Most orthopaedic surgeons went to medical school to take care of patients and advance the science of medicine. Those altruistic goals serve as a path to personal fulfillment.

However, an increasing number of physicians are frustrated with the practice of medicine, given the pressures to meet what often seem to be unrealistic expectations from patients. In addition to managing patient needs, physicians have growing responsibilities in other areas: managing an increasing administrative burden, stewarding the financial aspects of medical care, and meeting legal compliance obligations within an increasingly complex regulatory environment. The situation is likely to lead to burnout, which is bad for physicians and equally bad for patients.

In order to fully appreciate this phenomenon, we must define burnout, appreciate its impact, and lay out strategies for addressing this threat to physician practice and patient safety.

Burnout is recognized as the triad of emotional exhaustion, depersonalization, and a perception of decreased personal accomplishment. Emotional exhaustion is characterized by a feeling of, “I just can’t take it anymore!” and the sense that tasks are overwhelming and that there is no “light at the end of the tunnel.” Depersonalization manifests as a physician no longer viewing patients as human beings, but rather as objects. This often is identified as an increasing sense of callousness toward patients. Finally, a sense of decreased personal accomplishment frequently is verbalized as, “It just doesn’t matter,” or “What difference does it make?” Such statements often originate from inner feelings that an individual is not positively impacting society, or in the case of a physician, the care of patients.

Physician burnout has been associated with a variety of negative consequences. For affected physicians, burnout has been associated with relationship difficulties, substance abuse, depression, and suicide. Such challenges, along with lapses in professionalism, increase staff turnover. Perhaps most important is the detrimental impact on patients. Physician burnout is associated with increased medical errors and reduced patient satisfaction.

Given the impact on the medical profession and patients, an organized and defined approach to addressing physician burnout is warranted. Fortunately, this has been recognized and supported by organized medicine and many institutions.

At the University of Cincinnati (UC) College of Medicine (COM), the dean’s office tasked a Physicians Well-being Advisory Group with developing an institutional approach to combatting physician burnout and promoting physician well-being. The group’s primary goals are to help physicians assess and acknowledge burnout and to compile resources for physicians who may be approaching a “breaking point” or who are actively in a crisis situation (i.e., suicidal ideation). Additional goals include promoting physician well-being and continuously reassessing needs related to health and wellness.

The UC COM Physicians Well-being Advisory Group utilizes the Physician Well-being Index, a tool that assesses and tracks physician wellness. The index is a nine-item inventory designed to evaluate multiple dimensions of distress, and it has strong validity across medical students, resident physicians, and practicing physicians. The dean’s office strongly encourages faculty to utilize the survey on a quarterly basis. Deidentified data are analyzed to gauge the magnitude of burnout in the faculty of the departments and COM. From an individual standpoint, the survey provides an objective sense of personal stress and wellness over time for a given individual.

Recognizing that the Physician Well-being Index may enlighten a physician on his or her personal stress, the UC COM Physicians Well-being Advisory Group has compiled a list of resources (see sidebar) available to physicians who decide they need help. The most important is a 24-hour crisis phone number for any physician who has suicidal ideation. Anonymity is guaranteed, and the line is staffed by members of the psychiatry department who can refer a physician to an outside facility if the doctor is concerned about privacy. Other resources, some supported by the COM and others that are external, address stress and resiliency, fatigue, financial concerns, alcohol and substance abuse, career development, and work-life balance. Certainly, other stressors exist, but these resources serve as a starting point for the individual physician.

Finally, the Physicians Well-being Advisory Group at UC COM is developing a faculty workshop focused on reducing stress and promoting well-being among physicians. Ultimately, the workshop will occur on an annual basis and, over time, incorporate other providers, including resident physicians and medical students. These efforts by UC COM do not address all aspects of physician burnout and stress; however, this is a concerted effort by the institution to acknowledge burnout and introduce resources to help physicians combat this threat to our profession.

Physicians Well-being Advisory Group provides health and wellness recommendations

Mental health crisis management:

• immediate-action phone line for mental health/crisis management
• access to health system addiction services
• urgent access and phone numbers to inpatient psychiatric service and psychiatric emergency room
• suicide prevention hotline: phone: 1.800.273.8255 (TALK), website: https://suicidepreventionlifeline.org
• expedited scheduling in psychiatry department for healthcare providers
• employee assistance program that provides immediate, 24/7 availability of counseling services to faculty and staff

Physical health and wellness:

• Be Well UC initiative: a repository for general wellness items, programs, and events at the University of Cincinnati, available at: www.uc.edu/hr/bewelluc.html
• campus recreation center
• employee assistance program that provides resources for legal services, elder care, and child care
• health system concierge services that can assist with postal and shipping services, dry cleaning, and referral services (boarding for pets, house cleaning, car service, etc.)

Michael T. Archdeacon, MD, MSE, is the Peter J. Stern Professor and chairman of the Department of Orthopaedic Surgery at the University of Cincinnati Medical Center. He serves on the Physician Well-being Advisory Group for UC COM, as well as the Patient Safety Committee for AAOS.

References:

1. Shanafelt TD, Bradley KA, Wipf JE, et al: Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358-67.
2. Shanafelt TD, Balch CM, Bechamps G, et al: Burnout and medical errors among American surgeons. Annals of Surgery 2010;251:995-1000.
3. Dyrbye LN, Thomas, MR, Massie S, et al: Burnout and suicidal ideation among U.S. medical students. Ann Intern Med 2008;149:334-41.
4. West CP, Huschka MM, Novotny PJ, et al: Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA 2006;296:1071-8.
5. Dyrbye LN, Massie FS, Eacker A, et al: Relationship between burnout and professional conduct and attitudes among U.S. medical students. JAMA 2010;304:1173-80.
   
6. West CP, Tan AD, Habermann TM, et al: Association of resident fatigue and distress with perceived medical errors. JAMA 2009;302:1294-300.
7. Maslach C, Jackson SE, Leiter, MP: MBI: The Maslach Burnout Inventory: Manual. Palo Alto, CA: Consulting Psychologists Press; 1996.
8. Tawfik DS, Profit J, Morgenthaler TI, et al: Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc 2018;93:1571-80.
9. West CP, Dyrbye LN, Erwin PJ, et al: Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272-81.
10. Dyrbye LN, Satele D, Shanafelt T: Ability of a 9-item well-being index to identify distress and stratify quality of life in U.S. workers. J Occup Environ Med 2016;58:810-7.