Surgeon Distress as Calibrated by Hours Worked and Nights on Call

Daily physical activity habits influence surgeons' stress in the operating room: a prospective cohort study

BACKGROUND

Exercise training improves heart rate variability, and evidence suggests it can mitigate the detrimental effects of stress. This study aims to evaluate the relationship between surgeons' physical activity habits and their stress, assessed as heart rate variability, at the start of surgery.

MATERIALS AND METHODS

This multispecialty prospective cohort study included surgeons from fourteen cardiac, endocrine, digestive, gynecologic, orthopedic, thoracic, and urologic surgical departments of four university hospitals. Surgeons wore accelerometers 24/7 from 1 November 2020 to 31 December 2021 to quantify the mean daily step counts and daily sedentary time for 7 days prior to each operation. RMSSD, the root mean square of successive differences between normal heart beats, is a heart rate variability (HRV) metric that reflects cardiac vagal tone. We evaluated RMSSD during the first 5 minutes of surgeries performed over five 15-day periods. Data were analyzed using a multivariable linear mixed model with a random effect for surgeons.

RESULTS

We analyzed 722 surgeries performed by 37 surgeons (median age = 47 (IQR 42-55); 29 (78.4%) male). On average (SD), surgeons walked 9762 (2447) steps and were sedentary 391 (102) minutes daily. The model showed a positive relationship between steps and cardiac vagal tone, with an increase in lnRMSSD (0.028, 95% CI 0.003 to 0.053, P = 0.026) for every 1000 more steps per day, but not for sedentary behavior. Surgeon professors presented lower lnRMSSD (-0.437, -0.749 to -0.126, P = 0.006), as did surgeons who spent less total time operating over the study period (-0.337, -0.646 to -0.027, P = 0.033), compared to their counterparts.

CONCLUSIONS

Higher daily step counts the week before surgery were associated with increased cardiac vagal tone, indicating lower stress levels at the beginning of surgery. This relationship highlights the influence of physical activity on surgeons' stress in the operating room.

Assessing surgeon stress during urological interventions: A descriptive study using heart rate variability (uRRology)

INTRODUCTION

In a difficult environment like surgery with continuous exposure to stress, surgeon's health and well-being is affected. The heart rate variability (HRV) is a valid stress indicator. This study aims to provide descriptive data regarding stress during urological intervention using HRV.

METHODS

This prospective, unicentric study, included urological interventions from June to December 2023. Surgeons were surveyed on general characteristic, and surgical skills level. Beat-by-beat heart rate (HR) recorded using POLAR A300® chest belt. HRV were analyzed in time (mean HR and the root mean square of successive differences [RMSSD]) and frequency (Fast Fourier transformation spectrum high frequency [FFT spectrum HF]) domain. Their baseline collected outside the operating room, 3 events during intervention examined: incision, closure, and adverse events. Visual stress and difficulty scale during intervention were completed. The differences between baseline and events were calculated.

RESULTS

A total of 171 urological interventions were included. Senior surgeons performed 54 (31.58%) and juniors 117 (68.42%). During interventions, seniors had significantly higher median difference of HR (incision: -11.92 [12.74] bpm versus -2.27 [10.99] bpm for juniors, P≤0.0001; closure: -10.73 [13.71] bpm, versus -4.18 [12.30] bpm for juniors, P=0.0005), lower HF (incision: 0.01 [0.07] hz, versus -0.006 [0.03] hz for juniors P≤0.0001; closure: 0.02 [0.06] hz, versus 0.00 [0.02] hz for juniors, P≤0.0001), and lower RMSSD (incision: -3.34 [13.09] ms for seniors versus -7.63 [10.57] ms for juniors, P=0.0098). No significant difference in RMSSD during closure (P=0.2049).

CONCLUSION

Study demonstrated the possibility to assess HRV in standard medical practice, senior surgeons experienced more physiological changes during interventions.

LEVEL OF EVIDENCE: 4

Declining Medicare reimbursement in spinal imaging: a 15-year review

OBJECTIVE

To analyze and quantify the change in United States of America Medicare reimbursement rates for the 30 most commonly performed spinal imaging procedures.

MATERIALS AND METHODS

The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was utilized to find and extract the 28 most billed spinal imaging procedures. All data was adjusted for inflation and listed in 2020 US dollars. Percent change in reimbursement and Relative Value Units between 2005 and 2020, both unadjusted and adjusted, were calculated and compared. Additionally, percent change per year and compound annual growth rate were calculated and compared.

RESULTS

After adjusting for inflation, the average reimbursement for all analyzed spinal imaging procedures between the years 2005 and 2020 decreased by 45.9%. The adjusted reimbursement rate for all procedures decreased at an average 4.3% per year and experienced an average compound annual growth rate (CAGR) of - 4.4%. Magnetic resonance imaging (MRI) had the most substantial adjusted decline of all imaging modalities at - 72.6%, whereas x-ray imaging had the smallest decline at - 27.33%. The average total RVUs per procedure decreased by 50.1%, from 7.96 to 3.97.

CONCLUSION

From the years 2005 to 2020, Medicare reimbursement significantly decreased for all advanced imaging modalities involving the most common spinal imaging procedures. Among all practices, imaging procedures may be experiencing some of the largest decreases from Medicare reimbursement cutbacks.

Not all call is created equally: The impact of culture and sex on burnout related to in-house call

BACKGROUND

In-house call (IHC) has previously been shown to result in increased burnout in acute care surgeons (ACSs). There is wide variation, however, in the implementation and culture of work surrounding IHC across trauma centers and within the demographics of practicing ACSs. We hypothesized that local work practices and culture surrounding IHC as well as sex of ACSs would impact burnout.

METHODS

Continuous physiologic data were collected over 6 months from 224 ACSs who wore a fitness wearable. Acute care surgeons were sent daily surveys to record work, personal activities, and feelings of burnout. The Maslach Burnout Inventory was completed by ACSs at the beginning and end of the study period.

RESULTS

Forty-eight (21.5%) of ACS reported being expected to complete the usual workday after IHC, 94 (42.2%) were expected to finish work from IHC, and 81 (36.3%) were expected to leave immediately after IHC was over. Acute care surgeons expected to complete a usual workday postcall were more likely to be burned out, and IHC resulted in a greater increase in their daily feelings of burnout than among ACSs who reported working in other work cultures. Females showed higher levels of daily burnout than males but no difference in the degree to which IHC led to burnout.

CONCLUSION

In-house call results in increased burnout in all ACSs; however, IHC had a larger impact on daily feelings of burnout in ACSs expected to work without adjustments to their work schedule postcall. Although female ACSs reported higher levels of daily burnout than male ACSs, IHC increased daily feelings of burnout equally between the two sexes. Taken together, these findings necessitate caution about work expectations surrounding IHC and suggest a need for the deliberate creation of a postcall culture for ACS.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

How should we manage fatigue in on-call workers? A review of guidance materials and a systematic review of the evidence-base

On-call work is known to contribute to disrupted sleep, fatigue, and an increased risk of incidentor injury. This review aimed to a) identify current on-call management strategies that are suggested or required by regulatory bodies, and b) determine if there is empirical evidence to support these strategies in managing the fatigue of on-call workers. A grey literature search produced 65 relevant guidance materials. A systematic inductive thematic process identified consistent strategies included in these materials: 1) regularity/predictability of shifts, 2) fatigue management policy, 3) prescriptive rule sets, 4) fitness for work assessment, 5) on-the-day control measures, 6) risk assessment, 7) training and education, and 8) call management. Subsequently, a systematic review identified 17 original studies on the effectiveness of fatigue management strategies in on-call workers. Very little research has been done on fatigue management strategies for on-call workers outside of some prescriptive hours of work limitations. These limitations generally reduced fatigue, but often had the unintended consequence of increasing workload, which may inadvertently increase overall risk. Training, education, and call management (e.g., protected naps during on-call periods) also had some supporting evidence. The current gap in evidence emphasises the critical need for research on tailored on-call fatigue management strategies.

Caffeine, Alcohol, and Drug Use as Work Adjuncts Among Neurosurgeons. Prevalence, Contributing Factors, and Proposed Strategies

BACKGROUND

Neurosurgeons may resort to caffeine, alcohol, and various drugs to maintain peak performance as they grapple with work demands and escalated stress. The prevalence of this controversial strategy remains largely unexplored.

METHODS

An anonymous survey of 23 questions formulated by our research group was distributed through personal contacts and neurosurgical societies. Inquiries revolved around the use of medications and other substances for job-related reasons. Data were analyzed via regression and descriptive statistics in python.

RESULTS

In total, 215 neurosurgeons (43 residents) were included, with 213 disclosing their gender (94 females). Out of all, 9.3% were <30, 38.1% were 30-39, 44.6% were 40-59, and 7.9% were >60 years old. Most (70.7%) practiced in Europe, 18.6% in Asia, 6.5% in North and South America, and the rest in Africa or Australia. While 132 participants stated they consume caffeine to manage challenging schedules, drugs for cognitive and mood enhancement were utilized by 18 and 35 respectively. Alcohol was employed for stress relief by 28 with 4 reporting as heavy drinkers. Drugs posed a solution to sleep disorders for 82, and helped 8 others in strengthening their hand dexterity. Notably, 12 of those claiming drug use initiated it in medical school. Exercise, self-care activities, and relational support were the main alternatives sought. Ultimately, most responders recommended extending mental health assistance and raising awareness about drug use.

CONCLUSIONS

Reflecting on our results on job-associated drug use by neurosurgeons, we propose the judicious use of pharmacological or nonpharmacological adjuncts, alongside the prioritization of neurosurgeons' well-being.

Control versus Choice in Deciding Career Pathway in Plastic Surgery: The Perfect Ratio

Background

The decisions and components of a career in medicine have changed. Historically, a career selection was often a decision between joining an institution or academic center versus the fiscal risks associated with private practice. This created a relatively simple risk versus reward equation: those in private practice made more money if it went well. The medical landscape has changed immensely, and priorities and remuneration have morphed, including concerns about promoting and sustaining well-being.

Methods

The authors performed a systematic review of scholarly databases to identify relevant resources to the topic of study. Additionally, the authors relied on their own cumulative experience in the field, including the work of Dr. Wayne Sotile of the Sotile Center for Physician Resilience.

Results

The first installment of this article proposes a new model in opposition to the current standard of "risk versus reward" where the tradeoff is instead "control versus choice," where autonomy is the new risk.

Conclusions

The five components that make up the majority of the ingredients in a plastic surgery career are clinical practice model, administrative duty, corporate support, academic involvement, and per diem or retainers. Much of finding or developing a practice model that suits the individual is figuring out an acceptable ratio of these ingredients. Inherent to this process is how much authority one has versus instituted control of any form, from hospital to university to insurance company.

The importance and benefits of defining full-time equivalence in the field of acute care surgery

Acute care surgery (ACS) encompasses five major pillars - trauma, surgical critical care, emergency general surgery, elective general surgery and surgical rescue. The specialty continues to evolve and due to high-acuity, high-volume and around-the-clock care, the workload can be significant leading to workforce challenges such as rightsizing of staff, work-life imbalance, surgeon burnout and more. To address these challenges and ensure a stable workforce, ACS as a specialty must be deliberate and thoughtful about how it manages workload and workforce going forward. In this article, we address the importance, benefits and challenges of defining full-time equivalence for ACS as a method to establish a stable ACS workforce for the future.

Controlled Hypothermic Storage for Lung Preservation: Leaving the Ice Age Behind

Controlled hypothermic storage (CHS) is a recent advance in lung transplantation (LTx) allowing preservation at temperatures higher than those achieved with traditional ice storage. The mechanisms explaining the benefits of CHS compared to conventional static ice storage (SIS) remain unclear and clinical data on safety and feasibility of lung CHS are limited. Therefore, we aimed to provide a focus review on animal experiments, molecular mechanisms, CHS devices, current clinical experience, and potential future benefits of CHS. Rabbit, canine and porcine experiments showed superior lung physiology after prolonged storage at 10°C vs. ≤4°C. In recent molecular analyses of lung CHS, better protection of mitochondrial health and higher levels of antioxidative metabolites were observed. The acquired insights into the underlying mechanisms and development of CHS devices allowed clinical application and research using CHS for lung preservation. The initial findings are promising; however, further data collection and analysis are required to draw more robust conclusions. Extended lung preservation with CHS may provide benefits to both recipients and healthcare personnel. Reduced time pressure between procurement and transplantation introduces flexibility allowing better decision-making and overnight bridging by delaying transplantation to daytime without compromising outcome.

Home Is Not Always Where the Sleep Is: Effect of Home Call on Sleep, Burnout, and Surgeon Well-Being

BACKGROUND

In-house calls contribute to loss of sleep and surgeon burnout. Although acknowledged to have an opportunity cost, home call is often considered less onerous, with minimal effects on sleep and burnout. We hypothesized home call would result in impaired sleep and increased burnout in acute care surgeons.

STUDY DESIGN

Data from 224 acute care surgeons were collected for 6 months. Participants wore a physiological tracking device and responded to daily surveys. The Maslach Burnout Inventory was administered at the beginning and end of the study. Within-participant analyses were conducted to compare sleep, feelings of restedness, and burnout as a function of home call.

RESULTS

One hundred seventy-one surgeons took 3,313 home calls, 52.5% were associated with getting called and 38.5% resulted in a return to the hospital. Home call without calls was associated with 3 minutes of sleep loss (p < 0.01), home call with 1 or more call resulted in a further 14 minutes of sleep loss (p < 0.0001), and home call with a return to the hospital led to an additional 70 minutes of sleep loss (p < 0.0001). All variations of home call resulted in decreased feelings of restedness (p < 0.0001) and increased feelings of daily burnout (p < 0.0001, Fig. 1).

CONCLUSIONS

Home call is deleterious to sleep and burnout. Even home call without calls or returns to the hospital is associated with burnout. Internal assessments locally should incorporate frequency of calls and returns to the hospital when creating call schedules. Repeated nights of home call can result in cumulative sleep debt, with adverse effects on health and well-being.

Workload and GP burnout: a survey and register-based study in Danish general practice

BACKGROUND

Burnout is common among GPs. Previous studies have indicated an association between high workload and burnout among doctors.

AIM

To assess the risk of burnout among single-handed GPs in Denmark in relation to self-reported and register-based workload.

DESIGN & SETTING

Questionnaire data from 312 Danish single-handed GPs and register data on their patients and provided services.

METHOD

Burnout was measured using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). A composite burnout score of quartile points was calculated. The questionnaire provided information on working hours. Register data included number of services and patient list size. Association between composite burnout score and workload was estimated with binomial regression analyses adjusting for the GP's age and sex, and social deprivation score of their patient lists.

RESULTS

Working >5 days a week in practice increased the risk of a high burnout score (adjusted risk ratio [RR] = 2.34, 95% confidence interval [CI] = 1.62 to 3.37). Spending >7.5 hours a day on patient-related tasks increased the risk of a high burnout score. The highest score was among GPs spending 8.5-9.5 hours a day on patient-related tasks (adjusted RR = 2.01, 95% CI = 0.90 to 4.51), although not statistically significant. There was no association between number of services and risk of burnout.

CONCLUSION

Working 5 days a week in practice significantly increased the risk of burnout in Danish single-handed GPs. Spending >7.5 hours a day on patient-related tasks tended to increase the risk. We found no association between a high number of services and increased risk of burnout.

Job stressors in relation to burnout and compromised sleep among academic physicians in India

BACKGROUND

Burnout among physicians, especially in the academic setting, is an urgent concern, with adequate sleep one of the key focal points.

OBJECTIVE

To identify job stressors contributing to burnout and compromised sleep among academic physicians, using a comprehensive, theory-based instrument, the Occupational Stressor Index (OSI), whose specific form was created 'for physicians by physicians'.

METHODS

This parallel mixed-methods cross-sectional investigation was conducted among 109 physicians employed in a public teaching hospital, Jodhpur, India. Work conditions were evaluated by the physician-specific OSI (part I). The Copenhagen Burnout Index and Pittsburgh Sleep Quality Index (PSQI) were the outcome instruments (part II). Seventy-six physicians completed parts I and II.

RESULTS

The physicians were from wide-ranging specialties, and 82% of the cohort were residents. Mean total OSI scores were 87.4±8.1, with unit-change yielding adjusted odds-ratios (95% confidence-intervals) for personal (1.10 (1.02-1.18)) and work-related burnout (1.12 (1.04-1.22)), and PSQI (1.09 (1.01-1.17)). Significant multivariable associations with burnout and/or sleep indices included: working 7 days/week, lacking work-free vacation, insufficient rest breaks, interruptions, many patients in intensive-care, no separate time for non-clinical duties, pressure to publish, injury/suicide attempts of colleagues/staff, performing pointless tasks. The latter were described as administrative/clerical. Lacking genuine rest breaks was mainly patient-related, further compromised by emergency work and lacking separate time for non-clinical duties. Long workhours and exhausting schedule were cited as most difficult parts of work, while reducing workhours, improving work schedule, and hiring more staff most frequently recommended.

CONCLUSION

Specific working conditions potentially contributory to burnout and compromised sleep among physicians working in academic medicine are identified using a methodologically-rigorous, in-depth approach. These findings inform evidence-based interventions aimed at preserving physician mental health and work capacity.

[Burnout in hospital-based surgeons. Approaches for prevention?]

BACKGROUND

Burnout among physicians is increasingly recognized as a public health issue including its scientific, political, and societal relevance. The effects of burnout go far beyond physician health as they affect the quality of care, patient safety, medical errors, and efficiency of health care.

OBJECTIVE

Assessment of the risk of burnout for hospital-based surgeons as well as associations between surgeon burnout and several work-related and person-related factors.

METHODS

From the representative Saxony physician survey from 2019, we utilized the subsample of 231 hospital-based surgeons. We conducted a regression analysis with workload, job satisfaction, work-life balance (WLB), resilience, inability to recover and health complaints as predictors of burnout (Maslach burnout inventory-General survey, MBI-GS).

RESULTS

Nearly half of the sample were female (49.4%), the average age was 42.0 years, 4.8% of participants exhibited burnout, 45.9% with some symptoms and 49.4% no burnout. Multivariate analysis showed significant positive associations between health complaints, inability to recover, a lack of job-based self-fulfillment and burnout. There were significant negative connections between WLB, the wish to remain in the job and burnout.

CONCLUSION

Burnout is a serious problem for surgeons. Preventive measures should focus on risk factors associated with the workplace and organization of work. Interventions targeted at the individual level should start at an early career stage.

Clinician Well-Being Assessment and Interventions in Joint Commission-Accredited Hospitals and Federally Qualified Health Centers

BACKGROUND

Clinician burnout is a longstanding national problem threatening clinician health, patient outcomes, and the health care system. The aim of this study is to determine the proportion of hospitals and Federally Qualified Health Centers (FQHCs) that are measuring and taking system actions to promote clinician well-being.

METHODS

This cross-sectional study used an electronic questionnaire from April 21 to June 27, 2022, to assess the current state of organizational efforts to assess and address clinician well-being among a national sample of 1,982 Joint Commission-accredited hospitals and 256 accredited FQHCs. Outcomes of interest included the proportion of hospitals and FQHCs that assessed the prevalence of clinician burnout, established a chief wellness officer position, established a wellness committee, made clinician well-being an organizational performance metric, and implemented other activities/interventions that target clinician burnout.

RESULTS

A total of 481 (21.5%) organizations responded to the survey (hospital n = 396 [20.0%], FQHC n = 85 [33.2%]). Response rates did not differ by organization size, type, teaching status or urban vs. rural location. Approximately one third (34.0%) of the organizations in the sample conducted an organizational well-being assessment among clinicians at least once in the past three years. Although nearly half of responding organizations reported implementing some kind of intervention to address clinician burnout, only 28.7% of organizations had adopted a comprehensive approach to address clinician well-being/burnout. Only 10.1% of hospitals and 5.4% of FQHCs reported having an established senior leadership position responsible for assessing and promoting clinician well-being at the organization level, and less than half (29.3% FQHCs, 37.6% hospitals) of organizations reported having an established wellness committee. Among 500+ bed hospitals, 61.2% had surveyed, 75.6% had established a well-being committee, 78.0% had implemented interventions to promote clinician well-being, and 26.8% had established a chief wellness officer.

CONCLUSION

Although half of Joint Commission-accredited hospitals and FQHCs reported taking steps to improve clinician well-being, a minority are measuring clinician well-being, and few are taking a comprehensive approach or established a chief wellness officer position to advance clinician well-being as an organizational priority. Organizational clinician well-being improvement efforts are unlikely to be successful without measurement and leadership in place to drive change.

At-Risk Work Hours Among U.S. Physicians and Other U.S. Workers

INTRODUCTION

Systematic reviews by the WHO have shown an increased risk of morbidity and mortality related to ischemic heart disease and stroke among individuals working an average of ≥55 hours/week.

METHODS

A cross-sectional survey of U.S. physicians and a probability-based sample of the general U.S. working population (n=2,508) was conducted between November 20, 2020, and February 16, 2021 (data analyzed in 2022). Among 3,617 physicians who received a mailed survey, 1,162 (31.7%) responded; among 90,000 physicians who received an electronic survey, 6,348 (7.1%) responded. Mean weekly work hours were assessed.

RESULTS

The mean reported weekly work hours for physicians and U.S. workers in other fields were 50.8 hours and 40.7 hours, respectively (p<0.001). Less than 10% of U.S. workers in other fields (9.2%) reported working ≥55 hours/week compared with 40.7% of physicians. Although work hours decreased among physicians working less than full time, the decrease in work hours was smaller than the reported reduction in professional work effort. Specifically, for physicians who worked between half-time and full-time (i.e., full-time equivalent=50%-99%), work hours decreased by approximately 14% for each 20% reduction in full-time equivalent. On multivariable analysis of physicians and workers in other fields adjusting for age, gender, relationship status, and level of education, individuals with a professional/doctorate degree other than an MD/DO (OR=3.74; 95% CI=2.28, 6.09) and physicians (OR=8.62; 95% CI=6.44, 11.80) were more likely to work ≥55 hours/week.

CONCLUSIONS

A substantial proportion of physicians have work hours previously shown to be associated with adverse personal health outcomes.

What Happens on Call Doesn't Stay on Call. The Effects of In-house Call on Acute Care Surgeons' Sleep and Burnout: Results of the Surgeon Performance (SuPer) Trial

OBJECTIVE

We sought to quantify the effects of in-house call(IHC) on sleep patterns and burnout among acute care surgeons (ACS).

BACKGROUND

Many ACS take INC, which leads to disrupted sleep and high levels of stress and burnout.

METHODS

Physiological and survey data of 224 ACS with IHC were collected over 6 months. Participants continuously wore a physiological tracking device and responded to daily electronic surveys. Daily surveys captured work and life events as well as feelings of restfulness and burnout. The Maslach Burnout Inventory (MBI) was administered at the beginning and end of the study period.

RESULTS

Physiological data were recorded for 34,135 days, which includes 4389 nights of IHC. Feelings of moderate, very, or extreme burnout occurred 25.7% of days and feelings of being moderately, slightly, or not at all rested occurred 75.91% of days. Decreased amount of time since the last IHC, reduced sleep duration, being on call, and having a bad outcome all contribute to greater feelings of daily burnout ( P <0.001). Decreased time since last call also exacerbates the negative effect of IHC on burnout ( P <0.01).

CONCLUSIONS

ACS exhibit lower quality and reduced amount of sleep compared with an age-matched population. Furthermore, reduced sleep and decreased time since the last call led to increased feelings of daily burnout, accumulating in emotional exhaustion as measured on the MBI. A reevaluation of IHC requirements and patterns as well as identification of countermeasures to restore homeostatic wellness in ACS is essential to protect and optimize our workforce.

How do spine surgeons cope with psychological distress: results of a cross-sectional study

Cross Sectional Study/Online Survey. In this study, we sought to assess stress, psychological distress, resilience, and coping strategies among spine surgeons in German-speaking countries. Recent studies have reported high rates of stress and burnout among surgeons. A survey via Survey Monkey™ was conducted among spine surgeons practicing in German-speaking countries using validated questionnaires for perceived stress, mental burden, resilience, and quality of life. Data on working situation and demographics were also collected. 582 surgeons responded to the survey, representing 15% of those surveyed. 79% of respondents were satisfied with their professional success. Mental burden was higher than in the general population, as was perceived stress. Chairpersons were exposed to the lowest levels of perceived stress and mental burden. Mental distress was high (GHQ ≥ 12) in 59% of residents and 27% chairpersons. Self-reported psychological resilience was higher than levels found in the general population and highest among chairpersons. Quality of life was comparable to levels reported in the general population. There were statistically significant correlations between perceived stress and mental burden scores (r s = 0.65, p < 0.001). Career level (senior physicians vs. residents, OR 0.26; 95% CI 0.10-0.66), perceived stress (OR 1.54; 95% CI 1.33-1.77), self-reported resilience (OR 0.53; 95% CI 0.33-0.84), and mental composite score (SOR 0.86; 95% CI 0.83-0.90) were predictors of high mental burden. There was no interaction between perceived stress and resilience on mental burden (p = 0.835). Spine surgeons are exposed to higher levels of stress than the general population, which are associated with higher mental distress. More professional experience and higher levels of psychological resilience are associated with lower levels of stress.

[Physician working hours and effects on health, satisfaction and healthcare]

Changes in the working environment with respect to innovative working time models are also increasingly affecting patient care. The number of physicians working part-time, for example, is continuously rising. At the same time, a general increase in chronic diseases and multimorbid conditions as well as the growing shortage of medical staff, leads to more workload and dissatisfaction among this profession. This short overview summarizes the current study situation and associated consequences regarding working hours of physicians and gives a first explorative overview of possible solutions.

Cardiac autonomic and cortisol stress responses to real operations in surgeons: relationship with individual psychobiological characteristics and experience

BACKGROUND

Surgeons are exposed to high levels of intraoperative stress, which could compromise their psychological well-being in the long term. This study aimed at exploring the effects of real operations on the activity of stress response systems (i.e., cardiac autonomic function and hypothalamic-pituitary-adrenal axis) during and in the aftermath of surgery, and the moderating role of individual psychobiological characteristics and different levels of experience (senior vs expert surgeons).

METHODS

Heart rate, heart rate variability, and salivary cortisol measures (as indexes of cardiac autonomic and hypothalamic-pituitary-adrenal axis activity, respectively) were assessed during real operations and in the perioperative period in a sample of surgeons (n = 16). Surgeons' psychometric characteristics were collected using questionnaires.

RESULTS

Real operations triggered both cardiac autonomic and cortisol stress responses which were independent from surgeons' level of experience. Intraoperative stress responses did not affect cardiac autonomic activity during the following night but were associated with a blunted cortisol awakening response. Moreover, senior surgeons reported higher levels of negative affectivity and depressive symptoms than expert surgeons prior to the surgery. Lastly, the magnitude of heart rate responses to surgery positively correlated with scores on negative affectivity, depression, perceived stress, and trait anxiety scales.

CONCLUSION

This exploratory study allows to put forward the hypotheses that in surgeons cardiac autonomic and cortisol stress responses to real operations (i) may be associated with specific individual psychological characteristics regardless of the level of experience, (ii) and may have a longer lasting impact on hypothalamic-pituitary-adrenal axis function with potential implications for surgeons' physical and psychological well-being.

Analysis of one- versus two-staged reconstruction in head and neck cancer patients: What are the benefits?

In head and neck oncology, surgical treatment frequently results in microvascular reconstruction. Oncologic resection followed by immediate reconstruction is often associated with prolonged working and surgical duration, challenging a surgeon's concentration level and potentially worsening patient outcome. To improve the surgeon's performance and to reduce risk of potential complications, we implemented a two-stage procedure in patients with head and neck cancer. This study critically analyzed the surgical outcomes, organizational benefits, and investigated job satisfaction among affected health care professionals. A retrospective data analysis of patients who had undergone microvascular reconstruction after oncologic head and neck surgery between 2010 and 2021 included 33 patients (n = 33). Twenty patients underwent single-stage reconstruction (group 1, n = 20) and 13 patients underwent two-stage reconstruction (group 2, n = 13) with 12.2 (± 7.4) days between surgeries. The mean surgical duration, and mean start and end time of the reconstructive surgery component differed significantly (p = 0.002). The mean total complication rate (p = 0.58) did not differ significantly, although a trend toward higher demands for blood products was observed in group 1. There was no significant difference in five-year survival (p = 0.28). A questionnaire on subjective work performance was answered by the affected health care professionals (n = 34) and it revealed that 88% preferred long surgeries to be scheduled first and that 97% work most efficiently in the morning. In conclusion, two-stage reconstruction is a suitable option in selected head and neck cancer patients offering the possibility of optimizing preoperative planning and organization. This may result in regular working hours, reduced surgeon fatigue, and improved job satisfaction without compromising patient outcomes or survival.

Indian Perspective of Burnout Among Plastic Surgeons

Introduction Over the last decade, the term “Burnout” has become familiar term in all walks of life, particularly medicine. Emotional exhaustion, depersonalization, and a low sense of personal accomplishment make up the triad. At least a third of plastic surgeons are having burnout according to the western literature. Data on burnout in Indian plastic surgeons is lacking. We have made an attempt to analyze the incidence and factors responsible for burnout among plastic surgeons in India.

Materials and Methods An online survey was conducted in India to assess burnout among plastic surgeons from June to November 2019. Consent, demographic information, stress-related factors, the abbreviated Maslach Burnout Inventory (aMBI), and Satisfaction with Medicine were all included section wise in the survey. Both used scales were validated. Data were gathered using Google forms, then uploaded to an Excel file and analyzed. A multivariable and univariable analysis of factors associated with burnout was carried out.

Results Twenty-two percent of 330 plastic surgeons who responded were assessed to have moderate to high emotional exhaustion, 5% had moderate to high depersonalization, and 3% had low personal accomplishment. The overall burnout rate was 8.2%. Seventy-three percent of plastic surgeons enjoyed a good to very good quality of life. Great over-volume of work, mid-career practicing plastic surgeons and professional satisfaction with work were found to have a significant association with burnout on multivariate analysis.

Conclusions Plastic surgeons in India suffer an overall burnout rate of 8.2% with a multifactorial etiology. This occupational hazard is preventable and reversible. Plastic surgeons need to be vigilant about this and seek help whenever required.

Associated factors of burnout among Chinese vaccination staff during COVID-19 epidemic: A cross-sectional study

Objective

During the COVID-19 epidemic, vaccination staff had three main aspects of work: routine vaccination for children and adults, COVID-19 vaccination and COVID-19 prevention and control. All these works significantly increased the workload of vaccination staff. This study aimed to investigate the prevalence and influencing factors of burnout among vaccination staff in Hangzhou, China.

Methods

A total of 501 vaccination staff from 201 community/township healthcare centers in Hangzhou were recruited using a cross-sectional survey through WeChat social platform. The Maslach Burnout Inventory-General Scale (MBI-GS) was used to assess the level of burnout. Descriptive statistics were made on the characteristics of participants. Univariate analysis using the chi-square test and multivariable analysis using binary logistic regression were conducted to determine the relative predictors of burnout. Univariate analysis and multiple linear regression were used to determine the relative predictors of exhaustive emotion, cynicism, and personal accomplishment.

Results

During the COVID-19 pandemic, 20.8% of the vaccination staff experienced burnout. Educational level above undergraduate education level, medium professional title, and more working time in COVID-19 vaccination work reported a higher degree of job burnout. The vaccination staff was experiencing a high degree of exhaustive emotion, cynicism, and low personal accomplishment. Professional title, working place, and working time for COVID-19 vaccination were associated with exhaustive emotion and cynicism. Professional title and participation time for COVID-19 prevention and control were associated with personal accomplishment.

Conclusions

Our findings suggest that the prevalence rate of burnout is high among vaccination staff during the COVID-19 pandemic, especially with a low level of personal accomplishment. Psychological intervention for vaccination staff is urgently needed.

Hospital physicians´ working hour characteristics and sleep quality: a cross-sectional analysis of realized working hour and survey data

Background

Hospital physicians’ work includes on-call duties to provide 24/7 health care. Previous studies using self-reported survey data have associated long working hours and on-call work with sleep difficulties. To reduce recall bias, we complemented survey data with payroll-based objective data to study whether hospital physicians’ realized working hours are associated with sleep.

Methods

The study was nested within the Finnish Public Sector study. We used survey data on 728 hospital physicians (mean age 43.4 years, 62% females) from 2015 linked to realized daily working hour data from 3 months preceding the survey. The associations of working hour characteristics with sleep quantity and quality were studied with multinomial logistic regression analysis adjusted for demographics, overall stressfulness of life situation, control over scheduling of shifts, and hospital district.

Results

One fourth (26%) of the participants reported short (≤6.5 h) average sleep duration. Frequent night work (> 6 shifts/91 days) was associated with short sleep (OR 1.87 95%CI 1.23–2.83) compared to no night work. Approximately one third (32%) of the physicians reported insufficient sleep. Physicians with long weekly working hours (> 48 hours) had higher odds for insufficient sleep (OR 1.78 95%CI 1.15–2.76) than physicians with short weekly working hours (< 40 hours). Insufficient sleep was also associated with frequent on-call duties (> 12 shifts/3 months OR 2.00 95%CI 1.08–3.72), frequent night work (OR 1.60 95%CI 1.09–2.37), and frequent short shift intervals (≤11 hours; > 12 times/3 months OR 1.65 95%CI 1.01–2.69) compared to not having these working hour characteristics. Nearly half of the physicians (48%) reported at least one sleep difficulty at least two times a week and frequent night work increased odds for difficulties in initiating sleep (OR 2.43 95%CI 1.04–5.69). Otherwise sleep difficulties were not associated with the studied working hour characteristics.

Conclusion

We used realized working hour data to strengthen the evidence on on-call work and sleep quality and our results advice to limit the frequency of night work, on-call shifts, short shift intervals and long weekly working hours to promote hospital physicians’ sufficient sleep.

Domains of Physical and Mental Workload in Health Work and Unpaid Domestic Work by Gender Division: A Study with Primary Health Care Workers in Brazil

Various studies indicate that workload metrics can be used to assess inequities in the division of labor according to gender and in the mental health of health care professionals. In most studies, the workload is portrayed in a way that does not integrate the different fields of work, that is, work in health services and unpaid domestic work. The objective was to determine the effects of the workload domains of health work and unpaid domestic work according to the gender division of health professionals working in primary health care (PHC), and to analyze the workload as an inducer of anxiety disorders and episodes of depression. This cross-sectional study consisted of 342 health care professionals recruited for interview at primary health care units in the extreme south of Rio Grande do Sul, Brazil. Sociodemographic and occupational variables, workload in PHC and unpaid domestic work, and dichotomies of anxiety disorders and episodes of depression were considered. Poisson and multivariate linear regression models were used for data analysis. Cohen's standardized effect size was used to assess the magnitude of the difference between women and men in terms of workload. The female professionals presented higher scores in terms of PHC work and unpaid domestic work and higher proportions of episodes of depression and anxiety disorders compared to males. The male professionals showed that anxiety disorders presented a medium standardized effect size on domestic workload and the level of frustration with family involvement was higher in those with episodes of depression. The results illustrate that the workload metric is an important indicator of female vulnerability to working conditions in PHC and in the family environment.

Temporal Associations Between EHR-Derived Workload, Burnout, and Errors: a Prospective Cohort Study

BACKGROUND

The temporal progression and workload-related causal contributors to physician burnout are not well-understood.

OBJECTIVE

To characterize burnout's time course and evaluate the effect of time-varying workload on burnout and medical errors.

DESIGN

Six-month longitudinal cohort study with measurements of burnout, workload, and wrong-patient orders every 4 weeks.

PARTICIPANTS

Seventy-five intern physicians in internal medicine, pediatrics, and anesthesiology at a large academic medical center.

MAIN MEASURES

Burnout was measured using the Professional Fulfillment Index survey. Workload was collected from electronic health record (EHR) audit logs and summarized as follows: total time spent on the EHR, after-hours EHR time, patient load, inbox time, chart review time, note-writing time, and number of orders. Wrong-patient orders were assessed using retract-and-reorder events.

KEY RESULTS

Seventy-five of 104 interns enrolled (72.1%) in the study. A total of 337 surveys and 8,863,318 EHR-based actions were analyzed. Median burnout score across the cohort across all time points was 1.2 (IQR 0.7-1.7). Individual-level burnout was variable (median monthly change 0.3, IQR 0.1-0.6). In multivariable analysis, increased total EHR time (β=0.121 for an increase from 54.5 h per month (25th percentile) to 123.0 h per month (75th percentile), 95%CI=0.016-0.226), increased patient load (β=0.130 for an increase from 4.9 (25th percentile) to 7.1 (75th percentile) patients per day, 95%CI=0.053-0.207), and increased chart review time (β=0.096 for an increase from 0.39 (25th percentile) to 0.59 (75th percentile) hours per patient per day, 95%CI=0.015-0.177) were associated with an increased burnout score. After adjusting for the total number of ordering sessions, burnout was not statistically associated with an increased rate of wrong-patient orders (rate ratio=1.20, 95%CI=0.76-1.89).

CONCLUSIONS

Burnout and recovery were associated with recent clinical workload for a cohort of physician trainees, highlighting the elastic nature of burnout. Wellness interventions should focus on strategies to mitigate sustained elevations of work responsibilities.

Orthopaedic trauma on the weekend: Longer surgical wait times, and increased after-hours surgery

INTRODUCTION

Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients.

METHODS

All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression.

RESULTS

Weekends were associated with increased surgical wait times (8.9%, p<0.001) despite decreased surgical trauma volumes (9.1%, p<0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p<0.001). Surgical wait times increased midweek and remained high until Saturday.

CONCLUSION

With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.

Burnout Among Transplant Hepatologists in the United States

Burnout among transplant hepatologists has not been well characterized. The goal of this study was to describe the prevalence and predictors of burnout among practicing transplant hepatologists in the United States. We designed a 69-item survey, including the Maslach Burnout Inventory (MBI)-Human Services Survey and questions on provider demographics, practice characteristics, and psychological factors. The survey was administered to practicing US transplant hepatologists between October and December 2019. We described burnout using MBI subscales (emotional exhaustion [EE], depersonalization [DP], and personal accomplishment [PA]) and determined significant predictors of burnout, which we defined as high EE, using univariate and multivariate analyses. A total of 185 transplant hepatologists completed the survey (response rate = 25% of 738 practicing transplant hepatologists in the United States). A total of 40% reported high EE, whereas 17% and 16% reported high DP and low PA, respectively. On multivariate analysis, respondents with more than 5 colleagues (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.23-0.84) reporting adequate time for outpatient visits (OR, 0.42; 95% CI, 0.22-0.80), reporting greater comfort with their clinical caseload (OR, 0.61; 95% CI, 0.39-0.96), and reporting higher confidence in their prior training (OR, 0.49; 95% CI, 0.28-0.87) had a lower likelihood of high EE. Working 6 or more hours from home outside of work per week (OR, 2.04; 95% CI, 1.07-3.89) predicted a higher likelihood of burnout. Compensation, age, gender, career phase, caregiver status, and transplant center volume did not predict burnout. Of the surveyed transplant hepatologists, 40% experienced burnout, predicted mostly by factors related to work-time distribution, peer support, and affect. These findings should prompt development of system-level initiatives.

Challenges facing workstyle reform for Japanese obstetricians and gynecologists revealed from time studies

AIM

We aimed to grasp the actual working hours of Japanese obstetricians and gynecologists (OB/GYN doctors) as accurately as possible, using the same method of the Ministry of Health, Labour, and Welfare (MHLW).

METHODS

The time study targeted OB/GYN doctors working at 10 universities nationwide including Niigata University and 21 institutions which take a role of perinatal care in Niigata prefecture. Working hours per week were calculated based on the following categories: regular and overtime work inside the hospital, work outside the hospital, self-improvement, education, research, and others. Data on weekly working hours were converted to yearly data for analyses.

RESULTS

A time study of 10 universities nationwide revealed that 30% of doctors work overtime for more than 1860 h even if they do not include on-call shifts in their working hours. In 21 institutions in Niigata, physicians in Niigata University worked more overtime than other hospitals. It became clear that community health care was supported by dispatching physicians working at university. Furthermore, the results of simulations predicted the pessimistic situation of perinatal medical care in Niigata.

CONCLUSIONS

Our study showed the possibility to exist much more OB/GYN doctors who work more than 1860 h of overtime work per year than the data presented by the MHLW based on nation-wide survey in 2019. The fact that the working hours at the side jobs had a great influence on the increase in overtime work of physicians in University was the same result as the report of MHLW published in 2021.

Predicting physician burnout using clinical activity logs: Model performance and lessons learned

BACKGROUND

Burnout is a significant public health concern affecting more than half of the healthcare workforce; however, passive screening tools to detect burnout are lacking. We investigated the ability of machine learning (ML) techniques to identify burnout using passively collected electronic health record (EHR)-based audit log data.

METHOD

Physician trainees participated in a longitudinal study where they completed monthly burnout surveys and provided access to their EHR-based audit logs. Using the monthly burnout scores as the target outcome, we trained ML models using combinations of features derived from audit log data-aggregate measures of clinical workload, time series-based temporal measures of EHR use, and the baseline burnout score. Five ML models were constructed to predict burnout as a continuous score: penalized linear regression, support vector machine, neural network, random forest, and gradient boosting machine.

RESULTS

88 trainee physicians participated and completed 416 surveys; greater than10 million audit log actions were collected (Mean [Standard Deviation] = 25,691 [14,331] actions per month, per physician). The workload feature set predicted burnout score with a mean absolute error (MAE) of 0.602 (95% Confidence Interval (CI), 0.412-0.826), and was able to predict burnout status with an average AUROC of 0.595 (95% CI 0.355-0.808) and average accuracy 0.567 (95% CI 0.393-0.742). The temporal feature set had a similar performance, with MAE 0.596 (95% CI 0.391-0.826), and AUROC 0.581 (95% CI 0.343-0.790). The addition of the baseline burnout score to the workload features improved the model performance to a mean AUROC of 0.829 (95% CI 0.607-0.996) and mean accuracy of 0.781 (95% CI 0.587-0.936); however, this performance was not meaningfully different than using the baseline burnout score alone.

CONCLUSIONS

Current findings illustrate the complexities of predicting burnout exclusively based on clinical work activities as captured in the EHR, highlighting its multi-factorial and individualized nature. Future prediction studies of burnout should account for individual factors (e.g., resilience, physiological measurements such as sleep) and associated system-level factors (e.g., leadership).

Identifying and Prioritizing Workplace Climate Predictors of Burnout Among VHA Primary Care Physicians

OBJECTIVE

Burnout, or job-related stress, affects more than half of all US physicians, with primary care physicians (PCPs) experiencing some of the highest rates in medicine. Our study analyzes national survey data to identify and prioritize workplace climate predictors of burnout among PCPs within a large integrated health system.

DESIGN

Observational study of annual survey data from the Veterans Health Administration (VHA) All Employee Survey (AES) for 2013-2017. AES response rate ranged from 56 to 60% during the study period. Independent and dependent variables were measured from separate random samples. In total, 8,456 individual-level responses among PCPs at 110 VHA practice sites were aggregated at the facility level by reporting year. We used the semi-automated LASSO procedure to identify workplace climate measures that were more influential in predicting burnout and assessed relative importance using the Shapely value decomposition.

PARTICIPANTS

VHA employees that self-identify as PCPs.

MAIN MEASURES

Dependent variables included two dichotomous measures of burnout: emotional exhaustion and depersonalization. Independent measures included 30 survey measures related to dimensions of workplace climate (e.g., workload, leadership, satisfaction).

RESULTS

We identified seven influential workplace climate predictors of emotional exhaustion and nine predictors of depersonalization. With few exceptions, higher agreement/satisfaction scores for predictors were associated with a lower likelihood of burnout. The majority of explained variation in emotional exhaustion was attributable to perceptions of workload (32.6%), organization satisfaction (28.2%), and organization support (19.4%). The majority of explained variation in depersonalization was attributable to workload (25.3%), organization satisfaction (22.9%), and connection to VHA mission (20.7%).

CONCLUSION

Identifying the relative importance of workplace climate is important for the allocation of health organization resources to mitigate and prevent burnout within the PCP workplace. In a context of limited resources, efforts to reduce perceived workload and improve organization satisfaction may represent the biggest leverage points for health organizations to address physician burnout.

Contribution of a positive psychology-based conceptual framework in reducing physician burnout and improving well-being: a systematic review

BACKGROUND

The PERMA Model, as a positive psychology conceptual framework, has increased our understanding of the role of Positive emotion, Engagement, Relationships, Meaning, and Achievements in enhancing human potentials, performance and wellbeing. We aimed to assess the utility of PERMA as a multidimensional model of positive psychology in reducing physician burnout and improving their well-being.

METHODS

Eligible studies include peer-reviewed English language studies of randomized control trials and non-randomized design. Attending physicians, residents, and fellows of any specialty in the primary, secondary, or intensive care setting comprised the study population. Eligible studies also involved positive psychology interventions designed to enhance physician well-being or reduce physician burnout. Using free text and the medical subject headings we searched CINAHL, Ovid PsychINFO, MEDLINE, and Google Scholar (GS) electronic bibliographic databases from 2000 until March 2020. We use keywords for a combination of three general or block of terms (Health Personnel OR Health Professionals OR Physician OR Internship and Residency OR Medical Staff Or Fellow) AND (Burnout) AND (Positive Psychology OR PERMA OR Wellbeing Intervention OR Well-being Model OR Wellbeing Theory).

RESULTS

Our search retrieved 1886 results (1804 through CINAHL, Ovid PsychINFO, MEDLINE, and 82 through GS) before duplicates were removed and 1723 after duplicates were removed. The final review included 21 studies. Studies represented eight countries, with the majority conducted in Spain (n = 3), followed by the US (n = 8), and Australia (n = 3). Except for one study that used a bio-psychosocial approach to guide the intervention, none of the other interventions in this review were based on a conceptual model, including PERMA. However, retrospectively, ten studies used strategies that resonate with the PERMA components.

CONCLUSION

Consideration of the utility of PERMA as a multidimensional model of positive psychology to guide interventions to reduce burnout and enhance well-being among physicians is missing in the literature. Nevertheless, the majority of the studies reported some level of positive outcome regarding reducing burnout or improving well-being by using a physician or a system-directed intervention. Albeit, we found more favorable outcomes in the system-directed intervention. Future studies are needed to evaluate if PERMA as a framework can be used to guide system-directed interventions in reducing physician burnout and improving their well-being.

Association of working hour characteristics and on-call work with risk of short sickness absence among hospital physicians: A longitudinal cohort study

Physicians often work long hours and on-call shifts, which may expose them to circadian misalignment and negative health outcomes. However, few studies have examined whether these working hour characteristics, ascertained using objective working hour records, are associated with the physicians' risk of sickness absence. We investigated the associations of 14 characteristics of payroll-based working hours and on-call work with the risk of short sickness absence among hospital physicians. In this cohort study, 2845 physicians from six Finnish hospital districts were linked to electronic payroll-based records of daily working hours, on-call duty and short (1-3 days) sickness absence between 2005 and 2019. A case-crossover design was applied using conditional logistic regression with the 28 day case and control windows to estimate odds ratios (ORs) and 95% confidence intervals (CI) for short sickness absence. After controlling for weekly working hours and the number of normal (≤12 h) shifts, a higher number of long (>12 h) shifts (ORs for ≥5 versus none: 2.54, 95% CI 1.68-3.84), very long (>24 h) shifts (ORs for ≥5 versus none: 2.62, 95%CI 1.61-4.27), and on-call shifts (OR for ≥5 versus none: 2.15, 95% CI 1.44-3.21) and a higher number of short (<11 h) shift intervals (OR for ≥5 versus none: 12.61, 95% CI 8.88-17.90) were all associated with the increased risk of short sickness absence. These associations did not differ between male and female physicians or between age groups. To conclude, the findings from objective working hour records show that long work shifts, on-call shifts and short shift intervals are related to the risk of short (1-3 days) sickness absence among hospital physicians.

Surgeon Perspectives on Benefits and Downsides of Overlapping Surgery: In-depth, Qualitative Interviews

OBJECTIVE

The aim of the study was to characterize surgeon perspectives regarding the benefits and downsides of conducting overlapping surgery.

BACKGROUND

Although surgeons are key stakeholders in current discussions surrounding overlapping surgery, little has been published regarding their opinions on the practice. Further characterization of surgeon perspectives is needed to guide future studies and policy development regarding overlapping surgery.

METHODS

Study information was sent to all members of 3 professional surgical societies. Interested individuals were eligible to participate if they identified as attending surgeons in an academic setting who work with trainees. Purposive selection was used to diversify surgeons interviewed across multiple dimensions, including subspecialty and opinion regarding appropriateness of overlapping surgery. In-depth, qualitative interviews were conducted with participants regarding their opinions on overlapping surgery.

RESULTS

The 51 surgeons interviewed identified a wide array of potential benefits and disadvantages of overlapping surgery, some of which have not previously been measured, including downsides to surgeon wellness and patient experience, less surgeon control over procedures, and difficulty in scheduling cases. Interviewees often disagreed as to whether overlapping surgery negatively or positively affects each dimension discussed, particularly regarding the impact on resident training.

CONCLUSIONS

The utilization of the novel perspectives presented here will allow for targeted assessment of physician perspectives in future quantitative studies and increase the likelihood that variables measured encompass the range of factors that surgeons find meaningful and relevant. Priority areas of future research should include examining effects of overlapping surgery on surgical training and surgeon wellness.

The impact of rest breaks on subjective fatigue in physicians of the General Hospital of Vienna

Aims

Medical doctors are affected by high levels of occupational burnout. Work organization such as sufficient rest breaks can decrease stress and fatigue; however, rest breaks are often skipped under high workload and time pressure. The present study sought to investigate the effect of self-determined rest breaks on acute and daily levels of fatigue in physicians of the General Hospital of Vienna.

Methods

Rest breaks and fatigue were recorded throughout day shifts over a time span of 4 weeks with a mobile assessment device. A total of 12 physicians of a university clinic participated in the study. Data were analyzed using generalized estimating equations.

Results

Analyses were based on a total of 115 workdays including 93 rest breaks and 800 fatigue assessments. Physicians took an average of 0.81 rest breaks per day. Fatigue was lower in the 30 min after the break than in the hour before the break; however, the number of rest breaks did not affect the increase of fatigue during shifts.

Conclusion

Self-determined rest breaks were effective in reducing acute fatigue in hospital physicians during work. The failure to find an effect on the increase of work-related fatigue may be due to the infrequency of rest breaks in hospital physicians.

Emotional intelligence, burnout, and professional fulfillment in clinical year medical students

BACKGROUND

Emotional intelligence (EI) has been associated with decreased burnout in surgical residents but has not been extensively studied in medical students. We hypothesized that higher EI would lead to decreased levels of burnout among medical students at a US medical school.

METHODS

The authors administered three separate EI measures and compiled an EI score by adding the normalized score on each test. These measures were the DRS-15, the Grit Scale, and the Reading the Mind Between the Eyes Quiz. The Professional Fulfillment Index (PFI) was used to determine levels of burnout experienced two weeks before survey completion.

RESULTS

The population included 68 medical students. PFI and EI scores were positively correlated (R = 0.55, p < .001). The separate EI measures indicated that both Grit (R = 0.43, p < .001) and DRS-15 (R = 0.56, p < .001) were correlated with PFI. The Eyes Quiz did not show a significant correlation with PFI (p = .2).

CONCLUSIONS

The results confirmed our hypothesis that EI would be correlated with decreased levels of burnout among this group of students. Some areas of potential future study include whether these same results hold true at other medical schools and if improving EI has a benefit of decreasing burnout.

Physicians' Total Burden of Occupational Stressors: More than Threefold Increased Odds of Burnout

OBJECTIVES

To assess the relation between total job stressor burden and physician burnout, identifying potentially contributory modifiable stressors, using a comprehensive, theory-based instrument created for physicians by physicians.

METHODS

From 2018 to 2019, we conducted a cross-sectional study in a public teaching hospital in India. Of 305 clinically active physicians, 293 were reached and 42.7% participated. Job stressors were assessed via the physician-specific Occupational Stressor Index (OSI) and burnout by the Copenhagen Burnout Index (CBI).

RESULTS

The 76 fully participating physicians were 68% male, 84% residents, and 70% age 30 or younger, from various specialties. Mean scores for total OSI: 87 ± 7.8; personal burnout: 46.6 ± 18.2; work-related burnout: 41.4 ± 20.7; and patient-related burnout: 31.7 ± 22.4. Total OSI scores were significantly associated with personal and work-related burnout, adjusting for working-years as physicians and sex. Total OSI scores >88 showed adjusted odds ratios (±95% confidence intervals): 3.99 (1.31, 12.1) and 6.50 (1.85, 22.8) for personal and work-related burnout, respectively. The high demands aspect of the OSI showed significant multivariate relations to personal, work-related, and patient-related burnout. Patient-related burnout was significantly more likely among male physicians in these multivariate analyses. Physicians outside preventive/diagnostic areas, with heavier burdens and more emergency cases were less likely to fully participate.

CONCLUSIONS

The total burden of job stressors is powerfully associated with personal and work-related burnout. The clinically defined total OSI cutpoint >88 warranting urgent intervention is corroborated by >3-fold odds of personal and work-related burnout. Lowering total OSI scores is an immediate priority, starting with potentially modifiable stressors that are already maximum/near-maximum (inadequate rest breaks, nightshifts, work hours, insufficient work-free vacation time, and infection hazards). These issues affect patient care.

The Actual Operative Costs of Liver Transplantation and Normothermic Machine Perfusion in a Canadian Setting

BACKGROUND

Liver transplantation is an effective treatment for end-stage liver disease. However, waiting lists continue to lengthen as demand exceeds supply. Use of extended criteria donors has helped but is associated with increased rates of complications. The application of normothermic machine perfusion (NMP) has been shown to be protective, especially in more marginal grafts. Despite this benefit, no cost-effectiveness studies have been published.

OBJECTIVE

This study serves as a prelude to a cost-effectiveness analysis of the costs of liver procurement, transplantation, and machine perfusion in a Canadian setting.

METHODS

The total costs were calculated for 106 in-province procurements, the set cost for 237 out-of-province procurements, and 343 liver transplantations. These costs include overheads, supplies, anaesthesia technologist and nursing salaries, and physician billings. Base and modified costs for all procedures were calculated, with consideration of physician billing modifiers. The total cost per run of NMP was calculated, with a range based on variations in the exchange rates for Great British pounds (₤) to Canadian dollars ($Can), year 2019 values.

RESULTS

Costs were $Can30,770.22 for in-province and $Can44,636.73 for out-of-province liver procurement and transplantation. These increased to $Can35,659.22 and 48,076.18 when considering modifiers. The minimum cost per NMP run was $Can18,593.02.

CONCLUSIONS

Although the cost per run is substantial, NMP could potentially lead to cost savings by decreasing night-time salary premiums, complications, and patient length of stay. A formal cost-effectiveness study of NMP in liver transplantation is underway to help clarify the financial benefit or burden of this new technology.

Transplant Surgery Pipeline: A Report from the American Society of Transplant Surgeons Pipeline Taskforce

BACKGROUND

Transplant surgery fellowship has evolved over the years and today there are 66 accredited training programs in the US and Canada. There is growing concern, however, about the number of US-trained general surgery residents pursuing transplant surgery. In this study, we examined the transplant surgery pipeline, comparing it with other surgical subspecialty fellowships, and characterized the resident transplantation experience.

METHODS

Datasets were compiled and analyzed from surgical fellowship match data obtained from the National Resident Matching Program and ACGME reports and relative fellowship competitiveness was assessed. The surgical resident training experience in transplantation was evaluated.

RESULTS

From 2006 to 2018, a total of 1,094 applicants have applied for 946 transplant surgery fellowship positions; 299 (27.3%) were US graduates. During this period, there was a 0.8% decrease per year in US-trained surgical residents matching into transplant surgery (p = 0.042). In addition, transplant surgery was one of the least competitive fellowships compared with other National Resident Matching Program surgical subspeciality fellowships, as measured by the number of US applicants per available fellowship position, average number of fellowship programs listed on each applicant's rank list, and proportion of unfilled fellowship positions (each, p < 0.05). Finally, from 2015 to 2017, there were 57 general surgery residency programs that produced 77 transplant surgery fellows, but nearly one-half of the fellows (n = 36 [46.8%]) came from 16 (28.1%) programs.

CONCLUSIONS

Transplant surgery is one of the least competitive and sought after surgical fellowships for US-trained residents. These findings highlight the need for dedicated efforts to increase exposure, mentorship, and interest in transplantation to recruit strong US graduates.

Mindfulness Among Medical Oncology Doctors and Its Relation With Burnout: Turkish Oncology Group (TOG) Study

PURPOSE

Medical oncology physicians have been identified as one of the main risk groups for the development of burnout. Mindfulness as being aware of the moment nonjudgmentally seems to be a protective factor against burnout. We aimed to reveal mindfulness levels among medical oncology doctors and the potential impact of mindfulness on burnout syndrome.

METHODS

In this cross-sectional study, the data of 285 medical oncology doctors were analyzed. The Mindful Attention Awareness Scale was used for mindfulness evaluation, and the Maslach Burnout Inventory was used for burnout assessment. After defining mindfulness levels among medical oncology doctors, the relationship between mindfulness and burnout was analyzed by the Pearson correlation and bivariate logistic regression tests.

RESULTS

The mean Mindful Attention Awareness Scale score of participants was 54.52 ± 13.77. Mindfulness was associated with age (P < .001), having a hobby (P = .008), regular exercise (P = .001), professional title (P = .02), and professional experience (P = .02). As the level of mindfulness increased, emotional exhaustion and depersonalization decreased, whereas personal accomplishment increased significantly (all P < .001). In the regression analysis, mindfulness was significantly associated with all three subscales of burnout (all P < .01).

CONCLUSION

We have demonstrated for the first time on such a large scale that higher levels of mindfulness were related with lower burnout among medical oncology physicians. These findings suggest the potential benefits of mindfulness-based interventions in reducing burnout levels in medical oncologists.

Does Burnout Exist in Academic Oral and Maxillofacial Surgery in the United States?

INTRODUCTION

Information regarding burnout in academic oral and maxillofacial surgeons (OMSs) in the United States (US) does not exist. The purpose of this project was to answer the following question: "Does burnout exist in academic OMSs in the United States?"

MATERIALS AND METHODS

A 15-question anonymous survey was created based on Expanded Physician Well-Being Index (WBI, MedEd Web Solutions). The survey was sent electronically to fellows of the American Academy of Craniomaxillofacial Surgeons (AACMS) consisting of demographics, professional obligations, wellness indicators (burnout, emotional hardening, depression, anxiety, fatigue, overwhelmed), and overall quality-of-life statements. Responses were quantified according to a scaled scoring system specific for WBI. Multivariable logistic regression was then used to create a predictive model of being "at risk" of burnout.

RESULTS

Surveys were sent to 180 active AACMS fellows; 110 completed the questionnaire (61.1%). One hundred eight active fellows met inclusion criteria. Majority were males between the ages of 41 and 50. About a quarter spent more than 20 years in an academic setting. Activities concentrated on patient care, teaching, and/or administrative duties. More than half of respondents felt emotionally hardened, anxious/irritable, and/or overwhelmed. About a third had adequate time for personal and family life. Most felt that their work was meaningful. Using WBI, the average score was 2.21, meaning that as a whole oral-maxillofacial surgery academicians are not considered at risk for burnout. Risk factors for burnout were age >40 years old, female gender, patient care more than 55 hours per week, call more than 10 times per month, and majority of time spent on teaching responsibilities.

CONCLUSIONS

According to WBI, OMSs as a group are not at risk for burnout. Certain traits (age, gender, more than 55 weekly hours and/or more than 10 call shifts per month, high percentage of time teaching responsibilities) are at higher risk for burnout.

Individual differences and emotional labor: the effects of core self-evaluations on depersonalization

This paper examines the role of core self-evaluations (CSEs) in the relationships among emotional demands, emotional dissonance, and depersonalization. Data were collected from a non-random sample of 423 teachers who worked in primary, secondary, and higher education institutions. Results from structural equation modeling analysis showed that CSEs displayed both direct and indirect effects on depersonalization through employees' perceptions and reactions to emotional labor. Specifically, those individuals with more positive CSEs tended to perceive the emotional aspects of their job as less demanding, thus being less likely to experience emotional dissonance and, in turn, depersonalization. This research demonstrated that CSEs play a vital role in explaining employees' reactions to emotional labor and, therefore, their effects should be properly accounted for in future studies. Implications for practice and future lines of research are discussed in this paper.

Prevalence and associated factors for burnout among attending general surgeons: a national cross-sectional survey

BACKGROUND

Burnout resulting from long-term and unmanaged workplace stress is high among healthcare professionals, especially surgeons, and affects both individuals and the quality of patient care. The objective of this study was to determine the prevalence and associated factors for burnout among attending general surgeons and to identify possible preventive strategies.

METHODS

A national cross-sectional survey using a 35-item questionnaire was conducted among members of the Turkish Surgical Society. The survey evaluated demographics, professional and practice characteristics, social participation, and burnout as well as interventions to deal with burnout. Burnout was defined as a high score on the emotional exhaustion (EE) and/or depersonalization (DP) subscales. Surgeons with high scores on both the EE and DP and a low score on personal accomplishment (PA) were considered to have severe burnout.

RESULTS

Six hundred fifteen general surgeons completed the survey. The median EE, DP, and PA scores were 34 (IQR, 20-43), 9 (IQR, 4-16), and 36 (IQR, 30-42), respectively. Overall, the prevalence of burnout and severe burnout were 69.1 and 22.0%, respectively. On multivariable analysis, factors independently associated with burnout were working in a training and research hospital (OR = 3.34; P < 0.001) or state hospital (OR = 2.77; P = 0.001), working ≥ 60 h per week (OR = 1.57; P = 0.046), and less frequent participation in social activities (OR = 3.65; P < 0.001).

CONCLUSIONS

Burnout is an important problem among general surgeons with impacts and consequences for professionals, patients, and society. Considering that burnout is a preventable condition, systematic efforts to identify at-risk populations and to develop strategies to address burnout in surgeons are needed.

Extinguishing burnout: National analysis of predictors and effects of burnout in abdominal transplant surgery fellows

Burnout among surgeons has been attributed to increased workload and decreased autonomy. Although prior studies have examined burnout among transplant surgeons, no studies have evaluated burnout in abdominal transplant surgery fellows. The objective of our study was to identify predictors of burnout and understand its impact on personal and patient care during fellowship. A survey was sent to all abdominal transplant surgery fellows in an American Society of Transplant Surgeons-accredited fellowship. The response rate was 59.2% (n = 77) and 22.7% (n = 17) of fellows met criteria for burnout. Fellows with lower grit scores were more likely to exhibit burnout compared with fellows with higher scores (3.6 vs 4.0, P = .026). Those with burnout were more likely to work >100 hours per week (58.8% vs 27.6%, P = .023), have severe work-related stress (58.8% vs 22.4%, P = .010), consider quitting fellowship (94.1% vs 20.7%, P < .001), or make a medical error (35.3% vs 5.2%, P = .003). This national analysis of abdominal transplant fellows found that burnout rates are relatively low, but few fellows engage in self-care. Personal and program-related factors attribute to burnout and it has unacceptable effects on patient care. Transplant societies and fellowship programs should develop interventions to give fellows tools to prevent and combat burnout.

Predictors of Burnout and Depression in Surgeons Practicing in East, Central, and Southern Africa

BACKGROUND

Surgeons are at risk of burnout and depression, which can lead to medical errors, inefficiency, exhaustion, conflicts, and suicide. Significant challenges exist in sub-Saharan Africa that may increase the prevalence of burnout and depression, but no formal evaluation has identified stressors specific to this environment.

METHODS

A survey was distributed to all members of the College of Surgeons of East, Central, and Southern Africa (COSECSA). Burnout, depression, and stressors were assessed with validated measures: Maslach Burnout Inventory for Medical Personnel, Patient Health Questionnaire (PHQ) 9, and Holmes-Rahe Life Stress Inventory.

RESULTS

There were 131 participants (98 African and 33 non-African surgeons). The incidence of moderate to severe depression was 48% (n = 63), and the incidence of burnout was as high as 38% (n = 48). There were no significant differences between African and non-African surgeons in marital status, number of children, partners in practice, or distribution of time. More African surgeons experienced birth of a child (18% versus 3%, P = 0.04) but had less workplace conflict (7.1% versus 10.7%, P = 0.045) than non-African surgeons. African surgeons more consistently felt they were positively influencing others (P = 0.008), enjoyed working with patients (P = 0.009), and were more satisfied (P = 0.04). For all surgeons, predictors of increased PHQ-9 depression were serious professional conflict (P = 0.02), difficulty accessing childcare (P = 0.04), and racial discrimination (P = 0.003). In the Maslach model, predictors of burnout were difficulty accessing childcare (P = 0.05) and denial of promotion based on gender (P = 0.006).

CONCLUSIONS

Burnout and depression in surgeons practicing in East, Central, and Southern Africa are substantial. Despite significant challenges, African surgeons tended to have a more positive outlook on their work. Improvements can be made to reduce burnout and depression by focusing on work conditions, equality of promotion opportunities, workplace conflict management, childcare support, and increasing the numbers of surgeons in practice.

Impact of Nighttime Lung Transplantation on Outcomes and Costs

BACKGROUND

Previous studies in the field of organ transplantation have shown a possible association between nighttime surgery and adverse outcomes. We aim to determine the impact of nighttime lung transplantation on postoperative outcomes, long-term survival, and overall cost.

METHODS

We performed a single-center retrospective cohort analysis of adult lung transplant recipients who underwent transplantation between January 2006 and December 2017. Data were extracted from our institutional Lung Transplant Registry and Mid-America Transplant services database. Patients were classified into 2 strata, daytime (5 AM to 6 PM) and nighttime (6 PM to 5 AM), based on time of incision. Major postoperative adverse events, 5-year overall survival, and 5-year bronchiolitis obliterans syndrome-free survival were examined after propensity score matching. Additionally we compared overall cost of transplantation between nighttime and daytime groups.

RESULTS

Of the 740 patients included in this study, 549 (74.2%) underwent daytime transplantation and 191 (25.8%) underwent nighttime transplantation (NT). Propensity score matching yielded 187 matched pairs. NT was associated with a higher risk of having any major postoperative adverse event (adjusted odds ratio, 1.731; 95% confidence interval, 1.093-2.741; P = .019), decreased 5-year overall survival (adjusted hazard ratio, 1.798; 95% confidence interval, 1.079-2.995; P = .024), and decreased 5-year bronchiolitis obliterans syndrome-free survival (adjusted hazard ratio, 1.556; 95% confidence interval, 1.098-2.205; P = .013) in doubly robust multivariable analyses after propensity score matching. Overall cost for NT and daytime transplantation was similar.

CONCLUSIONS

NT was associated with a higher risk of major postoperative adverse events, decreased 5-year overall survival, and decreased 5-year bronchiolitis obliterans syndrome-free survival. Our findings suggest potential benefits of delaying NT to daytime transplantation.

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part II, Attending Physicians

OBJECTIVE

To ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians.

STUDY DESIGN

Cross-sectional survey.

SETTING

Twelve US academic otolaryngology programs.

METHODS

A questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well-being Index for distress, the 2-item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire-2 screen for major depressive disorder, and the Generalized Anxiety Disorder-2 screen for generalized anxiety disorder.

RESULTS

The survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well-being Index screen (odds ratio for each 10-hour increase, 2.61; 95% CI, 1.73-3.93; P < .001). In a univariable setting, hours worked in a typical week was significantly associated with a positive Maslach Burnout Inventory screen.

CONCLUSION

Distress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well-being and mitigate professional burnout.

Factors associated with burnout syndrome in surgeons: a systematic review

INTRODUCTION

To date, studies have shown a high prevalence of burnout in surgeons. Various factors have been found to be associated with burnout, and it has significant consequences personally and systemically. Junior doctors are increasingly placing their own health and wellbeing as the most important factor in their decisions about training. Finding ways to reduce and prevent burnout is imperative to promote surgical specialties as attractive training pathways.

METHODS

The MEDLINE, PsychInfo and EMBASE databases were searched using the subject headings related to surgery and burnout. All full text articles that reported data related to burnout were eligible for inclusion. Articles which did not use the Maslach Burnout Inventory or included non-surgical groups were excluded; 62 articles fulfilled the criteria for inclusion.

FINDINGS

Younger age and female sex tended to be associated with higher levels of burnout. Those further in training had lower levels of burnout, while residents suffered more than their seniors. Burnout is associated with a lower personal quality of life, depression and alcohol misuse. Academic work and emotional intelligence may be protective of burnout. Certain personality types are less likely to be burnt out. Mentorship may reduce levels of burnout.

CONCLUSIONS

Workload and work environment are areas that could be looked at to reduce job demands that lead to burnout. Intervening in certain psychological factors such as emotional intelligence, resilience and mindfulness may help to reduce burnout. Promoting physical and mental health is important in alleviating burnout, and these factors likely have a complex interplay.