Health and Wellness for the Vascular Surgeon

Introduction

The epidemic of physician burnout has been declared a public health crisis, and a growing focus for occupational intervention. Symptoms of burnout are particularly problematic among surgeons and surgical trainees in comparison to the general population (53% vs. 26%). Burnout is characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment and arises from a chronic disparity between people and their work setting. The 2019 11th Revision of the International Classification of Diseases (ICD-11) has newly specified burnout as an occupational phenomenon, in contrast to a medical condition. Personal ramifications of such may include broken relationships, alcohol and substance abuse, depression, suicidal ideation and suicide. Physicians have higher rates of suicide than the general population, with relative risks of 1.1–3.4 for men, and 2.5–5.7 for women. ^, Moreover, compared with white male professionals, physicians’ proportionate mortality ratio is higher for suicide than for all other causes of death. ^,

Burnout also threatens quality of patient care, safety, patient satisfaction, productivity, and physician retention (i.e., turnover and premature retirement). A recent meta-analysis, which included 47 studies of over 42,000 physicians, revealed physician burnout to be associated with an increased risk of patient safety incidents, poorer quality of care due to low professionalism, and reduced patient satisfaction. A survey of over 7900 surgeons revealed 9% reporting concern that they had made a major medical error in the last 3 months. More than 70% of surgeons attributed the error to individual rather than system level factors and further analysis revealed a direct association between burnout scores and the likelihood of committing a major medical error. By multivariate analysis, a positive depression screen and burnout were factors independently associated with perceived medical errors, and this relationship persisted into longitudinal studies independent of fatigue.

Burnout is a major driver of physician turnover and multiple large, national studies of US physicians have indicated that burnout is one of the largest factors determining whether or not physicians intend to leave their current position over the next 24 months. ^, Burnout has also been linked to premature retirement by surgeons and has been shown to decrease professional work effort in prospective, longitudinal studies. ^, As one example, a 2014 survey of American physicians revealed that 1 in 5 US physicians intend to reduce their clinical work hours in the next year, and 1 in 50 US physicians intend to leave medicine altogether in the next 2 years to pursue a different career. Physician turnover results in direct costs associated with recruitment alongside lost revenue during recruitment, onboarding, and the time it takes for a new physician to reach optimal efficiency in a new system. Historical studies suggest that the cost to replace a physician is 2 to 3 times the physician’s annual salary, and likely higher for subspecialty physicians. It has been estimated that physician burnout results in $4.6 billion/year related to physician turnover, and reduced productivity (approximately $7600 per employed physician/year). These direct costs of turnover fail to account for the disruptive impact of turnover on patients, other members of the care team, and the organization’s culture and reputation.

Burnout in Vascular Surgery

Vascular surgeons appear to be at high risk for occupational burnout, as supported by a study of US surgeons across 14 surgical specialties which identified vascular surgeons as having the second highest rate of burnout and the lowest level of career satisfaction. Approximately one-third of vascular surgeons in this study reported symptoms of depression and, when compared to other surgical specialties, vascular surgeons report the highest incidence of suicidal ideation. Moreover, vascular surgeons were the most likely (36%) to suggest they “would not become a surgeon again” in comparison to general surgeons (32%), cardiothoracic surgeons (27.5%), urologic surgeons (26%), orthopedic surgeons (20%), and pediatric surgeons (15.6%). Vascular surgeon burnout may compromise the recruitment of trainees and new physicians into the specialty in addition to the retention of existing vascular surgeons. ^, These risks are especially poignant given the impending workforce challenges described by a 2016 U.S. Department of Health and Human Services Report on Surgical Supply and Demand projecting a 520 full-time equivalent (FTE) deficit of vascular surgeons by 2025. ^{, ,}

In a 2018 survey of 2905 active Society for Vascular Surgery (SVS) members, 41% of respondents met criteria for burnout, as defined by high emotional exhaustion and/or depersonalization scores. Importantly, 37% endorsed symptoms of depression in the past month and 8% indicated they had considered suicide in the last 12 months. Based on multivariable analysis, age, work-related physical pain, and work–home conflict were independent predictors for burnout. Unpublished data from the same survey data stratified results by gender noting a similar prevalence of burnout among men and women at approximately 40%. However, the prevalence of suicidal ideation within the past year was significantly (twofold) higher for women than men (12.9% for women vs. 6.6% for men). Furthermore, conflict between work–life balance was greater in women than in men, with women reporting more time spent working at home on the electronic medical record (6.4 vs. 4.7 hours; P < 0.0001) and other nonclinical work-related tasks (6.5 vs. 5.4 hours; P < 0.05) compared to men. Predictors of burnout in women in the survey included not enough family time and work-related pain. In addition, work-related pain was an independent predictor for suicidal ideation for both men and women. Taken together, symptoms of burnout and depression are common among vascular surgeons, and there are gender-based differences driving career dissatisfaction and burnout.

Optimizing Health and Wellness

Physician burnout is multifactorial, attributed to key drivers that encompass: (1) meaning in work; (2) excessive workload; (3) inefficient work environment and/or inadequate support; (4) problems with work–life integration; (5) loss of autonomy and control; (6) culture and values; and (7) community at work. These drivers fall into three major domains: efficiency of practice and a culture of wellness are primarily organizational responsibilities, while maintaining personal resilience is primarily the obligation of the individual physician. These domains reciprocally influence the others necessitating a balanced approach to building a stable platform that will drive sustained improvements in physician well-being and the overall performance of our healthcare system. Growing data support that physicians are not resilience-deficient, and that burnout rates are substantial even among the most resilient physicians, further supporting efforts to address system issues in the clinical care environment to reduce burnout and promote physician well-being.

The aforementioned drivers of burnout and wellness are each influenced by national, organizational, work unit, and individual factors. Organizations have the opportunity to make profound and effective changes with limited investment. A systematic review and meta-analysis of 15 randomized controlled trials and 37 observational studies supported that individual-focused interventions (i.e., mindfulness, self-care training, stress management) and structural organizational interventions (i.e., duty hour restrictions, clinical work process optimizations) can successfully reduce burnout domain scores.

Shanafelt et al. have previously proposed a framework of shared responsibility to drive system-level solutions across nine domains :

• 1.

  Acknowledge and assess the problem

• 2.

  Harness the power of leadership

• 3.

  Develop and implement targeted work unit interventions

• 4.

  Cultivate community at work

• 5.

  Use rewards and incentives wisely

• 6.

  Align values and strengthen culture

• 7.

  Promote flexibility and work–life integration

• 8.

  Provide resources to promote resilience and self-care

• 9.

  Facilitate and fund organizational science.

Each domain warrants independent consideration.