Discussion Discussion: Burnout Phenomenon in U.S. Plastic Surgeons: Risk Factors and Impact on Quality of Life Robert X. Murphy, Jr., M.D., M.S. Bethlehem, Pa.

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am sure it comes as no surprise to anyone reading Dr. Rawlani and colleagues’ article that “burnout” seems to be a much more pervasive topic of discussion in the medical community today than it had been in the past. The authors note that an earlier study performed by the American College of Surgeons demonstrated a 40 percent burnout rate among American surgeons. In this study, the authors make a similar attempt to quantify the rate and explore the nature of the burnout phenomenon among U.S. plastic surgeon members of the American Society of Plastic Surgeons. Ultimately, Dr. Rawlani et al. establish that almost 30 percent of respondents to their survey are, in fact, burned out (and 15 percent could actually be clinically depressed) and identify significant risk factors as being subspecialty, number of hours worked and night calls per week, annual income, practice setting, and academic rank. Although it is certainly intuitive that having a supportive and healthy family life would mitigate and that hours worked and night calls per week would be obvious contributors to burnout, several other interesting issues are called to the fore by their findings. For example, why would the two subspecialties that suffer from this phenomenon most (i.e., microsurgeons and aesthetic surgeons) be at such similar risk with practice patterns that seem so disparate? After all, recognizing the significant pressures under which we all labor, one would think that not having nights on call would be a significant protective factor for our aesthetic colleagues. Furthermore, although one can certainly understand that an annual income less than $250,000 could contribute to burnout, it is somewhat counterintuitive that those with an annual income over $750,000 would be similarly at risk. Finally, what is it about being a program director or being in practice for greater than 15 years that obviates the risk for burnout? From the Immediate Past President, American Society of Plastic Surgeons; and the Division of Plastic Surgery, Department of Surgery, Lehigh Valley Health Network. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000977

It is interesting to note that, in the authors’ exhaustive list of references, the topic of burnout was actually broached as early as 1986 in family practice physicians and in family practice residents in 1987. Surely, these were times with pressures that were much different from those we know today. Furthermore, the list of references is replete with articles documenting burnout among resident physicians in family medicine, internal medicine, obstetrics and gynecology, orthopedics, and otolaryngology–head and neck surgery. How can this be? How can our youngest physicians, who are not exposed to the circumstances listed by the authors as significant risk factors for burnout, be experiencing the same phenomenon even before entering practice? Although the demographic and situational variables discussed in this article are certainly very important, it may well be that the phenomenon of burnout is, in part, nature as much as nurture. To be specific, the stage for burnout might be set by what we, as young, idealistic, caregivers, bring into the profession as we enter medical school. Even though our profession self-selects from among the most academically competitive individuals, we are no different from any other segment of the general population. Thus, if our residents are suffering from burnout in this Accreditation Council for Graduate Medical Education–overseen environment of duty-hour limitations and the redirection from service-based education to education that eliminates the service component, how can that be? Certainly one argument could be the pressures our young physicians face by graduating with significant debt. However, the average income in our specialty is quite generous compared with that of our colleagues in other fields. This is a pressure, yes, but one that in and of itself has its limits. Could it be that plastic surgeons with more experience Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.

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Plastic and Reconstructive Surgery • February 2015 may have developed greater resilience when challenged with work, resulting in decreased vulnerability to burnout? Could it be that our young colleagues begin to experience a “depersonalization” of the profession as their initial forays into the clinical world, wondrous though they may be, are confounded somewhat by an ever-expanding demand for completion of non–patient-related issues such as computer entry for electronic medical record purposes that are known to slow work flow and steal time that might be better used to maintain a work-life balance? Could it be that residents and young attending surgeons are not experiencing the sense of collegiality enjoyed by many of us of an older generation as customary avenues for social support and exchange such as participation in medical staff and medical society meetings, which are becoming a thing of the past? Could any or all of these conditions set the stage for the subsequent development of burnout? Quite possibly, because the personal benefits of having a partner and children at home, those associated with ongoing daily interaction with young residents, and being older and presumably more likely to participate in traditional meetings seem to attest to the protective nature of the human touch. So what must we do as a specialty and as caregivers, ourselves, to help address this daunting issue facing our profession? The most straightforward intervention is to look to our professional organizations to help provide the resources that can relieve some of the daily stressors in our practice lives, to provide the “professional nurture,” if you will. As an organization, the American Society of Plastic Surgeons has embarked on a number of ventures to assist surgeons in their daily practice. By providing educational resources that meet the individual needs of our member surgeons, by providing access to a group purchasing organization that helps members’ practices compete in a

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cost-efficient fashion, by leveraging the collective strength of its thousands of members to support their practices with a national marketing strategy, and by assuming the role of specialty advocate in state capitals and in Washington, D.C., the American Society of Plastic Surgeons seeks to help member surgeons be competitive without having to rely on individual resources so that more focus can be placed on their patients. However, the “nature” of physicians and how each individual’s unique personality contributes toward his or her vulnerability to burnout is a much more difficult, and perhaps more important, question to answer if we are to address the phenomenon of burnout within our own specialty and within the house of medicine. Is the time approaching when we, as medical school deans and residency program directors, should be evaluating an applicant’s performance on personality inventories and psychological profiles as much as we do with Medical College Admission Tests and United States Medical Licensing Examinations? Certainly, we, as a society, facing a significant physician shortage evolving over the next several years, cannot afford to lose expertly trained and talented physicians prematurely to burnout and exacerbate the problem further. The authors are to be congratulated on exploring this rather ubiquitous phenomenon of burnout as expressed within our own specialty. In the future, studies looking at both the personality traits of those physicians impacted by burnout and the incidence of burnout by age groupings could provide invaluable insight with regard to the nature of this vexing problem. Robert X. Murphy, Jr., M.D., M.S. Cosmetic and Reconstructive Specialists of the Lehigh Valley 2597 Schoenersville Road, Suite 305 Bethlehem, Pa. 18017

Discussion: Burnout phenomenon in U.S. plastic surgeons: risk factors and impact on quality of life.

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