AANS Neurosurgeon | Volume 27, Number 3, 2018

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Feeling the Burn: Neurosurgery, Burnout and Patient Safety

Editor’s Note: The Council of State Neurosurgical Societies (CSNS) Ad Hoc Neurosurgical Committee for Patient Safety consists of the following individuals, whose contributions were vital to this article: chair Gregory H. Smith, DO; Wayel Kaakaji, MD; Sherry Taylor, MD; John McGregor, MD; Krystal Tomei, MD; Brad Zacharia, MD; Jack Dunn, MD; Charles Rosen, MD, PhD, FAANS; and Jason Hauptman, MD, PhD.

Disclaimer: The content expressed in this article reflects the authors’ views and not the necessarily those of the American Association of Neurological Surgeons.

There is a certain mythology surrounding surgeons in this country: they are stalwart, stoic and unflappable in the midst of professional and personal turmoil. This mythology has been popularized through portrayals of surgeons in popular culture, such as on television shows. The reality can be quite different.

All physicians have had the experience of too many call nights in a row, when we do not want to answer the pager anymore, or long sleepless nights at home due to family turmoil that bleeds into work, causing us to fall asleep during a patient interview and examination. Sometimes it manifests itself in the OR with a near miss on a spinal procedure. Fatigue can also lead to careless in surgical preparation, resulting in breach of sterile technique. The end result of these lapses can be missed diagnoses, inappropriate surgery, infections and other serious complications.

Every neurosurgeon can relate to above scenarios. We have all been there. Physicians are subject to the same personal and professional trials and tribulations as anyone else. Oftentimes, our jobs are relentless and demanding. A trauma patient does not care how many hours of sleep you have had in the last week. Only more recently has the veneer of invincibility in the public perception of surgeons started to crack with some of the more jarring statistics regarding physicians and burnout.

Physician Burnout and Fatigue
Burnout has become a growing buzzword in health care circles, and it does not affect only physicians. However, the rates of burnout among physicians are at all-time high levels. It is worthwhile to consider this issue and its impact not only on physicians, but more importantly, on the patients for whom they care. Several definitions exist for burnout, and the debate continues on how it should be classified. According to ICD-10, burnout is defined as a problem related to life-management difficulty resulting in a state of vital exhaustion (1). Burnout can be defined generally as a psychologic syndrome characterized by emotional exhaustion, loss of meaning in work, loss of self-efficacy and depersonalization. Studying physician fatigue and its root causes are extremely important in our current healthcare environment. As patient safety has become more of an area of focus as a quality metric, the link with physician burnout continues to be explored.

Although being a physician offers a unique combination of humanistic satisfaction with intellectual discovery, the job also comes with distinctive stressors that can lead to disappointment, frustration and even burnout. A frequently used tool to measure burnout is the Maslach Burnout Inventory, which defines burnout as a psychological process resulting in feeling overwhelmed and frustrated by unforeseen stressors. Symptoms of burnout can include depression, cynicism and disconnection to list a few (2). Nearly every medical specialty has explored the idea of burnout particular to their profession with self-reported rates varying between 55 percent of critical care providers to 41 percent of ophthalmologist in a recent Medscape survey (3). In addition, the problem is increasing with 54 percent of physicians reporting at least one symptom of burnout in 2014 versus 45 percent in 2011, and these numbers are much higher than in the general population (4). Regarding neurosurgery, a recent article published in the Journal of Neurosurgery conducted a survey of 783 neurosurgeons and found the rate of burnout to be 62.9 percent among nonacademic neurosurgeons and 47.7 percent for academic neurosurgeons. Poor work life balance, anxiety over future earnings and health care reform were cited as major factors contributing to burnout and career satisfaction (5).

A Dangerous Relationship
Burnout can have major implications on a physician’s personal health, career and relationship with patients. The relationship between burnout and patient safety has not been thoroughly researched in regards to neurosurgery but has been in other specialties. Major medical errors reported by surgeons can be related to the degree of burnout and mental quality of life. A study of 7,905 members of the American College of Surgeons (ACS) reported that burnout and depression were independent predictors of reporting a major medical error with an incremental increased risk with increasing emotional exhaustion. Conversely, an increasing sense of personal accomplishment and mental quality of life was associated with fewer medical errors (6). Surgeons also self-report that a high level of personal burnout results in a lower perception of the quality of care they deliver (7). A study of anesthesia trainees revealed residents with symptoms of burnout were less likely to adhere to best practices and safety standards (8). The problem is not restricted to the operating room. Among critical care providers, depression was associated with a higher rate of medical error (9).

It does not take a great deal of imagination to see how burnout and loss of emotional reserves can lead to patient care errors. Depersonalization can lead to failure to make a connection with a patient in the clinic, to hear their real chief complaint, leading to diagnostic errors and failure to judge whether surgery is appropriate. Furthermore, loss of meaning in work can lead to carelessness in the operating room – not paying as close attention to sterile technique or hemostasis – with grave consequences. Failure to pay attention to details when reviewing patients’ imaging can lead to missed diagnoses or even wrong site surgeries. Burnout is not a theoretical problem; it can have real life devastating consequences for our patients.

Don’t Get Burned
Among neurosurgeons, many factors were found to lower the chances of burnout. In particular, neurosurgeons that are surgically productive, have children, feel intellectually stimulated, have a good life/career balance and are academic neurosurgeons were more likely to be satisfied with their career in neurosurgery (5). Taking an active leadership role in your health care institution has also been suggested to be preventative against burnout (10). The tumult surrounding the Affordable Care Act and healthcare reform is frequently cited as another contributing factor to physician stress and burnout.

Many training programs (11,12) and medical organizations (13) have implemented education for their members to attenuate the effects of burnout and to improve self-efficacy and self-care. Physician engagement will certainly be key to prevention of burnout. We must take a lead in this effort by being active and vocal for ourselves, our colleagues and our patients and fight against the forces that erode our mental health and the quality of our work. We must reach out to colleagues that we perceive to be at risk. We must respectfully, but vociferously, inform the leadership at our institutions what reforms work for patient care and which ones get in the way. In the end, the only people we can expect to fight physician burnout are the physicians themselves. We owe it to ourselves and to our patients.

References

1. ICD-1 Version: http://apps.who.int/classifications/icd10/browse/2016/en#/Z73.0

2. Maslach C, Jackson S, Leiter M. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996

3. Peckham, Carol. Medscape Lifestyle Report 2016: Bias and Burnout. 2016. http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview?src=wnl_physrep_160127_mscpedit&uac=140126DN&impID=971900&faf=1#page=1

4. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.

5. McAbee JH, Ragel BT, McCartney S, Jones GM, Michael LM 2nd, DeCuypere M, Cheng JS, Boop FA, Klimo P Jr. Factors associated with career satisfaction and burnout among US neurosurgeons: Results of a nationwide survey. J Neurosurg. 2015 Jul;123(1):161-73. doi: 10.3171/2014.12.JNS141348. Epub 2015 Feb 13. PubMed PMID: 25679276.

6. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J. Burnout and medical errors among American surgeons. Ann Surg. 2010 Jun;251(6):995-1000. doi: 10.1097/SLA.0b013e3181bfdab3. PubMed PMID: 19934755.

7. de Oliveira GS Jr, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, McCarthy RJ. The prevalence of burnout and depression and their association with adherence to safety and practice standards: A survey of United States anesthesiology trainees. Anesth Analg. 2013 Jul;117(1):182-93. doi: 10.1213/ANE.0b013e3182917da9. Epub 2013 May 17. PubMed PMID: 23687232.

8. Garrouste-Orgeas M, Perrin M, Soufir L, Vesin A, Blot F, Maxime V, Beuret P, Troché G, Klouche K, Argaud L, Azoulay E, Timsit JF. The Iatroref study: Medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015 Feb;41(2):273-84. doi: 10.1007/s00134-014-3601-4. Epub 2015 Jan 10. PubMed PMID: 25576157.

9. Klein J, Grosse Frie K, Blum K, von dem Knesebeck O. Burnout and perceived quality of care among German clinicians in surgery. Int J Qual Health Care. 2010 Dec;22(6):525-30. doi: 10.1093/intqhc/mzq056. Epub 2010 Oct 8. PubMed PMID: 20935011.

10. Hamade YJ, Aoun RJ, Zimmerman RS, Bendok BR. The Modern Neurosurgical Leader as a Cure for Team Burnout. 2015 Aug;77(2):N13. doi: 10.1227/01.neu.0000467292.26010.c3. PubMed PMID: 26181785.11. http://www.kevinmd.com/blog/2016/02/generation-x-physician-embraces-millennial-doctor-perspective.html

12. http://www.neurosurgeryblog.org/2015/09/01/millennial-doctors-heal-thyself/

13. http://www.ama-assn.org/ama/pub/news/news/2015/2015-06-08-ama-launches-steps-forward.page

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