Time Out: The Impact of Physician Burnout on Patient Care Quality and Safety in Perioperative Medicine
This article has been corrected.
VIEW CORRECTIONPublished Online: June 6, 2023
Abstract
Perioperative care delivery is a patient-centered, multidisciplinary process. It relies heavily on synchronized teamwork from a well-coordinated team. Perioperative physicians—surgeons and anesthesiologists—face enormous challenges in surgical care delivery due to changing work environments, post-COVID consequences, shift work disorder, value conflict, escalating demands, regulatory complexity, and financial uncertainties. Physician burnout in this working environment has become increasingly prevalent. It is not only harmful to physicians’ health and well-being, but it also affects the quality and safety of patient care.
Additionally, the economic costs associated with physician burnout are untenable due to the high turnover rate, high recruitment expenses, and potential early permanent exit from medical practice. In this deteriorating environment of unbalanced physician supply/demand, recognizing, managing, and preventing physician burnout may help preserve the system’s most valuable asset and contribute to higher quality and safety of patient care. Leaders in government agencies, health care systems, and organizations must work together to re-engineer the health care system for better physicians and patient care.
Background
Emerging from the COVID pandemic, the US health care system faces new challenges in patient care quality, access, equality, and financial sustainability because of the accelerating rate of physician burnout and exit. Perioperative care is a significant portion of the health care system, accounting for 60% of hospital costs and 10% of hospital margins.1 As such, the consequences of perioperative physician burnout can be severe and pervasive and may have avalanching effects. Today, burnout among perioperative physicians (ie, surgeons, anesthesiologists, intensivists, and hospitalists) is ever-increasing due to evolving workplace stressors and occupational environments.
Burnout is a prolonged and unmitigated stress response to chronic workplace stressors encompassing human life’s physical, psychological, and social domains.2 Burnout is characterized by exhaustion, cynicism, and a personal feeling of inefficacy.3 The estimated burnout rate for surgeons ranged from 30–40%4 and 10–50% for anesthesiologists before the pandemic5; the COVID pandemic likely accelerated this.6 Compared to pre-pandemic levels, emotional exhaustion and depersonalization increased to 39% and 61%, respectively, among all physicians.7 For anesthesiologists, the prevalence of burnout syndrome increased by more than 64%, from 37.5% in 2020 to 61.7% in 2021. The high burnout rate can also be seen in general surgeons, who suffer a burnout rate of 58.6% and have decreased career satisfaction from 42.6% to 23.8%.8 Not only does this led to lower efficiency and engagement, but it is also associated with lower-quality patient care and poor outcomes. Physicians who experience burnout syndrome often admit to a greater likelihood of up to 2.2 of making medical errors.9,10
Perioperative physician burnout is unique in some ways, developing over time, and may even start as early as medical school. The personal sacrifices made throughout training and clinical practice accumulate over the years. The chronic stress from unpredictable care demands, sleep deprivation, and workplace challenges gradually decreases the sense of accomplishment and value of personal sacrifice. When the unpredictable care demand arises in conjunction with expanding regulatory, legal, and organizational mandates, the lack of support, social reward, and autonomy can exacerbate the mismatch between personal and organizational objectives.11 Consequently, although the daily physical demand is high for perioperative physicians, the psychological stress can be even higher.12
This review focuses on the relationship between perioperative physician burnout and the quality of surgical patient outcomes. Our primary objective is to define the perioperative characteristics that contribute to physician burnout, with a secondary objective to illustrate methods to mitigate it.
The Development of Perioperative Physician Burnout
Despite the widespread media attention and renewed interest, “burnout” is not a medical condition or illness. According to the World Health Organization (WHO), burnout is an occupational phenomenon.13 First described in 1975 by Dr Herbert J Freudenberger, who noted burnout symptoms in child psychotherapists working in New York14; Dr Christina Maslach and her colleagues studied the burnout phenomena in detail. The Maslach Burnout Inventory (MBI), a 22-item self-administered questionnaire, is widely accepted today in the science community and WHO.2 As per ICD-11, the syndrome of burnout has 3 categorical symptoms15:
1.
Physical exhaustion and energy depletion
2.
Increasing mental distance, negativity, or cynicism toward one’s job
3.
Reduced professional efficacy.
However, perioperative physician burnout is unique as it entails a unique working environment and interdepartmental collaboration.16 Multiple factors affect perioperative physician burnout, which can be divided into organizational, cultural, and individual factors. Perioperative working environments are unique among all health care delivery facilities as they are specific to the operating room demands and multidepartmental interplay.
Individual factors
Physicians often exhibit higher burnout resilience when compared to the general working population.17,18 However, when compounding factors from medical training to practice have accumulated over a lifetime,19 resilience wanes and burnout sets in.20 Although necessary for their professional success, the intrinsic personality and characteristics of surgeons or anesthesiologists can also increase the risk for burnout in and of itself. These include strong commitment, discipline, life-long devotion, and time commitment.21
These, unfortunately, cause delays for the already delayed fulfillment of life goals and livelihood earnings, leading to chronic aggregation of stress and burnout. Additional individual factors that contribute to burnout are the following22,23:
Organizational factors
It is well known that the dysfunctions of the health care system in the United States contribute to physician burnout.2 When surgical workload is high, resources are scarce, and capacity is constrained, occupational conditions get worse. Occupational environments have many elements, including the external working environment, internal culture, community, and organizational value, all of which have slowly deteriorated over the years.30 The operating room shutdowns during the COVID pandemic, the subsequent exodus of perioperative health care workers, and economic instability have further exacerbated the chronic physician supply–demand imbalance, work–life imbalance, and value conflict.31,32 Some factors unique to perioperative operational burnout are as follows: 1) surgical logistics interplaying with the health care system, teams, patients, and patient’s families33; 2) complex and changing regulatory and legal mandates on practice methods, procedures, pharmaceuticals, and equipment use23; 3) multidepartmental initiatives that lack clarity for appropriate coordination34; and 4) clinical pathways and workflow implementation from nonsurgical departments that also override physician judgments and autonomy despite the potential to reduce burnout.35,36
The COVID-19 pandemic highlighted these factors during the complex need for “fast-tracking” policy-to-action and knowledge-to-action changes that led to stress as the necessity of required procedures and patient care remained.37,38 These often serve as system disruptors. For example, the need to rapidly implement infection prevention protocols with limited evidence and organizational support in a system with depleted resources can result in a deteriorating working environment.39 Despite efforts, as the pandemic eased, there were large surgical backlogs, heavy staff losses, and unpredictable supply chain disruptions. This further increased physicians’ workloads and complexity that additional personal sacrifices could not easily overcome.
Culture and community
Modified in 2017, the World Medical Association (WMA) Declaration of Geneva stated that physicians should “attend to [their] own health, well-being, and abilities in order to provide care of the highest standard.”40 The WMA declaration fundamentally recognizes the importance of physician well-being as a constituent of the health care system, occupational environment, professional culture, and organizational values. Unfortunately, the implementation of the WMA declaration, a much-needed cultural overhaul in medicine, became further delayed due to the COVID pandemic. This effort to rejuvenate the workplace through implementing the WMA Declaration of Geneva and “happiness in medicine” may positively change physician burnout.41 A perioperative environment consists of distinguished occupational cultures and organizational traditions. Perioperative physicians are often under tremendous pressure to consistently perform at the highest level regardless of the time of day or operation constraints. Culturally, it is a patient’s and the hospital’s understanding that delays will produce consequences for one’s health, the financial bottom line, or both. However, it is tricky as it always requires the physician’s top physical and psychological conditions, especially at night with dysregulated sleep and diet schedules. This dilemma continues with the associated social media nuances, consumer reviews, marketing tactics,42 and changing patient expectations in a world of immediate access.23,25
A paradigm shift focusing on greater equity, inclusion, and diversity (EID) has brought renewed awareness to how gender, race, ethnicity, sexual orientation, and gender identity interplay within social structures and organizations; this can also contribute to burnout risk. Women surgeons and anesthesiologists comprise a significant portion of the perioperative workforce and face unique challenges related to their gender. These challenges include microaggression, sexual harassment, compensation inequity, and lack of representation in leadership positions. In fact, 94% of women surgeons and anesthesiologists experienced sexist microaggressions, and 81% of minority perioperative physicians experienced racist/ethnic microaggressions.43 The findings are particularly worrisome because there are more women in medicine, and more women physicians are choosing to leave their medical careers early at an accelerating rate.44
There continues to be an environment of unpredictable surgical care delivery due to the complexity of the disease and unknown human factors.45 In this dynamic environment, patient-centered and safe surgical care command high physical and psychological investment for perioperative physicians. Despite the priority on perioperative quality and safety, errors can still occur.23 Unfortunately, those devastating errors can lead to “second victim syndrome.”46,47 Additionally, the authors observed that the industrial-like metrics for productivity,48 efficiency,49 long hours, extensive shifts,50 and cost cutting with increased perioperative throughput add another dimension of complexity and stress to perioperative physicians, increasing their likelihood of burnout.
The Pathophysiology of Physician Stress and Burnout
Burnout due to occupational stress has become widespread in the perioperative workspace. Even though burnout is not classified as a disease, the physiological reactions to burnout resemble many disease processes, such as the hypothalamus–pituitary–adrenal (HPA) axis and the hypothalamic–pituitary–thyroid (HPT) axis derangement at the least. In fact, burnout syndrome bears all the hallmarks of chronic psychological stress disorders and shift worker disorder. Perioperative physicians work shifts ranging from 8 to 24 hours or longer. Shift work disorder is defined as a misalignment between sleep patterns and those in line with societal norms. It is well illustrated that working outside 6 am to 7 pm or more than 40 hours a week is a risk factor for emotional exhaustion and reduced quality of care, the specific symptoms of burnout and shift worker disorders.51
Not isolated from other life events, burnout generated from the working environment can interplay with other life events throughout one’s lifespan, both physically and psychologically. As a result of occupational stress, burnout contributes to the cumulative burden of life, which is associated with a cascade of immune and neuroendocrine derailments called allostasis accommodation. These responses are known to deteriorate total health and cognitive dysfunction and to accelerate aging through epigenetic means.52 They are also linked to the development of chronic diseases, such as hypertension, metabolic syndromes, diabetes, and cancers. Chronic psychological stress of any form is associated with a 22% higher mortality rate for all causes and a 31% higher mortality rate for cardiovascular events.53
Impact of Physician Burnout on Surgical Patient Care
Despite extensive burnout research, the impact of burnout of professionals on others is poorly understood, especially in the health care industry, where the consequences may be related to patient morbidity and mortality. This issue is especially relevant in the perioperative space, where high-quality surgical and professional activities determine immediate and long-term surgical outcomes.54
Globally, perioperative death is the third most common cause of death, with approximately 4.2 million deaths per year .55 Despite relentless efforts over the last few decades at both organizational and individual levels, there has been only slight improvement. It is widely suspected that there may be a reciprocal relationship between physician burnout and surgical outcomes.56 This has also inspired the assumption that inadequately addressing physician well-being and burnout may be partially responsible for many failed improvement initiatives in the past.57 A negative correlation between physician burnout and patient safety has been observed. Physician burnout can double the risk of patient safety58 and contribute to up to 7% to 10.6% of serious medical mistakes.59 Using medical malpractice as an indicator,60 although not an accurate quality indicator, higher surgeon burnout was linked to more frequent medical malpractice suits with an average cost of $371,054.61 It is of note that burnout at any point during a physician’s care may increase the chance of medical error, and a medical error at any point in a physician’s life may increase the frequency and intensity of burnout.62
Burnout affects the interpersonal team dynamics essential for a highly reliable surgical team. Although studied more in critical care settings than perioperative settings, it has been shown that emotionally exhausted physicians can engage less in teamwork. Indeed, physician burnout can corrupt team spirit and culture and result in low-quality work and a high mortality rate, in an Intensive Care Unit setting at least.63 Patient satisfaction is another indicator of quality health care. Many studies have demonstrated a strong association between physician burnout and patients’ care experience and satisfaction, where physicians experiencing a high degree of burnout have significantly lower patient satisfaction scores.64
Costs Associated With Perioperative Physician Burnout
Physician burnout is becoming an emerging threat to the health care system and public health. Today, due to burnout, more physicians are leaving than entering the field, creating an alarming shortfall of approximately 45,000 to 90,000 physicians across all specialties.65 This is especially concerning as our aging population grows and health care demand rises. The high rate of physician burnout imposes a high direct and indirect cost on the health care systems at a staggering $4.6 billion/year.66 There are many other hidden costs as well.
Productivity and efficiency
Physician productivity is hard to measure and varies from specialty to specialty, and from institution to institution, depending on their business model and operational systems. Often used to evaluate business and operational fundamentals, perioperative physicians are held accountable for perioperative productivity and efficiency.67
Turnover/early retirement
The estimated costs of physician turnover range between $268,000 and $957,000 per physician because of recruitment and start-up efforts.68 When combined with a high turnover rate of more than 26%,69 the financial burden significantly impacts health systems and organizations.70 Burnout is strongly associated with a physician’s plan to reduce workload and scope of practice or to leave the workforce early or entirely. This problem inevitably causes a drop in health care capacity and, conversely, may further increase the workload for the remaining physicians and potentiate their burnout rate. This vicious cycle may subject health care organizations to elevated financial burdens and regulatory and operational risks.
Human cost
Unfortunately, medicine is one of the few professions with a higher-than-average suicide and suicide attempt rate.71 In the service of others, physicians often ignore themselves physically and mentally. Physician suicides are intimately linked to depression and other mental disorders, often consequential to physician burnout. Shockingly, there are an average of 300–400 physician suicides per year, equivalent to a large medical school class size.72 Despite its growing concern and multiple initiatives for mitigation—such as hotlines, programs, access, culture changes, and preventive programs—the risk cannot be ignored. Furthermore, despite high resilience at the beginning of a medical career, physicians suffer from a higher rate of suicide as compared to the general population. Societies and training programs for most surgical and anesthesia specialties continue to monitor this figure. Studies demonstrate the increase in suicide rate year over year, with some of the highest rates in surgical specialties, which may, unfortunately, worsen in the current state of burnout.73
Strategies to Mitigate Perioperative Physician Burnout
Physician burnout is an occupational phenomenon that also negatively affects patients and families. Produced primarily through the chronic accumulation of work-related stressors, physician burnout is a moral imperative that the health care industry and government agencies must address across the continuum of medical education, residency training, physician practice, and practice environments. Decreasing physician burnout is not only a good business practice that can yield positive dividends to the health care industry but also a moral obligation toward our physicians and patients. Even though physician burnout is multifactorial with no simple or quick solution, the paradigm shift toward improvement must start now at the individual and organizational levels.74
Individual
For many years, physician burnout was mislabeled as a personal matter within the medical community, health care industry, and public domains.75 This conceptual error delayed the understanding of this critical issue and resulted in many missed opportunities for effective prevention and management. Although physician demographic factors, such as age, gender, surgical subspecialties, and marital status, play a role in burnout,76 it is the complex interactions between the individual’s susceptibility and the working environment that determine the occurrence and outcomes of burnout. Protective modalities such as mindfulness, resilience reinforcement, and relationship building are helpful.77 However, special attention should be paid to the whole spectrum of human well-being or PERMA elements through positive psychology: Positive emotions (of which happiness and life satisfaction are all aspects), Engagement, Relationships, Meaning, and Achievement. It is essential to know that no one element is more important than the others but, rather, that each contributes to the whole.78 Many tools can be leveraged for the PERMA purpose, such as didactic education, workshops, and personal coaching.
Organization
Increasing workloads without adequate staff and resource support are often cited as essential contributors to physician burnout.79 The burnout rate can increase greatly when the workload is heavy and unproportionate to a physician’s compensation. Major practice changes, such as the adoption of the electronic medical record (EMR) and the emergence of physicians’ email “in-basket” management, have been recognized among the key drivers leading to physician burnout in recent years. Physicians spend about 2 hours on the EMR for every 1 hour of direct patient care.80 The EMR contributes to physician burnout in many ways, including the functionality, usability, time, and frequency, as well as the availability and effectiveness of organizational support. Organizations should pay special attention to technology that can reduce the burden of the EMR, digital messages, and nuisance alerts.
Culture and community
Additionally, both macroaggressions and microaggressions, either from patients or colleagues, are widespread in the perioperative environment. It creates psychologically unsafe working environments and is linked to increased physician burnout.81 A psychologically safe culture and practice environment with the EID principle in mind should be the top priority for any organization and its leaders, especially in the areas of communication and signage. Special committees such as “joy in medicine” committees41 and workflows must be created with allocated time in order to quickly implement regulations without passing the strain of interpretation and fear of regulation on to the frontline health care practitioners.36 Methods to mitigate and help perioperative physicians with social media nuances, systems to assist with messaging demands, and integrated technologies with training must become priorities.82 These cannot be passed down to individuals as they affect the entire workplace culture and are not limited to a single person. Awareness and dialog of these culturally related factors that lead to burnout should be undertaken as a priority of a system and its leadership.
It is incumbent for us to understand that optimal and safe patient care requires foremost the optimization of the health and well-being of the physicians. For the long-term benefit of the health care industry and its customers, a collective effort to measure, monitor, and mitigate the physician burnout risk as outlined should be made systemically and proactively.
Footnotes
Author Contributions
Chunyuan Qiu, MD, MS, participated in manuscript preparation, critical revision, and conceptualization. Philip Shin, MD, participated in manuscript preparation, critical revision, and conceptualization. Vimal Desai, MD, participated in manuscript preparation, critical revision, and conceptualization; Janet Hobbs, EdD, participated in manuscript preparation, critical revision, and conceptuatlization; Antonio Hernandez Conte, MD, MBA, FASA, participated in manuscript preparation, critical revision, and conceptualization.
Corrected Version Notice
This version has been corrected. For further details, visit the related corrigendum.
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