CSA Task Force on Physician Wellness hopes this will be the first of recurring offerings on related subjects written by its members centered around different aspects of wellness. Our intention is to present the work being done with particular relevance to anesthesiologists, and to stimulate thought and discussion among you, our colleagues.
One morning, during my third year of medical school in 1978, I had what I then thought of as a nervous breakdown. Those words were commonplace at that time, and I didn’t know what else to call this upsetting and bewildering experience. I was 23 years old and nothing like that ever happened to me before or since.
I was several weeks into my medicine rotation at the San Francisco VA Hospital, and I remember feeling increasingly overwhelmed by a mountain of clinical duties I was not competent to perform, medical knowledge I pitifully lacked, and looming expectations far beyond my capabilities. That day I was incapable of getting out of bed, terrified, mostly by the incomprehensible nature of what was happening to me.
My recollection now is of a waking nightmare, terrible racing thoughts, and anxious depression beyond words. I managed to “call in sick” to my team’s resident, and spent the morning tossing in bed, pacing through my apartment, and asking myself what was happening and what was I going to do. After desperately talking to my girlfriend, another student in my class, I was slowly able to right myself and keep my mind from foundering. The next day I showed up at the hospital, carried on more or less as normal, and have rarely spoken of this event since then.
The cover of the May 2021 issue of Anesthesiology headlines “Burnout among Anesthesiologists”, and features a study titled “Burnout Rate and Risk Factors among Anesthesiologists in the United States” by investigators from Memorial Sloan Kettering Cancer Center, Boston Children’s Hospital, and Harvard Medical School. This study was encouraged and supported by the ASA and its Committee on Physician Wellness. The publication is accompanied by an editorial, Burnout: The “Other” Pandemic. It is impossible to avoid this subject these days.
The findings suggest that a majority of U.S. anesthesiologists are at risk for burnout, and that nearly 60% of us exhibit emotional exhaustion and depersonalization (“high risk of burnout”) and 14% of us presently suffer from these maladies plus a low sense of personal accomplishment (“burnout syndrome”). Based on a survey sent to essentially all ASA members in early March 2020, these results likely underestimate the further impact that the COVID-19 pandemic has had over this past year, on the well-being of anesthesiologists across our nation.
As I think back on that time of crisis I had as a medical student more than 40 years ago, it is clear to me that I was experiencing in a very acute episode, the “three burnout dimensions” that are the core of the Maslach Burnout Inventory Human Services Survey, used in this study. These risk factors are increased emotional exhaustion, increased depersonalization, and decreased sense of personal accomplishment. I recall that year as I moved though the various clinical “rotations” of third year curriculum, never feeling as though I had mastered anything, since just when I would begin to understand the basics of the specialty to which I was assigned, the rotation ended and I would again find myself, the lowliest and most useless member of a new team, expected to do things I had no clue about. In those days, “pimping” the medical student was a common and often cruel amusement but was accepted as a sort of rite of passage. These were perhaps the most depersonalizing experiences I have ever had. Thankfully medical education has evolved in a more humane direction.
That is perhaps less true of medical practice, at least where physicians are concerned. Last week the AMA reported “for the first time, most physicians worked outside of physician-owned practices in 2020, as doctors continue to gravitate toward employment by hospitals and other organizations.” The relentless erosion of autonomy experienced by physicians in recent decades has been cited as a major contributor to cynicism, a characteristic of depersonalization. Most anesthesiologists, like other physicians, have always accepted long and unpredictable hours, disruptions of family life, and the many stresses that accompany our responsibilities for our patients’ welfare. Until recently these adversities were in some way compensated by broad autonomy and privileged authority that is unique to the profession of medicine. The rigors and sacrifices of a physician’s life were ameliorated by the community’s respect and appreciation. As medical practice has become more businesslike, conformity and adherence to the requirements of the new paradigms of EHRs, burdensome regulation, practice management companies, and corporate employment have taken a large and insidious toll on physician wellbeing. I was fortunate to have completed my medical education at a time when it was within the means of most middle-class families to finance, without being shackled by decades of debt repayment worry, but this is exactly what our youngest colleagues now must face along with the stresses of being a new doctor.
We all know this. The COVID-19 pandemic has brought a heightened awareness of our fragility. In medical institutions and departments of anesthesiology across the country, physician wellness has become a more important priority than ever before. We talk about self-care, work-life balance, reaching out and supporting one another, and finding our own individual paths to personal resilience. These are important conversations because the wellbeing of our patients depends so much on our own.
Yet this is not enough. In his editorial, Dr. Steve Hyman, a leading researcher on the wellbeing of anesthesiologists, emphasizes that while the subject has been extensively studied and urgently recognized to be a rampant problem, burnout and discontent among us continues to grow. He suggests “future burnout research should focus not only on the incidence of burnout, but also on specific modalities that can mitigate or prevent burnout altogether….To address individual issues without addressing workplace issues does not provide a comprehensive solution to the problem.” Therefore, while we continue to support and befriend each other, and seek to recognize and understand our individual spiritual and psychologic health, it is the world in which we struggle that we must also bend to our aid. Finding ways to do this, through our medical staffs, professional organizations, and society at large, is an imperative for our wellbeing and the safety of our patients.
Alfonso AM, Cadwell JB, Staffa SJ, Zurakowski D, Vinson, AE: Burnout rate and risk factors among anesthesiologists in the United States. Anesthesiology 2021; 134:683-96
Hyman, SA: Burnout: the “other” pandemic. Anesthesiology 2021; 673-75