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| EDITORIAL |
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| Ahead of print publication |
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Burnout of a peripheral government surgeon: Need to extinguish?
Shrirang Vasant Kulkarni, Manish Kumar Sondhi
Department of GI Surgery and Liver Transplantation, Army Hospital Research and Referral, New Delhi, India
| Date of Submission | 13-Aug-2022 |
| Date of Acceptance | 16-Aug-2022 |
| Date of Web Publication | 21-Nov-2022 |
Correspondence Address:
Shrirang Vasant Kulkarni,
Department of GI Surgery and Liver Transplantation, Army Hospital Research and Referral, New Delhi - 110 010
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmms.jmms_132_22
ABC, 40, a surgeon at a remote lurk,
Recently turned short-tempered, often late with work.
He's exhausted, disconnected and blunt in emotion,
Long lost seem, jogging and badminton.
Evenings busy "recreating," often alone, emergency calls a burden!
| Introduction | |  |
Although rarely, unfortunately, one does hear of an earlier hard-working surgeon now working hardly or being turned into a "nonoperating surgeon." In fact, there is an alarmingly high rate of burnout among surgeons, which, in turn, carries an enormous personal and professional toll and strains the social and financial resources of the health-care system.
Meta-analysis by Kesarwani et al. in 2020 indicates that approximately one-fourth of the doctors in India suffer from burnout, while alarmingly high rates up to 66% among the US military general surgery residents were reported by Modlin et al.[1],[2] The last few years have seen an ever-increasing interest in the topic with an exponential growth in the number of articles published [Figure 1]. | Figure 1: Ever-increasing number of PubMed hits for the search term "burnout" between 1967 and June 2022
Click here to view |
| Burnout: What Is It? | | |
The first written descriptions of what is referred to as "burnout" today may date back to the Old Testament, in which Moses' father-in-law says, "You will only wear yourselves out. The work is too heavy for you; you cannot handle it alone!"
Maslach et al. described the three key dimensions of burnout: overwhelming emotional exhaustion with feelings of cynicism, detachment from the job (depersonalization), and a sense of ineffectiveness with a lack of personal accomplishment.[3] The intriguing aspect is that the World Health Organization during the International Classification of Diseases has included the same three components while defining burnout "as a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed," but stressed that the definition is applied strictly in the occupational context only.[4] Burnout does not necessarily mean excessive work-related exhaustion only but includes frustration, loss of hope, and other work-related stress draining energy both mentally and physically.
| Inducement of Burnout | | |
Although burnout is the result of external influences on the surgeon's mind, his/her personality including grit, upbringing, role models, expectations from life and profession, moral values, the level of stress tolerance, resiliency, and organized or available coping mechanisms do play a major role.
Surgeons are expected to deliver high-standard services with near-zero errors, while the mismatches between clientele expectations and ground realities are ever increasing. Handful examples of legal battles between demanding clientele and surgeons in the recent past show that the surgeon has to fight his own battle, unprotected by the organizational back-up. Should the honeymoon phase of enthusiasm in a young surgeon fade away, acute or chronic stressors slip in easily, and the phase of apathy may be no longer away.
In professional lives in a nonprofit setup, when the health-care provider delivers satisfactorily, he may receive, at most, a bit of praise. However, in case of a mistake, "awards" of punishment may be heavy. This is particularly substantial and severe in the surgical discipline, where the risks outnumber other medical fields.
Nonavailability of equipment, investigations, and trained workforce lead to a different cause of burnout: futility! Facing such adverse situations an individual surgeon may be an ideal candidate for frustration and burnout, especially if it lingers on for a long time.
The imbalance between career, family, and personal growth poses stress. Proneness to disturbed family life, postings to nonfamily places, frequent relocations, nonavailability of suitable accommodation, and above all disturbed schooling and parental care of children only add to it.
Mandatory service for certain years as a general surgeon and heavy weightage of confidential reports toward the consideration of eligibility for subspecialty courses may dissuade a few surgeons from trying their best to fit in the government's requirements-based vacancies. As of now, hardly any structured program for the same is laid out, possibly due to operational constraints.
"Nothing should go wrong under my diktat" are constant fears of the top brass, which may dissuade a surgeon doing the basic job, one is supposed to do. The moment a difficult/critical case arrives, the entire emphasis is to transfer the patient alive to a higher center. This psychosis denies of the peripheral surgeon a chance of managing the patient for which he/she is primarily posted there, denting learning within safety limits and morale, and leaving with work-related frustration.
The typical young enthusiast surgeon in a peripheral location may be almost devoid of work, and a surgeon posted to a busier bigger center may be quite busy. Moreover, both are liable for burnout from entirely different causes – the "Chakravarti" (peripheral surgeon) from frustration and the "Kendravarti" (central one) from exhaustion. If the surgeon keeps rotating in peripheries only, apart from expertise, one suffers from the inability to publish any research articles as mandated by the National Medical Council toward teachership in general surgery, and thus spirals down toward burnout very fast in a routine general surgical practice, especially when there is no scope to advance academically!
Less familiar stressors like the COVID-19 pandemic may further make matters complex. Recently, Gupta et al. have proposed an intelligent algorithm to detect burnout in health-care workers in the COVID era using electrocardiographic and artificial intelligence in the BRUCEE-LI study, the results are awaited.[5]
| Burnout: So What? | | |
Career as a surgeon is both rewarding and challenging. The road to becoming a surgeon is a long arduous endeavor and can bring significant challenges not only to the surgeon but also to his/her family.
Various studies have associated burnout with personal consequences such as poor dietary choices, lack of physical activity, and substance abuse, including alcohol, tobacco, and self-prescribed or illicit drugs.[6] Becoming a "Second Victim" of an adverse professional outcome is not uncommon.
Professionally, burnout may be associated with increased number of errors of omission and commission with detrimental effects on the safety and quality of care provided.[7]
Burnt-out surgeons are more likely to seek an exit from clinical practice, in the form of early retirement or moving into other fields. This is a costly process, for every surgeon who leaves the field may add to the workload of others.
| What Next? | | |
"Put on your own oxygen mask before assisting others."
Due to its variable nature, with no consensus for preventing, treating, or curing burnout, most of the remedies are traditionally divided into individual, group, and national level.
At the individual level, the focus should be on being mindful and engaged in self-care and regular physical activity, with stress-reduction techniques. Surgeons, while keeping their knives sharp, should remember the old proverb "all work and no play make Jack a dull boy," and let the constantly "on call" brain not discharge the energy continuously. At the same time, the profession of being a surgeon should be felt as "a calling," rather than a compelling one.
At the group level, encouraging the role of senior surgeons and fostering of mutual support with strong relationships should help. A recent systematic review showed better staff well-being with institutional policies such as "Schwartz Rounds," which may provide a safe place where health-care givers could openly share and reflect on the emotional, social, and ethical challenges faced during their routine job, making them more able to make personal connections with colleagues and patients with an insight into their own responses and feelings.[8]
At the higher level, the makeover of old human resource policies is the demand of the day. A possible reduction in the years of coercive service as a general surgeon before applying for subspecialty training may be encouraging. Astute and unbiased posting policies should be followed in letter and spirit. Avenues like recognition of teachership in local government medical colleges should be encouraged along with liberalized short refresher courses. Dynamic initiatives by the Armed Forces Medical Services (AFMS) and National Institution for Transforming India (NITI) Aayog like the Scheme for RE-deployment of Superannuated Teachers of the AFMS are certainly worth emulating.[9]
| Conclusion | | |
The fact of peripheral government surgeon burnout must be acknowledged boldly, as "facts do not cease to exist because they are ignored." Recognition of the problem is the first step toward the solution even though it seems as complex as the problem. This profession requiring master craftsmanship mandates constant exposure to a stimulating environment. To place limits on surgeons' work beyond what is judicious will only risk blunting the skills of this unique and essential workforce. When we can acknowledge the problem and walk on with confidence and enthusiasm, the solution should be on the way!
Acknowledgments
The authors would like to acknowledge the valuable inputs of:
- Col V Baskaran (Retd), Ex Director & Senior Consultant MIOT Hospitals, Chennai
- Brig J K Banerjee (Retd), Professor GI Surgery, Bharati Vidyapeeth Medical College & Hospital, Pune.
| References | | |
| 1. | Kesarwani V, Husaain ZG, George J. Prevalence and factors associated with burnout among healthcare professionals in India: A systematic review and meta-analysis. Indian J Psychol Med 2020;42:108-15.  [Full text] |
| 2. | Modlin DM, Aranda MC, Caddell EC, Faler BJ. An analysis of burnout among military general surgery residents. J Surg Educ 2020;77:1046-55. |
| 3. | Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397-422. |
| 4. | |
| 5. | Gupta MD, Bansal A, Sarkar PG, Girish MP, Jha M, Yusuf J, et al. Design and rationale of an intelligent algorithm to detect BuRnoUt in HeaLthcare workers in COVID era using ECG and artificiaL intelligence: The BRUCEE-LI study. Indian Heart J 2021;73:109-13. |
| 6. | Shanafelt TD, Dyrbye LN, West CP, Sinsky CA. Potential impact of burnout on the US physician workforce. Mayo Clin Proc 2016;91:1667-8. |
| 7. | Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995-1000. |
| 8. | Taylor C, Xyrichis A, Leamy MC, Reynolds E, Maben J. Can Schwartz Center Rounds support healthcare staff with emotional challenges at work, and how do they compare with other interventions aimed at providing similar support? A systematic review and scoping reviews. BMJ Open 2018;8:e024254. |
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[Figure 1]
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