Equity360: Gender, Race, and Ethnicity—All Orthopaedic Surgeon Burnout Is Not Created Equal

The recent COVID-19 pandemic and response intensified public awareness of burnout in health care professionals, including orthopaedic surgeons. Characterized as the state of mental exhaustion, depersonalization, and a decreased sense of personal accomplishment [10], burnout commonly affects physicians [21, 22] and increases the risk of poorer clinical performance and medical errors [24]. What we are less aware of is that not all physicians are impacted equally by burnout.

Women and non-White physicians, especially, are more prone to burnout [18]. For instance, women physicians are 20% to 60% more likely to experience burnout compared with men physicians [5, 25]. Furthermore, burnout impacts women physicians differently than men physicians [5, 25]. Women internalize their burnout, experiencing more intense and frequent anxiety, worry, depressive symptoms, and emotional exhaustion, whereas men tend to externalize, with depersonalization being more prevalent [6, 12]. As burned out physicians are more likely to leave the profession [22, 24], burnout negatively impacts diversity in orthopaedic surgery by increasing the loss of women and non-White surgeons.

Causes

Emotional Exhaustion

Challenges with work-life integration contribute to emotional exhaustion, leading to burnout and career dissatisfaction [17]. Married women doctors with children spent 8.5 hours more on parenting and domestic activities than did their counterparts who were men [15]. Women orthopaedic surgeons are significantly more likely to delay marriage, postpone starting a family, undergo fertility treatments, and take on the majority of parenting compared with men colleagues [19].

This difference in domestic work is real. A few years ago, one of us (MIO) was on a panel with a nationally known male department chair speaking on lessons learned over their careers to an audience of women orthopaedic surgeons. She asked people in the room to share the last time they cleaned the bathroom at home. The chair could not recall ever having done this domestic task. Nearly all the women surgeons in the room had recently performed this chore.

Recognition and Reward

Despite similar demographics and work profiles, women physicians earn less than men physicians [13, 19], potentially influencing women physicians to feel they are less worthy than their counterparts who are men. Secondary sources of income are less likely for women because industry sponsorship and research grants favor higher-profile physicians, most of whom are men [9, 16]. Women orthopaedic surgeons are significantly less likely to perform consulting, be invited as course faculty, or have leadership positions than men orthopaedists [19].

Further, women and underrepresented surgeons are disproportionately steered toward labor-intensive diversity activities which, while important, detract from time spent on specialty-focused activities [4, 8]. Diversity projects are not regarded on an equal plane as other work for compensation, promotion, awards, society memberships, and leadership positions [20].

Bullying, harassment, and marginalization of achievements erode personal accomplishment at work. Women surgeons are subject to harassment and bullying more often than men [11], and they experience it from many sources: patients, hospital staff, and colleagues [14, 23]. At a national orthopaedic meeting in 2022, one of the authors (CML) was at the podium to co-moderate a research paper session. Her co-moderator entered the room and he asked, over the microphone, if she was “there to advance the slides.” Neither of the authors of this commentary has ever asked a co-moderator if she or he was there to advance slides.

The Way Forward

A resilient and diverse orthopaedic work force is our greatest resource in caring for patients. Orthopaedics can be a leader in addressing burnout in our profession, especially for women and people of color. To do so, we must address factors at both the systemic and individual level.

Data

Data are needed to understand burnout among orthopaedic surgeons. How do prevalence and manifestations of burnout differ based on gender, race, and ethnicity? How do contributing factors differ between men and women, as well as White and non-White surgeons? The AAOS strategic plan includes a focus on recruitment and retention of women and underrepresented persons in orthopaedics [1]. We call on the AAOS, which includes the Board of Specialty Societies, to survey our profession on burnout at regular intervals and to share these results.

Zero Tolerance for Bullying and Harassment

No one should experience or tolerate bullying or harassment. Hard stop. Each of us has a responsibility to address bullying and harassment in our profession.

Equal Recognition and Reward

Behaviors that marginalize the accomplishments of women or any demographic group should be called out and corrected. Achievements of women and non-White surgeons—including diversity activities—should be recognized as important contributions and promoted at institutions, within orthopaedic societies, and by industry.

Fair and Transparent Compensation

Orthopaedic leadership should review compensation to ensure that surgeon pay is based on transparent and fair metrics. Diversity activities should be considered when creating compensation metrics. Pay disparity sends a message that devalues diverse individuals. Fair compensation is an effective tool in alleviating burnout.

Support For Surgeon Parents

Support for parents, especially mothers, is essential to mitigate burnout. As child-rearing and domestic responsibilities continue to fall disproportionately to women in medicine, addressing such issues are paramount to promoting women in orthopaedics. Leaders need to guard against the “Daddy bonus” in which fathers are favorably perceived while the “Mommy penalty” results in working moms being perceived as “exhausted and distracted at work” [7].

Respect for Work-Life Boundaries

Although it is important to care for patients, constant availability via phone, email, and electronic health record messaging places tremendous pressure on physicians to respond immediately. For those who bear more domestic responsibilities, this can create tension and add to emotional exhaustion. Healthcare leaders need to establish basic working norms, putting guardrails around off-hours communications and providing message coverage for physicians during their time away from work. In our culture of dashboards and metrics-driven performance benchmarks, leaders need to consider the mental health of their physician workforce and set reasonable boundaries [3].

Mentorship and Sponsorship

Early and midcareer surgeons—particularly women and individuals of color—need intentional guidance from senior leaders to fulfill career goals. There is a perceived responsibility for diverse surgeons to work on diversity projects rather than specialty-focused activities [4, 8]. These younger surgeons can be directed toward endeavors that generate broader professional recognition and foster a sense of personal accomplishment.

Mental Health Support

Erasing the stigma of obtaining help for mental health issues is needed in our society as well as our profession. In the last 2 years, 40% of physician suicides have been among orthopaedic surgeons [26], and death by suicide is nearly five times more likely for women physicians compared with other academic fields [2]. With medical boards, hospitals, and insurance plans querying surgeons regarding mental health issues, orthopaedic surgeons may elect to hide such issues for fear of exclusion from licensure, privileges, and health plan participation. Women physicians, who express burnout as anxiety and depression, may not want to be perceived as emotionally unstable. Fear of disclosure of mental health concerns results in physicians suffering in silence. Internalization may increase the risk of devastating consequences like suicide. Orthopaedic leaders can support erasing this stigma by promoting education of residents and faculty on the risk of mental health issues, burnout, and suicide.

Supporting Each Other

Each of us will experience times of great personal stress. Loss of loved ones, serious illness, challenges with children can all be major life stressors. Work-life balance may be particularly stressful for orthopaedic surgeon mothers or those with aging parents who require care. Adverse patient outcomes, allegations of malpractice, and other stressors may result in loss of professional confidence, fear, and mistrust of patients. Let us make time to support each other, recognize value in each other, decrease burnout, and potentially save each other’s lives.