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 login to view 6 more bullets professional quality of life both the positive and negative effects an individual experiences as a provider two domains login to view 2 more bullets 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 login to view 1 more bullet two components login to view 2 more bullets 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 login to view 1 more bullet focused on quantitative research and measuring burnout login to view 1 more bullet 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 login to view 2 more bullets 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 login to view 2 more bullets 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 login to view 4 more bullets breakdown of community lack of respect or support from peers or administration login to view 1 more bullet lack of camaraderie poor organizational culture insufficient rewards insufficient compensation or reimbursement login to view 1 more bullet 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 login to view 1 more bullet 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 login to view 2 more bullets inhibited parasympathetic nervous system activated hypothalamic-pituitary-adrenal axis login to view 1 more bullet functional and structural changes of brain login to view 3 more bullets immune system dysfunction login to view 1 more bullet 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 login to view 3 more bullets 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 login to view 3 more bullets Professional Fulfillment Index 16-item survey assess 3 domains login to view 3 more bullets Mini - Z 10-item survey validated against MBI assess 3 domains and risk factors for each login to view 3 more bullets Treatment Emergent Hospital Admission / Care indications suicidal ideation mental health crisis substance abuse Outpatient Cognitive / Multimodal Treatment indications early disease with login to view 2 more bullets modalities leave of absence or Sabbatical login to view 4 more bullets medical treatment and therapy login to view 8 more bullets work environment modifications login to view 5 more bullets 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 login to view 1 more bullet workplace community login to view 1 more bullet 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 login to view 1 more bullet exercise regularly improve sleep habits adjunct individual-level interventions login to view 5 more bullets 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 login to view 1 more bullet orthopedic residents login to view 2 more bullets only 10% of residents seek help and more than 50% physicians hesitant to seek mental health care risk factors login to view 2 more bullets protective factors login to view 11 more bullets diagnosis Patient Health Questionnaire-9 (PHQ-9) login to view 6 more bullets treatment lifestyle changes login to view 5 more bullets psychotherapy login to view 1 more bullet anti-depressant medications transcranial magnetic stimulation alternative treatments login to view 5 more bullets Substance disorders epidemiology orthopaedic residents login to view 7 more bullets practicing surgeons login to view 2 more bullets diagnosis Alcohol Use Disorder Identification Test (AUDIT) login to view 7 more bullets treatment SAMHSA national helpline login to view 1 more bullet inpatient versus outpatient rehab multifaceted approach login to view 13 more bullets 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 login to view 1 more bullet 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 login to view 3 more bullets treatment systems approach login to view 8 more bullets communicating medical errors login to view 15 more bullets