Dr. Maroon: Four Questions about Wellness and Burnout
Joseph C. Maroon, MD, FAANS(L), is clinical professor and vice chairman of the Department of Neurological Surgery and Heindl Scholar in Neuroscience at the University of Pittsburgh Medical Center. In addition to being a neurosurgeon, he is a sports medicine expert, health and nutrition expert and Ironman triathlete. He is also the author of several books, including the recently published, “Square One: A Simple Guide to a Balanced Life.”
Michael Y. Oh, MD, FAANS, sat down with Dr. Maroon (JM) to speak to him about physician wellness and burnout.
In your CNS Presidential address, “From Icarus to Aequanimitas,” you spoke about the importance of balance and the negative consequences of not possessing it. That was 1986. What do you think about the current focus on physician wellness and burnout?
JM: We are finally recognizing physician burnout: the mental and physical exhaustion, the sense of being over-whelmed, over-worked, over-committed and over-stressed is finally being recognized by our national organizations. For neurosurgeons, the incidence of burnout is as high as 67 percent during their career. Fortunately, the problem is now recognized and we have reports, like from the Mayo Clinic, that say 50 percent of all physicians will experience burnout in their career. But what do we do about it? That is what I write about in my book, Square One. Chuck Noll used to say football is not complicated; it’s about blocking and tackling. A balanced life is not complicated, the formula is readily apparent and it is about work, physical fitness, relationships and spirituality. And you have to maintain all four to have balance. What usually happens in residency and early in one’s career is that you lose spirituality and physicality first, because the work is so consuming. Relationships fall next, then what is left is just more work. What is happening now is that there is more awareness of the causes of burnout and more emphasis on the importance of mindfulness; to be aware of where you are and what you are doing so you are not an automaton.
In your book, “Square One: A Simple Guide to a Balanced Life”, you describe the four sides of a square that are necessary for a balanced life. Which side is the most difficult to develop and cultivate?
JM: For me, work and career was a given, but when I hit rock bottom and ended up working at a truck stop the physical side saved my life. Exercise suppresses the cortisol levels that rise with stress and aerobic activity increases the release of endorphins and endocannabanoids. Exercise also increases BDNF levels that enhances neurogenesis, synaptogenesis and reduces stress. I also recommend a Mediterranean-type of diet, not the junk we often put into our bodies, including bottles of phosphoric acid that leaches calcium from your bones (Coke and Pepsi), trans-fatty acid in french fries that lead to vascular disease and meat from hormone infused and antibiotic treated cows. We need to be aware of these nutritional issues so we can do something about it. And it doesn’t take a lot, just 30 minutes of aerobic activity three times a week.
On the relationship side, I have to say I am not such an expert, but I have to also say that this is critical and, probably, the hardest part of a balanced life to maintain. You have to have a spouse that is very supportive and understanding of where you are and where you want to go in life. If you lack that, the friction will get to the point where the marriage will not work. You have to have two mature individuals coming together with common goals and similar squares and an understanding that the relationship journey is a marathon not a sprint.
The spirituality side depends on your upbringing and culture. You can incorporate the spiritual into work: I don’t force it on them, but I find that most patients really appreciate and welcome the opportunity to say a prayer with them before their surgery. But, it is also easy to fall away from your spiritual community because of time demands of work. Spirituality is so important, because it really is about the meaning of life.
If you had a more balanced life earlier in your career, do you think you would have been as successful?
JM: Earlier in my career, I had no insight and was totally about work. I was a flat line rather than a square and I neglected my family. I neglected my kids through this egocentric development of my career. Knowing what I know now, I think I would have been just as successful (maybe with different achievements) and I would have been able to attain these accomplishments without the tsunamis that, at several points in my life, washed away important people and relationships.
If an individual can attain the kind of balance that William H. Danforth described in his book “I Dare You,” one becomes more efficient with less stress. Stress also leads you to make bad decisions and I have paid a high price for the poor decisions I made during those unbalanced periods of my life. My axiom #1 is that if you are missing one side of the square, you can still get by, but you are not functioning at your highest level. You can’t be at your best when you are distracted by the anxiety, depression and tension of not having a semblance of work-life balance. If you are missing two or more sides of the square, then you are going to implode.
Can you really “have it all” (have great work, physical health, relationships and spirituality) at all times?
JM: Your question implies that you can’t have it all at all times and you are right. You can’t have a perfect square at all times, but you also can’t devote yourself exclusively to work. There will be times when some things have to give and one side of the square or another will suffer. But if you want to be the best neurosurgeon you can be, you cannot ignore any side of the square.
With current work-hour restriction for neurosurgery residents, there is really no excuse to not attend to all sides of a balanced life. There is also more awareness of the mind-body connection and more understanding of the psycho-neuro-immunology field and the affects of stress and exercise. The residents coming through now are very aware of this and I think we are producing better neurosurgeons who are better able to interact with people on a human level.
For practicing neurosurgeons, there has been a big change in the last 10-15 years. Electronic medical records is one example, but the larger challenge we face is that we are all diminished in our roles: we are gumballs, we are numbers and the perception of physicians is much less than it was. In order to combat these causes of burnout, we have to have resilience. Although adversity is the best teacher, we have to have insight and make decisions to correct it. I think it is the community you belong to that gives you the backstop to burnout.
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