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Commentary on

:
Career Satisfaction and Burnout Among U.S.
Neurosurgeons: A Feasibility and Pilot Study
by Klimo et al. pp. E59 E68.
How to Identify the Edge of a Cliff in the Dark: Burnout and Neurosurgery
Christopher S. Eddleman, Salah G. Aoun, H. Hunt Batjer
T
he practice of medicine, and neurosurgery in particular,
has changed significantly over the past decade, moving
from a physician-driven practice to a practice driven by
patient safety concerns, medicolegal and medical error issues,
and administration oversight. The effort to improve patient
outcomes and increase safety has not only focused on the quality
of care received by the patient but also has extended toward
ensuring that practitioners are in good physical and mental
working condition. The 80-hour work week limitation has already
been implemented with respect to resident training with this
purpose in mind (1, 9). However, there are currently no assur-
ances that physicians in practice maintain the same level of
mental and physical stability. As with other professions, physi-
cians can suffer over time from exhaustion, isolation, and over-
exposure, potentially leading to burnout. Through the efforts of
the American College of Surgeons (ACS), the concept of burnout
among physicians in general, and specifically surgeons, has
become a new target in the challenge to improve clinical
performance (10).
Burnout is defined by three major components: emotional
exhaustion, depersonalization, and a low sense of personal
accomplishment. Emotional exhaustion implies the feeling of
being psychologically drained and the inability to meet
successfully the emotional demands of one’s profession.
Depersonalization is a coping mechanism that transforms
the physician’s relationship with his or her patients into
a mechanical interaction devoid of emotion and imprinted with
cynicism (3, 5, 7, 8, 10). A lost sense of personal accom-
plishment often accompanies emotional exhaustion and
depersonalization, stripping the medical profession of its
message and meaning. Physicians today have to deal with
administrative overload, declining reimbursement, an
increasing threat of malpractice, and the ever-increasing
inability to balance their work with their family life. Although
the culture in surgical medicine dictates that we push through
adversity and forge on, many physicians find it difficult to cope
with these conditions for an extensive period of time, ulti-
mately resulting in burnout.
The burnout syndrome should be addressed seriously and
promptly because it has a profound impact on the patient, the
treating physician, and the medical specialty as a whole. In
a survey by the ACS of approximately 8000 surgeons from
various specialties, the documented prevalence of burnout was
40% (3). Burnout and stress in the workplace have been shown
to increase medical errors, decrease the quality of patient care,
and disrupt the patient-physician relationship (6, 11). Burnout also
has been shown to be one of the greatest predictors of
a surgeon’s satisfaction with his or her career and choice of
specialty and to be a cause of early retirement at an age of peak
productivity. It can also have dire personal consequences, such
as drug and alcohol addiction, sleep disorders, chronic cardio-
vascular disease, divorce, and suicide (3). More globally, rumors
of burnout and excessive stress, coupled with the diminishing
rewards of a surgical career, have lowered the interest of new
promising medical graduates in joining the surgical profession,
especially given that training is long, is mentally and physically
taxing, and is met with increasing administrative and public
scrutiny, as is the case with neurosurgery.
H. Hunt Batjer, M.D.
Professor and Chair
Department of Neurological Surgery
The University of Texas Southwestern
Key words
- Burnout
- Career
- Lifestyle
- Maslach Burnout Inventory
- Neurosurgery
- Satisfaction
- Stress
Abbreviation and Acronym
ACS: American College of
Surgeons
Department of Neurological Surgery, The University of Texas Southwestern,
Dallas, Texas, USA
To whom correspondence should be addressed: H. Hunt Batjer, M.D.
[E mail: hunt.batjer@utsouthwestern.edu]
Citation: World Neurosurg. (2013) 80, 5:e111 e113.
http://dx.doi.org/10.1016/j.wneu.2013.01.063
WORLD NEUROSURGERY 80 [5]: e111 e113, NOVEMBER 2013 www.WORLDNEUROSURGERY.org e111
Perspectives
Three steps are mandatory to prevent the burnout phenomenon.
First is the recognition of its presence or potential risk factors.
Second is early detection through validated instruments. Third is
establishing methods of prevention and proactive creation of
a state of resilience, preferably during residency training or in the
beginning of one’s independent career.
Various independent risk factors for burnout among surgeons have
been identified and include a younger age, certain surgical
specialties, the number of call nights per week, the inability to find
a working balance between work and family life, the lack of
appropriate financial compensation, and belonging to a private
versus an academic institution (10). The lack of “intrinsic” rewards
at work is a factor that seems to be very strongly correlated to
burnout. Intrinsic rewards consist of a show of gratefulness from
the patient and the hospital working staff toward the treating
physician (2). The presence of these intrinsic rewards may explain
why certain specialties, such as pediatric and cardiothoracic
surgery, where caseloads are heavy and working hours are long,
have the lowest rates of burnout compared with other fields; it has
been shown that these specialties provide the physician with
a nurturing environment and an infrastructure that was built over
years to provide an emotionally rewarding and minimally stressful
working place (4).
In an effort to provide a reliable tool for the early detection of
excessive stress and burnout among neurosurgeons to reduce
medical errors and improve patient care, Klimo et al. created
a 107-item questionnaire to survey 169 American neurosur-
geons regarding their quality of life and career satisfaction. The
survey addressed professional stress, the quality of professional
life, and burnout. Respondents also were asked to evaluate the
survey as a practical tool that could be used routinely. Response
rate was 50%, with most participants belonging to academic
institutions.
The results were surprising, considering the fact that neurosur-
gery is a laborious field that requires a long period of training,
involves a very busy schedule, and is becoming increasingly prone
to litigation: 95% of respondents were satisfied with their career
with 88% stating that they would choose the same specialty
again. Most respondents (>50%) were satisfied with their rela-
tionship with their patients and with the intrinsic and extrinsic
rewards generated by their profession. The greatest dissatisfac-
tion was the lack of time for personal growth and development.
Burnout rate was 27%, a rate much lower than the published
average, with 14% experiencing high emotional exhaustion, 27%
experiencing high depersonalization, and 27% experiencing a low
sense of accomplishment. Most participants reported the risk of
lower future income and uncertainties regarding health care
reform as potential stressors. Only 55% stated that they would
recommend the specialty to their child.
There are a few factors that could potentially explain the
lower rates of distress encountered among neurosurgeons
participating in this survey. First, neurosurgery residency is known
to be a challenging and taxing period with one of the highest
dropout rates among all surgical specialties (25%e30%). Burnout
may occur at an earlier stage compared with other medical disci-
plines, with only the most resilient and enduring individuals grad-
uating as faculty. Second, the intrinsic rewards obtained in
neurosurgery can be substantial: procedures can be life-changing,
diseases are often serious, and patients are usually very grateful.
In addition, and similar to pediatric and cardiothoracic surgery, the
working environment is often supportive, knowing the often
stressful situations that constitute a neurosurgical practice. Third
and most importantly, participation to this survey was optional,
and results are prone to a selection bias. Neurosurgeons with
a high burnout score may have chosen not to participate, a fact
that poses new questions: How do we increase response rates to
surveys that require the release of privileged personal information
and could be devastating to the participants if anonymity is lost?
Even if responses are confidential, what guarantees are there to
the participants that security will not be breached and that their
data will not become part of the public domain? What incentives
should be provided to increase response rate in a population
where time is a rare commodity better spent with family or on
personal growth? Neurosurgeons are showered daily with surveys
from commercial and pharmaceutical agencies, and those are
often unanswered even though they usually offer some form of
compensation in return for completion. Finding the appropriate
incentive, perhaps in the form of early access to the analyzed data
of the survey, is essential to increase participation.
What are the practical, mediatic, and legal implications of
releasing data proving that a great percentage of surgeons that
are entrusted daily with people’s lives are burned out and more
prone to committing errors? Will this information be used as
a discrimination tool during recruitment? Will it be grounds for
litigation, termination of employment, mandatory “rehabilita-
tion,” or other forms of disciplinary action? Until further light is
shed on the matter through more extensive and similarly anon-
ymous studies, current efforts should be directed toward iden-
tifying conditions that can be associated with poor working
environments and improving the quality of human interactions
within the workplace to increase the surgeons’ circle of support.
Significant care should also be taken to ensure that residents and
trainees become aware of the burnout process and learn to
recognize it early. They should be reminded that they are working
toward a greater purpose and learn to develop their perception of
their potential for action or “perceived energy.” This concept is
applicable to all specialties, and instilling resilience early during
medical education should help lessen the impact of burnout on
both physicians and patients.
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Citation: World Neurosurg. (2013) 80, 5:e111 e113.
http://dx.doi.org/10.1016/j.wneu.2013.01.063
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