Extract
Burnout has many definitions but the most commonly accepted is "a
state of physical, emotional or mental exhaustion caused by long-term
involvement in situations that are emotionally
demanding."1
It tends to be most common among medical professionals as a result of long
working hours, stresses associated with the responsibilities of patient care,
and emotional contact with
patients2. According
to Jones, burnout—a syndrome of progressive emotional, attitudinal, and
physical exhaustion—is a critical occupational hazard for people in a
wide range of helping
professions3. Those
who are affected find themselves plagued by chronic fatigue, low energy,
irritability, and a negative attitude toward themselves, toward others, and
toward their jobs. Because they are emotionally depleted and cynical, they may
have a negative impact on those around them, including the individuals with
whom they work and the patients they treat. Among the members of the so-called
helping professions, physicians are clearly most afflicted with burnout and,
as we noted in our previous
report4, they have
by now been quite intensively studied. Characteristically, burnout syndrome
involves the development of a cynical attitude and the loss of concern for
people with whom one is working. In addition to physical exhaustion, which
harms physical health through many
pathways5, burnout
is also characterized by an emotional exhaustion wherein the professional
experiences growing negative feelings, cynicism, or disrespect for patients
and colleagues. "A very cynical and dehumanized perception of these
people often develops in which they are labeled in derogatory ways and
therefore treated
accordingly."6
Burnout has many definitions but the most commonly accepted is "a
state of physical, emotional or mental exhaustion caused by long-term
involvement in situations that are emotionally
demanding."1
It tends to be most common among medical professionals as a result of long
working hours, stresses associated with the responsibilities of patient care,
and emotional contact with
patients2. According
to Jones, burnout—a syndrome of progressive emotional, attitudinal, and
physical exhaustion—is a critical occupational hazard for people in a
wide range of helping
professions3. Those
who are affected find themselves plagued by chronic fatigue, low energy,
irritability, and a negative attitude toward themselves, toward others, and
toward their jobs. Because they are emotionally depleted and cynical, they may
have a negative impact on those around them, including the individuals with
whom they work and the patients they treat. Among the members of the so-called
helping professions, physicians are clearly most afflicted with burnout and,
as we noted in our previous
report4, they have
by now been quite intensively studied. Characteristically, burnout syndrome
involves the development of a cynical attitude and the loss of concern for
people with whom one is working. In addition to physical exhaustion, which
harms physical health through many
pathways5, burnout
is also characterized by an emotional exhaustion wherein the professional
experiences growing negative feelings, cynicism, or disrespect for patients
and colleagues. "A very cynical and dehumanized perception of these
people often develops in which they are labeled in derogatory ways and
therefore treated
accordingly."6
Gabbe et al.7
undertook a cross-sectional study, in which a questionnaire was sent to 131
chairs of academic departments of obstetrics and gynecology in the United
States and Puerto Rico, and had a 91% response rate. The study found that 22%
of the chairs were very dissatisfied with their positions. Using the Maslach
Burnout Inventory-Human Service Survey (MBI-HSS), the study revealed a high
subscale score for emotional exhaustion, together with a moderate-to-high
level of depersonalization or cynicism, yet with a high score for personal
accomplishment. More importantly, burnout was more common in new chairs and in
those who had less spousal support.
Leaders in orthopaedics, such as department chairs, past chairs, acting
chairs, and program directors, may be experiencing substantial yet different
stress as a result of increased oversight and bureaucracy associated with
patient care, teaching, and research; decreased reimbursement for patient care
services; and a reduction in protected time for undertaking such activities.
We therefore wanted to ascertain the prevalence and severity of burnout among
orthopaedic leaders in the United States. This is important because of the
adverse effects that burnout among leaders may have on the quality of
department work, morale, attendance, turnover, mental and physical health, and
family
relationships8.
After obtaining approval from the University of Virginia institutional
review board, a cross-sectional questionnaire-based survey was undertaken with
use of the 2004-2005 membership directory of the American Orthopaedic
Association. Two hundred and eighty-two past, current, and acting
chairs—along with program directors from academic departments of
orthopaedic surgery in the United States—were contacted by e-mail and
mail. For our study, we classified an individual as an acting chair if that
individual was at an institution that had an active search for a chair and if
that individual checked the "acting chair" box on the
questionnaire.
The chairs were contacted directly through a third-party survey group
(Leever Research Services, Naperville, Illinois). The responses were kept
confidential, and the data were double-entered into a password-protected
computer file. A second mailing of the questionnaire was sent to those who had
not responded initially and was followed by an e-mail reminder. Control
numbers were removed from the data file at the time of analysis, and the hard
copy surveys were destroyed.
The questionnaire was developed with use of a format similar to that
utilized by Gabbe et al. and the American Gynecological and Obstetrical
Society7. The
eight-page questionnaire was divided into seven sections and included thirty
major questions. There were also sixty-four minor questions that delved into
some of the major topics but in greater detail. A letter accompanied the
questionnaire requesting the participation of each individual and, although
the letter expressed the principal investigator's concerns about the
well-being of chairs in academic departments of orthopaedics, the word
"burnout" was not used.
The first section was composed of sixteen questions collecting information
on program size, demographic data, income, subspecialty, and hours worked per
week. The second section explored effectiveness or self-efficacy and asked,
"On a 0 to 10 scale, how would you rate your effectiveness as a
chair?"
The third section asked, "During the past year, to what degree have
you and your department been affected (i.e. with decreased morale,
productivity, or collegiality or fiscally) by the following problems?"
The respondents were instructed to select from a list of nineteen stressors
and to grade them on a 5-point Likert scale from "not at all" to
"extreme amount" and to answer an open-ended question at the end
asking how these affected them (Table
I)7.
The fourth section (questions 19 and 20) asked the respondents to rate job
satisfaction currently, one year ago, and five years ago and to anticipate
what it would be in one year. In addition, in order to quantify the likelihood
that the chair would step down in the next one to two years, the questionnaire
asked the respondents to rate that variable from "very
dissatisfied" to "very satisfied."
The fifth section had questions about the balance between personal life and
professional life and about satisfaction with family life, and the individual
was asked to list three positive and three negative ways in which he or she
dealt with stress. The questionnaire also asked whether the institution where
the individual worked had a chair support group that assessed the individual's
control of his or her professional life and reported self-efficacy.
The sixth section of the questionnaire had twenty-two questions from the
MBI-HSS8. Nine of
those questions evaluated emotional exhaustion; five, depersonalization; and
eight, personal accomplishments. A subscale was calculated for each of the
three components.
The seventh, and final, section asked three questions that assessed family
and spousal support of the respondent's position.
Statistical Analyses
The results for individual survey questions were tabulated, and standard
confidence interval formulas for proportions were used. Scores on the MBI-HSS
were categorized into low, medium, and high according to established
definitions. Chi-square tests were used to compare responses among chairs in
the different burnout categories. Correlations were used to assess
associations between burnout scores and other survey questions.
One hundred and ninety-five final data records from the 282 surveys were
received and processed, representing a final response rate of 69%.
Demographic data are summarized in Table
II. On the average, the chairs had held faculty positions at two
prior institutions before becoming a chairperson. Only 6% of the responding
surgeons described themselves as specializing in general orthopaedics; 19%, as
specializing in traumatology; 19%, in hip and knee reconstruction; 19%, in
sports medicine; 7%, in orthopaedic oncology; 14%, in pediatric orthopaedics;
12%, in hand surgery; and 7%, in shoulder and elbow surgery. The surgeons
worked an average of 68.3 hours per week (range, ten to 120 hours per week),
and, on the average, >55 % of this time was allocated to patient care.
The highest stressors, in order of decreasing frequency, were excessive
workload, increasing overhead, departmental budget deficits, tenure and
promotion, disputes with the dean, loss of key faculty, staff dismissal, night
and weekend work, and hospital budget deficits.
When asked how much these problems affected their lives, 70% of the
respondents indicated that the stressors had a moderate to extreme impact. Of
the 147 emotionally exhausted respondents, thirty-seven (25%) reported
frequent irritable behavior with their spouses, significant others, and family
members when they were preoccupied with work matters. Eighty-eight percent of
the 147 respondents reported that they were sometimes irritable with the
people in their lives.
The respondents were asked to list three positive and three negative ways
in which they managed stress; 218 responses were listed. The most frequent
positive responses were physical activity and exercise (42%), family support
(18%), leisure activity (15%), and hobbies (9%). Fifteen percent responded
that they would work harder at addressing the source of the stress. The most
frequent negative responses were irritability (31%), sleep disturbance (17%),
withdrawal (15%), overworking (10%), procrastination (7%), alcohol use (7%),
and overeating (5%).
Survey responses suggested that perceived job satisfaction had declined
substantially over the previous five years, and there was anticipation that,
in a year, the job satisfaction would decrease even further. Twenty-six
percent of the respondents reported that they were currently dissatisfied with
their position compared with 22% who had been dissatisfied one year earlier
and 10% who had been dissatisfied five years earlier. Only 20% reported that
they were satisfied with their current position.
When asked how satisfied they were with the balance between their personal
life and their professional life, only 15% of the respondents noted that they
were satisfied and 45% responded that they were somewhat dissatisfied to very
dissatisfied. With regard to their family life, 20% of the respondents were
somewhat dissatisfied or very dissatisfied. Seventy-two percent reported that
the long hours hurt their family life or other relationships. Eighty-nine
percent responded that they took work home because of the concern that it
would not otherwise get done. Sixty-nine percent reported that their friends
and family have given up expecting them to show up for family or social events
on time. Seventy-two percent took work activity on vacation. Only 13%
responded positively to the question regarding the availability of a support
group in their institution for persons in their position.
When the respondents rated their effectiveness as a leader, considering all
facets of the job, on a scale from 0 (least effective) to 10 (most effective),
they had a mean score (and standard deviation) of 7.3 ± 1.5. Ten
percent of the twenty-one past chairs, 25% of the eight acting chairs, 18% of
the 110 current chairs, and 37% of the fifty-four residency program directors
felt that they had either slight control over their personal lives or none at
all. Thirty-four percent of the past chairs, 13% of the acting chairs, 38% of
the current chairs, and 60% of the program directors felt that their
professional life would get worse over the next several years, with the
majority (19% to 50%) believing that this was due to factors beyond their
control. Unfortunately, 30% of the present chairs, 38% of the acting chairs,
and 45% of the program directors felt that their current professional role got
in the way of developing their own life goals.
As has been described previously, burnout is defined as a high level of
emotional exhaustion, a high level of depersonalization and/or cynicism, and a
low level of personal
accomplishment5.
Table III summarizes the
overall results on the MBI-HSS for this study. Sixty-seven percent of the past
chairs, 75% of the acting chairs, 81% of the current chairs, and 72% of the
residency program directors scored high on the personal accomplishment
subscale. However, 76% of the past chairs, 88% of the acting chairs, 73% of
the current chairs, and 82% of the program directors reported moderate-to-high
emotional exhaustion. On the depersonalization scale, 66% of the past chairs,
88% of the active chairs, 61% of the current chairs, and 76% of the residency
program directors had moderate-to-high scores. No significant differences were
identified between positions.
Of the 147 respondents with moderate-to-high emotional exhaustion, 77%
reported that they were somewhat dissatisfied with the balance between their
personal life and professional life and 40% were somewhat to very dissatisfied
with their family life. Of the emotionally exhausted respondents, 26% reported
being frequently irritable with their spouses, significant others, and family
members when they were preoccupied with work matters, and another 88% of the
emotionally exhausted respondents reported that they were sometimes irritable
with their spouses or family members. Forty-three percent of the emotionally
exhausted respondents reported that spousal support was available sometimes,
and another 13% reported that it was available once in a while.
The American Psychological Association defines self-efficacy as an
individual's capacity to act effectively to bring about desired results,
especially as perceived by the
individual9. In our
survey, there was a significant relationship between the self-efficacy score
and burnout. As self-efficacy increased, burnout decreased (p < 0.01).
Table IV compares subscale
scores on the MBI-HSS between United States otolaryngology chairs,
obstetric-gynecology chairs, as well as other physician groups including
normative data for the medical profession. Excessive work (p < 0.01),
overhead (p < 0.01), departmental and hospital budget deficits (p <
0.01), tenure and promotion issues (p < 0.05), disputes with deans (p <
0.05), loss of key faculty (p < 0.05), and staff dismissal (p < 0.05)
correlated significantly with emotional exhaustion. Excessive work (p <
0.01), staff dismissal (p < 0.01), credentialing issues (p < 0.01), and
spousal support (p < 0.01) correlated significantly with depersonalization
and cynicism (Table V). There
was a 100% rate of being a so-called workaholic. When the respondents (not
including past chairs) were asked what the likelihood was that they would step
down from their position over the next two years, 14% indicated that it was
moderately likely; 13%, that it was very likely; and 10%, that it was
extremely likely.
Our study provides the first investigation into burnout in orthopaedic
leadership, focusing on departmental chairs and program directors. The
strengths of the study are that it is a prospective investigation that uses
validated psychometric measures, and we attained a fairly high response rate
(69%). The 31% nonresponse rate was probably related to the respondent burden
of completing a long questionnaire in an already busy group of individuals.
For completeness, other members of the field of orthopaedics should have been
surveyed as it would be important to know the views of residents, fellows, and
members of the private orthopaedic community as well.
Burnout syndrome appears to be a response to chronic stress as opposed to
acute stress. The medical literature began to address the problem of physician
distress some twenty years
ago2. Although the
problem is common among academic faculty (among whom 37% to 47% experience
burnout), it is also prevalent in private
practice10. This
may reflect the degree of dissatisfaction, which is common to all practicing
orthopaedic surgeons, with regard to third-party payers and government
agencies, paperwork, community demands, isolation from other physicians, and
poor working relationships with medical colleagues. Burnout was once thought
to be a late-career phenomenon, but studies have now suggested that younger
physicians experience it nearly twice as frequently as their older colleagues
and the onset may occur as early as
residency10.
Burnout has many consequences including absenteeism, turnover in personnel,
cynicism, and decreased job satisfaction as evidenced by our survey. More
concerning effects include the spillover into personal life. When physicians
return home, they are tense, unhappy, or upset, leading to friction in
personal relationships and isolation from significant others or family
members. Perhaps the most compelling report on stress among medical personnel
came from the more than 3500 physicians who responded to a Canadian national
survey, which revealed that the majority of physicians thought that their
workload was too heavy (62%), that their family and personal life suffered
because they had chosen medicine as a profession (55%), and that opportunities
to change careers were limited
(65%)11. Our data
appear to concur with these results.
Although we did not delve into the question of the quality of care provided
by the respondents, burnout may also have other serious implications including
effectiveness as a caregiver. Measured depersonalization has been associated
with an increased frequency of physicians reporting suboptimal patient care
practices11. As is
evident from our data, an important role is played by such factors as
workload, malpractice suits, lack of control over the practice environment,
and problems with the balance between personal and professional life and
practice setting. Other studies have shown that characteristics, such as sleep
deprivation, personality type, and methods of dealing with death and/or
suffering, can lead to
burnout12.
Only 13% of the respondents reported that their institution had suppor
groups for chairs or program chairs. There is clearly a need to develop and
evaluate effective interventions to maintain leaders in these roles. That is
why we recommend that institutions provide the foundation for the development
of support groups among their departmental leaders. The weakness in this
approach, though, is that institutional support groups will be less effective
in dealing with field-specific issues, and that is why we recommend that
orthopaedic societies also provide this similar support for its members.
Many of those surveyed felt that they had either slight or no control over
their personal lives, and many felt that their professional life would get
worse over the next several years, with a large proportion (=50%) believing
that this was due to factors beyond their control. A number of new guidelines
that have added considerable restrictions to academic health centers have been
instituted over the last five years, and they have affected every aspect of
academic orthopaedic practice including, but not limited to, research
practices (i.e., HIPAA [the Health Insurance Portability and Accountability
Act]), education programs (the eighty-hour workweek), and clinical practice
(the Center for Medicare and Medicaid Services Pay for Performance
guidelines). These new restrictions, combined with the increasing demand for
reporting, transparency, and audits, have given the chair or program director
less control over his or her role. Karasek developed the stress-disequilibrium
theory, which proposes that low levels of control can cause chronic disease
through chronic deregulation of our highly integrated physiological
systems13.
Specifically, burnout (or its alternative, "engagement")
mediates the relationship between the characteristics of one's work
environment (such as workload, control, rewards, community, fairness, and
values) and the important results of work (such as quality of work results,
absenteeism, turnover, health-care costs, and others). Burnout can be the
first stop on the way to depression, cardiovascular problems, stroke, and
other debilitating health
problems14. It can
also serve as an important call to action to restructure work into a positive
experience that results in positive outcomes, rather than burnout and negative
outcomes.
It is important to point out that 26% of the respondents reported that they
were currently dissatisfied with their position compared with 22% who had been
dissatisfied one year earlier and 10% who had been dissatisfied five years
earlier. This may correlate to a number of health-care issues and processes
that have taken place over this period or it may be an issue of recall bias,
i.e., remembering the so-called good old days. It was also surprising to us
that only 20% of the respondents reported that they were satisfied with their
current position. This is certainly not consistent with the commonly perceived
orthopaedic leader's persona. The opportunity to respond anonymously and with
confidentiality may have allowed these leaders to feel that they could truly
express their views.
Job stress can have spillover effects into the surgeon's family, home, and
personal life. For all leaders, it is important to maintain a balance among
the competing demands of work and home. The problems associated with a lack of
balance are not isolated to the individual doctor; rather, they affect the
physician's family and the organization in which the physician works. Indeed,
77% of those with moderate to high emotional exhaustion reported that they
were somewhat dissatisfied with the balance between work and family.
Work-family conflict can cause stress and suffering for spouses and
children and for colleagues in the work environment. We described in our
previous report that regardless of whether the work-family conflict originates
primarily from job pressures, family demands, or self-imposed expectations,
there are accelerants that can amplify or inflame the
conflict4. These
accelerants were reported by the respondents in this study and included
alcohol, sleep disturbances, overwork, toxic departmental and institutional
cultures, and withdrawal. A large number of the respondents (119) reported
that they handled stress negatively by taking it out on their family, either
displacing themselves from family situations or delving into more work.
Identifying these accelerants within the family and then knowing the early
warning signs of their impending activation can go a long way toward early
detection and prevention of conflict within the family and workplace.
Emotional exhaustion and depersonalization are common among those working in
the healthcare profession, especially in the medical field, and the best
antidote is a well-structured work organization, which ensures efficiency and
a collaborative team in the operating room, the laboratory, and the office.
When these factors are ignored, the impact of stress on the individual is
revealed through its negative effect on family relationships, personal
productivity, and the quality of care for the patient.
At the professional level, peer support and unity around pressing issues
are useful in reducing the negative impact on both occupational and personal
stress. Support can be provided to assist subordinates, such as office staff,
residents, and fellows, as well as peers and colleagues. Peer counseling and
occupational health and safety measures, including occupational and mental
health services, have proven to be effective. One important obstacle to
achieving success with these programs is a lack of acceptance, which may lead
to a substantial communication barrier. Work groups that provide workshops and
presentations for all levels of the orthopaedic community need to be formed.
These presentations should focus on topics such as violence in the workplace,
suicide awareness, and stress management. They should be offered at the
hospital as well as off-site and during conferences. Individuals should be
assured that these presentations are informal and that discussion is welcomed.
The informal setting and educational nature of these sessions should encourage
involvement and participation. One such program that was effective in
implementing this strategy was the Kelly Air Force Base occupational health
psychology
program15.
At the personal level, leaders can be proactive by taking steps to ensure
that burnout is avoided and that, when burnout occurs, recovery is possible.
We need to emphasize that there is no magic, no surefire cure, no standard
protocol, and no quick fix. People do not burn out overnight, and they do not
recover overnight. The long-term solution is lifestyle change and the
determination to break out of a rut. Some useful steps include the following:
(1) Take regular pit stops. We all know when we need a rest break. Arrange for
a time-out to take a deep breath and recharge. (2) Practice good self-control.
Develop awareness of increasing tension, signs of getting toward the edge, and
the development of poor interpersonal communication exchanges. You need to
know yourself, but it is just as important to remember that your spouse and
family are your best resource to help you to make sure that you are attuned to
your own mind and body. (3) Pay attention to how you talk to yourself.
Thoughts and ideas have consequences in behavior and action. How we talk to
ourselves, positively or negatively, can be the leading edge of how we act and
behave. If you do not like what you say to yourself, change and start talking
more constructively and positively. (4) Burn hot but stay cool. Take your work
seriously, but do not take yourself too seriously; lighten up and stay cool.
There is a time for high-intensity work and a time to cool and recover. (5)
Protect your investment. You are the most important and valuable asset you
have. Take good care of yourself and your loved ones, and then they will take
good care of you.
Note: The authors thank the AOA Academic Leadership Committee
and the Goolsby Leadership Academy.
Bauer J, Hafner S, Kachele H, Wirsching
M, Dahlbender RW. [The burn-out syndrome and restoring mental health at the
working place]. Psychother Psychosom Med Psychol.
2003;53: 213-22.
German.53213
2003
[PubMed][CrossRef]
Christe-Seeley J. Marriage and medicine:
the physician as a partner, parent, and person. Can Fam
Physician. 1986;32:
360-8.32360
1986
Jones JW, editor. The burnout
syndrome: current research, theory, interventions. Park Ridge, IL:
London House Press; 1981.
1981
Quick JC, Saleh KJ, Sime WE, Martin W,
Cooper CL, Quick JD, Mont MA. Symposium. Stress management skills for strong
leadership: is it worth dying for? J Bone Joint Surg Am.
2006;88:
217-25.88217
2006
[PubMed][CrossRef]
Melamed S, Shirom A, Toker S, Berliner
S, Shapira I. Burnout and risk of cardiovascular disease: evidence, possible
causal paths, and promising research directions. Psychol Bull.
2006;132:
327-53.132327
2006
[PubMed][CrossRef]
Neidle EA. Faculty approaches to
combating professional burnout. J Dent Educ.
1984;48:
86-90.4886
1984
[PubMed]
Gabbe SG, Melville J, Mandel L, Walker
E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and
prevention. Am J Obstet Gynecol.
2002;186:
601-12.186601
2002
[PubMed][CrossRef]
Maslach C, Jackson SE, Leiter MP.
Maslach burnout inventory manual. Palo Alto, CA: Consulting
Psychologists Press; 1996. p
3-17,36-7.3
1996
VandenBos GR, editor. APA
dictionary of psychology. Washington, DC: American Psychological
Association; 2007.
2007
Deckard GJ, Hicks LL, Hamory BH. The
occurrence and distribution of burnout among infectious diseases physicians.
J Infect Dis. 1992;165:
224-8.165224
1992
[PubMed][CrossRef]
Sullivan P, Buske L. Results from CMA's
huge 1998 physician survey point to a dispirited profession.
CMAJ. 1998;159:
525-8.159525
1998
[PubMed]
Shanafelt TD, Bradley KA, Wipf JE, Back
AL. Burnout and self-reported patient care in an internal medicine residency
program. Ann Intern Med.
2002;136:
358-67.136358
2002
[PubMed]
Karasek R. The stress-disequilibrium
theory: chronic disease development, low social control, and physiological
de-regulation. Med Lav.
2006;97:
258-71.97258
2006
[PubMed]
Shanafelt TD, Sloan JA, Habermann TH.
The well-being of physicians. Am J Med.
2003;114:
513-9.114513
2003
[PubMed][CrossRef]
Quick JC, Tetrick LE, Adkins JA, Klunder
C. Occupational health psychology. In: Weiner IB, editor. Handbook of
psychology. Vol 9, Health psychology. New York: John Wiley;
2003. p 569-89.569
2003