CIRCUMSPECTUS MEDICINAE: TEXT AND CONTEXT

Professional Burnout Among Plastic Surgery Residents Can it be Prevented? Outcomes of a National Survey Benoit Chaput, MD,* Nicolas Bertheuil, MD,† Jérémie Jacques, MD,‡ Delphine Smilevitch, MD,* Farid Bekara, MD,§ Pauline Soler, MD,k Ignacio Garrido, MD, PhD,* Christian Herlin, MD, PhD,§ and Jean-Louis Grolleau, MD* Background: Plastic surgery residencies require significant investments of time and psychological resources. We herein determine the prevalence of burnout syndrome among plastic surgery residents and identify potentially protective factors. Methods: A national cross-sectional study was conducted among French plastic surgery residents in March 2013. We distributed a validated measure of burnout (Maslach Burnout Inventory) in addition to a general questionnaire collecting sociodemographic and professional information. Results: Fifty-two residents (61%) responded; their mean age was 29 years. A total of 25% and 13.5% of residents scored highly on the depersonalization and high-level emotional exhaustion burnout subscales, respectively, and 48.1% indicated perceived low-level personal accomplishment. The occurrence of a weekly ward round by a senior surgeon (reported by 67.3% of respondents) appears to protect against burnout (P = 0.007); regular staff meetings in the unit (75% of respondents) were also protective because they limited depersonalization (P = 0.048) and promoted personal accomplishment (P = 0.031). The number of hours worked/ week was not significantly associated with burnout. Despite these data, 69.2% reported satisfaction with their careers. Conclusions: Almost one third of plastic surgery residents exhibited a high degree of burnout; the risks were increased by being in the early years of training, feeling dissatisfied with career plans, and working in units in which senior surgeons did not make weekly ward rounds and in which regular staff meetings, which offer the opportunity to discuss cases or problems with other professionals, were not scheduled. Burnout increases the risk of medical errors and suicide among residents. Therefore, we suggest that screening for burnout is essential. Key Words: burnout, plastic surgery resident, Maslach Burnout Inventory, career satisfaction (Ann Plast Surg 2015;75: 2–8)

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professional investment did not provide the expected results. According to Maslach, burnout comprises 3 interdependent parameters: a high degree of emotional exhaustion (EE), depersonalization (DP), and low-level personal accomplishment (PA).2 Emotional exhaustion is characterized by a lack of interest in work, whereas DP refers to the perception of oneself as an impersonal “object”; low-level PA is characterized by a lack of satisfaction or self-recognition of the work performed. Professional burnout can impair the quality of life, and lead to a deterioration in the quality of care, by increasing the likelihood of medical errors.3–5 Plastic surgery residency represents one of the most sought-after and challenging training programs,6 with students subjected to constant stress and competition to demonstrate their utilities. Professional burnout was assessed in the Maslach Burnout Inventory Human Services Study (MBI-HSS), which evaluated oncology,7 otolaryngological head and neck surgery,8 obstetrics and gynecology,9,10 and urology11 residents, and senior plastic surgeons.12 However, to date, no report has been concerned with plastic surgery residents. The antecedents of burnout differ markedly between residents and senior surgeons; facilitating a more complete understanding of burnout in residents throughout training could limit the effects thereof. For residents to achieve surgical proficiency, it is important that they view themselves positively and continually derive satisfaction from their careers.13 We herein performed a national survey, using MBIHSS, to evaluate the prevalence of professional burnout among plastic surgery residents. We tried to identify protective factors against burnout; these could be amenable to modification so that plastic and reconstructive surgery residency could be improved and burnout risk reduced.

reudenberger1 was the first to introduce the concept of “burnout,” characterizing it as loss of motivation to work when substantial

METHODS Study Population

Received February 3, 2015, and accepted for publication, after revision March 16, 2015. From the *Department of Plastic, Reconstructive, Aesthetic and Burns Surgery, University Hospital Toulouse Rangueil, Toulouse; †Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Sud. SITI Laboratory and INSERM U917, University of Rennes 1, Rennes, STROMAlab, UMR5273 CNRS/UPS/ EFS-INSERM U1031, Rangueil Hospital, Toulouse; ‡Gastroenterology Department, University Hospital of Limoges, Limoges; §Department of Plastic Reconstructive Surgery, Lapeyronie Burn and Wound Healing Center, Montpellier; and kAgence Régionale d'Hospitalisation Midi-Pyrénées, Toulouse, France. Conflict of interest and sources of funding: none declared. Reprints: Chaput Benoit, MD, Plastic and Reconstructive Surgery Unit, CHU Rangueil, Avenue Jean Poulhès, Toulouse, 0033672391770, France. E-mail: [email protected]. Presented at the 57th Congress of French Plastic Society (SoFCPRE), France, November 2012. Each author has read and agrees the current “guide for author.” B.C. participated in design, data acquisition, and article review. N.B., J.J., I.G., C.H., J.-L.G. participated in article review D.S. participated in data acquisition. F.B. participated in design and article review. P.S. participated in statistical analysis. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7501–0002 DOI: 10.1097/SAP.0000000000000530

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A national cross-sectional study was conducted among French plastic surgery residents. We distributed a questionnaire to 80 residents in training at the national plastic surgery congress in Paris, France, in March 2012.

Questionnaire Administration We distributed questionnaires by hand at the beginning of the meeting and collected them after 1 hour. Before completing the questionnaire residents were informed of the rationale for the research, after which they provided written informed consent. To reduce bias, the questionnaire was anonymous and confidential. The study was approved by the review board of the French Society of Reconstructive and Aesthetic Plastic Surgery and performed in accordance with the principles of the Declaration of Helsinki (1964) and the French Law on Bioethics (July 7, 2011).

Questionnaire Content The questionnaire was divided into two parts: Annals of Plastic Surgery • Volume 75, Number 1, July 2015

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Annals of Plastic Surgery • Volume 75, Number 1, July 2015

• General questionnaire (concerned with the following): – Resident characteristics (ie, sex, age, marital status, number of children); – Extraprofessional activity (specific sports or leisure activity engaged in ≥ once per week outside of work); – Professional schedule: years of residency, subspecialty interests (hand, breast, burns, aesthetic, facial, or mixed surgery); – Whether the resident was receiving training instruction from senior surgeons (evaluated using a 3-point Likert scale); – Whether the resident maintained good relations with other residents; – Whether a weekly ward round from a senior surgeon took place; – Whether there was a regular staff meeting allowing for discussion of professional and personal issues (at least twice a month); – Number of hours worked per week ( 80 h), – Whether the resident undertook night shifts/received a day off after a night shift; – Whether the resident considered their salary sufficient; – Whether the resident desired a public- or private-sector career; – Whether the resident experienced job/career satisfaction (evaluated on a 3-point Likert scale). • The MBI-HSS

The MBI-HSS comprises 22 items assessing the 3 components of burnout: EE (9 questions), PA (8 questions), and DP (5 questions).2,12 Each answer was categorized as high, moderate or low, with each question scored using a 7-point Likert scale. Higher scores for EE and DP corresponded to higher degrees of perceived burnout; for PA, lower scores corresponded to increased burnout (low EE: ≤ 18; high EE: ≥ 27; low DP: ≤ 5; high DP: ≥ 10; low PA: ≤ 33; high PA: ≥ 40). In the classical definition, scores inductive of burnout in all three subscales are required. However, because low scores on PA may be less important in determining if a physician exhibits burnout,2,12 we indexed burnout by high scores on the EE and/or DP subscale(s) only.

Statistical Analysis Statistical analysis was performed by a bio-statistician (PS) using the Stata for Windows software package (ver. 10.0; Stata Corporation, College Station, TX). The measurement of central tendency for quantitative variables was based on means, with 95% confidence intervals calculated for each estimate. The distribution of qualitative variables was indexed with percentage values. A 95% confidence interval was calculated for each value. Results were compared using Pearson χ2 test or Fisher exact test. A value of P less than 0.05 was taken to indicate statistical significance.

Professional Burnout Among Residents

TABLE 1. Sociodemographic and Extraprofessional Characteristics (n = 52) n = 52

n (%)

Age, y 28.9 (range, 25–34) Sex Male 26 (50) Female 26 (50) Marital status Couple 32 (61.5) Single 20 (38.5) Children Yes 10 (19.2) No 42 (80.8) Extraprofessional Do you practice a specific sport outside of work (at least once a week) Yes 25 (48.1) No 27 (51.9) Do you have a specific leisure outside of work (at least once a week) Yes 30 (57.7) No 22 (42.3)

Professional Assessment and Career Characteristics These data are summarized in Table 2; 53.8% (n = 28) of respondents were between their first and third year of residency, and almost 60% (n = 31) were interested in undertaking mixed surgical activities (ie, no specific subspecialty). Breast surgery was the most popular subspecialty (21.2%; n = 11) and only 13.5% (n = 7) of respondents were interested exclusively in purely aesthetic surgery; 80.8% (n = 42) of respondents considered the training provided by senior surgeons to be good. A total of 82.7% (n = 43) of respondents reported good relationships with other residents. Regular (weekly) senior surgeon ward rounds were reported by 67.3% (n = 35) of respondents, with regular staff meetings in the unit reported by 75% (n = 39) of our sample. A total of 98% (n = 51) of respondents reported working for more than 50 hours per week and 40.4% (n = 21) worked for more than 80 hours. Nightshifts were undertaken by 53.8% (n = 28) of respondents, but only 14.3% (n = 4) were off work the following day, which is typically a legal requirement. A total of 78.8% (n = 41) of respondents indicated that their salary was insufficient, and 55.8% (n = 29) wished to remain in the public sector; 69.2% (n = 36) declared full satisfaction with their career.

The MBI-HSS RESULTS Demographics and Response Rate Of the 80 residents receiving plastic and reconstructive surgery training, 52 (65%) responded. The mean age of respondents was 28.9 years (range, 25–34 years). Men and women were equally represented (both n = 26).

Personal and Social Assessment These data are summarized in Table 1; 61.5% (n = 32) of respondents lived as part of a couple, and 19.2% (n = 10) had children. A total of 48.1% (n = 25) of respondents partook in sporting activities at least once per week, with 57.7% (n = 30) partaking in a specific leisure activity (ie, a hobby or activity in an association or club).

Figure 1 illustrates the burnout rate of our resident population using the criteria of high DP and EE and low PA. Professional burnout indexed by high levels of only the 2 most important subscales was indicated in 28.8% (n = 15) of respondents; 25% (n = 13) and 13.5% (n = 7) of residents scored highly for DP and EE, respectively, whereas low PA was observed in 48.1% (n = 25) of the sample. Table 3 summarizes the sociodemographic and extraprofessional factors associated with burnout among our residents. Age, marital status, and engagement in sports or leisure activities were not associated with professional burnout; in broad terms, neither sociodemographic nor extraprofessional factors appeared to significantly influence the development of professional burnout; the most important factors appear to be professional factors (listed in Table 4). Curricular advancement was associated with a trend toward increased PA. In younger residents (first to third year), professional burnout tended to co-occur with reduced self-rated PA (32.7% low PA vs

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Annals of Plastic Surgery • Volume 75, Number 1, July 2015

Chaput et al

TABLE 2. Professional and Career Characteristic n = 52

n (%)

Year of residency 1–2 3 4–5 Subspeciality interest Hand Breast Burns Aesthetic exclusively Facial Mixed Quality of training instruction from senior surgeons? Good Moderate Poor Do you maintain good relations with the other residents? Fairly good Fairly bad Is there a weekly ward round from a senior in the unit? Yes No Is there a regular staff meeting in the unit (at least twice a month)? Yes Rarely No No. hours worked per week? 80 h Do you perform night shifts? Yes No Do you have a day off after a night shift? (n = 28) Yes No Do you consider your salary sufficient? Yes No Would you like a public or private sector career? Public Private Are you satisfied with your professional career? Yes Moderate No

6 (11.5) 22 (42.3) 24 (46.1) 1 (1.9) 11 (21.2) 0 (0) 7 (13.5) 1 (1.9) 31 (59.6) 42 (80.8) 2 (3.8) 8 (15.4) 43 (82.7) 9 (17.3) 35 (67.3) 17 (32.6) 39 (75) 1 (1.9) 12 (23.1) 1 (1.9) 30 (57.7) 21 (40.4) 28 (53.8) 24 (46.2) 4 (14.3) 24 (85.7) 11 (21.2) 41 (78.8) 29 (55,8) 23 (44,2) 36 (69.2) 15 (28.8) 1 (1.9)

21.2% high to moderate PA; P = 0.070). However, for residents of fourth and fifth year, this tendency is reversed (30.8% high to moderate PA vs 15.4% low PA). The occurrence of a weekly ward round by a senior surgeon (reported by 67.3% of respondents) appears to be a significant protective factor against professional burnout and was associated with high to moderate feelings of PA (44.2% high to moderate PA vs 23.1% low PA; P = 0.007). Regular staff meetings in the unit (reported by 75% of respondents) also conferred significant protection against burnout 4

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and were associated with low to moderate DP (61.6% low to moderate DP vs 13.5% high DP; P = 0.048) and high to moderate PA (46.2% high to moderate PA vs 28.8% low PA; P = 0.031). The number of hours worked per week and the presence or absence of nightshift working/post-nightshift days off were not significantly associated with professional burnout. However, the absence of a post-nightshift day off was systematically more frequent in residents with high EE (10.7% absence of day off vs 3.6% presence of day off ) and DP (25% absence of day off vs 3.6% presence of day off ), and in residents with low PA (60.7% absence of day off vs 10.7% presence of day off ). Fulfillment and career satisfaction were also significantly associated with high to moderate PA (44.2% high to moderate PA vs 25% low PA; P = 0.005). Finally, 78.8% of residents reported that their salaries were insufficient, but this factor was not significantly associated with professional burnout.

DISCUSSION Burnout syndrome, described by Maslach, is characterized by 3 dimensions—EE, DP, and PA—used to assess severity. Burnout represents chronic stress with symptoms (including irritability, fatigue, sleep disorder, and lack of interest and personal investment in work) that are frequently difficult to assess because of their variety and nonspecificity.10 This poorly understood syndrome is of increasing interest to the medical community because it is suspected of having a causal role in medical errors and impaired quality of care,3,4,13 and the associations with increased risks of depression7 and suicide.7 According to Campbell et al,14 78% of medical residents will experience an episode of professional burnout during their training, of whom 49% will remain in burnout when beginning their career as a senior surgeon. Shanafelt et al15 reported an average rate of professional burnout of 40% among all specialty surgeons in the United States. According to Golub et al7, professional burnout is higher during training compared to post-residency, which is supported by Campbell et al.14 The proportion of our residents experiencing professional burnout was almost 30%, but levels were in the lower range compared to studies on residents from other specialties in which burnout rates ranged from 21% to almost 80%.8 However, it should be noted that the values can vary by country or culture. We aimed to identify factors promoting, and protecting against, progression to professional burnout. Several studies have assessed professional burnout among obstetrics and gynecology9,10,16; ear, nose, and throat8; and urology surgery11 residents. The present study reports burnout rates among plastic surgery residents, for the first time. Almost one third of our sample exhibited high levels of professional burnout, indexed using the EE and/or DP subscales most indicative of the syndrome. Several authors have suggested that low PA would be less predictive of professional burnout, with this subscale playing a more descriptive role.2,12 Nevertheless, PA appears important during training and was low in 48.1% of our residents (compared with a markedly lower (8%) incidence reported elsewhere in senior surgeons).17 We suggest that the importance of the PA subscale tends to be overlooked, particularly in the context of training. Several risk factors for professional burnout in senior surgeons were documented previously by Kuerer et al,18 including age younger than 50 years, female gender, and poor physical health. Balch et al19 also cites high work hours per week and the requirement to answer emergency calls as additional burnout risk factors, whereas Shanafelt et al15 highlighted having children and a working spouse. Streu et al,12,17 and more recently Qureshi et al,12,17 reported that almost one third of senior US plastic surgeons scored highly on subscales predicting professional burnout, similar to our results. Furthermore, Streu et al12 reported that private, group, and primarily © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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Annals of Plastic Surgery • Volume 75, Number 1, July 2015

Professional Burnout Among Residents

FIGURE 1. Professional burnout scores of French plastic surgeons residents using the MBI-HSS.

reconstructive practice were also associated with professional burnout, and, in a previous study, that plastic surgeons performing primarily cosmetic versus reconstructive surgery had a superior work-life

balance,20 a higher degree of career satisfaction,21 and a reduced risk of professional burnout.12 In a survey among US plastic surgeons, Qureshi et al17 identified other significant burnout risk factors, including

TABLE 3. Sociodemographic Characteristics Associated With Professional Burnout Among Plastic Surgeons

n = 52

Age, y

Professional Burnout Among Plastic Surgery Residents: Can it be Prevented? Outcomes of a National Survey.

Plastic surgery residencies require significant investments of time and psychological resources. We herein determine the prevalence of burnout syndrom...
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