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AANS Neurosurgeon | Volume 26, Number 3, 2017

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Like Aloe for Sunscreen: Harm Reduction & Prevention in Neurosurgery Resident Burnout

Burnout has emerged as one of the most complex and controversial issues in medical education, with resident physician suicide rates at an all-time high and academic investigations aimed at understanding burnout expanding exponentially. These efforts are commendable and constitute a critical step towards physician wellness; however, while many burnout management strategies are as effective as aloe, to neurosurgery residents, they are a far cry from sunscreen.

Although the first formal analyses focused on resident and medical student burnout were published fewer than 20 years ago, the past decade has seen an explosion in burnout literature, including the first large-scale national survey of >7,000 physicians in 2011.4-6,10 Multiple subsequent studies have reproduced the myriad links between burnout among resident or attending physicians and unfavorable outcomes ranging from depersonalization and loss of empathy to increased medical errors, poor patient satisfaction, higher physician turnover and elevated risk of suicide.9,11

Several burnout studies have appeared in neurosurgical literature, reporting equivocal results. One study identified low rates of burnout among residents and early career neurosurgeons, while another compared outcomes after elective aneurysm surgery between neurosurgeons who performed emergency procedures the night before and those who did not, finding no significant differences.3 By contrast, one notable report identified supra-normal burnout rates among neurosurgeons, but with surprisingly high levels of career satisfaction.2,7,8 This invites a paradoxical question — how can one group of surgeons be simultaneously the most burnt out and the most satisfied with their careers?

At Mayo Clinic, we are privileged to train in a vanguard institution that has prioritized the development of cutting-edge burnout management resources.11 Interestingly, our personal experiences as neurosurgery residents within this system have highlighted a critical difference in how our peer group experiences burnout and why symptom-directed initiatives will inevitably fall short for our subspecialty.

Across the board, studies have identified the same family of factors as underlying burnout, which one author described as “circumstantial,” and which largely equate to excessive workload. Long hours, increased clerical burden, decreased time off and frustrations of systemic inefficiencies.1

Correspondingly, both institutional initiatives and resident-directed recommendations for burnout management attempt to offset those burdens. Such efforts are laudable and make a dent in the daily toll; however, they still amount to aloe on sunburn — symptomatic relief, rather than true prevention.

Neurosurgery is a high-risk, high-reward environment, and trainees self-select not only knowing what they are signing up for, but often with a sense of passion, pride and devotion that many readers will recognize. Grit and resilience are woven into each of us as individuals long before we are neurosurgeons and, together with the foreknowledge that neurosurgery residency will be defined by burnout risk from day one, our residents may display a degree of immunity to “circumstantial” factors. This also provides an explanation for why even neurosurgeons who score positively on burnout indices simultaneously report high career satisfaction — they are, after all, doing exactly what they set out to do.

So why, then, is burnout observed at all among neurosurgery residents? One possibility is that nobody is truly immune and even the most fortified residents will still eventually suffer from chronic exposure. Another is confounding — burnout studies in neurosurgery rely on survey data and the same cultural factors that increase resiliency may also lead to reporting bias, denial or obfuscation.


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A likely explanation is that the same impassioned dedication that is protective from “circumstantial” factors may also leave neurosurgery residents vulnerable to insidious causes of “existential” burnout — alienation from one’s identity and purpose as a doctor, rather than simply being overwhelmed by the daily challenges of doctoring.1 Neurosurgery residents expect to be overwhelmed. In many situations, we relish the chance to become stronger, more experienced doctors. In exchange, we expect a training environment within which, given the incredibly high stakes of our work, we will be protected so long as we unambiguously act in the best interests of our patients.

At Mayo Clinic, we are reminded daily of the proud traditions of not only Will and Charlie Mayo, whose ubiquitous maxim “The needs of the patient come first” resonates with every decision we make. In addition, the great neurosurgical leader Thoralf Sundt, MD, reminded trainees of what it truly takes to live out that mission as a neurosurgery resident, typically by referencing a quote from his West Point days: “You are here for discipline — not justice.”

Unfortunately, across the landscape of neurosurgical training in America these principles have significantly eroded. In large part, this reflects a general assault against medical training. Not only have protocols overtaken thoughtful medical decision-making in many spheres, but the rise of anonymous reporting systems have positioned residents such that if they deviate from the protocol, they will live in fear of punishment, regardless of whether the patient would have suffered serious harm before the protocol was completed. Making matters worse, resident authority has been severely undermined in the institutional culture of hospitals today. Should a young physician find themselves in such a situation and attempt to educate colleagues regarding why the orders are deviating from protocol, they will be painted as condescending, meddlesome, difficult or demanding. This further amplifies the fear of retribution and the sense of helplessness possessed by so many Neurosurgery residents across the country today. Indeed, we suspect that this and related issues underlie the negative feedback cycle linking burnout to poor patient outcomes.

One could argue that institutional standardization efforts are not new and that relationships between residents and members of the care team have always been challenging. There is some truth to that, but the forces assaulting resident education have now also managed to permeate and dissolve the protective bonds that made our community more impervious in the past.

A great strength of our specialty’s culture of excellence is that it empowers residents to earn trust from peers, seniors and staff rapidly. This gives all of us confidence that, in a conflict, we need not hesitate to defend a resident carrying out his or her mission — the disciplined commitment to the needs of the patient. Shockingly, this fundamental relationship has been outflanked by a system that devalues individual thought and resets the terms of engagement such that the question is no longer “Did they try to do the right thing for the patient?” but rather “Was the protocol followed?”

Protocolized medicine is just one instance of a burnout driver in neurosurgery, but the theme has many manifestations: residents who were bred to work hard, think fast and act quickly are marginalized by systems outside their control. Neurosurgery is losing its ability to defend and reinvigorate them with the meaning, camaraderie and commitment to excellence that are required to survive the job without terminal alienation. There is no easy solution to this problem, but the first step is recognition.

Our final message is that it’s time for neurosurgery to further advance the conversation on burnout. Our specialty has a remarkable history of looking out for its own in the isolating and demanding environment that we proudly consider our domain and burnout is the most recent challenge that neurosurgery must rise to meet. It is time for more commanders and lieutenants to focus on daily advocacy for our soldiers in this often hostile and lonely battlefield, with a mind toward burnout prevention. For us, its influence is more hidden — particularly in today’s health care climate — and the effects more insidious. Let us put away the aloe and take out the sunscreen, before we all get burned.

References

1. Abedini, N. C., Stack, S. W., Goodman, J. L., & Steinberg, K. P. (2018). “Its Not Just Time Off”: A Framework for Understanding Factors Promoting Recovery From Burnout Among Internal Medicine Residents. Journal of Graduate Medical Education, 10(1), 26-32.

2. Attenello, F. J., Buchanan, I. A., Wen, T., Donoho, D. A., Mccartney, S., Cen, S. Y., . . . Klimo, P. (2018). Factors associated with burnout among US neurosurgery residents: A nationwide survey. Journal of Neurosurgery, 1-15.

3. Bekelis, K., Missios, S., & Mackenzie, T. A. (2017). Outcomes of Elective Cerebral Aneurysm Treatment Performed by Attending Neurosurgeons after Night Work. Neurosurgery, 82(3), 329-334.

4. Center, C., Davis, M., Detre, T., Ford, D. E., Hansbrough, W., Hendin, H., . . . Silverman, M. M. (2003). Confronting Depression and Suicide in Physicians. Jama, 289(23), 3161. 

5. Dahlin, M., Joneborg, N., & Runeson, B. (2005). Stress and depression among medical students: A cross-sectional study. Medical Education, 39(6), 594-604.

6. Guthrie, E., Black, D., Bagalkote, H., Shaw, C., Campbell, M., & Creed, F. (1998). Psychological stress and burnout in medical students: A five-year prospective longitudinal study. Journal of the Royal Society of Medicine, 91(5), 237-243.

7. Mcabee, J. H., Ragel, B. T., Mccartney, S., Jones, G. M., Michael, L. M., Decuypere, M., . . . Klimo, P. (2015). Factors associated with career satisfaction and burnout among US neurosurgeons: Results of a nationwide survey. Journal of Neurosurgery, 123(1), 161-173. 

8. Shakir, H. J., Mcpheeters, M. J., Shallwani, H., Pittari, J. E., & Reynolds, R. M. (2017). The Prevalence of Burnout Among US Neurosurgery Residents. Neurosurgery. 

9. Shanafelt, T. D., Dyrbye, L. N., & West, C. P. (2017). Addressing Physician Burnout. Jama, 317(9), 901.

10. Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, C., Satele, D., Sloan, J., & West, C. P. (2015). Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic Proceedings, 90(12), 1600-1613. 

11. Shanafelt, T. D., & Noseworthy, J. H. (2017). Executive Leadership and Physician Well-being. Mayo Clinic Proceedings, 92(1), 129-146.

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