SPECIAL TOPIC Burnout Phenomenon in U.S. Plastic Surgeons: Risk Factors and Impact on Quality of Life Hannan A. Qureshi, B.A. Roshni Rawlani Lauren M. Mioton, M.D. Gregory A. Dumanian, M.D. John Y. S. Kim, M.D. Vinay Rawlani, M.D. Chicago, Ill.
Background: Recent studies by the American College of Surgeons reveal that nearly 40 percent of U.S. surgeons exhibit signs of burnout. The authors endeavored to quantify the incidence of burnout among U.S. plastic surgeons, determine identifiable risk factors, and evaluate its impact on quality of life. Methods: All U.S. residing members of the American Society of Plastic Surgeons were invited to complete an anonymous survey between September of 2010 and August of 2011. The survey contained a validated measure of burnout (Maslach Burnout Inventory) and evaluated surgeon demographics, professional and personal risk factors, career satisfaction, self-perceived medical errors, professional impairment, and family-home conflicts. Results: Of the 5942 surgeons invited, 1691 actively practicing U.S. plastic surgeons (28.5 percent) completed the survey. The validated rate of burnout was 29.7 percent. Significant risk factors for burnout included subspecialty, number of hours worked and night calls per week, annual income, practice setting, and academic rank. Approximately one-fourth of plastic surgeons had significantly lower quality-of-life scores than the U.S. population norm, and this risk increases in burned out surgeons. In addition to having lower career satisfaction and more work-home conflicts, plastic surgeons with burnout also had a nearly two-fold increased risk of self-reported medical errors and selfreported impairment. Conclusions: Over one-fourth of plastic surgeons in the United States experience validated burnout, with concomitant attenuated career satisfaction and quality of life. Multivariate analysis identified predisposing factors that may aid in better understanding risk profiles that lead to burnout; therefore, efforts to understand and thereby avoid this burnout phenomenon are warranted. (Plast. Reconstr. Surg. 135: 619, 2015.)
B
urnout syndrome—defined as emotional exhaustion, depersonalization, and perceived lack of personal accomplishment that leads to decreased effectiveness at work—is a common occurrence among health care professionals in the United States.1 A national survey of 7905 surgeons conducted by the American College of Surgeons demonstrated that 40 percent of U.S. surgeons suffer from burnout.2 The potential ramifications of physician burnout include suboptimal patient care, decreased patient satisfaction, increased rates of medical errors, and increased medicolegal litigation.2–9 Moreover, among U.S. surgeons, burnout is thought to be the greatest From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine. Received for publication January 16, 2014; accepted July 22, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000855
determinant of career dissatisfaction and to have a strong influence on early retirement.2,10,11 Given the impact of physician burnout on physician quality of life and patient care, efforts have been made to investigate possible predictors of burnout. Several risk factors for burnout have been identified, including work hours, call burden, subspecialty choice, control over work schedule, reimbursement schedule, work-family stressors, surgeon age, and surgeon sex.2,3,10–24 Although burnout among several surgical specialties has been investigated, burnout specifically within plastic surgery has yet to be evaluated on a large scale.3,12–23 We assume there are definite risk factors for burnout in plastic surgery that may reflect the Disclosure: The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.
www.PRSJournal.com
619
Plastic and Reconstructive Surgery • February 2015 nature of our work, the varying patient populations we treat, and the recent changes in the national economic climate. To better understand burnout, including incidence and risk factors, we administered a validated survey of all U.S. residing members of the American Society of Plastic Surgeons. Furthermore, although a paucity of evidence exists to determine whether burnout affects patient care in plastic surgery, other studies have shown a correlation between physician psychological health and medical errors. Therefore, we also evaluated surgeon depression and quality of life, and surgeon impairment measures, to allow us to clearly understand the influence of surgeon wellbeing on patient care.
MATERIALS AND METHODS Participants All American Society of Plastic Surgeons members residing in the United States with a mailing address on file were invited to complete a nonsponsored online survey between September of 2010 and August of 2011. Survey responses were collected through September of 2011. Survey The survey was derived from the 2008 American College of Surgeons burnout survey to allow for a comparison of results.2 American Society of Plastic Surgeons members were sent a letter stating that a non–Society-sponsored survey was being conducted on all American Society of Plastic Surgeons members evaluating the impact of burnout in plastic surgery. Members were notified that participation was voluntary and that all responses were anonymous. The survey was hosted by surveymonkey.com. The 79 total survey questions evaluated surgeon burnout, quality of life, depression, and impairment, in addition to demographics, practice characteristics, career satisfaction, self-perceived medical errors, and work-family-home conflicts. Five validated survey tools were used to assess various domains: burnout (Maslach Burnout Inventory), depression (Primary Care Evaluation of Mental Disorders), quality of life (SF-8 Health Survey), and alcohol (Alcohol Use Disorders Identification Test) and substance abuse (single item).1,6,25–31 Standardized questions evaluating career satisfaction, medical errors, practice characteristics, and work-home conflicts were adopted from the previous 2008 American College of Surgeons study. Some questions were modified
620
slightly to increase their application to plastic surgery (i.e., “Would you become a surgeon again?” was changed to “Would you become a plastic surgeon again?”). Burnout was measured using the validated Maslach Burnout Inventory, which is the criterion standard for diagnosis of burnout in physicians.1,14,19,32 Specifically, the Maslach Burnout Inventory uses 22 questions to evaluate the three subscales of burnout: emotional exhaustion, depersonalization, and personal accomplishment.1 Each question is graded on a seven-point Likert scale allowing for calculation of scores for each of the three subscales: emotional exhaustion (possible range, 0 to 54), depersonalization (possible range, 0 to 30), and personal accomplishment (possible range, 0 to 48). Scores can subsequently be stratified into high, moderate, and low levels according to the scoring guidelines specific to physicians.1 Individuals with high scores on emotional exhaustion (score >27) or depersonalization (score >10) or low scores on personal accomplishment (score 25 Academic rank Missing Assistant professor Associate professor Full professor None Administrative role Missing Chair or chief Program director Practice executive None Work hours (per week) Missing Mean (hr) 80 Nights on call (per week) Missing ≤1 2 3 ≥4 Operative load Missing Average no. of cases per week Average hr operating per week Non–patient care activities Missing Resident education Research Administration None Time dedicated to non–patient care activities Missing 0–10% of time 11–25% of time 25–50% of time >50% of time Non–patient care activity time protected? Missing Yes No
622
Table 1. Continued No. (%) or Mean (Range) 1691 87 248 (15.5) 226 (14.1) 64 (4.0) 578 (36.0) 173 (10.8) 171 (10.6) 144 (9.0) 383 570 (43.6) 738 (56.4) 91 11.5 (0.9–28) 278 (17.4) 442 (27.6) 531 (33.2) 285 (17.8) 64 (4.0) 360 165 (12.4) 311 (23.4) 103 (7.7) 752 (56.5) 134 29 (1.9) 36 (2.3) 445 (28.6) 1081 (69.4) 202 78.2 (36–113) 96 (6.4) 348 (23.4) 719 (48.3) 326 (21.9) 210 344 (23.2) 503 (34.0) 415 (28.0) 219 (14.8) 238 8.1 (2–27) 26.3 (4.5–65) 309 478 (34.6) 337 (24.4) 670 (48.5) 115 (8.3) 423 203 (16.0) 755 (59.5) 222 (17.5) 88 (6.9) 310 387 (28.0) 994 (72.0) (Continued)
No. (%) or Mean Characteristic (Range) Annual income Missing 426 Average annual net income $391,388 (U.S. dollars) ($117,000–$4,250,000) Method of compensation Missing 275 Salaried, no incentive pay 261 (18.4) Salaried, bonus pay based on billing 425 (30.0) Incentive based pay based on billing 598 (42.2) Other 132 (9.3)
Burnout was shown to increase the risk of adverse professional and personal outcomes, detailed in Table 6. Overall, physicians experiencing burnout were more than twice as likely to have low career satisfaction (OR, 2.62; p < 0.001) and self-reported impairment (OR, 2.20; p < 0.001) compared with doctors not suffering from burnout. Burnout also correlated with elevated odds of self-reported medical errors (OR, 1.89; p < 0.001), an increased risk of having work-home conflicts (OR, 1.98; p < 0.001), and screening positive for depression (OR, 1.21; p = 0.044). Table 2. Participant Characteristics Characteristic No. of plastic surgeons Demographics Missing Male Female Age, yr Current relationship status Missing Single Married Partnered Divorced Widowed or widower Previous divorce Missing Yes No Have children Missing Yes No Partner or spouse works outside home* Missing Yes No Schedule leaves time for personal life Missing Yes No Experience work-home conflict in last month Missing Yes No
No. (%) or Mean (Range) 1691 23 1243 (74.5) 425 (25.5) 50.8 (33–74) 130 200 (12.8) 1047 (67.1) 90 (5.8) 168 (10.8) 56 (3.6) 141 413 (26.6) 1137 (73.4) 54 1455 (88.9) 182 (11.1) 388 592 (45.4) 711 (54.6) 480 526 (43.4) 685 (56.6) 490 401 (33.4) 800 (66.6)
*Asked only of surgeons who reported being married or partnered.
Volume 135, Number 2 • Burnout in Plastic Surgery Table 3. Burnout Characteristics among Participating Plastic Surgeons Characteristic
No. (%)
No. of plastic surgeons Burnout* Missing Burned out Emotional exhaustion Missing Low score Moderate score High score Depersonalization Missing Low score Moderate score High score Personal accomplishment Missing Low score Moderate score High score
1691 141 460 (29.7) 95 615 (38.4) 584 (36.6) 397 (24.9) 86 719 (44.8) 564 (35.1) 322 (20.1) 88 133 (8.3) 210 (13.1) 1260 (78.6)
*Calculated by a high score on emotional exhaustion and/or depersonalization.
Table 4. Depression, Quality of Life, and Impairment among Participating Plastic Surgeons Characteristic
No. (%) or Mean (Range)
No. of plastic surgeons Depression Missing Positive screen QoL Missing Mental QoL, mean score Poor mental QoL* Physical QoL, mean score Poor physical QoL* Self-reported impairment† Missing Yes No Alcohol abuse Missing Screen positive Substance abuse Missing Screen positive Sleep deprivation‡ Missing Average hours per night >6 hr per night 70) Subspecialty (microsurgery or aesthetics) Night calls per week (>2) Method of compensation (nonsalary) Annual income Junior academic rank Chairman or chief Operative load (time or no. of cases) Participation in nonclinical activities (any) Program director Greater years in practice (>15) Personal Spouse works Married or partnered Have children Older age (>60 yr)
OR (95% CI)
p
2.42 (1.95–3.0)
Background: Recent studies by the American College of Surgeons reveal that nearly 40 percent of U.S. surgeons exhibit signs of burnout. The authors endeavored to quantify the incidence of burnout among U.S. plastic surgeons, determine identifiable risk factors, and evaluate its impact on quality of life. Methods: All U.S. residing members of the American Society of Plastic Surgeons were invited to complete an anonymous survey between September of 2010 and August of 2011. The survey contained a validated measure of burnout (Maslach Burnout Inventory) and evaluated surgeon demographics, professional and personal risk factors, career satisfaction, self-perceived medical errors, professional impairment, and family-home conflicts. Results: Of the 5942 surgeons invited, 1691 actively practicing U.S. plastic surgeons (28.5 percent) completed the survey. The validated rate of burnout was 29.7 percent. Significant risk factors for burnout included subspecialty, number of hours worked and night calls per week, annual income, practice setting, and academic rank. Approximately one-fourth of plastic surgeons had significantly lower quality-of-life scores than the U.S. population norm, and this risk increases in burned out surgeons. In addition to having lower career satisfaction and more work-home conflicts, plastic surgeons with burnout also had a nearly two-fold increased risk of self-reported medical errors and selfreported impairment. Conclusions: Over one-fourth of plastic surgeons in the United States experience validated burnout, with concomitant attenuated career satisfaction and quality of life. Multivariate analysis identified predisposing factors that may aid in better understanding risk profiles that lead to burnout; therefore, efforts to understand and thereby avoid this burnout phenomenon are warranted. (Plast. Reconstr. Surg. 135: 619, 2015.)
B
urnout syndrome—defined as emotional exhaustion, depersonalization, and perceived lack of personal accomplishment that leads to decreased effectiveness at work—is a common occurrence among health care professionals in the United States.1 A national survey of 7905 surgeons conducted by the American College of Surgeons demonstrated that 40 percent of U.S. surgeons suffer from burnout.2 The potential ramifications of physician burnout include suboptimal patient care, decreased patient satisfaction, increased rates of medical errors, and increased medicolegal litigation.2–9 Moreover, among U.S. surgeons, burnout is thought to be the greatest From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine. Received for publication January 16, 2014; accepted July 22, 2014. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000855
determinant of career dissatisfaction and to have a strong influence on early retirement.2,10,11 Given the impact of physician burnout on physician quality of life and patient care, efforts have been made to investigate possible predictors of burnout. Several risk factors for burnout have been identified, including work hours, call burden, subspecialty choice, control over work schedule, reimbursement schedule, work-family stressors, surgeon age, and surgeon sex.2,3,10–24 Although burnout among several surgical specialties has been investigated, burnout specifically within plastic surgery has yet to be evaluated on a large scale.3,12–23 We assume there are definite risk factors for burnout in plastic surgery that may reflect the Disclosure: The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.
www.PRSJournal.com
619
Plastic and Reconstructive Surgery • February 2015 nature of our work, the varying patient populations we treat, and the recent changes in the national economic climate. To better understand burnout, including incidence and risk factors, we administered a validated survey of all U.S. residing members of the American Society of Plastic Surgeons. Furthermore, although a paucity of evidence exists to determine whether burnout affects patient care in plastic surgery, other studies have shown a correlation between physician psychological health and medical errors. Therefore, we also evaluated surgeon depression and quality of life, and surgeon impairment measures, to allow us to clearly understand the influence of surgeon wellbeing on patient care.
MATERIALS AND METHODS Participants All American Society of Plastic Surgeons members residing in the United States with a mailing address on file were invited to complete a nonsponsored online survey between September of 2010 and August of 2011. Survey responses were collected through September of 2011. Survey The survey was derived from the 2008 American College of Surgeons burnout survey to allow for a comparison of results.2 American Society of Plastic Surgeons members were sent a letter stating that a non–Society-sponsored survey was being conducted on all American Society of Plastic Surgeons members evaluating the impact of burnout in plastic surgery. Members were notified that participation was voluntary and that all responses were anonymous. The survey was hosted by surveymonkey.com. The 79 total survey questions evaluated surgeon burnout, quality of life, depression, and impairment, in addition to demographics, practice characteristics, career satisfaction, self-perceived medical errors, and work-family-home conflicts. Five validated survey tools were used to assess various domains: burnout (Maslach Burnout Inventory), depression (Primary Care Evaluation of Mental Disorders), quality of life (SF-8 Health Survey), and alcohol (Alcohol Use Disorders Identification Test) and substance abuse (single item).1,6,25–31 Standardized questions evaluating career satisfaction, medical errors, practice characteristics, and work-home conflicts were adopted from the previous 2008 American College of Surgeons study. Some questions were modified
620
slightly to increase their application to plastic surgery (i.e., “Would you become a surgeon again?” was changed to “Would you become a plastic surgeon again?”). Burnout was measured using the validated Maslach Burnout Inventory, which is the criterion standard for diagnosis of burnout in physicians.1,14,19,32 Specifically, the Maslach Burnout Inventory uses 22 questions to evaluate the three subscales of burnout: emotional exhaustion, depersonalization, and personal accomplishment.1 Each question is graded on a seven-point Likert scale allowing for calculation of scores for each of the three subscales: emotional exhaustion (possible range, 0 to 54), depersonalization (possible range, 0 to 30), and personal accomplishment (possible range, 0 to 48). Scores can subsequently be stratified into high, moderate, and low levels according to the scoring guidelines specific to physicians.1 Individuals with high scores on emotional exhaustion (score >27) or depersonalization (score >10) or low scores on personal accomplishment (score 25 Academic rank Missing Assistant professor Associate professor Full professor None Administrative role Missing Chair or chief Program director Practice executive None Work hours (per week) Missing Mean (hr) 80 Nights on call (per week) Missing ≤1 2 3 ≥4 Operative load Missing Average no. of cases per week Average hr operating per week Non–patient care activities Missing Resident education Research Administration None Time dedicated to non–patient care activities Missing 0–10% of time 11–25% of time 25–50% of time >50% of time Non–patient care activity time protected? Missing Yes No
622
Table 1. Continued No. (%) or Mean (Range) 1691 87 248 (15.5) 226 (14.1) 64 (4.0) 578 (36.0) 173 (10.8) 171 (10.6) 144 (9.0) 383 570 (43.6) 738 (56.4) 91 11.5 (0.9–28) 278 (17.4) 442 (27.6) 531 (33.2) 285 (17.8) 64 (4.0) 360 165 (12.4) 311 (23.4) 103 (7.7) 752 (56.5) 134 29 (1.9) 36 (2.3) 445 (28.6) 1081 (69.4) 202 78.2 (36–113) 96 (6.4) 348 (23.4) 719 (48.3) 326 (21.9) 210 344 (23.2) 503 (34.0) 415 (28.0) 219 (14.8) 238 8.1 (2–27) 26.3 (4.5–65) 309 478 (34.6) 337 (24.4) 670 (48.5) 115 (8.3) 423 203 (16.0) 755 (59.5) 222 (17.5) 88 (6.9) 310 387 (28.0) 994 (72.0) (Continued)
No. (%) or Mean Characteristic (Range) Annual income Missing 426 Average annual net income $391,388 (U.S. dollars) ($117,000–$4,250,000) Method of compensation Missing 275 Salaried, no incentive pay 261 (18.4) Salaried, bonus pay based on billing 425 (30.0) Incentive based pay based on billing 598 (42.2) Other 132 (9.3)
Burnout was shown to increase the risk of adverse professional and personal outcomes, detailed in Table 6. Overall, physicians experiencing burnout were more than twice as likely to have low career satisfaction (OR, 2.62; p < 0.001) and self-reported impairment (OR, 2.20; p < 0.001) compared with doctors not suffering from burnout. Burnout also correlated with elevated odds of self-reported medical errors (OR, 1.89; p < 0.001), an increased risk of having work-home conflicts (OR, 1.98; p < 0.001), and screening positive for depression (OR, 1.21; p = 0.044). Table 2. Participant Characteristics Characteristic No. of plastic surgeons Demographics Missing Male Female Age, yr Current relationship status Missing Single Married Partnered Divorced Widowed or widower Previous divorce Missing Yes No Have children Missing Yes No Partner or spouse works outside home* Missing Yes No Schedule leaves time for personal life Missing Yes No Experience work-home conflict in last month Missing Yes No
No. (%) or Mean (Range) 1691 23 1243 (74.5) 425 (25.5) 50.8 (33–74) 130 200 (12.8) 1047 (67.1) 90 (5.8) 168 (10.8) 56 (3.6) 141 413 (26.6) 1137 (73.4) 54 1455 (88.9) 182 (11.1) 388 592 (45.4) 711 (54.6) 480 526 (43.4) 685 (56.6) 490 401 (33.4) 800 (66.6)
*Asked only of surgeons who reported being married or partnered.
Volume 135, Number 2 • Burnout in Plastic Surgery Table 3. Burnout Characteristics among Participating Plastic Surgeons Characteristic
No. (%)
No. of plastic surgeons Burnout* Missing Burned out Emotional exhaustion Missing Low score Moderate score High score Depersonalization Missing Low score Moderate score High score Personal accomplishment Missing Low score Moderate score High score
1691 141 460 (29.7) 95 615 (38.4) 584 (36.6) 397 (24.9) 86 719 (44.8) 564 (35.1) 322 (20.1) 88 133 (8.3) 210 (13.1) 1260 (78.6)
*Calculated by a high score on emotional exhaustion and/or depersonalization.
Table 4. Depression, Quality of Life, and Impairment among Participating Plastic Surgeons Characteristic
No. (%) or Mean (Range)
No. of plastic surgeons Depression Missing Positive screen QoL Missing Mental QoL, mean score Poor mental QoL* Physical QoL, mean score Poor physical QoL* Self-reported impairment† Missing Yes No Alcohol abuse Missing Screen positive Substance abuse Missing Screen positive Sleep deprivation‡ Missing Average hours per night >6 hr per night 70) Subspecialty (microsurgery or aesthetics) Night calls per week (>2) Method of compensation (nonsalary) Annual income Junior academic rank Chairman or chief Operative load (time or no. of cases) Participation in nonclinical activities (any) Program director Greater years in practice (>15) Personal Spouse works Married or partnered Have children Older age (>60 yr)
OR (95% CI)
p
2.42 (1.95–3.0)
