Perspectives

Commentary on:Career Satisfaction and Burnout Among U.S.Neurosurgeons: A Feasibility and Pilot Studyby Klimo et al. pp. E59 E68.

M.D.

Professor and Chairepartment of Neurological Surgery

H. Hunt Batjer,

D

The University of Texas Southwestern

How to Identify the Edge of a Cliff in the Dark: Burnout and Neurosurgery

Christopher S. Eddleman, Salah G. Aoun, H. Hunt Batjer

he practice of medicine, and neurosurgery in particular,has changed significantly over the past decade, moving

T from a physician-driven practice to a practice driven by

patient safety concerns, medicolegal and medical error issues,

and administration oversight. The effort to improve patientoutcomes and increase safety has not only focused on the quality

of care received by the patient but also has extended towardensuring that practitioners are in good physical and mental

working condition. The 80-hour work week limitation has alreadybeen implemented with respect to resident training with this

purpose in mind (1, 9). However, there are currently no assur-ances that physicians in practice maintain the same level of

mental and physical stability. As with other professions, physi-cians can suffer over time from exhaustion, isolation, and over-

exposure, potentially leading to burnout. Through the efforts ofthe American College of Surgeons (ACS), the concept of burnout

among physicians in general, and specifically surgeons, hasbecome a new target in the challenge to improve clinical

performance (10).

Burnout is defined by three major components: emotional

exhaustion, depersonalization, and a low sense of personalaccomplishment. Emotional exhaustion implies the feeling of

being psychologically drained and the inability to meetsuccessfully the emotional demands of one’s profession.

Depersonalization is a coping mechanism that transformsthe physician’s relationship with his or her patients into

a mechanical interaction devoid of emotion and imprinted withcynicism (3, 5, 7, 8, 10). A lost sense of personal accom-

plishment often accompanies emotional exhaustion and

Key words- Burnout- Career- Lifestyle- Maslach Burnout Inventory- Neurosurgery- Satisfaction- Stress

Abbreviation and AcronymACS: American College ofSurgeons

WORLD NEUROSURGERY 80 [5]: e111 e113, NOVEMBER 2013

depersonalization, stripping the medical profession of itsmessage and meaning. Physicians today have to deal with

administrative overload, declining reimbursement, anincreasing threat of malpractice, and the ever-increasing

inability to balance their work with their family life. Althoughthe culture in surgical medicine dictates that we push through

adversity and forge on, many physicians find it difficult to copewith these conditions for an extensive period of time, ulti-

mately resulting in burnout.

The burnout syndrome should be addressed seriously and

promptly because it has a profound impact on the patient, thetreating physician, and the medical specialty as a whole. In

a survey by the ACS of approximately 8000 surgeons fromvarious specialties, the documented prevalence of burnout was

40% (3). Burnout and stress in the workplace have been shownto increase medical errors, decrease the quality of patient care,

and disrupt the patient-physician relationship (6, 11). Burnout also

has been shown to be one of the greatest predictors ofa surgeon’s satisfaction with his or her career and choice of

specialty and to be a cause of early retirement at an age of peakproductivity. It can also have dire personal consequences, such

as drug and alcohol addiction, sleep disorders, chronic cardio-vascular disease, divorce, and suicide (3). More globally, rumors

of burnout and excessive stress, coupled with the diminishingrewards of a surgical career, have lowered the interest of new

promising medical graduates in joining the surgical profession,especially given that training is long, is mentally and physically

taxing, and is met with increasing administrative and publicscrutiny, as is the case with neurosurgery.

Department of Neurological Surgery, The University of Texas Southwestern,Dallas, Texas, USA

To whom correspondence should be addressed: H. Hunt Batjer, M.D.[E mail: hunt.batjer@utsouthwestern.edu]

Citation: World Neurosurg. (2013) 80, 5:e111 e113.http://dx.doi.org/10.1016/j.wneu.2013.01.063

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PERSPECTIVES

Three steps are mandatory to prevent the burnout phenomenon.First is the recognition of its presence or potential risk factors.

Second is early detection through validated instruments. Third isestablishing methods of prevention and proactive creation of

a state of resilience, preferably during residency training or in thebeginning of one’s independent career.

Various independent risk factors for burnout among surgeons have

been identified and include a younger age, certain surgicalspecialties, the number of call nights per week, the inability to find

a working balance between work and family life, the lack ofappropriate financial compensation, and belonging to a private

versus an academic institution (10). The lack of “intrinsic” rewardsat work is a factor that seems to be very strongly correlated to

burnout. Intrinsic rewards consist of a show of gratefulness from

the patient and the hospital working staff toward the treatingphysician (2). The presence of these intrinsic rewards may explain

why certain specialties, such as pediatric and cardiothoracicsurgery, where caseloads are heavy and working hours are long,

have the lowest rates of burnout compared with other fields; it hasbeen shown that these specialties provide the physician with

a nurturing environment and an infrastructure that was built overyears to provide an emotionally rewarding and minimally stressful

working place (4).

In an effort to provide a reliable tool for the early detection ofexcessive stress and burnout among neurosurgeons to reduce

medical errors and improve patient care, Klimo et al. createda 107-item questionnaire to survey 169 American neurosur-

geons regarding their quality of life and career satisfaction. Thesurvey addressed professional stress, the quality of professional

life, and burnout. Respondents also were asked to evaluate thesurvey as a practical tool that could be used routinely. Response

rate was 50%, with most participants belonging to academicinstitutions.

The results were surprising, considering the fact that neurosur-

gery is a laborious field that requires a long period of training,involves a very busy schedule, and is becoming increasingly prone

to litigation: 95% of respondents were satisfied with their careerwith 88% stating that they would choose the same specialty

again. Most respondents (>50%) were satisfied with their rela-tionship with their patients and with the intrinsic and extrinsic

rewards generated by their profession. The greatest dissatisfac-tion was the lack of time for personal growth and development.

Burnout rate was 27%, a rate much lower than the publishedaverage, with 14% experiencing high emotional exhaustion, 27%

experiencing high depersonalization, and 27% experiencing a lowsense of accomplishment. Most participants reported the risk of

lower future income and uncertainties regarding health carereform as potential stressors. Only 55% stated that they would

recommend the specialty to their child.

e112 www.SCIENCEDIRECT.com WORLD NEU

There are a few factors that could potentially explain thelower rates of distress encountered among neurosurgeons

participating in this survey. First, neurosurgery residency is knownto be a challenging and taxing period with one of the highest

dropout rates among all surgical specialties (25%e30%). Burnoutmay occur at an earlier stage compared with other medical disci-

plines, with only the most resilient and enduring individuals grad-

uating as faculty. Second, the intrinsic rewards obtained inneurosurgery can be substantial: procedures can be life-changing,

diseases are often serious, and patients are usually very grateful.In addition, and similar to pediatric and cardiothoracic surgery, the

working environment is often supportive, knowing the oftenstressful situations that constitute a neurosurgical practice. Third

and most importantly, participation to this survey was optional,and results are prone to a selection bias. Neurosurgeons with

a high burnout score may have chosen not to participate, a factthat poses new questions: How do we increase response rates to

surveys that require the release of privileged personal informationand could be devastating to the participants if anonymity is lost?

Even if responses are confidential, what guarantees are there tothe participants that security will not be breached and that their

data will not become part of the public domain? What incentivesshould be provided to increase response rate in a population

where time is a rare commodity better spent with family or onpersonal growth? Neurosurgeons are showered daily with surveys

from commercial and pharmaceutical agencies, and those areoften unanswered even though they usually offer some form of

compensation in return for completion. Finding the appropriateincentive, perhaps in the form of early access to the analyzed data

of the survey, is essential to increase participation.

What are the practical, mediatic, and legal implications of

releasing data proving that a great percentage of surgeons thatare entrusted daily with people’s lives are burned out and more

prone to committing errors? Will this information be used asa discrimination tool during recruitment? Will it be grounds for

litigation, termination of employment, mandatory “rehabilita-tion,” or other forms of disciplinary action? Until further light is

shed on the matter through more extensive and similarly anon-ymous studies, current efforts should be directed toward iden-

tifying conditions that can be associated with poor workingenvironments and improving the quality of human interactions

within the workplace to increase the surgeons’ circle of support.Significant care should also be taken to ensure that residents and

trainees become aware of the burnout process and learn torecognize it early. They should be reminded that they are working

toward a greater purpose and learn to develop their perception oftheir potential for action or “perceived energy.” This concept is

applicable to all specialties, and instilling resilience early duringmedical education should help lessen the impact of burnout on

both physicians and patients.

REFERENCES

1. ACGME: ACGME Accreditation Council forGraduate Medical Education.

2. Bakker AB, Schaufeli WB, Sixma HJ, Bosveld W,Van Dierendonck D: Patient demands, lack ofreciprocity, and burnout: a five-year longitudinal

study among general practitioners. J Organ Behav21:425-441, 2000.

3. Balch CM, Shanafelt TD, Sloan J, Satele DV,Kuerer HM: Burnout and career satisfactionamong surgical oncologists compared with othersurgical specialties. Ann Surg Oncol 18:16-25,2011.

ROSURGERY, http://

4. Balch CM, Shanafelt TD, Sloan JA, Satele DV,Freischlag JA: Distress and career satisfactionamong 14 surgical specialties, comparing academicand private practice settings. Ann Surg 254:558-568,2011.

5. Becker JL, Milad MP, Klock SC: Burnout,depression, and career satisfaction: cross-

dx.doi.org/10.1016/j.wneu.2013.01.063

PERSPECTIVES

sectional study of obstetrics and gynecology resi-dents. Am J Obstet Gynecol 195:1444-1449, 2006.

6. Campbell DA Jr, Sonnad SS, Eckhauser FE,Campbell KK, Greenfield LJ: Burnout amongAmerican surgeons. Surgery 130:696-702, 2001[discussion 702-695].

7. Gendreau M: Career satisfaction in emergencymedicine and burnout: all is not well. Ann EmergMed 52:577, 2008.

8. Glasheen JJ, Misky GJ, Reid MB, Harrison RA,Sharpe B, Auerbach A: Career satisfaction andburnout in academic hospital medicine. ArchIntern Med 171:782-785, 2011.

WORLD NEUROSURGERY 80 [5]: e111 e1

9. Jagannathan J, Vates GE, Pouratian N, Sheehan JP,Patrie J, Grady MS, Jane JA: Impact of theAccreditation Council for Graduate MedicalEducation work-hour regulations on neurosur-gical resident education and productivity.J Neurosurg 110:820-827, 2009.

10. Shanafelt TD, Balch CM, Bechamps GJ, Russell T,Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J,Freischlag JA: Burnout and career satisfaction amongAmerican surgeons. Ann Surg 250:463-471, 2009.

11. Wetzel CM, Kneebone RL, Woloshynowych M,Nestel D, Moorthy K, Kidd J, Darzi A: The

13, NOVEMBER 2013 www

effects of stress on surgical performance. Am J Surg191:5-10, 2006.

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