Discussion Discussion: Burnout Phenomenon in U.S. Plastic Surgeons: Risk Factors and Impact on Quality of Life John G. Hunter, M.D., M.M.M. New York and Brooklyn, N.Y.
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umerous studies have shown that stress and “burnout” decrease physician job satisfaction and increase medical errors. Burnout is characterized by several consistent attributes, principally emotional exhaustion, depersonalization, and diminished sense of personal accomplishment.1 Burnout has been demonstrated in multiple recent publications to be common among physicians and surgeons in the United States and elsewhere.2,3 In the first national study evaluating burnout phenomenon in a large sample of U.S. physicians from all specialties (using the validated, widely accepted Maslach Burnout Inventory), compared with a probability-based sample of the overall U.S. population, Shanafelt et al. found that physicians were more likely to have burnout symptoms (37.9 percent versus 27.8 percent; p < 0.001) and work-life balance dissatisfaction (40.2 percent versus 23.2 percent; p < 0.001).2 Burnout has also been shown to be more prevalent, relative to the general U.S. population, at the early stages of physician careers: medical school, residency and the first 5 years of practice (p < 0.0001 for all).4 Qureshi and colleagues, in this interesting publication, discuss the burnout phenomenon among U.S. plastic surgeons, and its consequences. Based on the responses of 1691 American Society of Plastic Surgeons members to a validated, 79-question survey, they report a 29.7 percent responder burnout rate. Besides a lower career satisfaction rate, which is disturbing enough, plastic surgeons experiencing burnout reported higher rates of medical errors and impairment (i.e., alcohol/drug abuse, mental illness)—both of which constitute public health threats.5 From the Division of Plastic Surgery, Weill Cornell Medical College and New York-Presbyterian Hospital; and the Department of Surgery, New York Methodist Hospital. Received for publication August 4, 2014; accepted August 13, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000853
A recent publication assessing burnout in U.S. plastic surgeons, also based on a survey of American Society of Plastic Surgeons members and using the Maslach Burnout Inventory, found a similar (29 percent) burnout rate. Although based on a smaller, randomly selected sample (708 members), it had a much higher response rate than the authors’ study (71 percent versus 28.5 percent). As Qureshi et al. also report, long work hours, emergency department call responsibilities, and poor health correlate highly with plastic surgeon burnout.6 The need to identify and effectively address the real and serious problem of physician burnout and its many consequences—including negative impact on quality of patient care and physician retention and migration—is increasingly appreciated in the United States and elsewhere. Effective interventions to reduce the primary predictors of physician burnout worldwide, namely, high emotional exhaustion and depersonalization levels, must be developed and used.7 Strategies to avoid burnout have been discussed by Shanafelt et al. They found, on multivariate analysis, that surgeons following Centers for Disease Control and Prevention exercise recommendations, finding meaning in their work, maintaining a positive outlook and appropriate work-life balances were significantly less likely to experience burnout (p < 0.0001).8 With this publication, Qureshi and colleagues contribute to the important conversation underway about physician burnout and its consequences for society. This is the second publication to date specifically addressing this issue among American Society of Plastic Surgeons members, and is based on the largest plastic surgeon sample included in any published physician burnout study. The authors report a plastic surgeon burnout rate similar to that reported by Streu et al.,6 giving power to their findings, despite problems, in my opinion, with their study. Disclosure: The author has no financial disclosures to report or conflicts of interest to declare.
www.PRSJournal.com
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Plastic and Reconstructive Surgery • February 2015 Although 1691 American Society of Plastic Surgeons members returned the authors’ survey, the low response rate (28.5 percent) is problematic, as response bias may have been introduced. Comparison with overall American Society of Plastic Surgeons membership demographics, which could have addressed this potential problem, was not performed. Another concern is the number of missing responses in the surveys returned, which acts to further reduce actual response rate. Both the low response rate and the number of missing responses may have been an unintended consequence of the authors’ desire for thoroughness, resulting in a 79-question survey. Up to 25 percent of the responses to questions listed in Tables 1 and 2 were missing. For the important discussion points regarding the “partner/spouse work out of home” and “work-home conflict” questions, 23 percent and 29 percent, respectively, of returned surveys had missing responses. Missing responses also may confound the conclusions drawn about questions in Table 4. The most apparent variance of the authors’ American Society of Plastic Surgeons responder cohort, compared with 2010 aggregate American Society of Plastic Surgeons membership demographics, is in “practice setting” (Table 1). Although 43.6 percent of Qureshi et al. responders reported practicing in an academic setting, overall American Society of Plastic Surgeons membership demographics for the same period, according to the American Society of Plastic Surgeons Executive Office, indicate that 13 percent of members reported an academic practice.9 Although the authors’ findings may be more reflective of burnout among academic plastic
628
surgeons, their conclusions are likely still valid for the larger U.S. plastic surgeon community. Qureshi and colleagues bring needed attention to the burnout phenomenon in plastic surgery. Robust protective strategies and initiatives are needed to reduce burnout incidence and improve career satisfaction. John G. Hunter, M.D., M.M.M. 47 East 63rd Street New York, N.Y. 10065 [email protected]
references 1. Marsh JL. Avoiding burnout in an orthopaedic trauma practice. J Orthop Trauma 2012;26(Suppl 1):S34–S36. 2. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–1385. 3. Upton D, Mason V, Doran B, Solowiej K, Shiralkar U, Shiralkar S. The experience of burnout across different surgical specialties in the United Kingdom: A cross-sectional survey. Surgery 2012;151:493–501. 4. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–451. 5. Qureshi HA, Rawlani R, Mioton LM, et al. Burnout phenomenon in U.S. plastic surgeons: Risk factors and impact on quality of life. Plast Reconstr Surg. 2015;135:000–000. 6. Streu R, Hansen J, Abrahamse P, Alderman AK. Professional burnout among US plastic surgeons: Results of a national survey. Ann Plast Surg. 2014;72:346–350. 7. Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout across regions and specialties: A meta-analysis. Hum Resour Health 2013;11:48. 8. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: The personal health habits and wellness practices of US surgeons. Ann Surg. 2012;255:625–633. 9. ASPS Members’ Practice Type & Demographic. July 9, 2010. Personal communication with ASPS Executive Office (Research and Scientific Affairs), July 29, 2014.
N
umerous studies have shown that stress and “burnout” decrease physician job satisfaction and increase medical errors. Burnout is characterized by several consistent attributes, principally emotional exhaustion, depersonalization, and diminished sense of personal accomplishment.1 Burnout has been demonstrated in multiple recent publications to be common among physicians and surgeons in the United States and elsewhere.2,3 In the first national study evaluating burnout phenomenon in a large sample of U.S. physicians from all specialties (using the validated, widely accepted Maslach Burnout Inventory), compared with a probability-based sample of the overall U.S. population, Shanafelt et al. found that physicians were more likely to have burnout symptoms (37.9 percent versus 27.8 percent; p < 0.001) and work-life balance dissatisfaction (40.2 percent versus 23.2 percent; p < 0.001).2 Burnout has also been shown to be more prevalent, relative to the general U.S. population, at the early stages of physician careers: medical school, residency and the first 5 years of practice (p < 0.0001 for all).4 Qureshi and colleagues, in this interesting publication, discuss the burnout phenomenon among U.S. plastic surgeons, and its consequences. Based on the responses of 1691 American Society of Plastic Surgeons members to a validated, 79-question survey, they report a 29.7 percent responder burnout rate. Besides a lower career satisfaction rate, which is disturbing enough, plastic surgeons experiencing burnout reported higher rates of medical errors and impairment (i.e., alcohol/drug abuse, mental illness)—both of which constitute public health threats.5 From the Division of Plastic Surgery, Weill Cornell Medical College and New York-Presbyterian Hospital; and the Department of Surgery, New York Methodist Hospital. Received for publication August 4, 2014; accepted August 13, 2014. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000853
A recent publication assessing burnout in U.S. plastic surgeons, also based on a survey of American Society of Plastic Surgeons members and using the Maslach Burnout Inventory, found a similar (29 percent) burnout rate. Although based on a smaller, randomly selected sample (708 members), it had a much higher response rate than the authors’ study (71 percent versus 28.5 percent). As Qureshi et al. also report, long work hours, emergency department call responsibilities, and poor health correlate highly with plastic surgeon burnout.6 The need to identify and effectively address the real and serious problem of physician burnout and its many consequences—including negative impact on quality of patient care and physician retention and migration—is increasingly appreciated in the United States and elsewhere. Effective interventions to reduce the primary predictors of physician burnout worldwide, namely, high emotional exhaustion and depersonalization levels, must be developed and used.7 Strategies to avoid burnout have been discussed by Shanafelt et al. They found, on multivariate analysis, that surgeons following Centers for Disease Control and Prevention exercise recommendations, finding meaning in their work, maintaining a positive outlook and appropriate work-life balances were significantly less likely to experience burnout (p < 0.0001).8 With this publication, Qureshi and colleagues contribute to the important conversation underway about physician burnout and its consequences for society. This is the second publication to date specifically addressing this issue among American Society of Plastic Surgeons members, and is based on the largest plastic surgeon sample included in any published physician burnout study. The authors report a plastic surgeon burnout rate similar to that reported by Streu et al.,6 giving power to their findings, despite problems, in my opinion, with their study. Disclosure: The author has no financial disclosures to report or conflicts of interest to declare.
www.PRSJournal.com
627
Plastic and Reconstructive Surgery • February 2015 Although 1691 American Society of Plastic Surgeons members returned the authors’ survey, the low response rate (28.5 percent) is problematic, as response bias may have been introduced. Comparison with overall American Society of Plastic Surgeons membership demographics, which could have addressed this potential problem, was not performed. Another concern is the number of missing responses in the surveys returned, which acts to further reduce actual response rate. Both the low response rate and the number of missing responses may have been an unintended consequence of the authors’ desire for thoroughness, resulting in a 79-question survey. Up to 25 percent of the responses to questions listed in Tables 1 and 2 were missing. For the important discussion points regarding the “partner/spouse work out of home” and “work-home conflict” questions, 23 percent and 29 percent, respectively, of returned surveys had missing responses. Missing responses also may confound the conclusions drawn about questions in Table 4. The most apparent variance of the authors’ American Society of Plastic Surgeons responder cohort, compared with 2010 aggregate American Society of Plastic Surgeons membership demographics, is in “practice setting” (Table 1). Although 43.6 percent of Qureshi et al. responders reported practicing in an academic setting, overall American Society of Plastic Surgeons membership demographics for the same period, according to the American Society of Plastic Surgeons Executive Office, indicate that 13 percent of members reported an academic practice.9 Although the authors’ findings may be more reflective of burnout among academic plastic
628
surgeons, their conclusions are likely still valid for the larger U.S. plastic surgeon community. Qureshi and colleagues bring needed attention to the burnout phenomenon in plastic surgery. Robust protective strategies and initiatives are needed to reduce burnout incidence and improve career satisfaction. John G. Hunter, M.D., M.M.M. 47 East 63rd Street New York, N.Y. 10065 [email protected]
references 1. Marsh JL. Avoiding burnout in an orthopaedic trauma practice. J Orthop Trauma 2012;26(Suppl 1):S34–S36. 2. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–1385. 3. Upton D, Mason V, Doran B, Solowiej K, Shiralkar U, Shiralkar S. The experience of burnout across different surgical specialties in the United Kingdom: A cross-sectional survey. Surgery 2012;151:493–501. 4. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443–451. 5. Qureshi HA, Rawlani R, Mioton LM, et al. Burnout phenomenon in U.S. plastic surgeons: Risk factors and impact on quality of life. Plast Reconstr Surg. 2015;135:000–000. 6. Streu R, Hansen J, Abrahamse P, Alderman AK. Professional burnout among US plastic surgeons: Results of a national survey. Ann Plast Surg. 2014;72:346–350. 7. Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout across regions and specialties: A meta-analysis. Hum Resour Health 2013;11:48. 8. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: The personal health habits and wellness practices of US surgeons. Ann Surg. 2012;255:625–633. 9. ASPS Members’ Practice Type & Demographic. July 9, 2010. Personal communication with ASPS Executive Office (Research and Scientific Affairs), July 29, 2014.
