive for providing the highest-quality, compassionate care.”

The Medscape survey also revealed that the rate of burnout is lowest among the youngest and oldest general surgeons and GIs, peaking in midlife, with 35% of burned-out general surgeons between the ages of 46 and 55 years and 33% of burned-out GIs between the ages of 36 and 45; this percentage decreases to 11% of general surgeons and 5% of GIs after age 65, probably related to retirement or reduced hours.

Consistent with most specialties, female general surgeons appeared to be slightly more burned out than their male counterparts (43% vs. 39%). Medscape proposed that women may experience greater burnout because of more conflicts between work and home life.

In terms of physical health, the survey found that burned-out physicians tended to weigh more and exercised less than their less stressed counterparts: 55% of burned-out general surgeons reported being overweight or obese (vs. 46% of their peers not experiencing burnout), and 55% of burned-out general surgeons claimed to exercise two times per week (vs. 67% of their peers). Drinking and smoking habits as well as religiousness did not appear to be associated with level of burnout.

Other studies examining physician lifestyle have observed emotional exhaustion to be a major reason for physician burnout. A 2009 study that surveyed 3,233 general surgeons and 4,628 surgical subspecialists found that 41% of general surgeons reported burnout, which included high levels of emotional exhaustion and depression and low ratings of mental quality of life (Ann Surg 2009;250:463-471). Another study that looked at the degree of stress and burnout in 410 endoscopists found that emotional exhaustion was the major contributor to burnout, reported in 30% to 63% of respondents (Am J Gastroenterol 2011;106:1734-1740). The complexity of procedures and age were also main reasons for burnout, with interventional GIs and younger attendings reporting higher levels.

Effect of Burnout

Although the impact of burnout is not well understood, it may be serious, in some instances resulting in medical errors and physicians leaving medicine.

“We do not know the full impact of stress and burnout in gastroenterologists, but prior studies have shown that higher levels of burnout tend to result in early retirement; thus, those physicians with the most experience may prematurely leave medicine,” said Rajesh N. Keswani, MD, assistant professor in medicine-gastroenterology and hepatology at Northwestern University Feinberg School of Medicine, Chicago. “Even more concerning, it has been suggested in the surgical literature that higher levels of burnout were associated with medical errors (although unclear if the burnout was the cause of increased errors).”

Supporting this idea, a survey of more than 7,900 members of the American College of Surgeons showed that the number of hours worked and nights on call per week have a strong impact on surgeons’ level of burnout, depression and career satisfaction (JACS 2010;211:609-619). For instance, surgeons who worked more than 80 hours per week reported more medical errors than those who worked fewer than 60 hours per week (10.7% vs. 6.9%; P<0.001), and these overworked surgeons were twice as likely to attribute the error to burnout (20.1% vs. 8.9%; P=0.001).

“There is an unhealthy scarcity mentality that is becoming pervasive in health care systems. Not enough patients, money, time, reimbursements, etc.,” Dr. Kuerer said. “Hospitals and their physicians are afraid that they will not be able to compete. To some extent this promotes innovation, but also has the risk of demoralizing and demotivating not only physicians but all employees in the system.”

Burnout Survey and Beyond

Commenting on the usefulness of the Medscape survey, Dr. fitzgibbons said, “I don’t put much faith in these questionnaires because they’re not objective enough. I could see myself answering the questions very differently from one day to the next.” But, he added, “I think burnout is an important issue, which is on the increase as medicine changes.”

Lawrence Cohen, MD, a gastroenterologist and clinical professor of medicine at Mount Sinai School of Medicine, New York City, believes the survey overrated the number of GIs who suffer from burnout based on how Medscape defined the term. “I define physician burnout as physical and emotional exhaustion combined with diminished sense of personal satisfaction and accomplishment,” said Dr. Cohen. “Based upon my anecdotal experience, I would say that fewer than 10% of GIs [not 37%] suffer from true burnout. While I do believe that the vast majority of GIs are working harder than previously, they remain fully engaged in their professional activities, are satisfied emotionally and continue to be rewarded intellectually.”

Dr. Maa thinks such surveys can be helpful if they “provide constructive feedback on how to make improvements” and “raise awareness with patients, the federal government and other quality improvement organizations of the demands being placed upon physicians across specialties.”

The key next step to understanding the problem of physician burnout is developing ways to combat it. Many studies have demonstrated that the increased levels of burnout in physicians may be reversible with a variety of focused interventions.

“The studied interventions generally consist of counseling and mindfulness-based stress reduction exercises,” Dr. Keswani said. “Perhaps more intriguing is the potential use of senior physicians as mentors to prevent burnout in junior colleagues.”

Mr. Khullar believes that an important component of the solution is to create an environment that focuses on the importance of patient care and allows doctors to process and feel energized by these encounters.

“At my medical school, there was an option to attend weekly sessions at which students discussed what they were enjoying or struggling with in their training,” he said. “Similarly, a friend recently told me of an attending that always made sure his team took time to thoroughly discuss a patient’s death or other difficult experiences on the wards. Things like that go a long way [toward] preventing burnout and maintaining professional satisfaction.”

Dr. Maa agreed that acknowledging burnout in colleagues and oneself may help reduce it, but he also proposed taking actions that extend beyond the hospital.

“I believe the crucial next steps are for surgeons to vigorously engage in the health care reform debate, and pave new career paths and goals, particularly in the fields of government and public policy,” he said.

Although the problem of burnout is important, what keeps Dr. fitzgibbons motivated is simple: loving the job. “One can always complain, but in the end being a surgeon is a wonderful job,” he said. “I would never want to have another career.”