During the past few years, the medical community has become increasingly aware of the problem of physician burnout. Burnout—a pathologic response to stress manifested by the triad of emotional exhaustion, depersonalization, and diminished sense of personal accomplishment—is common among healthcare workers, including orthopaedic surgeons.
I have been involved in several projects looking at burnout in orthopaedics. In 2009, we reported that more than half of the orthopaedic residents and more than a quarter of orthopaedic faculty surveyed showed elevated levels of burnout. In October 2012, we published findings that spouses and significant others are also at risk, particularly during the orthopaedic training years.
According to the recent Physician Stress and Burnout Survey, burnout affects not only physicians in training, but also practicing physicians in a variety of disciplines. In a two-part series in AAOS Now, Alan H. Rosenstein, MD, discussed the results of the survey and offered strategies for combating stress and burnout. (See “Physician Stress and Burnout: Prevalence, Cause, and Effect,” AAOS Now, August 2012, and “Physician Stress and Burnout: Taking Care of Yourself,” AAOS Now, September 2012).
So why revisit this issue? Because the deleterious effects of burnout extend beyond the physician and his or her family; physician burnout is a patient safety issue.
The impact on patient safety
Physician burnout has been associated with increased medical errors and suboptimal patient care. Depersonalization—a detached, cynical view of patients and coworkers—bears a particular relationship to medical errors and patient outcomes. A survey of matched hospital patient-doctor pairs revealed that elevated physician depersonalization levels were associated with decreased patient satisfaction and longer postdischarge recovery times. This association persisted even after adjusting for severity of illness and demographic factors.
Among surgeons who reported a major medical error in the preceding 3 months, each one point increase in depersonalization (scale range: 0–33) was associated with an 11 percent increase in the likelihood of reporting an error. Similarly, each one point increase in emotional exhaustion (scale range: 0–54) was associated with a 5 percent increase in the likelihood of error.
All of these studies involved a single snapshot of physicians. It is impossible to determine whether depersonalization was a contributing factor to making the error or if making an error puts a physician at risk for depersonalization.
If burnout is a proximal cause of medical error, efforts by individuals and institutions to combat stress and burnout may help to reduce the incidence of medical errors. Institutional support to optimize physician function and minimize the burden of busy work can provide physicians adequate time and energy to engage in self-care activities. Engaging in exercise or hobbies and making the time to spend at least 30 minutes a day alone and awake with your significant other correlate with decreased burnout among orthopaedic surgeons.
Fostering a culture change
However, it may be that depersonalization serves as a dysfunctional coping mechanism, enabling a physician to psychologically separate from the injured patient. This is where medical institutions and professional organizations need to take the lead in promoting a culture change.
Committing a medical error elicits deep feelings of shame. These feelings can be particularly disabling to us as physicians, because we notoriously expect perfection in ourselves. In truth, it is unlikely that any reprimand or chastisement handed out in a morbidity and mortality conference or quality review meeting comes close to matching the severe criticism that we as physicians heap upon ourselves after committing an error.
The persistence of a culture of blame and shame in medical institutions adds humiliation to the pervasive sense of incompetence and failure that can arise in the wake of an error. Such a culture undermines efforts toward transparency and fosters underreporting of errors. Furthermore, it alienates colleagues and contributes to burnout and, possibly, additional errors.
For the well-being of our patients, our colleagues, and ourselves, we must foster a culture change. By creating an atmosphere of acceptance and support, we can encourage disclosure of errors and enable the identification and eradication of contributing systems failures. Just as important, we can assist our colleagues in owning, addressing, and recovering from the error.
We have all made—or will make—errors. Normalizing the event does not minimize it and combats the isolation that may devolve into depersonalization. In the face of a medical error—either our own or a colleague’s—we should look for, and take steps to prevent or address, burnout.
M. Catherine Sargent, MD, is a member of the AAOS Patient Safety Committee. She can be reached at firstname.lastname@example.org
- Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty. J Bone Joint Surg Am, 2009. 91(10): p. 2395–2405.
- Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice: part 2: spouses and significant others. J Bone Joint Surg Am. 94(19): p. e1451-6.
- Rosenstein AH, Physician Stress and Burnout: Prevalence, Cause, and Effect. AAOSNow, 2012(August).
- Rosenstein AH, Physician Stress and Burnout: Taking Care of Yourself. AAOSNow, 2012(September).
- Williams ES, Manwell LB, Konrad TR, Linzer M, The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev, 2007. 32(3): p. 203-12.
- Halbesleben JR, Rathert C, Linking physician burnout and patient outcomes: exploring the dyadic relationship between physicians and patients. Health Care Manage Rev, 2008. 33(1): p. 29-39.
- Shanafelt TD, Bradley KA, Wipf JE, Back AL, Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med, 2002. 136(5): p. 358-67.