CORR Insights®: How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents?

Where Are We Now?

Directly impacting the life of every patient an orthopaedic surgeon interacts with is, at times, an overwhelming burden. Yet, as orthopaedic surgeons, this is what we do every day. And while orthopaedic surgeons frequently state they have high levels of job satisfaction [1], our daily routines are often filled with interruptions, patients with serious and sometimes life-threatening problems, increasing administrative duties, and the constant threat of “failure.” This is to say nothing of the well-documented stresses our careers cause in our personal lives. People in our career got here because they had many successes in life. Some of them seem to succeed almost effortlessly. But the pressures I’ve described cause the margin between “I have the best career in the world” and “I don’t know if I can do this anymore” to become very, very thin. Everyone has a breaking point, even high achievers. As it was nicely articulated in a recent CORR® Clinical Faceoff article [12], surgeons are humans who “cannot give what they don’t have” in terms of emotional, spiritual, and physical wellbeing. Unfortunately, this fact has only recently begun to be acknowledge in our profession [1, 8, 12].

That is why it was with great anticipation that I read the article by Verret et al. [11] titled “How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents?” The authors clearly show that orthopaedic surgeons at every career stage can experience burnout and that residents experience higher rates of burnout than attending surgeons do. While we have all encountered periods of feeling overwhelmed and being unable to cope with the stresses related to our profession, this study highlighted how residents struggle to adapt to these stresses more than both attendings and fellows. Yet, one area of study that was common for both attendings and residents was the desire to have more control over their environment. This is a difficult fact to face in our profession, where days, stress levels, and the best of plans can change in a moment’s notice. We all struggle to accept this reality at times. However, it is also clear from this study [11] that some individuals are able to tolerate these changes and periods of emotional exhaustion better than others are. Determining the how and why of this finding remains a critical part of developing solutions to the problem of burnout in our profession.

Where Do We Need to Go?

I don’t think we should make sweeping changes to residency programs to try to protect our residents from burnout; residency is supposed to be hard, and part of training is developing the tools necessary to encounter, process, and overcome stressful events. Removing this would simply shift burnout from residents to early-career attendings, because the skills and resources needed to process stress would not be developed during our graduate medical education years.

Instead, I think we need to help individuals who are burned out to process what they are feeling, and stay in the game. What can we do to treat residents and attendings who are suffering from this emotional state? Should such skills and resources be provided to everyone or are there certain individuals who appear to need them more than others? We have plenty of data pointing to the problem [2, 3]; we now need to fix it. This is no easy task because burnout undoubtedly is related both to individual and environmental factors, and some of them may be impossible to control. But because mitigating this problem would literally save surgeons’ lives, it is essential that we try.

Completing such studies would likely require the participation of some brave individuals in our field who have felt, or are currently feeling, burned out. It is not easy to admit feelings of burnout, and this likely explains why so little progress has been made on this topic. Few residents, fellows, and attendings desire the label of “couldn’t handle it” or “needed extra help,” and such stigmas are also why so many individuals become burned out in the first place [7]. Instead of asking for help, many surgeons try to do more. Sometimes we are able to climb out from the hole. Other times, we end up falling in deeper; in any given moment, we may not even know which direction we’re heading in. While studies that rely on anonymous data or surveys are useful, they do little to assist in examining the causative relationships that are so important to identifying meaningful interventions for this pervasive problem.

How Do We Get There?

The first step towards developing studies that can further help us treat orthopaedic surgeons who are struggling with burnout starts by identifying those individuals. As I mentioned above, this is no easy task. However, having residents and attendings regularly complete questionnaires or surveys designed to identify individuals at risk of burnout, like those used in the current study [11], would help identify such a cohort. Treatment would then need to be imparted to these participants in a very individualized manner that depends on the underlying reason(s) for the orthopaedic surgeon’s burnout. Such a prospective study would be difficult to conduct but would finally provide us with strategies and techniques that may be helpful to individuals who are struggling with this challenging emotional state.

There are also some current technologies that can potentially assist us in conducting prospective studies on this topic. Many smartphone applications can alert individuals to fill out short questionnaires regarding their mood and emotional state [4, 10]. Similarly, sensors can be worn to track factors such as heart rate, stress level, and temperature [9]. Such applications could be used as part of a larger prospective study that also includes social data and personality testing for each individual, aimed at further identifying some of these critical details on the topic of how burnout happens and why some people may be more prone to experience it in some situations than others.

Of course, educating individuals on this topic and providing them with tools and strategies to try to prevent or mitigate the effects of burnout is also worth trying. This topic has been written about frequently in this journal [5, 6, 12], and a relatively simple study could be conducted by having some orthopaedic surgeons learn about and practice these techniques while others do not receive any formal education or training. It would be interesting to see just how impactful self-awareness of this problem may be in preventing it from occurring. The reality is that we all are likely to develop some of these symptoms at one point or another. Learning how to best proceed through these moments may be the difference between life and death.