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THE SILENT EPIDEMIC OF SURGEON
BURNOUT AND DEPRESSION
Here in the United States, we face momentous, and as yet unclear, changes in the delivery of health care. Approximately 46 million Americans lack any health insurance at this time, and tens of millions of others have grossly inadequate health insurance. Therefore, many millions of Americans are just one major illness away from a financial catastrophe.
In addition to the huge dilemma of how we go about making health care more efficient and more affordable for everyone, the United States, like most countries around the world, is in the midst of a dramatic shift in the average age of its population. As the graying of America continues (not to mention the ongoing epidemic of obesity across all age ranges, as well), the growing need for high quality, comprehensive health care will continue to present major challenges to our health care system here, and in many other countries around the world.
When I graduated from medical school in 1988, health care experts were predicting a huge surplus of physicians in this country, and in response to this concern, medical schools around the United States began cutting back their class sizes, and a de facto moratorium on opening new medical schools was initiated. Fast forward to 2010, and it has since become apparent that these dire predictions of an impending physician glut were absolutely incorrect. As our population grows older, and more diverse, the demand for physicians is increasingly in danger of outstripping the projected supply of doctors, including surgeons.
Aging patients have a higher incidence of illnesses and injuries that require the expertise of surgeons, and general surgeons in particular. Broadly trained and experienced general surgeons are the primary care doctors, and the workhorses, of the surgical world, and they manage an astonishing array of diseases and injuries. Unfortunately, and for a variety of reasons, comprehensive general surgeons are slowly withering in numbers, while the demand for their skills only continues to increase. Generational attitude shifts among recently graduating physicians have seen young new doctors gravitate towards less demanding “boutique” specialties, and away from the more challenging surgical specialties (like general surgery). Even among those young doctors who still elect to pursue residency training in general surgery, more than two-thirds will go on to train and practice in more restricted subspecialty surgery areas. (Disclaimer: As a surgical oncologist, I am one of those subspecialty surgeons. However, I still include a great deal of general surgery care in my practice, and I continue to take general surgery call in our medical center.) Another factor that discourages potential general surgeons is the enormous debt load that most newly minted doctors graduate from medical school with, and the resultant pressure that they feel to train in specialties that do not require the additional 5 to 10 years of training that general surgeons must complete. (Increasingly, new medical school graduates are, instead, seeking out specialties that are more financially lucrative, and require shorter durations of residency training, than general surgery.)
Yet another adverse factor that has harmed the recruitment of new general surgeons is the ongoing and progressive fragmentation of traditional general surgery practice into other subspecialty domains. For young doctors who are attracted to the diverse and clinically challenging sort of surgical practice that has historically made general surgery a highly desirable profession, the increasing practice restrictions imposed upon general surgeons have removed a major incentive to undergo the many years of training necessary to become a comprehensive general surgeon
Against the backdrop of these and other pressures that continue to dwindle the ranks of broadly trained and practicing general surgeons (as well as other critical core surgical specialists), the issue of surgeon burnout has only recently started to receive its due attention. The comprehensive practice of general surgery, and other demanding surgical specialties, can be grueling and exhausting, particularly in the private practice setting where declining reimbursements compel surgeons to work ever longer hours to maintain their income and lifestyle. (Future threatened cuts in reimbursements to surgeons will likely only further exacerbate surgeon workload problems, and eventual surgeon shortages, as new health care reform initiatives begin to roll out in the coming years.)
A newly published research study, which appears in the current issue of the Journal of the American College of Surgeons, reveals a very disturbing picture of burnout, exhaustion, and depression among surgeons, and the potentially adverse consequences of distressed surgeons on patient outcomes.
In this study, nearly 8,000 surgeon members of the American College of Surgeons responded to a detailed survey, which included self-assessments of their practice details, a validated depression screening tool, and validated assessments of both burnout and overall quality of life. The results of these surgeon surveys were, in a word, depressing.
Among the surgeons who reported working less than 60 hours per week, 30 percent described themselves as burned-out with their profession. Among surgeons who worked 60 to 80 hours per week, 44 percent felt burned-out, and among those surgeons who put more than 80 hours per week, 50 percent experienced significant feelings of burnout. In addition to the number of hours spent in clinical practice per week, the number of nights spent performing overnight surgery call was a highly significant predictor of surgeon burnout. These two surgeon workload factors were also highly statistically significantly linked to clinical depression, difficulties in finding a reasonable home-work balance, and increased conflicts at both home and at work. Additionally, the rates of both personal emotional exhaustion and feelings of depersonalization towards patients were directly associated with working more than 80 hours per week, and with performing 2 or more night calls per week.
Excessive hours spent in clinical practice, as well as performing 2 or more overnight calls per week, also correlated with a significant increase in the number of self-reported medical and surgical errors committed by exhausted and burned-out surgeons. Nearly 11 percent of surgeons who worked more than 80 hours per week admitted to committing medical or surgical errors, compared to about 7 percent of surgeons who worked less than 60 hours per week.
Surgeons who either worked more than 80 hours per week, or who took more than 2 night calls per week, were also significantly more likely to express regret regarding their choice of specialty, and more likely to indicate that they would not choose to become surgeons if they had an opportunity to choose their specialty all over again.
The results of this survey of surgeons across the United States have been generally confirmed by other similar studies, recently. These disturbing findings, as reported by surgeons themselves, paints a picture of a large population of highly essential physician specialists who are, increasingly, feeling burned-out, depressed, emotionally exhausted, regretful of their career choices, and progressively more prone to both depersonalizing their relationships with their patients and to committing more medical and surgical errors. In short, my chosen profession appears to be a profession that is, frankly, approaching a state of crisis.
Because of these enormous (and growing) pressures and stresses that are being experienced by many surgeons, including general surgeons, many public health experts are viewing the current and future surgical workforce with considerable consternation. As more and more surgeons hang up their white coats and put away their scalpels early in their careers, and as more and more newly graduated doctors shy away from the more demanding surgical specialties, our country appears to be headed for a potentially catastrophic mismatch between the demands of an aging population for surgical care and the diminishing pool of physicians who are willing to shoulder the heavy responsibilities, and significant stresses, of surgical practice.
It is my hope that the governmental agencies responsible for implementing current and future health reforms will pay close attention to this study, and others like it. If hard-working surgeons cannot sustain reasonable income levels (against the decades of grueling training required, and the hundreds of thousands of dollars in educational loans that most young doctors acquire) without working themselves into a state of exhaustion, burnout, and divorce, the ranks of general surgeons, and other core surgical specialists, will continue to become thinner and thinner. Ultimately, if things do not change, and soon, you and I might find it difficult to obtain access to high quality surgical care, particularly for emergency illnesses and injuries….
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Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author
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