“Towards the Mental Well Being and Health of the Faculty: Quo Vadis?”

Surgical Education Week 2012APDS Panel

Merril T. Dayton, MDProfessor and Chairman

SUNY Buffalo

Complex Times and Clarity of Thought

“There are known knowns. These are things that we know we know. There are known unknowns. That is to say these are things we know we don’t know. But there are also unknown unknowns. These are things we don’t know we don’t know.”

Donald Rumsfeld, October 3, 3006

These Are Difficult Times in General

Tornados

War

Devastating Earthquake and Tsunami

- Japan

These Are Difficult Times forAcademic Surgeons

Specific Stressors and Pressures:

• Lower reimbursement

• Loss of practice independence and

autonomy

• Higher malpractice suits and insurance rates

• Great pressure to publish

• Constant emphasis on greater clinical

activity

These Are Difficult Times forAcademic Surgeons

Specific Stressors and Pressures:

• Increased work load secondary to 80-hour work week

• Surgeon shortage leading to more work hours and more nights on call

• Inability to control time or work load

• Little reward for teaching activity

• Inadequate time to spend with spouse/family

Evidence of Stressors and PressuresTaking a Toll

American College of Surgeons Survey (June 2008)

• Sent to 24,922 members of ACS

• Returned by 7,905 (32%)

• Standardized survey tools used

• Burnout (Maslach)

• Depression (PCEMD)

• Mental and Physical QOL

Burnout and Career SatisfactionAmong American Surgeons

Negative Responses

• 40% of surgeons showed signs of burn out

• 30% screened positive for depression

• 28% had a low mental QOL score

Shanafelt, Ann Surg 2009;250:463-471

MDNews.com

Burnout and Career SatisfactionAmong American Surgeons

Negative Responses (cont.)

• 36 % felt their work schedule left inadequate time for personal life

• 32% had high emotional exhaustion

• 26% demonstrated high depersonalization

• 13% had a low sense of personal accomplishment

Shanafelt, Ann Surg 2009;250:463-471

Burnout and Career Satisfaction Among American Surgeons

Positive Responses

• 71% would become a physician again

• 74% would specifically become a surgeon

again

• 51% would recommend surgery career to kids

Shanafelt, Ann Surg 2009;250:463-471

Burnout and Career Satisfaction

Factors Associated With Greater Satisfaction

• Area of specialization (transplant, pediatric, trauma, etc)

• Rank of Full Professor

• Being in active military practice

• Time dedicated to non-patient activity

• More hours in the OR

Shanafelt, Ann Surg 2009;250:463-471

Burnout and Career Satisfaction

Factors Associated With Less Satisfaction

• Increasing nights on call

• Increasing hours worked per week

• Having compensations entirely based on billing

• Burnout the single greatest predictor of career

satisfaction

Shanafelt, Ann Surg 2009;250:463-471

Hours Worked, Burnout andMedical Errors

Balch, JACS 211:609, 2010

Hours Worked (hrs/week)

<60 60 -80 >80

Burnout 30% 44% 50%

Medical Errors 6.9% 9.8% 10.7%

Depression 25% 31% 39%

High Mental QOL 43% 43% 14%

SF-12 Physical Scale 55.3 55.9 85.5

Call Nights per Week and Burnout

Call Nights (Per Week)

<1 2 3 >3

High Mental QOL 44% 20% 12% 24%

Depression 22% 34% 34% 35%

Medical Error 7.3% 10% 10% 10%

Balch, JACS 211:609-619, 2010

Suicidal Ideation (SI) Among Surgeons

• 501/7905 surgeons (6.3%) had SI

• Prevalence in U.S. was 3.3% among general population

• Only 130 surgeons with SI sought help (26%)

• As many as 50% of individuals with SI may make an attempt at suicide

• 301 reluctant to seek help secondary to fear of license loss

• SI had adverse relationship with burnout and depression

Balch, JACS 211:609-619, 2010

Factors Independently Associated with SI

Characteristic OR pValue

Depression 7.01 <.001

Burnout 1.91 <.001

Major Medical Error 1.87 <.001

Youngest Child 19-22 1.56 .004

Incentive Pay Only .79 .03

Married .66 .02

Practice in Academic Center .58 <.001

Balch, JACS 211:609-619, 2010

Work-Home Conflicts and Burnout by SexAmong Surgeons

Characteristic Women Men

Burnout 43.3% 39%

Depression 33% 29%

Work-Home Conflict (3 wks) 62% 48%

Conflict with Spouses Career 53% 41%

Child-rearing Slowed Advancement 57% 20%

Low Mental QOL 34% 27%

Dyrbye, Arch Surg 2011;146:211-217

• Survey of faculty at single, large institution

• 47% of faculty felt their working hours had increased

(not born out by time studies – 70.4 vs 69.9)

Impact of 80-hr Work Week on Faculty

• 46% viewed global impact of 80 hr work week as harmful to faculty

• 50% of faculty felt patient care was worse

• 94% felt that the current lack of continuity compromised patient care

Winslow ,Curr Surg 2004 Nov-Dec;61(6):602-608.

Impact of 80-hr Work Week on Faculty

• Survey to all surgeons and non-surgeons at a single institution

• 56% felt they had less time to teach

• 43% less satisfied with job after 80 hr work week was instituted

• 42% reported greater work hours

• 33% had less time for extracurricular activities

• 33% felt patient care was worse

• Surgeons more likely to report the negative impact noted above

Vanderveen, Arch Surg, 2007 Aug;142(8):759-766

Impact of 80-hr Work Week on Faculty

• Prospective time studies at a single institution both before and 1 year

after 80 hr work week

• Significantly decreased burnout scores, less emotional exhaustion, better

QOL among residents

• Faculty felt their QOL was “somewhat worse” after inplementation

• Faculty concerns about shift mentality, less continuity of care, decrease

in patient-doctor relationship

Hutter, Ann Surg, Jun;243(6):864-875, 2006

Career and Lifestyle Changes Among Surgeons

• Survey sent to ABS diplomates (1988-2004)

• Surgeons worked 64 hrs/week

• 85% satisfied with their work

• 59% of surgeons believed they worked too hard

• 54% felt that the 80-hr work week had increased surgeons’ work

hours

Troppmann, JACS 2009; 209:160-169

Career and Lifestyle Changes Among Surgeons

• 40% would not recommend surgery career to their kids

• 34% did not achieve work-life balance

• Respondents lives could be improved by:

- Limiting ER call (77%)

- Diminishing litigation (92%)

- Improving reimbursement (94)

Troppmann, JACS 2009; 209:160-169

Health, Practice, Fate of General Surgeons

• Survey of all former residents of a surgical program (114) over 25 year period

• 89% were married, divorce rate of 21%

• Major health issues occurred in 32% of all, 50% of those were over 50

• 62% exercised at least 3/ week

• Body mass index increased from 23.9 to 26.6 from age 40 to 50

• Alcohol dependency occurred in 7.3%

• Overall 75% were satisfied with their career

• 20% voluntary or involuntary rate of retirementHarms, Ann Surg, 2005 Oct;242(4):520-529

Suboptimum Attention to Self Wellness by Surgeons

• “Ignorance, indifference, carelessness of physicians toward their own

health” (Arentz, Soc Sci Med 52:203, 2001)

• Physicians neglect to have physical exam and procrastinate when

seeking medical help

• Many do not have personal internist or family physician

• They often work even when unwell

Suboptimum Attention to Self Wellness by Surgeons

• Surgeons often rely on denial and avoidance as coping strategies

• Surgeons feel uncomfortable in the role of patient

• Fear others will interpret need for help as inability to cope

• Surgeons often ignore indicators of distress

• Surgeons possess certain traits which correlate with adverse health

outcomes (perfectionism, workaholism, Type A)

• Feel pressure from patient and colleagues to appear well

Surgeon Wellness: A Missing Quality Indicator

• Health systems should routinely measure surgeon wellness

• Patient care suffers when surgeons are unwell

• Error rates increase with burnout and depression

• Productivity plummets with mental health problems

• Physician wellness should receive the same priority as patient care and

financial viability

Wallace, Lancet 324:1714, 2009

Strategies to Prevent Surgeon Burnout

Personal

• Spend time with family and friends

• Emphasize self-care (nutrition, exercise)

• Supportive spouse or partner

• Religious or spiritual activity

• Influence personal happiness through personal values and choices

• Adopt a healthy philosophical outlook

Spicknard, JAMA 2002; 268:1447

Strategies to Prevent Surgeon Burnout

Work

• Have a mentor

• Provide adequate administrative support system

• Find meaning in your work

• Set some limits or boundaries

• Control environment workload

Spicknard, JAMA 2002; 268:1447

Chair’s Role in Assuring Mental Wellness

• Recruit faculty who “fit in” with your group, share your values

• Meet with them often at first

• Provide a thoughtful, proven mentor

• Help them be successful in clinical & research mission

• Create an environment of team support, acceptance

• Guard against excessive criticism, gossip, cheap shots

Chair’s Role in Assuring Mental Wellness

• Watch carefully for signs of burnout & provide counseling

• Genuine accolades, positive reinforcement go a long way

• Set the bar high, but know faculty well - be realistic

• Provide opportunities for leadership

• Be careful not to overload proven faculty

• Be positive, upbeat – remind faculty what a privilege it is to be

a surgeon

“A man who has long practiced surgery, and practiced it well, has a right to feel

that he has not lived in vain; but has done good to his fellow men.”

DaCosta

“Towards the Mental Well Being and Health of the Faculty: Quo Vadis?”

Surgical Education Week 2012APDS Panel

Merril T. Dayton, MDProfessor and Chairman

SUNY Buffalo