The Maslach Burnout Inventory: A Critical Tool for Assessing and Addressing Burnout in Neurosurgery

Burnout, a psychological condition arising from chronic workplace stress, has been a consistent challenge for physicians throughout history. Characterized by its high-stakes and high-stress environment, neurosurgery consistently has one of the most significant rates of burnout in the medical field. A  2020 review of 3,310 neurosurgeons and residents found that about half of those surveyed (51.1% and 45.4%, respectively) were experiencing burnout syndrome. To better understand and address this critical issue, the Maslach Burnout Inventory (MBI) has become a widely used tool for assessing burnout syndrome. In this article, we discuss the application of the MBI, its limitations and its potential to inform meaningful changes in this demanding specialty.

MASLACH BURNOUT INVENTORY

The Maslach Burnout Inventory (MBI), developed in 1981 by Drs. Christina Maslach and Susan E. Jackson, is a psychological assessment designed to measure burnout. Designed as a survey, it assesses an individual’s experience of burnout, evaluating it within a 3-dimensional construct composed of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA).

EE is one of the most recognizable aspects of burnout. For neurosurgeons, EE often presents as a familiar struggle, stemming from the overwhelming fatigue caused by the intense physical and mental demands inherent to the specialty. This often manifests as feelings of having no energy left to give and a sense of being drained, both inside and out of the operating room. A common thought is, “I am not sure how much longer I can do this for.” Studies have shown a strong correlation between burnout and the desire to leave the profession with both neurosurgeons considering early retirement and neurosurgery residents contemplating quitting.

The second dimension assessed by the MBI is DP. This is characterized by emotional detachment, apathy and cynicism and is believed to arise as a coping mechanism for the pressures of the field.  DP can lead to individuals’ having an impersonal attitude and diminished ability to empathize with patients. The incidence of DP within neurosurgery is not low;  a recent study of 282 neurosurgeons found that 48.6% exhibited high levels of depersonalization.

The final dimension of burnout considers one’s level of PA, defined as the fulfillment and achievement an individual derives from their career. A dearth of PA may suggest that one’s efforts are meaningless (even when successful). Neurosurgeons routinely care for patients with unfavorable prognoses; this may result in neurosurgeons’ questioning their abilities routinely. Resilience and a robust sense of PA is essential for ensuring both the satisfaction and longevity of a surgeon’s career.

METHODOLOGY OF THE MBI

The Maslach Burnout Inventory is a 22-item self-reporting survey evaluating the three dimensions of burnout. Individuals answer questions on the frequency with which they identify with a particular thought; this is rated on a Likert-style scale, from never (0 points) to every day (6 points). The EE category prompts individuals to rate their proximity to emotions like, “I feel used up at the end of the workday,” and “I feel like I’m at the end of my rope.” A high score suggests severe EE. Similarly, prompts evaluating DP use statements such as, “I feel I treat some patients as if they were impersonal ‘objects’,” and, “I don’t really care what happens to some patients.” A high score suggests severe depersonalization. And lastly, the PA category features statements such as, “I can easily understand how my patients feel about things,” and “I feel I’m positively influencing other people’s lives through my work.” A low PA score suggests a diminished sense of personal accomplishment. Burnout is suggested by a high EE, high DP, and low PE scores.

Over time, the MBI has been modified for specific groups including medical personnel (MBI-HSS MP), human services workers (MBI-HSS), educators (MBI-ES), general use (MBI-GS), and students (MBI-GS). For neurosurgeons, the MBI-HSS MP is the most appropriate questionnaire.

In the last decade, the MBI has been used to investigate neurosurgical burnout; correlations have been found between burnout and depression, medical errors and malpractice litigation. Whether the MBI is adequate for assessing neurosurgical burnout remains to be established.

LIMITATIONS OF THE MBI

Although the MBI-HSS MP is considered the gold-standard for assessing burnout in health care workers, it may be limited in the assessment of neurosurgeons. The MBI-HSS primarily addresses situations that lead to interpersonal burnout in the three aforementioned domains but does not account for institutional drivers of burnout. Long hours, inadequate infrastructure and high-stress situations combine to create a high-pressure environment. Future investigations into neurosurgical burnout should evaluate not only interpersonal dimensions as measured by the MBI-HSS MP, but also institutional variables.  

CONCLUSION

Neurosurgery is a rewarding and demanding profession; its practitioners are at risk of burnout. Neurosurgeons treat some of the most critically ill, high-risk patients with uncertain or poor prognoses; a fine line is walked by these physicians as they deliver care for others while simultaneously maintaining personal well-being. This balancing act underscores the importance of tools like the MBI in assessing EE, DP and PA on regular intervals. Ongoing research into the nature and measurement of burnout in neurosurgery is imperative; the MBI and similar tools will enable evidence-based interventions to improve training programs, academic institutions and private practices. Addressing burnout is essential to ensuring the health and longevity of neurosurgeons while ensuring quality care for patients.