1

Burnout among

surgeons

DR. SREEJOY PATNAIKHON. PROFESSOR IMA AMS

SHANTI OMNI SUPER SPECIALITY HOSPITAL

2

1. What are the Overall professions with the highest to lowest rate of depression.

2. Why do physicians have higher rates of depression than the general population?

3. Which physicians specialty has the highest suicide rate? Others?

4. How do most physicians commit suicide?

5. Which gender of physicians has the higher suicide rate?

Some Questions you may be thinking of.

4

•Nearly 1 million people worldwide commit suicide•10 million - 20 million people attempt suicide every year

•Incidence of suicide in India (as per a Lancet study) is the highest in the world. •20% of the total suicides of the world occur in India. •By 2010 the figure had reached 187,000 (with 40% adolescents).

•Doctors have the highest rate of suicide among all the professions i.e. is 2-4% as against only about 1-2% among general population •suicide rate among male and female doctors is the same.

•Male physicians have a 70% higher suicide rate than males in other professions; •and female physicians have a 400% higher rate than females in other professions

It is estimated that on average 400 Physicians

commit suicide a year in the United States!

Physician Suicide

Positive:

– Physicians worldwide have a lower mortality risk from cancer and heart disease relative to the general population

– Physicians have decreased smoking and other common risk factors for early mortality

* Source: Gagné P, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested case control study. Depress Res Treat. 2011;2011:936327.

Negative:

• Physicians are reluctant to address depression, a significant cause of morbidity and mortality that disproportionately affects them.

• Significantly higher risk of dying from suicide than the general population

• Among Medical Students: after accidents, suicide is the most common cause of death.

To Note:Suicide is usually a result of UNTREATED or INADEQUATELY TREATED DEPRESSION, connected with knowledge of and access to lethal means*

• Physicians have a higher rate of completion than the general population

• 1.4 – 2.3 times higher• Interestingly Female

physicians attempt suicide less than Males BUT same completion rate as males

• So they are more likely to complete a suicide making them 2.5 – 4 times more than the general population.*

* Sourcea: Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec 1999;156(12):1887-94.Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302

Most common psychiatric diagnosis among those physicians that complete suicide:

• Depression and Bipolar Disorder

• Alcoholism and other Substance Abuse

Most common means of suicide by physicians

• Medication Overdose and Firearms

Depression in Our Profession• Depression is as common among

the medical profession as the general population

– Males: 12%– Females: 18%

in medical students (15 – 30%)in interns and residents (30%)• Preliminary study found that

residents who experienced depression may be as much as 6 times more likely than nonaffected controls to make medication errors. Other studies have confirmed the association of depression with self-perceived medication and other errors.

Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. Mar 1 2008;336(7642):488-91.West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. Sep 23 2009;302(12):1294-300.

Lifetime rates of depression in women physicians were 39% compared to 30% in age matched women with PhD’s Higher than the General Population.

Lifetime rates of depression in male physicians (13%) may be similar to rates of depression in men in the general population, or they may be slightly elevated. Concerns of underestimating the prevalence secondary to limited self reporting

What is Depression?• Common symptoms of depression:

– Lost of interest in the things that were previously pleasurable

– Depressed and Sadness– Hopelessness

• Other may Include:– Anxiety– Increased feeling of guilt– Irritability– Impatience– Sleep disturbances– Tearfulness– Difficulty concentrating– Appetite changes (loss/gain)– Increased Isolation– Somatic Pain – Substance abuse

10

11

•Every day is a bad day.

•Caring about your work or home life seems like a total waste of energy.

•exhausted all the time.

•The majority of your day is spent on tasks you find either dull or overwhelming.

•You feel like nothing you do makes a difference or is appreciated

DO YOU FEEL LIKE THIS OFTEN?

12

Stress??

13

14

So are you

On the road to

burnout?

15

Burnout (from English to burn out, burn completely),

also called burnout syndrome, was named by New York psychoanalyst Herbert

Freudenberger 1970

Burnout is a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress.

It occurs when you feel overwhelmed and unable to meet constant demands. As the stress continues, you begin to lose the interest or motivation.OR It is a chronic psychological stress.

DEFINITION

17

• emotional and physicalexhaustion

• as a direct result of excessive study or work relatedstress

• can cause significant physical, emotional, psychological, and spiritual damage to people.

“Burnout is a syndrome made up of emotional exhaustion,

depersonalization, and reduced personal accomplishment “

(Beck1995)

“An emotional condition marked by tiredness, loss of interest, or frustration that

interferes with job performance. Burnout is usually regarded as the result of prolonged stress.”

(Medical Dictionary)

“a progressive loss of idealism , energy and patterns experienced by people in the

helping professions as a result of working conditions ’’

Jerry Edelwich and Archie Brodsky (1980

18

Gillespie distinguished two types of Burn out

• Characterized by the maintenance of assertive behaviour

• It relates to the factors organizations or external elements to the profession

Active Burn out

• Dominated by feelings of withdrawal and apathy.

• It has to do with internal psychosocial factors.

Passive Burn out

19

Why are we at a higher risk??

20

Being a Doctor is No Easy Task

•Practice of medicine is stressful•Physicians must interact with intense emotional aspects of life•Physicians are called on to cope and adapt with stress characteristic of their job

21

Are YOU in the Danger

Zone……..What You Can DO about it?

Numerous global studies involving

nearly every medical and surgical specialty

indicate that approximately 1 of

every 3 physicians is experiencing burnout

at any given time”

Tait Shanafelt MD JAMA. 2009;302(12): 1338-1340 (physician burnout.

HIGH Job Stress and LOW Personal Autonomy leads to higher chances of BURNOUT!

Increase prevalence among medical students, residents, and physicians.

23

24

Surgeons – The Heavyweights of the Medical Profession

25

General Surgeons582 surgeons who trained at the University of Michigan–Ann Arbor, 32% showed high levels of emotional exhaustion, 13% showed high levels of depersonalization, and 4% showed evidence of a low sense of personal accomplishment

An Australian studyof 126 surgeons indicated that burnout levels were significantly higher for surgeons than for the normative population, with 47.6% of the sample reporting high burnout levels

Another study10 of 501 colorectal and vascular surgeons in the United Kingdom showed that 32% had high burnout on at least 1 subscale of the Maslach Burnout Inventory.

Surgical Oncologists549 members of the Society of Surgical Oncology, 28% of respondents met the criteria for burnout. In addition, approximately30%of study participants screened positive for depressionTransplantation SurgeonsBertges and colleagues8 conducted a survey of 209 actively practicing transplantation surgeons. Burnout was present in 38% of respondentsHead and Neck SurgeonsJohnson and colleagues11 conducted a survey of 395 members of the American Society of Head and Neck Surgery and the Society of Head and Neck Surgeons in 1993. A total of 34%whoresponded believed they were“burned out

26

Burnout, The Greatest Threat to Surgeons’ Quality of Life

27

BURNOUT SIMPLIFIED…

The Concept of Burnout

• Burnout is a reaction to chronic, job-related stress.

• “A literal collapse of the human spirit” (Storlie 1979).

• “The loss of concern for the people with whom one is working”(Maslach 1976).

• “psychological withdrawal from work in response to excessive stress and dissatisfaction” (Cherniss 1980).

29

Maslasch and Jackson, configured IT as a three-dimensional syndrome

• absence or lack of energy, enthusiasm and a sense of scarcity of resources.

emotional and physical exhaustion

• treating customers , colleagues and the organization as objects.

depersonalization and dehumanization • a tendency of

workers to assess themselves negatively.

reduction of personal fulfilment

30

Understanding Burnout

• One of the most useful metaphors to understand Physician Burnout is a Bank Account. In this Bank is a store of your Energy.

• In my experience, that energy comes in three “flavors”

1.PHYSICAL ENERGY – your basic “get up and go”

2.EMOTIONAL ENERGY –emotionally available and compassionate

3.SPIRITUAL ENERGY –Purpose in your work … Your “WHY”

The 3 Energetic Bank Accounts

31

Understanding Burnout – The 3 Energetic Bank Accounts

• Every Single Day you work … there is a withdrawal from this Physical/Emotional/Spiritual Energetic Bank Account.

• The amount of the withdrawal is different from person to person and day to day.

• Your job –Keep Your Energetic Bank account in a Positive Balance.

• Your life outside of medicine, your health and your relationships depend on it.

When your batteries run out,the machine stops.

PHYSICIAN BURNOUT IS JUST ANOTHER NAME FORA NEGATIVE BALANCE IN THESE ACCOUNTS•Work drains you beyond your energetic, emotional and spiritual reserves. •You are unable to recharge your account.• You are overdrawn and it hurts. You can feel it and your colleagues and family can see and feel it as well.• In most cases you are a last person to recognize your own physical burnout.

32

When it comes to Surgeon burnout … they can operate for a very long time on a negative balance in the accounts.

33

SURGEON Burnout – The Three Symptoms

• you are dog-tired on one or more of the three levels – Energy, Emotion, SpiritEXHAUSTION

• you have lost your ability to care, empathize, and connect with your patients, staff and co-workers. You may even blame, shame or demonize the very people you are charged to care for – and feel guilty about it.

CYNICISM

•you may begin to doubt that your work really makes any difference or question the quality of what you do (this is a late and inconsistent symptom that is nearly absent in men)

DOUBT

34

Stagesof burnout

FREUDENBERGER

DEGREES OF BURNOUT

third degree

major physical and psychological breakdown

second degreeaccelerated physical and emotional deterioration

first degreefailure to keep up and gradual loss of reality

• 3 STAGE TRANSACTIONAL MODEL OF BURNOUT:

• STAGE 1: demands exceeding emotional resources• -STAGE 2: attempts to balance between demands and resources• -STAGE 3: maladaptive coping mechanisms develop

Maladaptive coping mechanisms

Responses

Physical Emotional

Adaptive coping mechanisms

balance restored responses resolved

What is a balanced life? Is this you?

Imbalanced: Physicians and Residents Life

WorkHealthPersonalHouseholdRecreationSpiritualExerciseFriendsFamilyPartner

Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

Does Burnout Lead to Depression or Is It The Other Way Around?

• Actually it can go both ways.

• Lets look at in terms of the Conservation of Resources (COR) theory which is based on the presence of downward spirals.– Deficiency of resources in one area, which leads to the

exhaustion of resources in other areas. – Depression Lack of energy Accelerated job burnout

OR– Overburdened at work Physical and mental

exhaustion Accelerate symptoms of depression

43

44

CAUSES OF BURNOUT

•work-related causes Lifestyle causes Personality traits

•little or no control over your work•Lack of recognition or rewards•Unclear or overly demanding job expectations•monotonous or unchallenging work•unorganized or high-pressure environment•constant noise & business• critical ill patients•crisis of patients and family's (Cooper, 2001) Grief and guilt about patient death or unsatisfactory outcome

•Working too much, without enough time for relaxing and socializing•Being expected to be too many things to too many people•Taking on too many responsibilities, without enough help •Not getting enough sleep•Lack of close, supportive relationships

•Perfectionist tendencies; nothing is ever good enough•Pessimistic view of yourself and the world, low self esteem, need for approval•The need to be in control; reluctance(unwillingness) to delegate to others•High-achieving, Type A personality•Setting unrealistic goals or having them imposed on oneself

Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575

46

CONSEQUENCES

Professional• Poor judgment in patient care decision

making• Hostility toward patients• Medical errors• Adverse patient events• Diminished commitment and

dedication to productive, safe,• and optimal patient care• Difficult relationships with co workers• Disengagement

Personal• Depression• Anxiety• Sleep disturbances

and fatigue• Broken relationships• Alcohol and drug

addictions• Marital dysfunction

and divorce• Early retirement• Suicide

47

SOLUTION

48

Dealing with Burnout: The "Three R" Approach

resilience

reverse

49

Assessing signs and symptoms and

consulting doctor for confirmation

Various questionnaires can be used for self-

assessment (“Maslach Burnout Inventory”

(MBI))

DIAGNOSIS

50

AFFECTIVE SIGNALSDepressed moodChanging moodTearfulnessEmotional exhaustionTension andAnxiety

COGNITIVE SIGNALSsense of failurehopelessness,powerlessnesspoor self esteemguiltinability to concentrateIncreasingly cynical(pessimistic) and negative outlookDecreased satisfaction and sense of accomplishment

PHYSICAL SIGNALSheadachenauseadizziness ,muscle painulcerFeeling tired and drained (exhausted) most of the time (chronic fatigue)Lowered immunity, feeling sick a lotChange in appetite or sleep habits

BEHAVIOURAL SIGNALShyperactivityincreased consumption of tobacco, beveragesabandonment of recreational activitiesIsolating yourself from othersWithdrawing from responsibilitiesTurnoverSkipping work or coming in late and leaving earlyAbsenteeismTaking longer to get things doneTaking out your frustrations on others

MOTIVATIONAL SIGNALSresignationdisappointmentboredom

51

SCALE MASLACH

Burnout Syndrome: What is it? ---Assesment

Christina Maslach ( an American social psychologist & Prof. at university of California) developed the most widely instrument for assessing burnout namely MBI.

Source: Maslach Burnout Inventory. The leading measure of burnout. Christina Maslach, Susan E. Jackson, Michael P. Leiter, Wilmar B. Schaufeli, & Richard L. Schwab

Maslach has coined BURNOUT as a 3D SYNDROME which measures 3 main areas:

•Exhaustion.•Cynicism or Depersonalization•Inefficacy

53

1. I feel emotionally drained from my work.2. I feel tired at the end of the workday.3. I feel tired when I wake up in the morning and have to go to work4. I understand easily as patients feel.5. I believe I treat some patients as if they were impersonal objects.6. Work all day with many people is an effort.7. Treatment of patients problems very effectively.8. I feel "burned" by my work.9. I think my work positively influenced the lives of people.10. I have become insensitive to people since I exercise this profession.11. I am concerned that this work hardening me emotionally.12. I am very active.13. I feel frustrated in my work.14. I think I'm working too.15. I do not really care what happens to my patients.16. Work directly with people gives me stress .17. I can easily create a atmosphere relaxed with my patients.18. I feel stimulated after working with my patients.19. I got many useful things in my profession.20. I am finished.21. In my work I try emotional problems calmly.22. I feel that patients blame me for any of your problems

There are three defined sub-scales, as described below:1. Sub-scale of emotional exhaustion . It consists of 9 questions. : 1, 2, 3, 6, 8, 13, 14, 16, 20 Rate the experience of being emotionally exhausted by the demands of the job.Maximum score 542. Sub-scale of depersonalization . It consists of 5 items. : 5, 10, 11, 15, 22Rate the degree to which each recognizes attitudesof coldness and detachment. Maximum score 303. Sub -scale of personal fulfillment . It consists of 8 items. 4, 7, 9, 12, 17, 18, 19, 21. Assesses feelings of self efficacyand self-fulfillment at work. Maximum score 48

0 = Never1 = A few times a year or less2 = Once a month or less3 = A few times a month or less4 = Once a week5 = A few times a week6 = Everyday

54

A high degree of burnout is reflected by high scores on the EE and DP subscales and a low score on the PA subscale.

55

MANAGEMENT APPROACHES

Depressive symptoms

BURNOUT

Depressive symptoms

psychotherapy

pharmacotherapy +

psychotherapy

56

•PERSON OR ORGANISATIONAL APPROACHES1. PERSON DIRECTED2. ORGANISATIONAL APPROACHES

•PSYCHOTHERAPEUTIC APPROACHES1. ETIOLOGICAL INTERVENTIONS2. SYMPTOMATIC INTERVENTIONS

•COPING STRATEGIES1. ACTIVE COGNITIVE COPING2. ACTIVE BEHAVIOURAL COPING3. COPING BY AVOIDANCE

PSYCHOTHERAPY

57

PERSON DIRECTED

psychotherapycounsellingadaptive skill trainingcommunicative skill trainingsocial support exercises for relaxation ORGANISATIONAL APPROACHES

training supervisors and managerschanging organisational practicestraining for better coping and stress management techniqueschange shift work system and introducing vacationscounselling and exercises

1.PERSON OR ORGANISATIONAL APPROACHES PERSON DIRECTED

ORGANISATIONAL DIRECTED COMBINED 

58

2.PSYCHOTHERAPEUTIC APPROACHES• experimental group therapy • group analytic therapy

B)SYMPTOMATIC INTERVENTIONSProper medicationsphysical relaxation techniques for fatiguebehavioral training for frustrationsocial supportidentifying interesting areas and motivating

A)ETIOLOGICAL INTERVENTIONScognitive restructuringself control trainingtraining of active coping rational training for frustration

COPING STRATEGIES objectivescoping oriented to problemcoping oriented to emotion

COPING METHODSACTIVE COGNITIVE

COPING (management by assessing potential

stressful events)ACTIVE BEHAVIOURAL

COPING(observable efforts managing stressful

conditions)COPING BY AVOIDANCE

( avoiding stressful conditions and problematic

situations)

60

Coz..Prevention is always better

than cure

61

HOW TO COPE UP YOURSELF?

1.RELAXATION2.CULTIVATE RICH NON-WORK LIFE3. UNPLUG4. SLEEP5. GET ORGANISED6.STAY ATTUNED7.KNOW WHEN IT’S U & WHEN IT’S THEM

•Notice self burnout and realistic recognition•Exercise: A study* show that Physical Exercise DOES decrease burnout and depression.•Supportive help and talking with others about issues and stressors•Professional resources•Forming firm Boundaries so to avoid increased stress and problems•Using Humor and Laughter•Finding Non-Medical Hobbies•Working in various clinical settings or changing up clinical duties periodically

DECREASING BURNOUT

* Source: Toker, S., & Biron, M. (2012, January 9). Job Burnout and Depression: Unraveling Their Temporal Relationship and Considering the Role of Physical Activity. Journal of Applied Psychology.

62

•Identify personal and professional values and priorities•Reflect on personal values and priorities•Strive to achieve balance between personal and professional life•Make a list of personal values and priorities; rank in order•of importance•Make a list of professional values and priorities; rank in order•of priorities•Integrate these 2 lists•Identify areas where personal and professional goals may be incompatible•Based on priorities, determine how conflicts should be managed•Enhance areas of work that are most personally meaningful•Identify areas of work that are most meaningful to you (patient care, patient education, medical education, participation in clinical trials, research, administration)•Find out how you can reshape your practice to increase your focus in this area/these areas•Decide whether improving your skills in a specific area would decrease your stress at work or whether seeking additional training in this or other areas would be helpful for you•Identify opportunities to reflect with colleagues about stressful and rewarding aspects of practice•Periodically reassess what you enjoy most about your work•Identify and nurture personal wellness strategies of importance to you•Protect and nurture your relationships•Nurture religion and spirituality practices•Develop hobbies and use vacations to pursue nonmedical interests•Ensure adequate sleep, exercise, and nutrition•Define and protect time for personal reflection at least once a month•Obtain a personal primary care physician and seek regular medical care

Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575

64

Start the day with a relaxing ritual

Adopt healthy eating, exercising, and sleeping habits. .

Set boundaries..

Take a daily break from technology.

Nourish your creative side.

Learn how to manage stress..

65

My thoughtsMY RESPONSIBILITY

• Learn to recognize burnout syndrome, depression, & suicidality in yourselves and educate medical students and residents to do so as well.

• Better identify those physicians at high risk of suicide.

• Conclude the need to establish regular source of health care and seek help for mood disorders, substance abuse, and/or suicidality.

• Assessment of Competence• Provision for Physical/Mental Rest and

Recreation• officially organising Stress Busting

Activities• Programme of Prevention of Depression

and Suicide among medical professional

OUR RESPONSIBILITY

• Organizing Well and On Time• Breaking Down Responsibilities• Set Reasonable Goals and Stick to Them• Maintain Good Health and Respect

Personal Needs• “Go Dark” with a Social-Media Shutdown• No self medications

MY

THOUGHTS

66

67

Everyday..

Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575

69

REMEMBER NOT TO FORGETSAYING WHO YOU ARE

WHILE BECOMING WHO YOU WANT TO BE

…Life is real! Life is earnest!   And the grave is not its

goal;Dust thou art, to dust

returnest,   Was not spoken of the

soul.

Not enjoyment, and not sorrow,

   Is our destined end or way;But to act, that each

tomorrow   Find us farther than

today......

Henry wordsworth Longfellow

The psalm of life

70

Thank you