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Statement on Burnout

Developed by: Quality Management and Departmental Administration
Approved by: ASA House of Delegates on October 13, 2021

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Prevention of burnout is important for maintenance of physical and mental health. It has many sources, including production pressure, workplace culture, and limited autonomy in the workplace. This results in poor job satisfaction and increases the rates of employee turnover, translating to higher costs for employers and reducing patient access to healthcare. 1 Burnout leads to increased cardiac disease among physicians, including hypertension and coronary disease.2  A prospective study of more than 90,000 people concluded that those who reported work-related job strain had a 16% increase in relative risk of symptomatic coronary disease while those who reported both job strain as well as effort-reward imbalance had a 41% increase in coronary artery disease relative to those who did not report either.3  Additionally, markers of abnormal glucose metabolism were found in physicians reporting symptoms of burnout.4  The risk of burnout is greatest during residency training particularly in the early years with an average rate of 50% significantly increasing risk of both substance abuse and suicide. 5

Recommendations

  1. Physician anesthesiologists and members of the care team should receive training in burnout recognition and countermeasures to minimize its effects.
  2. Anesthesiology residency training programs and fellowship training programs should educate, evaluate, and respond to residents in matters of wellness and suspected burnout.
  3. Individual physician anesthesiologists must be able to report burnout in themselves or others without fear of disciplinary action by their employer, residency or fellowship program, or healthcare system.
  4. Anesthesia and surgical practices, in partnership with hospitals, should identify sources of clinician and staff burnout and institute mitigation efforts.

Background summary of literature

Definition

The ICD-11 defines burnout as an occupational “syndrome… resulting from chronic workplace stress that has not been successfully managed.” It is characterized by feelings of “energy depletion or exhaustion,” “feelings of negativism or cynicism related to one’s job,” and “reduced professional efficacy.”6  Approximately 45% of physicians across all specialties report at least one symptom of burnout.7 

Anesthesiologists may experience higher rates of burnout and depression compared to other physician groups: Two-thirds of respondents report at least one element of burnout and demonstrate increased likelihood for depression.8 Burnout and depression are disproportionally associated with high rates of suicide rates among physicians, residents and even medical students, as compared to the general population. 

Clinician burnout impacts patient care, lowers patient satisfaction and increases healthcare costs.9 The Federation of State Medical Boards’ Report on Wellness cites a study of 210,000-400,000 deaths associated with preventable errors, a number of which were attributed to burnout and its drivers.10,11

Anesthesiologists are more likely to have personality traits such as perfectionism and self-denial which may make them more susceptible to experience burnout. Overall a number of common underlying causes of burnout include:

  1.  High expectations in term of quality of care from physicians by patients and the public.
  2. High clinician workload and work hours
  3. Challenging and traumatic events, including second victim experiences.
  4. Situations where an individual may feel their personal safety is at risk, such as experienced in the COVID-19 pandemic.
  5. Reduced physician autonomy through indiscriminate application of policies and protocols


Special Considerations for Residents and Fellows:
Anesthesiology Residents and Fellows are at greater risk of burnout. The unique rigors of postgraduate training exacerbate feelings of loneliness and isolation. The high-risk nature of anesthesiology practice, particularly in emergency situations, is a significant source of stress. Resident wellness is directly connected to their practice competence, professionalism, career satisfaction and their quality of care. Junior residents are more susceptible to stress.12

Measuring burnout:
Accurate measurement of the extent of burnout is needed to conduct needs assessment, develop appropriate interventions, and establish suitable ongoing monitoring.13  Physician wellbeing has the potential to affect workforce stability as well as the quality of care provided. 14

There are many tools for assessing burnout. The Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-HSS [MP]) and the Wellbeing Index (WBI) are commonly used. While each of these assessment tools have strengths and limitations, the 22-item MBI [MP] and the 9-item WBI are most widely used since they are the most pragmatic. 15

Mitigation strategies
Few studies have examined the effectiveness of burnout mitigation strategies for anesthesiologists. Most published studies have focused on emergency room physicians and critical care physicians. 

Suggested mitigation strategies include: 16 

  1.  Education about burnout recognition and wellbeing.
  2. Regular assessments for early identification, intervention with the provision of a supportive and accepting culture for affected clinicians.
  3. Providing counseling, support networks, and resiliency training to affected clinicians.
  4. Access to appropriate resources and confidential treatment for those at risk for substance abuse.
  5. Limiting work hours to allow clinicians to care for their personal health and provide for work-life balance. 
  6.  Workplace safety, both physical and psychological.
  7. Promotion of interdisciplinary teamwork, good communication skills, and shared decision making.
  8. Adequate staffing and support for clinicians. Development of peer support groups (PSG).

 
Targeted mitigation strategies for trainees should be a priority given the higher rates of burnout among junior colleagues, but support for clinicians should also be addressed. The creation and implementation of peer support groups (PSG) has been utilized in Canadian anesthesiology training programs to address each of these unique stressors and others in hopes of preventing, identifying, and mitigating burnout among trainees. 17

Conclusion
Burnout reduces physicians’ quality of life, decreases productivity, worsens patient outcomes, increases physician turnover and is associated with higher employment costs. Fundamentally, burnout should be treated as both an individual and a systems problem.

1Thomas LR, Ripp JA, West CP. Charter on Physician Well-being. JAMA. 2018;319(15):1541–1542. doi:10.1001/jama.2018.1331.
 2Yates SW. Physician Stress and Burnout. Am J Med. 2020 Feb;133(2):160-164. doi: 10.1016/j.amjmed.2019.08.034. Epub 2019 Sep 11. PMID: 31520624.
 3Dragano N, Siegrist J, Nyberg ST, Lunau T, Fransson EI, Alfredsson L, Bjorner JB, Borritz M, Burr H, Erbel R, Fahlén G, Goldberg M, Hamer M, Heikkilä K, Jöckel KH, Knutsson A, Madsen IEH, Nielsen ML, Nordin M, Oksanen T, Pejtersen JH, Pentti J, Rugulies R, Salo P, Schupp J, Singh-Manoux A, Steptoe A, Theorell T, Vahtera J, Westerholm PJM, Westerlund H, Virtanen M, Zins M, Batty GD, Kivimäki M; IPD-Work consortium. Effort-Reward Imbalance at Work and Incident Coronary Heart Disease: A Multicohort Study of 90,164 Individuals. Epidemiology. 2017 Jul;28(4):619-626. doi: 10.1097/EDE.0000000000000666. PMID: 28570388; PMCID: PMC5457838.
  4Deneva T, Ianakiev Y, Keskinova D. Burnout Syndrome in Physicians-Psychological Assessment and Biomarker Research. Medicina (Kaunas). 2019 May 24;55(5):209. doi: 10.3390/medicina55050209. PMID: 31137738; PMCID: PMC6571619.
 5Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009;1(2):236-242. doi:10.4300/JGME-D-09-00054.1.
 6World Health Organization. Burn-out an “occupational phenomenon”: International Classification of Diseases. https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases. Accessed November 9, 2020.
 7 Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600-13. doi: 10.1016/j.mayocp.2015.08.023. Erratum in: Mayo Clin Proc. 2016 Feb;91(2):276. PMID: 26653297.
 8Hyman SA, Shotwell MS, Michaels DR, Han X, Card EB, Morse JL, Weinger MB. A Survey Evaluating Burnout, Health Status, Depression, Reported Alcohol and Substance Use, and Social Support of Anesthesiologists. Anesth Analg. 2017 Dec;125(6):2009-2018. doi: 10.1213/ANE.0000000000002298. PMID: 28991114.
 9James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013 Sep;9(3):122-8. doi: 10.1097/PTS.0b013e3182948a69. PMID: 23860193.
 10Federation of State Medical Boards. Physician Wellness and Burnout: Report and Recommendations of the Workgroup on Physician Wellness and Burnout. April 2018. https://www.fsmb.org/siteassets/advocacy/policies/policy-on-wellness-and-burnout.pdf. Accessed November 9, 2020.
 11Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017 Jan;92(1):129-146. doi: 10.1016/j.mayocp.2016.10.004. Epub 2016 Nov 18. PMID: 27871627.
12Dyrbye LN, Satele D, Sloan J, Shanafelt TD. Ability of the physician well-being index to identify residents in distress. J Grad Med Educ. 2014 Mar;6(1):78-84. doi: 10.4300/JGME-D-13-00117.1. PMID: 24701315; PMCID: PMC3963800.
 13Lall MD, Gaeta TJ, Chung AS, Chinai SA, Garg M, Husain A, Kanter C, Khandelwal S, Rublee CS, Tabatabai RR, Takayesu JK, Zaher M, Himelfarb NT. Assessment of Physician Well-being, Part Two: Beyond Burnout. West J Emerg Med. 2019 Mar;20(2):291-304. doi: 10.5811/westjem.2019.1.39666.
14Rohland, B. M., Kruse, G. R., & Rohrer, J. E. (2004). Validation of a single-item measure of burnout against the Maslach Burnout Inventory among physicians. Stress and Health: Journal of the International Society for the Investigation of Stress, 20(2), 75–79. https://doi.org/10.1002/smi.1002.
15Dyrbye, L. N., D. Meyers, J. Ripp, N. Dalal, S. B. Bird, and S. Sen. 2018. A Pragmatic Approach for Organizations to Measure Health Care Professional Well-Being. NAM 16Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201810b.
  World Medical Association. WMA Statement on Physicians Well-Being. Adopted by the 66th WMA General Assembly, Moscow, Russia, October 2015. https://www.wma.net/policies-post/wma-statement-on-physicians-well-being/. Accessed November 9, 2020.
 17 Spence, Jessica, David Smith, and Anne Wong. 2018. “Stress and Burnout in Anesthesia Residency: An Exploratory Case Study of Peer Support Groups”. Qualitative Research in Medicine and Healthcare 2 (2). https://doi.org/10.4081/qrmh.2018.7417.