Burning the candle at both ends: Mitigating surgeon burnout at the training stages

Central MessageHere, we define and offer advice to combat cardiothoracic surgical trainee burnout from the individual, institutional, societal standpoints.PerspectiveCardiothoracic trainees are at great risk of developing symptoms. In this article, actionable institution, standpoints burnout.See Commentaries on pages 643 644.“In dealing with those who undergoing suffering, if you feel “burnout” setting in, demoralized exhausted, it is best, for sake everyone, withdraw restore yourself. The point have a long-term perspective.”—Dalai Lama Here, standpoints. Cardiothoracic burnout. See 644. surgery face particularly high due long working hours, delayed career gratification, stakes in patient outcomes.1Fann J.I. seasons thoracic surgeon.J Thorac Cardiovasc Surg. 2017; 154: 1477-1486Abstract Full Text PDF PubMed Scopus (1) Google Scholar survey administered alongside American Board Surgery in-training examination 2018, approximately 38.5% reported experiencing symptoms least weekly, 4.5% reporting having had suicidal thoughts during past year.2Hu Y.Y. Ellis R.J. Hewitt D.B. Yang A.D. Cheung E.O. Moskowitz J.T. et al.Discrimination, abuse, harassment, residency training.N Engl J Med. 2019; 381: 1741-1752Crossref (215) Alarmingly, suicide has been documented as second-leading cause death among residents.2Hu As community, must address notion self-preservation early training. What can do provide self-care synchrony our work ultimately cope negative effects emotional fatigue, physical wear, stress, such that continue bring very best clinical work? following Young Surgeon's Note aims delve into ways mitigate Physician complex phenomenon refers or mental deprivation often caused by overextension oneself sense inundation excessive levels stress.3Squiers J.J. Lobdell K.W. Fann DiMaio J.M. burnout: treating instead disease?.Ann 104: 1117-1122Abstract (52) It recently emerged an alarming issue led many physicians abandoning their careers, sometimes professional tenure.3Squiers By 2025, US Department Health Human Services predicts there will be nationwide shortage nearly 90,000 physicians, driven away medicine out practice burnout.4Jha A. Lliff Chaoui Defossez S. Bombaugh M. Miller Y. A Crisis Care: Call Action Burnout. Partnership Massachusetts Medical Society, Hospital Association, Harvard T. H. Chan School Public Health, Global Institute.https://cdn1.sph.harvard.edu/wp-content/uploads/sites/21/2019/01/PhysicianBurnoutReport2018FINAL.pdfDate accessed: April 4, 2020Google Early qualitative research delineation 3 dimensions burnout—exhaustion, cynicism, inefficacy.5Oquendo M.A. Bernstein C.A. Mayer L.E.S. key differential diagnosis physicians—major depression burnout?.JAMA Psychiatry. 76: 1111Crossref (28) Exhaustion described wearing out, loss energy, depletion, debilitation, fatigue. Cynicism was originally termed depersonalization inappropriate attitudes toward others, irritability, idealism, withdrawal. Lastly, inefficacy, which reduced personal accomplishment, productivity capability, low morale, inability cope.6West C.P. Huschka M.M. Novotny P.J. Sloan J.A. Kolars J.C. Habermann T.M. al.Association perceived medical errors resident distress empathy: prospective longitudinal study.J Am Med Assoc. 2006; 296: 1071-1078Crossref (882) Various metrics were proposed based different assumptions about burnout, relying validity measurement items (Table 1). Surgeons frequently exposed degrees stress.5Oquendo Burdensome workloads (eg, on-call responsibilities, research, administrative duties), ensuing difficulty balancing life, feelings losing autonomy control, failing find meaning all contribute (Figure 1).3Squiers ScholarTable 1Common workplace assessment instrumentsSurveyCharacteristicsAnalysisMaslach Burnout Inventory (MBI)•22-item questionnaire•Specifically designed assess experience earlier considered standard tool field•Emotional exhaustion measures being emotionally overextended exhausted one's work•Depersonalization unfeeling impersonal response recipients service, care treatment, instruction•Personal accomplishment competence successful achievement workMini Z•Used AMA•Was adapted previous performed Work life Survey (Linzer 2000,∗ Williams 2001†) MEMO 2009‡)•Comprises 10 1 open-ended question•Ten satisfaction, chaos, values alignment, teamwork, documentation time pressure, excess electronic record (EMR) use home, EMR proficiency•Analysis drivers mini Z externally validated single-item measure showed virtually variables associated item P < .001 level r 0.26 0.46 (for major predictors use, lack alignmentOldenburg Inventory•16-item positively negatively framed covers 2 areas: (physical, cognitive, affective aspects) disengagement (negative objects, content, general).•All scored 7-point scale, ranging (0) “never” (6) “every day”•High scores cynicism indicate burnout•Construct equivalence instruments used present study language educational groups.Copenhagen Inventory•19-item (degree psychological fatigue exhaustion), related work), client-related (or similar term patient, student, etc) burnout•There multiple questions each subscales responses form either always, often, sometimes, seldom, never/almost never degree, somewhat, degreeAMA, Association. ∗Linzer M, Konrad TR, Douglas J, al. Managed care, physician job satisfaction: results work-life study. Gen Intern 2000;15:441-50. †Williams E, T, Scheckler W, Understanding physicians: Intentions practice: role health. Care Manage Rev. 2001;26:7-19. ‡Linzer Manwell LB, ES, Working conditions primary care: reactions quality. Ann 2009;151:28-W9. Open table new tab Table 2Provoking factors strategies overcome stratified institutional levelsAspects individual's contributing burnoutProvoking burnoutStrategies burnoutIndividual1.Work–life balance (work duties)2.Meaning3.Moral/emotional distress4.Wellness1.Discover work2.Be cognizant workload reserve1.Embody gratitude2.Practice mindfulness3.Seek counseling1.Establishor maintain social support2.Develop professionally/personally meaningful outlets distress1.Practice attaining adequate sleep, nutrition, fitness, mindset behavior adaptability)Institution1.Toxic culture2.Implicit bias, discrimination3.Work–life balance1.Develop institution-wide programs wellness, proper culture, implicit bias2.Provide opportunities debriefing1.Enforce zero tolerance policies prevent discrimination, harassment2.Establish counseling1.Respect duty-hour restrictions2.Ensure access counseling assistanceSociety1.Stigma seeking help2.Lack community1.Destigmatize raising awareness1.Encourage involvement societies, organizations, support groups2.Integrate media judiciously3.Provide mentorship, networking, sponsorship AMA, manifests wide variety cognitive symptoms, changes appetite, insomnia, disengagement, hostility, broken diminished attention span focus, depression, anxiety, declining addition, may lead alcohol substance relationships divorce, even suicide.3Squiers Scholar,4Jha For surgeons, well-being intrinsically tied his her performance, majority surgeons attributed individual acute lapse judgment concentration, burnout.6West closely linked.5Oquendo Physicians both conditions, data suggesting one half some capacity,4Jha 12.8% male 19.5% female practicing screening positive compared 7% general population.5Oquendo Some authors advocate consideration depressive disorder, given overlap symptomatology between definitions diagnostic criteria disorder.4Jha Others, however, caution against conflating since risks misclassifying burnout.5Oquendo Given enduring stigma illness suicidality—a reinforced fear sanction licensing boards other health institutions—it might seem more “acceptable” admit than depression.4Jha However, inadequate treatment depression. Therefore, important correctly diagnose initiate appropriate pharmacologic psychotherapeutic interventions when necessary.5Oquendo Success relies heavily mastery fundamental technical skills well development prowess, intellectual agility, moral maturity. part longest most arduous training programs, prone decision-making, extended fatiguing call schedules, continuous evaluations, employment uncertainty, ongoing onslaught examinations after Furthermore, they deeply imbued affected instinctive duty patients. With covenant comes natural progression obligation develop connectivity patients, unexpected outcome causes significant stress. though ultimate liability patient's usually rests upon shoulders attending surgeon, named litigation, add burden part, ability work-related stressors evolves over experience, although faculty members still regard. attempt shield protect these developing, proactive mechanisms established, include but not limited to, Accreditation Council Graduate Education restrictions, protected academic salary, more.7Bilimoria K.Y. Chung J.W. Hedges L.V. Dahlke A.R. Love R. Cohen M.E. al.National cluster-randomized trial flexibility 2016; 374: 713-727Crossref (246) National Academy Medicine, collaboration Association Colleges, convened its first action collaborative July 2017 titled, “Clinician Well-Being Resilience.” They defined goals increasing visibility clinician stress improving organizations' understanding challenges well-being, identifying evidence-based solutions, monitoring effectiveness solutions. ways, message leadership culture learning environments rendered sensitive while lifting discussion describes depth number learn acknowledge manage 2).1.Acknowledge Burnout, Develop Coping StrategiesA third-year bad causing tear internal mammary artery assigned harvest. rest procedure goes well, received inferior operation. afraid attendings colleagues mistake extend future autonomy. He she heard any residents complication, cautious reach anyone… While no panacea exists complex, heterogeneous problem, good starting degree Currently, strive unrealistic exceptionalism infallibility, tends direct consequence Lack recognition leads missed intervention. need destigmatize concept end point, transitioning binary framework (ie, burned out?) spectrum across themselves adopt openness transparency, able debrief share vulnerabilities peers trusted senior reinforce constructive isolation, resources psychotherapy/counseling episodes chronic “maintenance.” Other coping investing outside interests, hobbies help sustain outlook philosophies go through training.2.Find Your Joy Meaning Avoid Moral InjuryA just finished grueling 24-hour shift. There consultation requests several patients decompensated passed overnight. provides sign then heads home rest, knowing return hospital next morning another chance cook meal read, exercise, partake months, begins wonder sacrifices worth it. Much emphasis placed finding “balance,” “work–life integration”; posit crucial antidote discovery meaning, leading greater fulfillment. stem factors, impactful relevant beyond oneself. training, lose sight broader impact own didactic education, patient-lived experience. also from—or eroded by—leadership. Bailey Madden8Bailey C. Madden Time reclaimed: temporality work.Work Employ Soc. 31: 3-18Crossref (76) 7 recurring themes undermine workers' including: incongruence organization, (2) hard work, (3) giving people pointless do, (4) unfairly, (5) overriding people's better judgment, disconnecting supportive relationships, (7) putting harm. These suggestions organizations and, specifically, departments, how shape organizational infrastructure avoid detracting meaning. Finally, stave off avoiding reconciling distress. injury affects identity, morality, relationship society. instance, occurs unable high-quality meets standards system. Over time, replaces hope gradually downgrades “calling” “job.” Institutions reconcile ways. Notably, only ethical complications endeavors hosting ethics morbidity mortality conferences debriefs. Ultimately, certain hardships inevitable systematically promoting aspects profession, legitimizing dilemmas faced, helping closure prove valuable combating burnout.3.Design Surgical Career Fit SuccessA fourth-year second year 2-year fellowship. Although initially relieved begin years, beginning insatiable urge operate amount balance, activities fulfill. reassurance initial choice, feels energized back hospital. If consider extreme dissatisfaction, counteracting should involve trainee's concerted effort design trajectory structure optimal “fit.” Before choosing path, thoroughly look various paths decide offers sustainable satisfaction happiness. external pressures, daunting challenging task requires introspection self-awareness. school, aspiring introduced “triple threat,” purported pinnacle surgery. marker true success, told, excel providing outstanding participating further science field, educating generation students trainees. make “quadruple threat” adding participation administration. realistically “buckets” could constitute life's work; therefore, right them factor preventing Identifying ideal combination pursuits stages tailored talents, goals, values. This influence subsequent choice activities, subspecialty, setting, “track” electing centers. deliberate areas prioritize allowing extrinsic success drive hopefully promote making contributions field.4.Create Environment Wellness: Importance Diversity InclusionThe intern group 15. division 12 surgeons. She learns halfway throughout co-resident hanging older program weekends doesn't know would welcome gatherings. occasionally catches staff operating room telling stories “last resident.” doing clinically tremendous ambitions, mentor whom struggles… inclusion vital components 2018 In-Training Examination 7409 262 demonstrated 32% discrimination self-identified sex 17% racial discrimination.1Fann women, victims likely report (odd ratio, 2.94; 95% confidence interval, 2.58-3.36) 3.07, 2.25-4.19).1Fann findings Society Thoracic Surgeons, 39% respondents (83% self-identify black/African/African American) felt unfairly treated marginalized, mistreated, harassed, excluded, bullied, promoted diminished) race, ethnicity, sex, sexual orientation, religion, age, disability status.9Erhunmwunsee L. Backhus L.M. Godoy Edwards Cooke D.T. Report workforce diversity inclusion—the members' bias experiences.Ann 108: 1287-1291Abstract (16) improved focused initiatives made available faculty, staff, trainees, public. Tracking maintaining transparency advancement minorities proven strategies. creation Workforce Inclusion step achieving goals.9Erhunmwunsee Specific growing aware sex-specific differences supporting equity on-site child facilities, meet resident-specific needs expectations.10Corsini E.M. Luc J.G.Y. Mitchell K.G. Turner N.S. Vaporciyan A.A. Antonoff M.B. Predictors personnel surgeon behaviors.Surg Today. 49: 927-935Crossref (8) Scholar, 11Meyerson S.L. Sternbach Zwischenberger J.B. Bender Resident room: expectations versus reality.Ann 1062-1068Abstract (38) 12Luc J.G. Yanagawa B. Surgeon teachers millennial learners: bridging gap.J 2020; ([Epub ahead print])Abstract Scholar5.Surround Yourself Those Who Support YouA first-year enters full highly ambitious independent residents. little community camaraderie official, departmental gatherings, siloed respective projects. interested aortic does connected enough advice. acceptance, inside settings, daily interactions.13Fann Moffatt-Bruce S.D. Dimaio Sanchez human nature surgery.Ann 101: 2059-2066Abstract (14) Scholar,14Kron I.L. mentorship.J 2011; 142: 489-492Abstract (29) experiences us place, purpose, belonging. Membership clubs whether formally informally, deterrent burnout.9Erhunmwunsee Trainees expand mentorship inspire An validating cultural shift organize sessions mitigating Together, efforts attract retain brightest field surgery.15Kim A.W. Reddy R.M. Higgins R.S.D. Joint Subcommittee Best Brightest“Back future”: recruiting surgery.J 2010; 140: 503-504Abstract (15) Social increased rapidly especially young contemporary technology connects around world fosters larger network, mentor, collaborate inspire. One example Media Network, formed 2015 publications journals highlight accomplishments specialty.16Luc Ouzounian Blitz Stamp N.L. Varghese Jr., T.K. al.The Network: lessons learned.J 158: 1127-1136Abstract creating communities like-minded individuals, shown enhancing networking space, geography.17Luc means mentorship: women surgery.Semin 2018; 30: 487-495Abstract (31) allows real-time asynchronous international conversations, unite campaigns issues matter including #ILookLikeASurgeon movement. expansive reach, permanence, peer review, pose challenges. users recognize permanence footprint, traditional professionalism online behavior, engagement; act accordance set employers practices. mindful potentially harmful contagion where repeated exposure modelling, reinforcement damaging wellness. Highly edited curated content masquerade “perfect” conveying complexities reality face. fall pitfall exchanging superficial encounters increasingly isolated struggles. To curb this, ensure surrounds you, limit seek necessary. impacts surgeons' safety issues. solution multipronged approach. perspective