Gendered Innovations in Orthopaedic Science: Burn and Crash

The challenge of providing orthopaedic care can drag on us all, regardless of age, sex, gender, race, stage of training, specialty, or mode of practice. Frustration born from loss of practice control and rising administrative burdens can sometimes overwhelm the rewards of patient care [4]. Physical and emotional exhaustion can lead to cynicism, ultimately impacting the patient-doctor relationship, and potentially impairing the skills central to performing as a safe orthopaedic surgeon.

For me, two decades into practice, the once-effusive joy at work has faded. Shifting from the employed setting, which defined my first 17 years as a surgeon, into private practice introduced a new set of challenges. While I felt safe joining in as other physicians generally complained about the irritations of work, I was not ready to express the personal impact of those stresses. Beyond feeling less engaged with my patients, could I be losing my edge as a surgeon? As a woman practicing orthopaedics, I felt an added burden. In a profession dominated by men, I was cautious about expressing symptoms that could be construed as a weakness. Was I alone?

Is Burnout a Sex/Gender Issue?

Free-floating frustration took on more definition when an email news headline led me to consider burnout as a cause. While not offering the rigor of peer-review publications, the email trailer featured the lifestyle results of the Medscape annual physician survey. This report has consistently demonstrated a higher risk of burnout among orthopaedic surgeons who are women. [9]; 63% of women versus 47% of men reported burnout, a substantial increase from the 47% and 39%, respectively, when the question was first asked in 2013.

Although a number of papers have addressed burnout in orthopaedics [1, 2, 11-13] only the article by Sargent and colleagues comments on gender differences [13]. Responses from women included 12% of the residents and 7% of faculty. The data demonstrated burnout risk was higher in women residents. Across surgical specialties, most articles that report on gender differences in burnout demonstrate a higher burnout risk in women [10]. These statistics allayed fears that my emotional response was somehow anomalous. Yes, this is a gender issue. No, I am not alone.

Sexual Dimorphism: Manifesting and Coping with Burnout

Indulging in self-diagnosis at least prompted me to better understand the disorder. The most widely used tool in studies evaluating burnout, the Maslach Burnout Inventory (MBI), distinguishes three components: (1) Emotional exhaustion, (2) depersonalization (detachment and cynicism) and (3) a low sense of personal accomplishment [1-3, 10, 11, 13]. The initiation and progression of each component can vary, with potential causes for burnout including bureaucracy of practice such as reporting and insurances issues, increased clinic load and work hours, and generalized loss of control of practice [1, 2, 9].

The higher risk of burnout among women surprised me; I suspected that men and women equally face the factors contributing to the problem. However, there is evidence that the manifestations and coping strategies may differ between men and women, providing a possible explanation for gender differences in expressing burnout.

Comparing the three MBI components, depersonalization was the most-frequent presenting component for men [3, 7]. In contrast, burnout in women appeared to be triggered most commonly by emotional exhaustion, a dimension characterized by depletion of emotional reserves from excessive demands. Pondering my own situation, I acknowledged that I had traded a largely self-sufficient patient population for the challenges of workers compensation and Medicaid patients for whom complex social issues often clouded the orthopaedic complaint. Further, the drain I felt from my patients was superimposed on concurrent emotional challenges in my personal life following the loss of my husband to cancer [8] and my children to college. Postulating that women are broadly more vulnerable to the emotional demands of patients and home life is frank sexism. But beyond my personal experience, this theory was offered by one study to explain the gender-disparate findings in burnout [3]. Similarly supporting the impact from home stressors, the Medscape survey reported gender discordance in happiness outside the workplace (65% men vs. 49% women) [9]. Beyond possible higher risk for developing symptoms, challenges adapting to life-stressors could lead more women to report burnout. Women tend to choose emotion-focused coping techniques—such as self-blame and withdrawal—which can amplify emotional exhaustion [3].

The personal-accomplishment dimension of the MBI embodies my perceived value as a physician and surgeon. For me, maintaining a sense of professional competence and successful achievement would provide a coping mechanism as the burnout progresses. Here again, women seem disproportionately impacted, suffering loss of personal accomplishment while men seem less likely to have their self-efficacy undermined by emotional exhaustion or the cynicism of depersonalization [3]. With substance abuse a potential coping mechanism, a study in surgical residents finding of alcohol abuse to be much more-common among women (41% vs. 26% for men) raises concerns [7].

Avoiding the Crash from Burnout

I wasn’t comfortable discussing professional challenges with colleagues. More importantly, the grousing I heard in the lounge may have been expressions of burnout, but I wasn’t really listening. Reflecting on those conversations, I suspect preoccupation with my own issues stymied the chance for empathy. Regardless of the gender of the surgeon, burnout has serious implications both for surgeons and for their patients. Authors more qualified than I offer sound strategies to treat burnout throughout the orthopaedic career [1, 2, 4-6, 12-14]. However, as physicians we should appreciate the value of early diagnosis for effective treatment. With so many men and women admitting to burnout in anonymous surveys, burnout shouldn’t be equated with feminine weakness. I suspect the same social stigma surrounding any emotional or psychological condition taints admission of burnout. The first step in accurate diagnosis is listening carefully to the patient, but most of us probably fail to offer that simple, powerful tool to our colleagues. Probably not even to ourselves.

For women and men alike, recognition and early self treatment with simple but powerful tools such as finding joy in kindness to patients could be a start [5]. Acknowledging and utilizing the skills of mental health professionals should be perceived as a next step no different from a referral to an internist for pre-operative medical optimization.

Encouraging a supportive environment of active listening could facilitate dialog about professional stressors and earlier recognition of burnout symptoms. Expanding the conversation beyond the workplace may be particularly important for the women in orthopaedics facing emotional exhaustion more acutely in the clinic setting and perhaps at home as well. Opening a conversation with a colleague who manifests changes or even reaching beyond to his/her spouse or family could change the course [4]. Finally, even when practice and personal challenges sap the joy of patient care, affirmation of the life-enhancing work we do can go a long way to buoy each other and perhaps keep burnout at bay.