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Updated: 7/1/2022

Burnout in Orthopaedics

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  • Summary
    • Burnout (Exhaustion syndrome and professional burnout) is a condition characterized by emotional exhaustion, depersonalization, and a sense of loss of personal accomplishment.
    • Diagnosis is made using validated questionnaires such as the Maslach Burnout Inventory and Professional Fulfillment Index.
    • Treatment involves a combination of leave of absence, medications, therapy, and workplace modifications.
  • Introduction
    •  Definitions
      • burnout 
        • occupational phenomenon  
        • syndrome conceptualized as resulting from chronic workplace stress that is not successfully managed (World Health Organization) 
        • three domains
          • emotional exhaustion
            • depleted feeling from excessive emotional and psychological demands
          • depersonalization
            • view others in a detached and impersonal manner
          • personal achievement
            • sense of competence or accomplishment 
      • professional quality of life
        • both the positive and negative effects an individual experiences as a provider
        • two domains
          • compassion satisfaction 
          • compassion fatigue
      • compassion satisfaction 
        • pleasure caregivers experience from helping others and the degree to which they feel successful 
        • protective against burnout 
      • compassion fatigue
        • emotional and physical exhaustion leading to a diminished ability to empathize with patients 
          • "cost of caring"
        • two components 
          • burnout 
          • secondary trauma stress
      • secondary Trauma 
        • post-traumatic stress disorder-like symptoms from repeated exposure to stressful event and  suffering of patients
    • History
      • Herbert Freudenberger (1970s)
        • psychologist who first described the term in 1974 and considered the founding father of the concept of burnout  
        • defined it as becoming exhausted by making excessive demands on energy, strength, or resources in the workplace
        • focused on qualitative and descriptive research
      •  Christina Maslach (1970s - 2000s)
        • psychology professor who further redefined burnout to include 3 domains
          • exhaustion, depersonalization, lack personal achievement 
        • focused on quantitative research and measuring burnout 
          • developed the Maslach Burnout Inventory (MBI) in 1981
      • World Health Organization (2019) 
        • recognized as an occupational health crisis 
        • defined it an occupation phenomenon and distinguished it from a medical diagnosis or disorder
  • Epidemiology
    • Incidence
      • 40-60% for orthopaedic surgeons  
      • varies by career level 
        • residents (40-50%) > attending (25-30%) > fellows (10%)
        • PGY-2 at greatest risk 
    • Burnout by subspecialty 
      • highest rates
        • Oncology, Sports, Trauma
      • lowest rates
        • Shoulder and Elbow, Pediatrics, Foot and Ankle
    • Risk factors
      • female 
      • early in training or practice career
      • racial minority 
      • pre-existing mental health conditions
      • alcohol and substance use
      • work-life imbalance
      • lack of exercise
      • inability to attend health maintenance appointments 
      • marital status (single)
      • lack of program support
      • larger residency programs (6 or more) 
    • Protective factors 
      • parenthood
      • married 
      • spending time with spouse
      • parent was a physician
      • deriving satisfaction from speaking about concerns with colleagues, family, and friends
      • duty hour limitations
      • compassion satisfaction 
      • peer support
      • good patient relationship 
    • Associated conditions
      • depression
      • suicide 
      • medical errors 
      • substance or alcohol abuse
      • burnout in spouse 
        • 25-30% experience burnout
        • up to 75% report burnout had a negative effect on personal relationship 
      • sleep deprivation 
        • 92% of residents and 79% of faculty 
      • hypertension
      • metabolic syndrome
      • cardiovascular disease
      • infertility
    • Economic Costs
      • health care system 
        • $4.6 billion estimated total annual cost due to physician burnout in US
          • 60% more likely to take a sick day
          • 2.5x more likely to look for new job
        • 8% of national health care expenditure attributable to stress alone
        • burned-out employees cost $3,400 out of every $10,000 in salary due to disengagement 
        • $125-190 million in additional health care cost from workplace stress 
      • patient
        • medical errors
        • lower quality of care
        • lower patient satisfaction 
      • physician 
        • suicide
        • depression
        • substance abuse 
        • malpractice
        • poor self-care
  • Etiology
    • Contributing variables
      • work overload
        • administrative and bureaucratic tasks
          • top contributor to burnout among orthopedist
          • quality metrics and reporting, prior authorization process, coding, excessive documentation  
        • unmanageable work schedules and inadequate staffing
        • workflow, interuptions, and distractions
        • inadequate technology usability
        • time pressure and encroachment on personal time 
        • constantly evolving health care industry and need to stay informed
          • health care reform and payment policies 
          • expansion of technology (AI, augmented reality, robotics, wearables) 
          • telemedicine
          • privacy, security and other compliance measures     
      • breakdown of community
        • lack of respect or support from peers or administration
          • 2nd largest contributor to burnout 
        • lack of camaraderie 
        • poor organizational culture
      • insufficient rewards
        • insufficient compensation or reimbursement 
          • 3rd largest contributor to burnout 
        • social rewards (ie recognition or praise) 
      • lack of control 
        • inflexible schedule
        • lack of practice autonomy
        • dismissal of feedback 
        • lack of cross coverage
        • limited maternity/paternity leave
      • conflict of values 
        • mismatch of values and expectations between physician and employer
        • disconnect between mission statement and daily proceedings 
        • degrade patient-physician relationship
          • sense of prioritizing cost and documentation over patient care
      • lack of fairness
        • inequity of workload or pay
        • unfair evaluations or performance reviews 
        • mishandling of promotions
    • Pathophysiology
      • multiple pathways/organs affected
        • upregulation of sympathetic nervous system 
          • sympathetic-adrenal-medullary (SAM) axis
          • catecholamine release
        • inhibited parasympathetic nervous system
        • activated hypothalamic-pituitary-adrenal axis
          • cortisol and DHEA imbalance
        • functional and structural changes of brain
          • decrease in volume of hippocampus and frontal lobes
          • decrease neurogenesis 
          • decoupling interconnections of brain  
        • immune system dysfunction 
          • pro-inflammatory state
        • end organ injury 
  • Presentation
    • Signs and symptoms 
      • emotional 
        • detachment
        • anxiety
        • sadness
        • lack of emotion
        • irritability
      • behavioral 
        • withdrawal
        • isolation
        • cynicism 
        • resentment
        • hostility
        • addictive behaviors
        • loss of motivation
        • frequently late or missing work substance abuse 
        • substance abuse 
      • cognitive
        • sense of failure and doubt
        • memory problems
        • difficulty concentration
        • lack of creativity 
      • physical 
        • lack of energy
        • sleep disturbances
        • generalized aches  
        • muscle tension
        • gastrointestinal issues
        • hypertension 
  • DIAGNOSIS 
    • Missed diagnosis
      • most common reasons burned-out orthopedic surgeons don't seek help
        • symptoms are not perceived to be severe enough (~50%)
        • too busy (40%)
    • Validated diagnostic questionnaires 
      • Maslach Burnout Inventory (MBI)
        • one of the most widely used and validated tools to measure burnout
        • 22-item self-reported questionnaire
        • all 3 domains of burnout assessed 
          • emotional exhaustion
          • depersonalization
          • personal accomplishment  
      • Professional Quality of Life scale (ProQOL)
        • comprehensive assessment of the positive and negative effects of helping others experiencing trauma or suffering
        • 30-item self-reported questionnaire
        • assess 3 domains
          • burnout
          • compassion satisfaction
          • secondary trauma stress
      • Professional Fulfillment Index 
        • 16-item survey
        • assess 3 domains 
          • work exhaustion
          • interpersonal disengagement   
          • professional fulfillment  
      • Mini - Z
        • 10-item survey validated against MBI
        • assess 3 domains and risk factors for each
          • satisfaction
          • stress
          • burnout
  • Treatment 
    • Emergent Hospital Admission / Care
      • indications
        • suicidal ideation
        • mental health crisis 
        • substance abuse
    • Outpatient Cognitive / Multimodal Treatment
      • indications
        • early disease with
          • physician (patient) not at risk
          • no evidence of impaired care to patient
      • modalities
        • leave of absence or Sabbatical  
          • disconnect from professional demands
          • rediscover values and work-life balance
          • reorganize priorities 
          • mental and physical recovery
        •  medical treatment and therapy 
          • medications
            • treat associated mental health conditions
          • mind-body therapy and mindfulness activities 
          • psychotherapy 
          • counseling session and workshops
            • time management
            • stress management
            • marriage counseling
        • work environment modifications
          • acknowledge limitations 
          • prioritize tasks and delegate
          • workplace analysis and identify stressors
          • improve workflow
          • don't take work home
  • PREVENTION 
    • Oranizational-level (POSNA model) 
      • individual 
        • provide members with programs to build personal resilience
        • provide tools to identify, monitor, and measure burnout 
        • survey members 
        • understand and address specific stressors
        • understand business model that health care systems can use to prioritize well-being
        • understand factors unique to different populations 
      • unit or care team (peer support)
        • develop community of caregivers committed to creating collaborative culture
        • primary focus on developing exception teams 
        • secondary focus on developing exception team members to support team
        • provide programs to build team work and nourish compassion
        • create support groups and referral systems 
        • instruct "teachable" attributes and skills related to compassionate care and team work
        • teach techniques fir recruiting and hiring based on empathy, compassion, and emotional intelligence
        • explore impact of disruptive behavior (ie harassment, bullying) 
      • organizational 
        • develop organizational structure to achieve objectives
        • each committee should examine their specific goals/objective through lens of reducing burnout and improving wellness
        • teach organizational leadership skills
        • offer leadership courses
        • collaborate with other organizations to promote wellness 
    • Individual-level  
      • awareness
        • open dialogue and communication
        • honesty and vulnerability amongst stakeholders
        • COMPASS group
      • improve workload, efficiencies, and support
        • effective multi-disciplinary teams 
        • decrease clerical and non-visit care burden
        • analytic support for data management
      • enhance work culture and environment 
        • leadership behaviors
          • develop talent, transparency, recognize contributions, treat all with respect  
        • workplace community 
          • wellness program, team building, group dynamics and workplace culture, conflict resolution training
      • work-life balance, flexibility, and autonomy
        • limit off hours work demands
        • part-time status without limiting advancement opportunity 
        • flexible schedule 
        • personal time for relationships and hobbies
      • meaningful work
        • 20% of time spent on meaningful work decreases risk of burnout
        • recruit to match talents and passions to job
        • resources to accomplish low-meaning tasks (clerical or administrative duties) 
      • self care 
        • eat nutritious food
          • avoid eating high-stress diet of junk food as coping mechanism 
        • exercise regularly 
        • improve sleep habits
        • adjunct individual-level interventions 
          • mindfulness activities
          • stress reduction techniques
          • self reflection 
          • gratitude journal
          • meditation or yoga
        • believe in something bigger than yourself
        • spend time with significant others and family 
        • fill environment with mood-boosters (lighting, music, scents)
  • Complications
    • Depression
      • epidemiology
        • 2x more likely to commit medical error with depression
        • practicing surgeons
          • 15-30% orthopedic surgeons
        • orthopedic residents
          • 13% rate of depression
          • 2x than general population 
        • only 10% of residents seek help and more than 50% physicians hesitant to seek mental health care
        • risk factors
          • exceeding duty hour restriction
          • lack of program support associated with depression 
        • protective factors
          • practicing surgeons 
            • marriage or spousal support
            • career satisfaction
            • autonomy
            • academic setting
          •  orthopedic residents
            • strong mentorship
            • educational opportunities 
            • dedicated mental health resources
            • surgical independence 
            • increased case volume/variety
      • diagnosis
        • Patient Health Questionnaire-9 (PHQ-9)
          • score severity (0-27) of depression and recommended course of action
            • minimal or none (0-4): monitor, no treatment required
            • mild (5-9): use clinical judgement to determine necessity of treatment
            • moderate (10-14): use clinical judgement to determine necessity of treatment
            • moderately severe (15-19): warrant active treatment 
            • severe (20-27): warrant active treatment 
      • treatment
        • lifestyle changes
          • exercise
          • social support
          • nutrition 
          • sleep
          • stress reduction 
        • psychotherapy
          • group vs individual therapy
        • anti-depressant medications
        • transcranial magnetic stimulation
        • alternative treatments
          • mindfulness meditation
          • yoga or tai chi
          • relaxation techniques
          • vitamin or herbal supplements 
            • fish oil, vitamin D, folate, St. John Wort
    • Substance disorders 
      • epidemiology
        • orthopaedic residents 
          •  61% alcohol dependence and 43% alcohol abuse
            • risk factors
              • men
              • white race
              • single or divorced
          • 7% of use recreational drugs
            • divorced or single was associated with drug use
        • practicing surgeons
          • 15% rate alcohol dependence or abuse 
          • ~30% of orthopedist have 5+ drinks per week
      • diagnosis 
        • Alcohol Use Disorder Identification Test (AUDIT)
          • scores ranges 0-12 with higher scores indicating greater consumption 
          • hazardous alcohol use 
            • 3 or more for women
            • 4 or more for men
          • alcohol abuse
            • 4 or more for women 
            • 5 or more for men
      • treatment
        • SAMHSA national helpline
          • confidential free help getting information and finding treatment
        • inpatient versus outpatient rehab
        • multifaceted approach 
          • education about substance use disorders
          • group and individual counseling
          • self-help group
            • 12-step programs (ie AA, NA)
          • medication
            • reduce withdrawal symptoms and cravings 
              • naltrexone, acamprosate and disulfiram for alcohol abuse
              • nicotine replacement, bupropion, and varencicline for nicotine addition 
              • methadone or naltrexone for opioid addiction 
            • relapse prevention 
          • treat concurrent mental health disorders
          • relapse prevention training
          • long term follow-up to monitor for relapse
    • Suicide
      • epidemiology 
        • orthopaedic surgeons have highest prevalence of death by suicide among all surgical specialities (28%)
        • 2nd highest rate (18%) of suicidal ideation
        • Asian/Pacific Islander surgeon more likely than general population
        • increased risk with mental health disorders, alcoholism, legal issues
        • men more likely to commit suicide at an older age than women (64 vs 39)
      • treatment 
        • seek immediate treatment, call 911 or national suicide prevention lifeline if having suicidal thoughts 
          • see contacts above
        • education and prevention
        • address underlying mental health issues and substance use disorders as stated above
    • Malpractice/ Errors
      • epidemiology
        • 17% increased odds of being named in a medical malpractice suit 
        • higher level of depersonalization and emotional exhaustion lead to incrementally more errors
        • 2x increased odds of  
          • adverse patient safety incidents
          • lower patient reported satisfaction 
          • exhibiting lower professionalism  
      • treatment
        • systems approach 
          • prevention strategies 
            • leverage standardized systems (EHR, barcoding systems)
            • improve communication (ie handoffs)
            • surgical timeouts 
            • collaborative efforts 
            • involve patient
          • monitoring and reporting methods 
          • root cause analysis
        • communicating medical errors 
          • ethical and professional obligation to report medical error to patient   
            • disclosure conversation includes 
              • communicate error directly with patient/family as soon as possible 
              • what happened
              • why it happened 
              • health implication to the patient
              • identify measure being put in place to prevent recurrences
            • during conversation physician should 
              • sit down
              • listen attentively
              • work to understand concerns of patient and family
              • show compassion
              • acknowledge emotional response and need
          • AAOS advisory statement
            • "good communication has a favorable impact on patient behavior, patient care outcomes, patient satisfaction, and often reduces the incidence of malpractice lawsuits"

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