Letter to the Editor: Career satisfaction and burnout among neurosurgeons

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TO THE EDITOR: “Burnout” often feels like a verboten concept, despite its threatening reality and potentially detrimental outcomes. Its wide-ranging effects can impact nearly every aspect of our lives, both personally and professionally. As a current resident and member of the American Association of Neurological Surgeons (AANS), my interest was captured by the article by McAbee et al.4 (McAbee JH, Ragel BT, McCartney S, et al: Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg 123:161–173, July 2015). Having completed the survey, and having recently had the question “Would you encourage your children to pursue a career in neurosurgery?” posed to me at a conference, I found myself truly contemplating the sacrifices and gains within our career. Burnout is synonymous throughout practice and residency alike, with increasing notoriety due to its shocking prevalence in health care. Bringing this topic to the forefront, the current article examined factors associated with satisfaction and burnout within neurosurgery.

Cross-sectional data from a national survey implicated significant self-reported burnout (56.7%).4 The strongest predictors of burnout in multivariate analysis, by odds ratio, include uncertainty about future earnings and health care reform (OR 1.96; 95% CI 1.41–2.72) and complaint of malpractice (OR 1.60; 95% CI 1.16–2.20). Predictors of satisfaction include a good work/life balance (OR 10.0; 95% CI 4.9–20.3), being challenged at work (OR 4.6; 95% CI 2.9–7.4), having children (OR 2.4; 95% CI 1.2–4.8), and completing > 300 cases per year (OR 1.77; 95% CI 1.03–3.03). Perhaps more important was the collective endorsement of job satisfaction (80%) among neurosurgeons, with approximately 70% reporting that they would choose this career again. Despite laborious demands and uncertain future benefit, neurosurgeons may experience a type of intrinsic fulfillment that extends beyond the limitations of burnout. Identifying occupational pros and cons, such as gratification and burnout, may aid in mitigating factors of exhaustion.

Burnout is highly prevalent amongst residents as well, with the largest study of 15,000 residents showing a prevalence of 51.5% (27%–75% depending on specialty).2,3 Largely, burnout is ignored or underrecognized. Acknowledgment of burnout in self-reflection or identification of burnout in colleagues is the first step to improvement. The Maslach Burnout Inventory (MBI) is a well-validated instrument to measure burnout in self-survey form.3 A shorter and nonproprietary method has been developed for use based on response to a single item.1 When burnout is identified, physicians should seek assistance. No specialized help currently exists for physicians in burnout, but assistance can be obtained through medical staff offices and counseling departments. In a study of 212 surgeons, assistance-seeking behaviors differed drastically; men tended to seek help from colleagues or friends, whereas women tended to seek help from professional counselors.5 Regardless of the mechanism of assistance, recognizing and addressing burnout will make us better and more satisfied physicians.

Learning how to avoid this state and to cope with burnout should begin early. Teaching identification of and coping mechanisms for burnout is the focus of intervention at the residency level. Neurosurgeons in academia will know that the US Accreditation Council for Graduate Medical Education (ACGME) has done much work in regard to burnout. Education about burnout and implementing mechanisms to avoid burnout has been a great focus of the ACGME's Clinical Environmental Review (CLER) Program.2 Work stress can be categorized into 6 domains, of which CLER seeks to improve workload, control, community, fairness, values, and balance between work and reward. Work load, perhaps commonly perceived to be the foremost factor in burnout, is a complex contributor and involves much more than merely work hours, including patient complexity and documentation efficiency. Hiring physician extenders may assist with the clerical demands of patient care. Meeting with counselors for emotional fatigue may help to process emotions associated with observing suffering and death. Yet, seeking assistance and learning coping mechanisms early in training is of utmost importance.

References

  • 1

    Dolan EDMohr DLempa MJoos SFihn SDNelson KM: Using a single item to measure burnout in primary care staff: a psychometric evaluation. J Gen Intern Med 30:5825872015

    • Search Google Scholar
    • Export Citation
  • 2

    Jennings MLSlavin SJ: Resident wellness matters: optimizing resident education and wellness through the learning environment. Acad Med 90:124612502015

    • Search Google Scholar
    • Export Citation
  • 3

    Lee YYMedford ARHalim AS: Burnout in physicians. J R Coll Physicians Edinb 45:1041072015

  • 4

    McAbee JHRagel BTMcCartney SJones GMMichael LM IIDeCuypere M: Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg 123:1611732015

    • Search Google Scholar
    • Export Citation
  • 5

    Sanfey HFromson JMellinger JRakinic JWilliams MWilliams B: Surgeons in difficulty: an exploration of differences in assistance-seeking behaviors between male and female surgeons. J Am Coll Surg 221:6216272015

    • Search Google Scholar
    • Export Citation

Disclosures

The authors report no conflict of interest.

Response

My coauthors and I would like to thank Dr. Smith and Ms. Glusman for their thoughtful letter regarding our paper on burnout among US neurosurgeons. As a fourth-year medical student and past president of my school's AANS Medical Student Chapter, this project was a timely and invaluable experience for me. My medical school class has completed multiple surveys that assessed burnout during different stages of our education. We found that the highest levels of burnout occurred after completing our third year. The research is clear that all current and future physicians are at risk for burnout. From premedical students to department chairpersons, we all have an innate drive to succeed academically, to provide for the care of patients (either on a volunteer basis or as a part of one's paid profession), and to establish positive relationships with colleagues and societies. But we often neglect self-care and self-reflection in many instances. Thus, there is a need for education on identification, prevention, and treatment of burnout at all levels of medical education and practice, because unchecked burnout has serious consequences for health care workers, their families, colleagues, and for the patients in their care.

To date, there have been several trial programs created to teach mechanisms for coping with burnout and to provide avenues for health and wellness support. For example, the Department of Neurosurgery at the Medical University of South Carolina has recently implemented a wellness program for its residents that provides protected time each week for moderate-intensity team-based exercise, free healthy meal options each day, and a health and wellness lecture series.9 The goal of the program is to teach, encourage, and support healthy living in an effort to reduce burnout and increase commitment to self-care. A similar study at the Mayo Clinic demonstrated a higher quality of life and lower levels of burnout for residents and fellows who participated in an incentivized exercise program.12 A required health course for medical students at Northwestern University encouraged them to identify an area for self-improvement and work toward achieving behavior change in that area.7 At the conclusion of the course, the majority of the students who participated in the program felt healthier and believed they could achieve future goals with similar strategies. These studies demonstrated that interventions need not directly address burnout to provide benefits and career longevity; rather they can simply promote an environment in which health care workers are encouraged to be mindful of the importance of self-care, maintaining a healthy lifestyle, and achieving a favorable work/life balance.

In addition to promoting healthy living, several interventions have focused on enhancing emotional, mental, and spiritual well-being through discussion groups, mindfulness training, and relaxation techniques.1,3,6 The Mayo Clinic Department of Radiology implemented a Stress Management and Resiliency Training (SMART) program for its physicians and saw improvements in stress, anxiety, quality of life, and mindfulness 12 weeks after a brief 90-minute group intervention with optional follow-up calls.11 A longer, facilitated small-group curriculum was developed and implemented for practicing physicians in the Mayo Clinic Department of Medicine that focused on mindfulness, reflection, shared experience, and small-group learning.13 Every other week, program participants received paid time off from clinical duties to attend group sessions. Increased empowerment and engagement at work as well as decreased depersonalization, emotional exhaustion, and overall burnout occurred for program participants, and was sustained for months after the intervention. Interestingly, participants in the trial control arm who received the same amount of paid time off from clinical duty, which they could use in any way they chose, also demonstrated a slight decrease in burnout levels compared with those physicians who did not receive any paid time off at all.

Individualized coaching sessions may also hold promise by coaching physicians in self-care areas, such as boundary setting and prioritization, self-compassion and self-care, and self-awareness.10 Many of these programs, and mindfulness training in general, attempt to teach physicians how to monitor their own lives for signs of burnout, to place more priority on self-care, and to implement stress reduction strategies as a mechanism to improve both their personal and professional lives. They also teach physicians how to deal mentally and emotionally with challenging situations by viewing difficult events of the human experience through a lens of gratitude, compassion, acceptance, meaning, and forgiveness.11

Because burnout is a problem for potentially all health care workers, institutional changes will need to be made. The study mentioned above that allows for periodic paid time off suggests that physicians may benefit from protected professional time spent doing what they perceive to be valuable. It is easy to imagine how this method could help physicians be more productive, achieve better work/life balance, and reduce stress.4 Other possible institutional policies include granting residents time off during business hours to access personal and family health care.2 By allowing residents to access the care they need, a healthier and more energized clinical team could emerge. Results from the Healthy Work Place Study involving primary care physicians in the upper Midwest and New York City showed that interventions centered around improved communication, changes in clinic work flow, or targeted quality improvement projects can decrease burnout, increase satisfaction, and decrease intention to leave.8

It is becoming increasingly obvious that institutional and organizational interventions are needed to improve burnout prevention in physicians, but such interventions can only occur with the support of hospital and departmental leadership. Not only is support necessary, but hospital leadership must lead by example, because the leadership characteristics of physicians' supervisors have a direct impact on burnout rate. Physicians who rated their supervisors favorably had less burnout and more satisfaction than those who rated them unfavorably.5 Thus, leadership development courses may be useful for helping leaders to foster an atmosphere of support and empowerment for their subordinates struggling with burnout.

Burnout is a real and potentially debilitating syndrome that threatens the modern physician. In a field as challenging and demanding as neurosurgery, the threat is even greater. By raising awareness of this syndrome, its signs, and its potential prevention strategies, we can better identify those at risk at an earlier stage in their career. By developing interventions, support groups, and organizational resources, we can provide the necessary treatment for those suffering from burnout and more effectively assist them in achieving their personal and professional goals. Finally, by creating an atmosphere in which physicians can pursue help for themselves or their colleagues without fear of judgment or penalty, we may be able to realize a system in which we are able to identify and address burnout long before it becomes detrimental to physicians or their patients.

References

  • 1

    Asuero AMQueralto JMPujol-Ribera EBerenguera ARodriguez-Blanco TEpstein RM: Effectiveness of a mindfulness education program in primary health care professionals: a pragmatic controlled trial. J Contin Educ Health Prof 34:4122014

    • Search Google Scholar
    • Export Citation
  • 2

    Cedfeldt ASBower EFlores CBrunett PChoi DGirard DE: Promoting resident wellness: evaluation of a time-off policy to increase residents' utilization of health care services. Acad Med 90:6786832015

    • Search Google Scholar
    • Export Citation
  • 3

    Epstein RM: Mindful practice. JAMA 282:8338391999

  • 4

    Gordon CEBorkan SC: Recapturing time: a practical approach to time management for physicians. Postgrad Med J 90:2672722014

  • 5

    Hamade YJAoun RJZimmerman RSBendok BR: The modern neurosurgical leader as a cure for team burnout. Neurosurgery 77:N132015

  • 6

    Krasner MSEpstein RMBeckman HSuchman ALChapman BMooney CJ: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302:128412932009

    • Search Google Scholar
    • Export Citation
  • 7

    Kushner RFKessler SMcGaghie WC: Using behavior change plans to improve medical student self-care. Acad Med 86:9019062011

  • 8

    Linzer MPoplau SGrossman EVarkey AYale SWilliams E: A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med 30:110511112015

    • Search Google Scholar
    • Export Citation
  • 9

    Quick D: MUSC Neurosurgery Department embarks on an unusual wellness program. Post and Courier July62015. (http://www.postandcourier.com/article/20150706/PC1211/150709602/1002/musc-neurosurgery-department-embarks-on-an-unusual-wellness-program) [Accessed October 30 2015]

    • Search Google Scholar
    • Export Citation
  • 10

    Schneider SKingsolver KRosdahl J: Physician coaching to enhance well-being: a qualitative analysis of a pilot intervention. Explore (NY) 10:3723792014

    • Search Google Scholar
    • Export Citation
  • 11

    Sood ASharma VSchroeder DRGorman B: Stress Management and Resiliency Training (SMART) program among Department of Radiology faculty: a pilot randomized clinical trial. Explore (NY) 10:3583632014

    • Search Google Scholar
    • Export Citation
  • 12

    Weight CJSellon JLLessard-Anderson CRShanafelt TDOlsen KDLaskowski ER: Physical activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program. Mayo Clin Proc 88:143514422013

    • Search Google Scholar
    • Export Citation
  • 13

    West CPDyrbye LNRabatin JTCall TGDavidson JHMultari A: Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 174:5275332014

    • Search Google Scholar
    • Export Citation

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Article Information

INCLUDE WHEN CITING Published online January 1, 2016; DOI: 10.3171/2015.8.JNS151891.

© AANS, except where prohibited by US copyright law.

Headings

References

  • 1

    Dolan EDMohr DLempa MJoos SFihn SDNelson KM: Using a single item to measure burnout in primary care staff: a psychometric evaluation. J Gen Intern Med 30:5825872015

    • Search Google Scholar
    • Export Citation
  • 2

    Jennings MLSlavin SJ: Resident wellness matters: optimizing resident education and wellness through the learning environment. Acad Med 90:124612502015

    • Search Google Scholar
    • Export Citation
  • 3

    Lee YYMedford ARHalim AS: Burnout in physicians. J R Coll Physicians Edinb 45:1041072015

  • 4

    McAbee JHRagel BTMcCartney SJones GMMichael LM IIDeCuypere M: Factors associated with career satisfaction and burnout among US neurosurgeons: results of a nationwide survey. J Neurosurg 123:1611732015

    • Search Google Scholar
    • Export Citation
  • 5

    Sanfey HFromson JMellinger JRakinic JWilliams MWilliams B: Surgeons in difficulty: an exploration of differences in assistance-seeking behaviors between male and female surgeons. J Am Coll Surg 221:6216272015

    • Search Google Scholar
    • Export Citation
  • 1

    Asuero AMQueralto JMPujol-Ribera EBerenguera ARodriguez-Blanco TEpstein RM: Effectiveness of a mindfulness education program in primary health care professionals: a pragmatic controlled trial. J Contin Educ Health Prof 34:4122014

    • Search Google Scholar
    • Export Citation
  • 2

    Cedfeldt ASBower EFlores CBrunett PChoi DGirard DE: Promoting resident wellness: evaluation of a time-off policy to increase residents' utilization of health care services. Acad Med 90:6786832015

    • Search Google Scholar
    • Export Citation
  • 3

    Epstein RM: Mindful practice. JAMA 282:8338391999

  • 4

    Gordon CEBorkan SC: Recapturing time: a practical approach to time management for physicians. Postgrad Med J 90:2672722014

  • 5

    Hamade YJAoun RJZimmerman RSBendok BR: The modern neurosurgical leader as a cure for team burnout. Neurosurgery 77:N132015

  • 6

    Krasner MSEpstein RMBeckman HSuchman ALChapman BMooney CJ: Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302:128412932009

    • Search Google Scholar
    • Export Citation
  • 7

    Kushner RFKessler SMcGaghie WC: Using behavior change plans to improve medical student self-care. Acad Med 86:9019062011

  • 8

    Linzer MPoplau SGrossman EVarkey AYale SWilliams E: A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med 30:110511112015

    • Search Google Scholar
    • Export Citation
  • 9

    Quick D: MUSC Neurosurgery Department embarks on an unusual wellness program. Post and Courier July62015. (http://www.postandcourier.com/article/20150706/PC1211/150709602/1002/musc-neurosurgery-department-embarks-on-an-unusual-wellness-program) [Accessed October 30 2015]

    • Search Google Scholar
    • Export Citation
  • 10

    Schneider SKingsolver KRosdahl J: Physician coaching to enhance well-being: a qualitative analysis of a pilot intervention. Explore (NY) 10:3723792014

    • Search Google Scholar
    • Export Citation
  • 11

    Sood ASharma VSchroeder DRGorman B: Stress Management and Resiliency Training (SMART) program among Department of Radiology faculty: a pilot randomized clinical trial. Explore (NY) 10:3583632014

    • Search Google Scholar
    • Export Citation
  • 12

    Weight CJSellon JLLessard-Anderson CRShanafelt TDOlsen KDLaskowski ER: Physical activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program. Mayo Clin Proc 88:143514422013

    • Search Google Scholar
    • Export Citation
  • 13

    West CPDyrbye LNRabatin JTCall TGDavidson JHMultari A: Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med 174:5275332014

    • Search Google Scholar
    • Export Citation

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