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NYSSA • The New York State Society of Anesthesiologists, Inc.
NYSSA • The New York State Society of Anesthesiologists, Inc.
Volume 76 Number 2
An anesthesiology resident on overnight call receives a pager call for a trauma arriving at his level 1 trauma center. He takes the airway box and runs to the ER. However, the trauma is called off. Apparently, it was an elderly man on anticoagulants who fell in the bathroom and was hypotensive en route to the hospital. The resident noticed that his attending anesthesiologist was conspicuously absent during this time. This is unusual, he thinks, and he wonders where the attending might be since he should have received the call too. The resident calls the attending’s phone. No response. He gently knocks on the attending call room door. No response. He then opens the door and finds his attending out cold! He shakes him and checks his pulse. He’s alive. The resident then calls the other on-call residents and the OB anesthesiologist for help, and they bring the attending to the ER. The attending had uncontrolled diabetes mellitus and had fallen into a keto-acidotic coma.
“That physician will hardly be thought very careful of the health of his patients if he neglects his own.”
— Galen (130-200 A.D.) 1
When it comes to well-being, we physicians sometimes lack insight and are reluctant to acknowledge any need for help for ourselves or our colleagues. We are intrinsically devoted to patients while neglecting self-reflection and care. It is inherent in the culture of medicine to glorify and value the almost pathologic levels of unrealistic self-sacrifice. Aren’t we supposed to be superheroes and invincible? We are responsible for creating a system where “personal boundaries are discouraged and perceived as a lack of dedication to the profession.”2
In a critical review of the definition, Simons and Baldwin (2021)3 describe well-being as “a state of positive feelings (hedonistic ideology) and meeting full potential (eudemonic philosophy) in the world which can be measured subjectively and objectively using a salutogenic approach.” This definition, they say, is for use globally, is more inclusive, and is free from cultural bias. Well-being overlaps with health, wellness, welfare and quality of life. In an earlier systematic review describing the definitions of well-being and wellness, Brady et al. (2018)4 proposed physician well-being as defined by “quality of life, which includes the absence of ill-being and the presence of positive physical, mental, social and integrated well-being experienced in connection with activities and environments that allow physicians to develop their full potentials across personal and work-life domains.” “Wellness goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life,” according to Shanafelt and colleagues.1
Given these definitions of physician well-being, many of us are clearly suffering. A large component of well-being is psychological and psychosocial, with numerous studies describing physician burnout, depression, substance abuse and suicide. Physical well-being, on the other hand, can be affected by chronic illnesses like cardiovascular and cerebrovascular diseases, cancers, diabetes, infections (e.g., HIV, hepatitis B, and COVID-19 in anesthesiologists) and chronic pain related to occupational injuries.5
Burnout was noticed in American society as a cultural “phenomenon” in the 1970s working class, with Bob Dylan (“Shelter From the Storm”) and Neil Young (“Ambulance Blues”) popularizing lyrics about it. Burnout encompasses physical and emotional exhaustion from “excessive demands on energy, strength, or resources” in the workplace, as defined by clinical psychologist Herbert Freudenberger in 1974. He volunteered at a free clinic in New York’s East Village, where people on the streets would use the term “burnout” to describe a heroin addict’s veins after repeated use. He observed that the psychosomatic symptoms of burnout (fatigue, headaches, decrepitude, frustration, and cynicism) are largely due to increased personal dedication and commitment arising from empathy toward people.6 Christina Maslach, a Ph.D. in social psychology at Stanford, mentioned “burnout” among individuals who do “people work of some kind.” Detachment is a protective strategy in human services personnel, she wrote, but “if the detachment becomes too extreme, the service professional experiences ‘burn-out,’ a phrase which is used by poverty lawyers to describe the loss of any human feeling for their clients.”7 She developed what is now called the Maslach Burnout Inventory (MBI), which is still being used to assess burnout, with the three main domains of emotional exhaustion, depersonalization and diminished sense of personal accomplishment.8
Among the numerous studies, papers and articles published on physician burnout, there was a major study conducted by Afonso and colleagues9 just before the advent of the COVID-19 pandemic. Using the MBI-Human Services Survey, this study identified a 59.2% prevalence of high risk of burnout in anesthesiologists. The risk of actual burnout syndrome was 13.8%. Working more than 40 hours per week, experiencing staffing shortages, perception of a low level of support in work-life, not having a confidante at work, age younger than 50, and identifying as underrepresented based on LGBTQ status were identified as independent risk factors for burnout. It was interesting to note that workplace factors were associated more with burnout among anesthesiologists than personal factors. Hyman et al.10 also found that physicians (and more commonly, residents), as opposed to nurses or nurse anesthetists, had higher levels of depersonalization and emotional exhaustion and are at a higher risk of burnout. In a cross-sectional survey study11 among anesthesiology residents conducted each year from 2013 to 2016, the prevalence of burnout, distress and depression was 51%, 32% and 12%, respectively. The main sources of stress described by them were the lack of control over time management, their busy work schedules (working nights and weekends), high-acuity patient care, the complexity of clinical tasks, and heavy clinical responsibility. The leadership isn’t spared either. In two studies by De Oliveira Jr. and colleagues12,13 on academic anesthesiology chairmen and program directors, the authors found that at least a moderate risk of burnout was present in more than 70% of the respondents, and a high risk was found in 20% to 28%, with 25% in either study reporting the likelihood of resigning from their high-stress jobs within the next two years. Even though the prevalence of burnout is higher among U.S. physicians compared with U.S. workers in other fields, the physicians had higher resilience scores. However, burnout is still high even in the most resilient.14
Burnout, depression, substance abuse and suicide are all intertwined. In a meta-analysis of physician suicide rates, depression and/or substance abuse were the main causes, with psychiatry and anesthesiology as the top two specialties at risk.15 Female physicians, who are at higher risk of emotional exhaustion, have suicide rates as much as 130% higher than the general population, and male physicians have rates that are at least 40% higher.16 Physicians are exposed to high stress levels daily, especially in high-acuity areas such as critical care and perioperative care; long and irregular work hours; higher than average malpractice claims; increased regulation and decreased physician autonomy; electronic medical record and documentation demands; and easy access to drugs with abuse potential.17
Substance abuse and addiction, while being common problems among anesthesiologists,18 are also important risk factors for “successful suicide” due to the ease of access to and knowledge of lethal medications. A retrospective cohort study of anesthesiology trainees from 1975 to 2009 found substance use disorder to be 2.16 per 1,000 resident years (2.68 in men and 0.65 in women; median age at incidence 31 years). The most commonly abused substances were intravenous opioids, alcohol, marijuana or cocaine, anesthetics/hypnotics and oral opioids. Of the 384 total users, 28 died during their training. The rate of at least one relapse in 30 years was 43%.19 Another similar study looked at anesthesiologists after completion of their training from 1977 to 2013 and found the prevalence to be 0.75 (95% CI, 0.70 to 0.80) per 1,000 physician years (median age at incidence 41 years). Thirty-eight percent of the fatalities were directly related to substance abuse. It was interesting to note that one in five deaths in working-age anesthesiologists who have completed training is due to substance abuse, with the median age of 42 at death.20 In an analysis of physician drug-related deaths from 1979 to 1995, anesthesiologists had a rate three times higher than internists. They also had higher deaths from suicide, HIV and viral hepatitis.21 Substance use disorder and suicide can be considered an occupational hazard for anesthesiologists. While physician mortality is lower than the general population, possibly due to awareness of healthier habits and lifestyles, the causes of death are mostly similar.22
The prevalence of depression and depressive symptoms in resident physicians has been studied across the globe over decades. A meta-analysis of 54 such studies found an overall prevalence of 28.8%, a 15.8% increase in depressive symptoms during the first year of residency across all specialties, and 20.9% to 43.2% of residents reporting a continuous increase of their symptoms over time.23 In a survey of anesthesiology residents, 22% screened positive for depression, with those working more than 70 hours per week drinking more than five drinks per week, and females found to be at higher risk.24 Perceived institutional support, work-life balance, strength of social support, workload, and student debt all impact physician well-being.25
| Common Problems Facing Physicians |
| Increased productivity requirements |
| Decreased federal funding for research |
| Increased work onus on faculty resulting from restrictive resident hours |
| Rapidly expanding knowledge base requiring continuous training |
| Excessive and irregular work hour |
| No allocation of “down time” |
| Increased bureaucracy and regulation with decreased physician autonomy |
| Decreased reimbursements |
| Electronic medical recordkeeping (less time with patients/patient care) |
| Student loan debt |
| For female physicians: lack of support, low feelings of being valued, not enough recognition |
According to the American Medical Association’s Principles of Medical Ethics,27 “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.” Most of us are also bound by the Hippocratic pledge of beneficence and our own altruism, putting patient welfare and autonomy first. For physicians, providing safe and high-quality care to our patients is fundamental. However, when our health or wellness is compromised, we may not be able to fulfill this obligation to our patients. Therefore, to preserve the quality of our performance and safeguard the well-being of our patients, we have a responsibility to maintain our own health and wellness. Because physicians are perfectionists with a strong sense of responsibility and control, we tend to delay seeking help. We are known to self-diagnose and medicate without consultation, to minimize our symptoms, and to tolerate them.15
Many physicians do not seek medical expertise for themselves for fear of being disabled, and they cannot fathom having a chronic illness, so they stay in denial for a longer period of time. Men are often more stoic and unlikely to convince themselves to seek help. Anger, frustration and guilt about not being able to work and help patients, as well as the fear of medical license restrictions or revocation, may further complicate matters, leading to more depression and substance abuse. The trend starts early in medical school. Rotenstein and colleagues28 found that while 27.2% of medical students had depression, only 15.7% sought treatment for their depressive symptoms for fear of the stigma attached. Physician wellness is a vital quality indicator of the performance of our healthcare systems.29 Some of the consequences of physician burnout at the institutional level include medication errors; decreased quality of patient care, patient satisfaction, and physician productivity; increased physician turnover; and not reaching organizational goals. In a prospective cohort looking at medication errors and depression, Fahrenkoff and colleagues30 found a 6.2 times higher likelihood of errors when residents suffered from depressive symptoms. Emotional outbursts and disruptive behavior pose further challenges for members of the care team and can cause patient harm and medico-legal consequences.31
Initial efforts to address physician well-being were largely based on the individual impaired physician. Personal strategies to decrease stress and promote resilience, such as mindfulness or cognitive behavioral techniques and physical exercise, were encouraged. Physician well-being received major attention in 2012 when a large-scale study reported a high risk of burnout in almost half the U.S. physician population.32 The increasing national awareness of physician burnout brought together health policymakers, who championed several initiatives. The first American Conference on Physician Health was held in 2017. Major academic institutions appointed chief wellness officers, a “Charter on Physician Well-Being” was published in JAMA,33 and the Accreditation Council for Graduate Medical Education (ACGME) and the National Academy of Medicine (NAM) came together to highlight the importance of an institutional or systems approach to address clinician well-being. The Common Program Requirements were revised by the ACGME for a more conducive learning environment for trainees34 while NAM issued a report providing a framework for a systems approach to enhance professional well-being, a research agenda and recommendations.35 A meta-analysis showed that while interventions targeted toward the work environment were associated with better results compared with physician-targeted interventions, there was a small but significant benefit toward burnout when directed individually.36 Meanwhile, Mayo Clinic, through implementation of its nine organizational strategies, was able to reduce the physician burnout rate by 7% despite an increase elsewhere in the country.37 Our own American Society of Anesthesiologists (ASA) approved a standing Committee on Physician Well-Being with four working groups to address the needs of the membership: Systems & Policy Impacting Well-being; Education & Endeavors; Mental Health & Suicide Prevention; and ASA Outreach.38
The perioperative team is a multidisciplinary one, with varied stakeholders, and relies on each person’s contribution in a coordinated manner. Residents are exposed to high levels of stressful situations and long work hours. Anesthesiologists, nurses and surgeons are challenged by the unpredictable work environment (for example, due to emergencies/trauma patients), problems with shift changes, regulatory demands, value conflicts and financial uncertainties, leading to stress and burnout that may be harmful to the well-being of the care team.39 Various strategies to prepare for this environment and prevent resident burnout include early recognition and assessment, inclusion of formal education in medical school and residency training curriculum, time off from clinical duties, a peer support system, and frequent screening for mental health issues. It is not surprising that compensation (93%), autonomy (77%), peer support programs (67%), work hours (60%), and mentorship (59%) were some of the institutional factors that were recognized to impact the well-being and burnout of surgical residents, as per a survey at two institutions.40 Transition to a better on-call shift from 24 to 16 hours has been shown to have positive effects on residents.41 Talking to peers after a catastrophic event helped 98% of anesthesiologists overcome guilt while 67% believed their ability to take care of patients safely was compromised and only 7% received time off.42 Physicians may be vulnerable to second victim syndrome, first described by Wu in 2000, after a catastrophic event that resulted in emotional and psychological trauma.43 The Resilience in Stressful Events (RISE)44 program at John Hopkins Hospital and Schwartz Lectures45 by the patient care team sharing their experiences are examples of successful peer support programs.
In a recent survey, 6.5% of physicians had suicidal ideation, with 73% of these individuals saying they would seek help if they had a serious emotional meltdown.46 We need to provide discreet and confidential access to treatment while creating an environment conducive to open discussions about stress and other mental health concerns. In a national U.S. survey of anesthesiology chairs about tackling physician wellness, more than 60% showed strong interest in burnout counseling and stress management support, a statistically significant number.47 Mental health days, wellness days (hanging out with pets), social outings to prevent loneliness, and massage therapy paid for by institutional insurances are helpful too. Despite constituting nearly 50% of medical school classes, female physicians still face challenges due to gender bias and have high rates of depression, alcohol consumption and risk for burnout and would benefit from equal professional opportunities for stress reduction.48 Switching to part-time work, however, may not necessarily prevent burnout.49 The introduction of paternity leave for fathers, lactation pods in work areas near the OR, childcare support, and adequate time off for maternity leave are some of the positive changes that can reduce stress.
Organizational/policy level interventions include: optimization of electronic medical records (EMR), reduction of administrative burdens, standardization of medical licensure across states without requirements for disclosures about past mental illness (no data to support any effects on patient safety50), social justice and healthcare equity for diverse populations, reduction of student loan debt, medical malpractice laws to prevent the practice of defensive medicine, and clear policies that define the scope of practice for advanced practice providers to foster a warm, professional team environment and the protection of physician autonomy.51
The COVID-19 pandemic laid bare some blatant discrepancies in our healthcare system, including how it takes care of its workforce. Most anesthesiologists or perioperative physicians were thrown onto the front lines, and with our altruistic selfishness we went, with some never to return. There were forces within and outside that pushed us into the corner. Some of us were fortunate in that we were protected by our own resilience while others quit. The after-effects were massive burnout and post-traumatic stress disorder. Our attitudes, beliefs and perceptions regarding our institutions were changed. It will take a long time to mend. Maybe the pandemic was the catalyst that we needed. Let’s take a cue from Thomas Schwenk’s viewpoint in JAMA (2018)52 about physician well-being and the regenerative power of caring, and put some “fresh air in the coal mine”!
Tazeen Beg, M.D., is an assistant professor of anesthesiology and division chief of anesthesia for endoscopy and non-operating room anesthesia at Stony Brook University Medical Center. Katrina Kerolus, M.D., is entering her clinical anesthesia-2 (CA-2) resident year at the Renaissance School of Medicine at Stony Brook.
References
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