The toll of perfectionism: Burnout in orthopedics
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Characterized by emotional exhaustion, depersonalization and a low sense of personal accomplishment, the published literature has shown between 40% and 60% of orthopedic surgeons will experience episodes of burnout during their career.
“A meta-analysis of the literature suggests that only 3% of surgeons experience chronic burnout, but one-in-three to two-in-three in the course of their career will have some periods of burnout,” Wayne M. Sotile, PhD, founder of the Center for Physician Resilience and author of The Thriving Physician, told Healio/Orthopedics Today. “It is significant because as burnout goes up, everything we do not want to happen tends to happen more [and] everything we do want to happen tends to happen less, both in our personal lives and in our professional lives.”
Source: Ellen Jaskol Photography
If left untreated, burnout can lead to depression and suicidal ideation, according to Peter Gold, MD, adult reconstruction surgeon at Panorama Orthopedics and Spine Center. He said it has been estimated about 13% of orthopedic surgeons have depression, which is double the amount in society at large, and the CDC reported that orthopedic surgeons had the highest rates of death by suicide among surgical subspecialties between 2003 and 2017.
“The CDC National Violent Death Reporting System from 2003 to 2017 showed that, out of all surgeon suicides, 28.2% were orthopedic surgeons, specifically,” Gold said. “So, we had the highest level of suicide out of all surgical subspecialties. When I saw that number, I was shocked. I did not think it would be us.”
Drivers of physician burnout
Melissa A. Christino, MD, orthopedic surgeon and co-chair of the Physician Wellness Council at Boston Children’s Hospital, said many factors can contribute to burnout, and what may affect one orthopedic surgeon may not affect another.
The causes of burnout can begin as early as medical school where “physicians in training learn to engage in excessively long periods of self-denial,” according to Sotile.
“As medical training progresses, there are elevations in incidences of depression, burnout, anger [and] disillusionment and there is diminishment in frequent participation in healthy pleasures, like exercise or advocational interests or hobbies, because the training is so daunting,” Sotile said.
Young orthopedic surgeons also have a “wait until” mentality, in which proving themselves as good orthopedic surgeons takes precedence over self-care and a good work-life balance, he said.
“If you survey about-to-finish training orthopedic surgeons and their lifemates, over 80% say they cannot wait for training to be done [because they will] have a better work-life balance. You resurvey young physicians 5 years post-training and their lifemates, over 90% say it got worse. It did not get better,” Sotile said. “It is because of having to repay educational debt, they bought a house oftentimes or they are having kids or are trying to prove themselves as having been a good hire.”
Burdens of culture, administration
The culture of the orthopedic specialty can also be a cause of or contributor to stress and burnout, according to Gold.
“The culture we have is one of extreme efficiency and perfectionism, so there is no room for errors. There is not a lot of grace when you make mistakes, and so I think those social factors make it difficult when things do go wrong, if we are not properly trained to handle those issues,” Gold told Healio/Orthopedics Today.
Despite the push for a team atmosphere within orthopedics, Gold said when a patient complication arises, the burden of the mistake is often placed solely on the surgeon.
“There is this push for a team atmosphere and everyone doing things together, but, ultimately, when a patient complication happens or something goes wrong, unfortunately, in medical culture right now, that team fades away and the surgeon is usually the one to blame,” Gold said.
John D. Kelly IV, MD, professor of clinical orthopedic surgery at the University of Pennsylvania, said more physicians are feeling the pressure of higher demands while having less control in the workplace.
Work-system factors, such as an increased workload, lack of resources, excessive administrative tasks, feeling underappreciated and being unable to provide high-quality care due to system limitations, are some of the most common factors that contribute to burnout, according to Christino.
Organizational inefficiency is another source of career dissatisfaction among orthopedic surgeons.
Sotile said physicians and surgeons have reported that a more efficient workplace staffed with competent people and a dynamic interchange between physician administrators and nonphysician administrators would increase career satisfaction.
“The orthopedic surgeons that we work with who still love their work have teams of people who facilitate that work and allow the orthopedic surgeon to spend most of his or her time doing what only they are qualified to do, whether it is in clinic or in the OR, rather than encountering frustration after frustration about not having the right tray or a 3-hour wait time before the next surgery due to lack of staffing or patients who have not been adequately screened in clinic,” Sotile said.
COVID-19 pandemic
While physician burnout was considered a health care crisis prior to the COVID-19 pandemic, Christino said the pandemic brought these issues more into the public eye.
Jeffrey M. Smith, MD, PCC, who is an orthopedic traumatologist and surgeon coach, said some physicians took the pandemic as an opportunity to reconnect with family and readjust their beliefs and values in relation to their work-life balance. Gold said he found that other physicians experienced a buildup of multiple stressors without any relief.
“Whether it was money, whether it was stress from home life, increasing pressures for patient safety, I think COVID multiplied all those stressors,” Gold said.
The pandemic also highlighted and exacerbated shortcomings in the health care system, sources said.
“In general, our health care system was functional only at a level of ‘just enough.’ Just enough physicians, nurses, resources, money, you name it, and, in many areas, not quite enough,” Smith told Healio/Orthopedics Today. “We have a lot of health care disparities, even in the U.S., certainly worldwide, and now there is something that maximally overstresses a system, and you are now going to have a response to this that clearly overstresses all the resources, including physicians and orthopedic surgeons.”
In addition, research into physician mental well-being during the pandemic showed eight of 10 health professionals reported being verbally, emotionally or physically abused in the medical workplace during the COVID-19 pandemic, according to Sotile.
“Mid-COVID, the research is chilling that three-fourths of health professionals across disciplines who are patient-facing have experienced some version or another of psychosocial distress, burnout, anxiety, depression, anger, moral distress, compassion fatigue or outrage at the fact that people are questioning science,” Sotile said.
Restore physician wellness
Not only does mental wellness affect the physician, but it can also affect the physician’s medical team, as well as their patients, by increasing medical errors and decreasing quality of care and patient satisfaction, sources told Healio/Orthopedics Today.
“This is a critical issue that has serious downstream effects for individuals, institutions and patient care, and I do think more needs to be done to address the burnout that continues to run rampant through our profession,” Christino said.
She said the idea that physicians need to prioritize their well-being for better patient care, surgeon performance and professional satisfaction is a shift in a culture that has physicians caring for patients “nearly at any expense.”
“Culture change takes time, intentional sustained action and resources, all of which are limited commodities in the current health care landscape,” Christino said. “Health care institutions need to take this on as a priority.”
She said organizational-level changes are critical to improving work environments, work systems flow and efficiency, and demands on physicians.
“While we can all work to improve ourselves and fight to protect time for our own wellness, it is these systems changes that can have the biggest impact, and these have been recently endorsed and described by the National Academy of Medicine and WHO,” Christino said.
Lead by example
When a physician starts showing signs of mental unwellness, the supervisor or leader of the department should help restore the physician’s wellness by providing the physician with opportunities to seek counseling, therapy, coaching or time off, Kelly said.
“There is no role for judgment in leadership. You have to look for the facts, look for the behaviors and recognize that people are doing the best they can every given moment. And if there is someone who is acting out, there is a problem,” Kelly, who is an Orthopedics Today Editorial Board Member, said. “There is pain at work that has manifested. So, I think it is important for leaders to recognize that and give people the help they deserve.”
Leaders can also have a role in helping break the stigma surrounding seeking help and show others that it is OK to make mistakes, according to Gold.
“I think it is the supervisor’s role to promote vulnerability and make it OK to need help, to ask for help and to create safe spaces for that,” Gold said. “Of course, as a supervisor, if you see somebody who is struggling, [you] need to reach out and ... provide resources for the surgeons, residents and fellows, if things are not going well.”
Center for well-being
Gold said a well-designed wellness program may provide resources for better physician well-being, such as peer-to-peer discussion groups, leadership or executive coaching, regularly scheduled counseling services for surgeons, and meditation training. A wellness program also could be a way for physicians to provide their institutions with education on surgeon mental health and wellness, as well as provide physicians with resources to help take better care of their patients, he said.
“The reason why we came to doing orthopedic surgery is that we want to help patients and, when you focus on creating a work environment where you are taking the best care of patients, I think, ultimately, that leads to physician wellness and physician happiness,” Gold said.
Despite being effective, wellness programs for physicians are “only one stop on the cafeteria line, and we need to install more stations,” Sotile said. These include having counselors and life coaches who are respectful to the complexities of life in medicine, programs that provide services to physicians, as well as their families, and an increased number of discussions around well-being.
“It takes more than a center for well-being,” Sotile said. “That is a necessary safe place for people to go, but it also takes a striving accountability for well-being with each other, of being supportive of each other and open with each other about ‘my well-being matters and your well-being matters.’”
Wellness programs also should have significant buy-in from leadership, including the chair of the department and the head of hospital administration, to have value and make an impact, according to Kelly.
“There has been a lot of literature that [shows that], unless there is significant buy-in from senior and immediate leadership, [a wellness program] is not going to happen,” Kelly told Healio/Orthopedics Today. “On the one hand, we have all of these wellness programs, but, on the other hand, the chair could be saying, ‘Well, you know, doctor, your cases are down this month. How do you explain this?’”
Focus on self
Although organizational change and change within the health care system may have the greatest impact on mental well-being among orthopedic surgeons, Smith said it is sometimes easier to focus on the changes individuals can make in their lives.
“If I cannot change the system, I can at least do what I can for myself,” Smith said.
Physicians need to practice setting boundaries and having time for their well-being, which may include different activities, depending on the individual, he said.
Kelly said surgeons need to identify their core values and beliefs, nourish those values and practice cultivating good habits to help build resilience, including living in the moment, seeking meaning in whatever the surgeon does, being imperfect, committing to self-care, and planning.
“When you get up in the morning and reflect and plan your day and what is important and what is not, you will have a more fulfilled life,” Kelly said.
Developing strong relationships with family and friends is also an important step in building good physician wellness, according to Gold.
“It has been shown that strong support from family at home is a huge factor in mental health and wellness,” Gold said. “If you can get home and leave work at work and be happy with a loving, supportive family at home, that is a huge stress recovery.”
Make a difference
While Smith said progress is being made in this area and awareness is being raised regarding the issue of burnout among orthopedic surgeons, he believes there is still a fair amount of “noise” related to this topic, so it feels “like we are doing something about it.”
“I think some of this is talk and a little bit of, if you will, checking a box rather than truly making a difference with either resources, time, energy or capital,” Smith said.
Instead of looking for an easy, quick fix to the problem, it is important to focus on issues that may seem modest or small, but ones that can add up to something more when they are addressed, he said.
“To me, a lot of it is just starting where you think there is the greatest buy-in from local people that you are trying to impact or even larger groups of people that you are truly trying to impact,” Smith said. “Start somewhere and keep building and growing.”
- References:
- Addressing health worker burnout: The U.S. surgeon general’s advisory on building a thriving health workforce. www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html. Published May 23, 2022. Accessed Dec. 8, 2022.
- Al-Humadi S, et al. Acad Psychiatry. 2021;doi:10.1007/s40596-021-01490-3.
- Al-Humadi SM, et al. Geriatr Orthop Surg Rehabil. 2021;doi:10.1177/21514593211035230.
- Christino MA, et al. Chapter 25: Physician and clinician well-being. In: Samora JB, Shea KG, eds. Quality improvement and patient safety in orthopaedic surgery. Cham, Switzerland: Springer; 2022:245-258. doi:10.1007/978-3-031-07105-8.
- Elkbuli A, et al. Ann Surg. 2022;doi:10.1097/SLA.0000000000004575.
- Federico V, et al. J Am Acad Orthop Surg Glob Res Rev. 2022;doi:10.5435/JAAOSGlobal-D-21-00227.
- Howell TG, et al. J Patient Exp. 2020;doi:10.1177/2374373519888343.
- Jennings JM, et al. J Am Acad Orthop Surg. 2022;doi:10.5435/JAAOS-D-21-00299.
- Mir H, et al. Bone Jt Open. 2021;doi:10.1302/2633-1462.211.BJO-2021-0153.
- Nugent RE, et al. Orthopedics. 2022;doi:10.3928/01477447-20220907-06.
- Shanafelt TD, et al. Mayo Clin Proc. 2022;doi:10.1016/j.mayocp.2022.09.002.
- Sotile WM, et al. J Pediatr Orthop. 2020;doi:10.1097/BPO.0000000000001503.
- Travers V. Orthop Traumatol Surg Res. 2020;doi:10.1016/j.otsr.2019.04.029.
- Walker S, et al. Journal of the Pediatric Orthopaedic Society of North America. 2019;doi:10.55275/JPOSNA-2019-37.
- Zaid M, et al. J Bone Joint Surg Am. 2021;doi:10.2106/JBJS.20.01125.
- For more information:
- Melissa A. Christino, MD, can be reached at 300 Longwood Ave., Fegan, 2nd Fl., Boston, MA 02115; email: erin.tornatore@childrens.harvard.edu.
- Peter Gold, MD, can be reached at 660 Golden Ridge Road, Suite 250, Golden, CO 80401; email: pgold12@gmail.com.
- John D. Kelly IV, MD, can be reached at 235 South 33rd St., Philadelphia, PA 19104; email: john.kelly@pennmedicine.upenn.edu.
- Jeffrey M. Smith, MD, PCC, can be reached at 3750 Convoy St., Suite 201, San Diego, CA 92111; email: jeff@surgeonmasters.com.
- Wayne M. Sotile, PhD, can be reached at PO Box 2290, Davidson, NC 28036; email: sotile@sotilemail.com.
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