The truth about physician burnout

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Writing in the Journal of NeuroInterventional Surgery, Kyle M Fargen (Wake Forest University, Winston-Salem, USA) and Joshua A Hirsch (Massachusetts General Hospital, Boston, USA) shed light on the growing endemic of physician burnout, particularly within neurointerventionalists.

Mental health is a significant concern for physicians. In the USA, there are 400 physician suicides a year; twice the suicide rate of the general American population. Death by suicide is the second leading cause of death among residents. Fifty-four per cent of doctors say they are burned out; 88% acknowledge they are moderately to severely stressed, and 59% of doctors say they would not recommend a career in medicine to their children.

These statistics are the result of recent research by Tait Shanafelt (Mayo clinic; Stanford Medicine, Stanford, USA) and colleagues, where the investigators surveyed almost 7,000 physicians. The same study reveals that between 2011 and 2014, there was an increase in the percentage of physicians reporting burnout, and a decrease in the number of surgeons who believed they experienced a good work-life balance. Neurointerventional physicians are at high risk of burnout; in the survey around 50% of neurosurgeons and neurologists and over 60% of radiologists reported burnout.

American psychologist Herbert Freudenberger defined burnout, which first appeared in print in a 1974 issue of the Journal of Social Issues, as, “A state of emotional, mental and physical exhaustion caused by excessive and prolonged stress. It is a chronic process of energy expenditure without appropriate periods of recovery.”

With the release of the results of DAWN and DEFUSE 3 trials, and the increased candidacy for mechanical intervention, Fargan and Hirsch note that the demand on neurointerventionalists is increasing. With most consultations occurring (60%) outside working hours, meaning that the risk of emotional, mental and physical exhaustion is increasing.

Michael Weinstein, a general surgeon at Thomas Jefferson University Hospital, Philadelphia, USA, wrote a first person account of his struggles with dysthymia, depression and suicidal ideation in the New England Journal of Medicine. Weinstein wrote: “I endured. I completed residency and fellowship and continued to endure for 16 years. Outside observers might have perceived me as ‘having it all’: a surgeon with leadership promise, with an amazing wife and two great kids, who’s paid more than I ever expected to earn.

“But enduring is not thriving. I had heard of burnout but didn’t really comprehend it. And though I had mental illness, I still saw it as a weakness, a personal fault. I remember early in my career hearing of a colleague who took a leave of absence for a ‘nervous breakdown.’ I joked about it, said he was weak. Now it was my turn.

“My work lost meaning; I was just going through the motions. I thought everything I tried to accomplish was a failure. I had trouble relating to patients and felt the urge to avoid encounters altogether. I cared less and less about anything I was doing. I didn’t know it then, but I had long experienced classic signs of burnout: emotional exhaustion, depersonalisation, and low perceived personal achievement. But the burnout had been waxing and waning for 22 years; now I was in the worst episode of major depression of my life.”

This recognition is crucial, Fargan and Hirsch explain: acknowledgement of physician burnout saves lives, and is the first step to recovery. Academic medical centres are starting to pay more attention to physician burnout and suicide, but it is still rare for a practicing doctor to be as forthcoming as Weinstein, or for mental health issues to be given a platform.

The myriad solutions to this problem revolve around understanding the causes of physician burnout. Writing in the Journal of Internal Medicine in June 2018, Colin West and co-authors claim that the “drivers of this epidemic are largely rooted within healthcare organisations and systems,” and include: “excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, lack of input or control for physicians with respect to issues affecting their work lives, organisational support structures and leadership culture.”

Fargen and Hirsch conclude, “Experts argue that physician burnout is best combated by shared responsibility between healthcare systems and by individual physicians. Fair compensation, development of shared schedules, hiring of non-physician providers for clerical responsibilities, and improved efficiency with elective schedules are potential avenues to reduce the risk of burnout.”

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