Todd J Albert is surgeon-in-chief at the Hospital for Special Surgery, New York, USA, and is the current president of the Scoliosis Research Society (SRS). At the 25th International Meeting on Advanced Spine Techniques (IMAST; 11–14 July, Los Angeles, USA), hosted by the SRS, Albert gave a stirring keynote address hoping to contribute to and widen the ongoing global discussion concerning physician burnout, and advocating for the adoption of certain individual- and institution-level interventions to help lessen the strain on surgeons’ mental health.
Mental health is a significant concern for physicians. In the USA, there are 400 physician suicides a year; twice the suicide rate of the general American population. Death by suicide is the second leading cause of death among medical residents. Fifty-four percent of doctors say they are burned out; 88% acknowledge they are moderately to severely stressed, and 59% of doctors say they would not recommend a career in medicine to their children.
These statistics are the result of recent research by Tait Shanafelt (Mayo clinic; Stanford Medicine, Stanford, USA) and colleagues, where the investigators surveyed almost 7,000 physicians. The same study reveals that between 2011 and 2014, there was an increase in the percentage of physicians reporting burnout, and a decrease in the number of surgeons who believed they experienced a good work-life balance. North American orthopaedic surgeons rate in the lowest third of all care workers for work-life satisfaction, and the highest for rates of burnout.
Albert opened his keynote address by defining the problem. He cited the American psychologist Herbert Freudenberger’s definition of burn out, which first appeared in print in a 1974 issue of the Journal of Social Issues, as, “A state of emotional, mental and physical exhaustion caused by excessive and prolonged stress. It is a chronic process of energy expenditure without appropriate periods of recovery.”
Dissecting this definition, Albert continued, “If you think about three elements of burnout: emotional exhaustion, depersonalisation, and a perceived lack of personal accomplishment, you can imagine it doesn’t feel so good to wake up when you’re feeling that way.”
“A lot of us went into medicine because we wanted to be like Marcus Welby [a kindly doctor in the eponymous American TV drama]—we did not want to care about finances, we just wanted to take care of people. And that feeling led to incredible respect and trust over the last century of patients for their doctors, but the question is: are we a little out of balance? With physicians having such altruistic intentions, we burden ourselves with incredible professional responsibilities, and ignore our own health, as well as that of those around us. Many of us have been trained by role models who work sick hours, will not take care of themselves, will not go home, will do research night and day, and will not care for their families. So we have to be a little careful, and wonder if it is out of balance.”
Like many physicians, Albert has experienced first-hand the effects of burn out: a trauma surgeon in Albert’s hospital in New York died by suicide at the end of 2017, which Albert described to the IMAST audience as “devastating for the people of our hospital.”
Michael Weinstein, a general surgeon at Thomas Jefferson University Hospital, Philadelphia, USA, who worked closely with Albert, wrote a first person account of his struggles with dysthymia, depression and suicidal ideation in the New England Journal of Medicine. Weinstein wrote: “I endured. I completed residency and fellowship and continued to endure for 16 years. Outside observers might have perceived me as ‘having it all’: a surgeon with leadership promise, with an amazing wife and two great kids, who is paid more than I ever expected to earn.
“But enduring is not thriving. I had heard of burnout but did not really comprehend it. And though I had mental illness, I still saw it as a weakness, a personal fault. I remember early in my career hearing of a colleague who took a leave of absence for a ‘nervous breakdown.’ I joked about it, said he was weak. Now it was my turn.
“My work lost meaning; I was just going through the motions. I thought everything I tried to accomplish was a failure. I had trouble relating to patients and felt the urge to avoid encounters altogether. I cared less and less about anything I was doing. I didn’t know it then, but I had long experienced classic signs of burnout: emotional exhaustion, depersonalisation, and low perceived personal achievement. But the burnout had been waxing and waning for 22 years; now I was in the worst episode of major depression of my life.”
Upon reading this article and realising that his friend and colleague had a history of struggling with poor mental health, Albert said, “He was the most emollient guy, I thought I knew him really well; I was shocked when I read this article [to find out] that he was submitted to a psychiatric institution three times for potential suicide. That to me is the biggest point I can make to you: recognition and sensitivity of those around us, who we work with; try and reach out and help. I felt terrible when I read this—that I was close to him for a long time, and really did not know this about him.”
This recognition is crucial: acknowledgement of physician burnout saves lives, and is the first step to recovery. Academic medical centres are starting to pay more attention to physician burnout and suicide, but it is still rare for a practicing doctor to be as forthcoming as Weinstein, or for mental health issues to be given the platform Albert provided at IMAST.
The myriad solutions to this problem revolve around understanding the causes of physician burnout. Writing in the Journal of Internal Medicine in June 2018, Colin West and co-authors claim that the “drivers of this epidemic are largely rooted within healthcare organisations and systems,” and include: “excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, lack of input or control for physicians with respect to issues affecting their work lives, organisational support structures and leadership culture.”
However, there are ways to help those struggling with chronically low mood, and in some cases to avoid the feeling of burnout altogether. Albert concluded his keynote address with an overview of some of the options, saying, “I would like to talk about potential solutions, rather than just complaining about the problem. Treatment falls into two main categories: physician directed, or organisation directed. Both are important and can make an impact.”
Amongst the physician directed solutions mentioned were cognitive behavioural therapy, wellness techniques, and coping mechanisms. Albert is one of many to argue in favour of teaching physicians these techniques to build up mental resilience; wellness training could be incorporated into university curriculums. Albert said in his speech, “I think the most important thing is for us as leaders, in whatever team we are in, to destigmatise the problem of somebody having these psychological issues, and create a safe and caring environment where it is safe to come forward and get treatment” (research has shown that orthopaedic surgeons are among the least likely to seek professional help).
Albert continued, “For our trainees, we have to foster relationships and mentorships, structure time for healthy activities, and structure interventions, again making it safe for them to come forward. Mindfulness techniques, exercise, having time with colleagues, encouraging time away; all are positive things.”
The organisation directed treatment options that Albert listed included a reduced workload for physicians, improved team work, and increased help with hospital bureaucracy. In the summer of 2017, Stanford Medicine (Stanford, USA) created a chief physician wellness officer position, the first to exist in the USA—Shanafelt was hired to fill the role on 1st September. At the time of his appointment, a Stanford Medicine press release reports Shanafelt commenting: “I think most health care leaders now realise this is a threat to their organisation, but there is also uncertainty that they can do anything effective to address it. They say, ‘It’s a national epidemic, what can we do?’ My experience has shown that an individual organisation that is committed to this at the highest level of leadership and that invests in well-designed interventions can move the needle and run counter to the national trend of physician distress and burnout.”
For Albert and his colleagues at the Hospital for Special Surgery (New York, USA), a physician retreat is available in the form of the Caspary estate. The Caspary family donated an estate in upstate New York for physicians and trainees. As Albert explains, “It is first come first served, there are three houses up in this beautiful estate, and it is used quite often, it’s a great get away—get off the map, get off the grid. Small things that I think make a difference.”
A wealth of literature also points to the fact that the well-being of physicians is linked to how well they can do their job: physicians who are burnt out are more likely to make errors. According to research by Shanafelt and colleagues at Stanford Medicine, physician burnout is at least equally responsible for medical errors as unsafe medical workplace conditions. Physicians experiencing burnout are also more likely to report having made a major medical error in the past three months than those who have not experienced burn out. Reducing physician burnout and promoting self-compassion among healthcare workers is therefore good for a healthy society.
Another treatment strategy Albert offered in his IMAST address, originally suggested by Shanafelt, is to increase the amount of help physicians have on the job. In a study conducted by investigators at Colorado University, the average number of assistants per healthcare provider was increased from 1.1 to 2.5. The rate of reported burnout decreased from 53% to 13%. Citing the estimated US$15–55 million cost of burnout at Stanford, Albert claimed that this increase in assistance is cost effective. The Hospital for Special Surgery where Albert is based now have 175 credentialed personal assistants to aid in administrative duties and ease the burden of work for care providers.
Albert also suggested alternative forms of compensation as a method of combating burnout. He said, “We can change the way that we pay people. We could use discretionary pay, give people time to take care of themselves, and allow people to do things that make them feel better, through their pay and their compensation. I think—and this is really important—we should implement a multifaceted wellness programme and resiliency programme, not only in residency, but in our professional units for our staff and the ancillary providers. At the Hospital for Special Surgery, we have a wellness calendar; for every season, there is a list of wellness tasks. We have programmes to create a culture of health, including meditation and a book club for wellness for our staff; for our residents, for our nurses and ancillary providers as well. If you can’t be there in person to do meditation, you can do meditation online. I think all of these things are important. All these things can improve your mental health. Self-care is very important: if you do that, your interpersonal relationships and your professional relationships are cared for; you will have better physical health, better mental clarity, better wellbeing, a stronger sense of meaning and purpose, and your patients will do better.”
Albert’s colleague Weinstein concluded his account of his experiences with burnout on a hopeful note. He wrote: “I have been open about my illness and, though I had feared re-entry, I returned to a supportive and compassionate group of co-workers. I have learned that many of us suffer in silence, fearing the stigma associated with mental illness. I feel compelled to share my story, which I’ve found offers others an opening to express their own suffering. I believe that by deploying tools for reflection and self-care and working together in a brave and disciplined way, we can remove our restraints and isolation—both figurative and literal.”
With his keynote address to the IMAST audience, and with an opening session at the upcoming SRS Annual Meeting (10–13 October, Bologna, Italy) focusing on physician well-being, Albert is part of a growing movement aimed at destigmatising mental health issues and reducing rates of burnout amongst healthcare workers.