Summary Burnout (Exhaustion syndrome and professional burnout) is a condition characterized by emotional exhaustion, depersonalization, and a sense of loss of personal accomplishment. Diagnosis is made using validated questionnaires such as the Maslach Burnout Inventory and Professional Fulfillment Index. Treatment involves a combination of leave of absence, medications, therapy, and workplace modifications. Introduction Definitions burnout occupational phenomenon syndrome conceptualized as resulting from chronic workplace stress that is not successfully managed (World Health Organization) three domains emotional exhaustion depleted feeling from excessive emotional and psychological demands depersonalization view others in a detached and impersonal manner personal achievement sense of competence or accomplishment professional quality of life both the positive and negative effects an individual experiences as a provider two domains compassion satisfaction compassion fatigue compassion satisfaction pleasure caregivers experience from helping others and the degree to which they feel successful protective against burnout compassion fatigue emotional and physical exhaustion leading to a diminished ability to empathize with patients "cost of caring" two components burnout secondary trauma stress secondary Trauma post-traumatic stress disorder-like symptoms from repeated exposure to stressful event and suffering of patients History Herbert Freudenberger (1970s) psychologist who first described the term in 1974 and considered the founding father of the concept of burnout defined it as becoming exhausted by making excessive demands on energy, strength, or resources in the workplace focused on qualitative and descriptive research Christina Maslach (1970s - 2000s) psychology professor who further redefined burnout to include 3 domains exhaustion, depersonalization, lack personal achievement focused on quantitative research and measuring burnout developed the Maslach Burnout Inventory (MBI) in 1981 World Health Organization (2019) recognized as an occupational health crisis defined it an occupation phenomenon and distinguished it from a medical diagnosis or disorder Epidemiology Incidence 40-60% for orthopaedic surgeons varies by career level residents (40-50%) > attending (25-30%) > fellows (10%) PGY-2 at greatest risk Burnout by subspecialty highest rates Oncology, Sports, Trauma lowest rates Shoulder and Elbow, Pediatrics, Foot and Ankle Risk factors female early in training or practice career racial minority pre-existing mental health conditions alcohol and substance use work-life imbalance lack of exercise inability to attend health maintenance appointments marital status (single) lack of program support larger residency programs (6 or more) Protective factors parenthood married spending time with spouse parent was a physician deriving satisfaction from speaking about concerns with colleagues, family, and friends duty hour limitations compassion satisfaction peer support good patient relationship Associated conditions depression suicide medical errors substance or alcohol abuse burnout in spouse 25-30% experience burnout up to 75% report burnout had a negative effect on personal relationship sleep deprivation 92% of residents and 79% of faculty hypertension metabolic syndrome cardiovascular disease infertility Economic Costs health care system $4.6 billion estimated total annual cost due to physician burnout in US 60% more likely to take a sick day 2.5x more likely to look for new job 8% of national health care expenditure attributable to stress alone burned-out employees cost $3,400 out of every $10,000 in salary due to disengagement $125-190 million in additional health care cost from workplace stress patient medical errors lower quality of care lower patient satisfaction physician suicide depression substance abuse malpractice poor self-care Etiology Contributing variables work overload administrative and bureaucratic tasks top contributor to burnout among orthopedist quality metrics and reporting, prior authorization process, coding, excessive documentation unmanageable work schedules and inadequate staffing workflow, interuptions, and distractions inadequate technology usability time pressure and encroachment on personal time constantly evolving health care industry and need to stay informed health care reform and payment policies expansion of technology (AI, augmented reality, robotics, wearables) telemedicine privacy, security and other compliance measures breakdown of community lack of respect or support from peers or administration 2nd largest contributor to burnout lack of camaraderie poor organizational culture insufficient rewards insufficient compensation or reimbursement 3rd largest contributor to burnout social rewards (ie recognition or praise) lack of control inflexible schedule lack of practice autonomy dismissal of feedback lack of cross coverage limited maternity/paternity leave conflict of values mismatch of values and expectations between physician and employer disconnect between mission statement and daily proceedings degrade patient-physician relationship sense of prioritizing cost and documentation over patient care lack of fairness inequity of workload or pay unfair evaluations or performance reviews mishandling of promotions Pathophysiology multiple pathways/organs affected upregulation of sympathetic nervous system sympathetic-adrenal-medullary (SAM) axis catecholamine release inhibited parasympathetic nervous system activated hypothalamic-pituitary-adrenal axis cortisol and DHEA imbalance functional and structural changes of brain decrease in volume of hippocampus and frontal lobes decrease neurogenesis decoupling interconnections of brain immune system dysfunction pro-inflammatory state end organ injury Presentation Signs and symptoms emotional detachment anxiety sadness lack of emotion irritability behavioral withdrawal isolation cynicism resentment hostility addictive behaviors loss of motivation frequently late or missing work substance abuse substance abuse cognitive sense of failure and doubt memory problems difficulty concentration lack of creativity physical lack of energy sleep disturbances generalized aches muscle tension gastrointestinal issues hypertension DIAGNOSIS Missed diagnosis most common reasons burned-out orthopedic surgeons don't seek help symptoms are not perceived to be severe enough (~50%) too busy (40%) Validated diagnostic questionnaires Maslach Burnout Inventory (MBI) one of the most widely used and validated tools to measure burnout 22-item self-reported questionnaire all 3 domains of burnout assessed emotional exhaustion depersonalization personal accomplishment Professional Quality of Life scale (ProQOL) comprehensive assessment of the positive and negative effects of helping others experiencing trauma or suffering 30-item self-reported questionnaire assess 3 domains burnout compassion satisfaction secondary trauma stress Professional Fulfillment Index 16-item survey assess 3 domains work exhaustion interpersonal disengagement professional fulfillment Mini - Z 10-item survey validated against MBI assess 3 domains and risk factors for each satisfaction stress burnout Treatment Emergent Hospital Admission / Care indications suicidal ideation mental health crisis substance abuse Outpatient Cognitive / Multimodal Treatment indications early disease with physician (patient) not at risk no evidence of impaired care to patient modalities leave of absence or Sabbatical disconnect from professional demands rediscover values and work-life balance reorganize priorities mental and physical recovery medical treatment and therapy medications treat associated mental health conditions mind-body therapy and mindfulness activities psychotherapy counseling session and workshops time management stress management marriage counseling work environment modifications acknowledge limitations prioritize tasks and delegate workplace analysis and identify stressors improve workflow don't take work home PREVENTION Oranizational-level (POSNA model) individual provide members with programs to build personal resilience provide tools to identify, monitor, and measure burnout survey members understand and address specific stressors understand business model that health care systems can use to prioritize well-being understand factors unique to different populations unit or care team (peer support) develop community of caregivers committed to creating collaborative culture primary focus on developing exception teams secondary focus on developing exception team members to support team provide programs to build team work and nourish compassion create support groups and referral systems instruct "teachable" attributes and skills related to compassionate care and team work teach techniques fir recruiting and hiring based on empathy, compassion, and emotional intelligence explore impact of disruptive behavior (ie harassment, bullying) organizational develop organizational structure to achieve objectives each committee should examine their specific goals/objective through lens of reducing burnout and improving wellness teach organizational leadership skills offer leadership courses collaborate with other organizations to promote wellness Individual-level awareness open dialogue and communication honesty and vulnerability amongst stakeholders COMPASS group improve workload, efficiencies, and support effective multi-disciplinary teams decrease clerical and non-visit care burden analytic support for data management enhance work culture and environment leadership behaviors develop talent, transparency, recognize contributions, treat all with respect workplace community wellness program, team building, group dynamics and workplace culture, conflict resolution training work-life balance, flexibility, and autonomy limit off hours work demands part-time status without limiting advancement opportunity flexible schedule personal time for relationships and hobbies meaningful work 20% of time spent on meaningful work decreases risk of burnout recruit to match talents and passions to job resources to accomplish low-meaning tasks (clerical or administrative duties) self care eat nutritious food avoid eating high-stress diet of junk food as coping mechanism exercise regularly improve sleep habits adjunct individual-level interventions mindfulness activities stress reduction techniques self reflection gratitude journal meditation or yoga believe in something bigger than yourself spend time with significant others and family fill environment with mood-boosters (lighting, music, scents) Complications Depression epidemiology 2x more likely to commit medical error with depression practicing surgeons 15-30% orthopedic surgeons orthopedic residents 13% rate of depression 2x than general population only 10% of residents seek help and more than 50% physicians hesitant to seek mental health care risk factors exceeding duty hour restriction lack of program support associated with depression protective factors practicing surgeons marriage or spousal support career satisfaction autonomy academic setting orthopedic residents strong mentorship educational opportunities dedicated mental health resources surgical independence increased case volume/variety diagnosis Patient Health Questionnaire-9 (PHQ-9) score severity (0-27) of depression and recommended course of action minimal or none (0-4): monitor, no treatment required mild (5-9): use clinical judgement to determine necessity of treatment moderate (10-14): use clinical judgement to determine necessity of treatment moderately severe (15-19): warrant active treatment severe (20-27): warrant active treatment treatment lifestyle changes exercise social support nutrition sleep stress reduction psychotherapy group vs individual therapy anti-depressant medications transcranial magnetic stimulation alternative treatments mindfulness meditation yoga or tai chi relaxation techniques vitamin or herbal supplements fish oil, vitamin D, folate, St. John Wort Substance disorders epidemiology orthopaedic residents 61% alcohol dependence and 43% alcohol abuse risk factors men white race single or divorced 7% of use recreational drugs divorced or single was associated with drug use practicing surgeons 15% rate alcohol dependence or abuse ~30% of orthopedist have 5+ drinks per week diagnosis Alcohol Use Disorder Identification Test (AUDIT) scores ranges 0-12 with higher scores indicating greater consumption hazardous alcohol use 3 or more for women 4 or more for men alcohol abuse 4 or more for women 5 or more for men treatment SAMHSA national helpline confidential free help getting information and finding treatment inpatient versus outpatient rehab multifaceted approach education about substance use disorders group and individual counseling self-help group 12-step programs (ie AA, NA) medication reduce withdrawal symptoms and cravings naltrexone, acamprosate and disulfiram for alcohol abuse nicotine replacement, bupropion, and varencicline for nicotine addition methadone or naltrexone for opioid addiction relapse prevention treat concurrent mental health disorders relapse prevention training long term follow-up to monitor for relapse Suicide epidemiology orthopaedic surgeons have highest prevalence of death by suicide among all surgical specialities (28%) 2nd highest rate (18%) of suicidal ideation Asian/Pacific Islander surgeon more likely than general population increased risk with mental health disorders, alcoholism, legal issues men more likely to commit suicide at an older age than women (64 vs 39) treatment seek immediate treatment, call 911 or national suicide prevention lifeline if having suicidal thoughts see contacts above education and prevention address underlying mental health issues and substance use disorders as stated above Malpractice/ Errors epidemiology 17% increased odds of being named in a medical malpractice suit higher level of depersonalization and emotional exhaustion lead to incrementally more errors 2x increased odds of adverse patient safety incidents lower patient reported satisfaction exhibiting lower professionalism treatment systems approach prevention strategies leverage standardized systems (EHR, barcoding systems) improve communication (ie handoffs) surgical timeouts collaborative efforts involve patient monitoring and reporting methods root cause analysis communicating medical errors ethical and professional obligation to report medical error to patient disclosure conversation includes communicate error directly with patient/family as soon as possible what happened why it happened health implication to the patient identify measure being put in place to prevent recurrences during conversation physician should sit down listen attentively work to understand concerns of patient and family show compassion acknowledge emotional response and need AAOS advisory statement "good communication has a favorable impact on patient behavior, patient care outcomes, patient satisfaction, and often reduces the incidence of malpractice lawsuits"