A Career in Surgical Oncology: Finding Meaning,Balance, and Personal Satisfaction

The practice of surgical oncology provides opportunities for both personal distress as well as personal satisfaction. While many surgical oncologists experience career burnout, others derive great meaning and satisfaction from their work. In this article, we review the literature on surgeon burnout, discuss potential personal and professional consequences, and consider steps individual surgeons can take to promote personal and professional satisfaction.     

How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons,Fellows, and Residents?

BackgroundConcerning levels of burnout have been reported among orthopaedic surgeons and residents. Defined as emotional exhaustion and depersonalization, physician burnout is associated with decreased productivity, increased medical errors, and increased risk of suicidal ideation. At the center of burnout research, person-centered approaches focusing on individual characteristics and coping strategies have largely been ineffective in solving this critical issue. They have failed to capture and address important institutional and organizational factors contributing to physician burnout. Similarly, little is known about the relationship between burnout and the working environments in which orthopaedic physicians practice, and on how orthopaedic surgeons at different career stages experience and perceive factors relevant to burnout.Questions/purposes(1) How does burnout differ among orthopaedic attending surgeons, fellows, and residents? (2) What specific areas of work life are problematic at each of these career stages? (3) What specific areas of work life correlate most strongly with burnout at each of these career stages?MethodsTwo hundred orthopaedic surgeons (residents, fellows, and attending physicians) at a single institution were invited to complete an electronic survey. Seventy-four percent (148 of 200) of them responded; specifically, 43 of 46 residents evenly distributed among training years, 18 of 36 fellows, and 87 of 118 attending physicians. Eighty-three percent (123 of 148) were men and 17% (25 of 148) were women. Two validated questionnaires were used. The Maslach Burnout Inventory was used to assess burnout, measuring emotional exhaustion and depersonalization. The Areas of Worklife Survey was used to measure congruency between participants and their work environment in six domains: workload, control, reward, community, fairness, and values. Participants were invited to openly share their experiences and suggest ways to improve burnout and specific work life domains. The main outcome measures were Maslach Burnout Inventory subdomains of emotional exhaustion and depersonalization, and Areas of Worklife Survey subdomains of workload, control, reward, community, fairness and values. We compared outcome measures of burnout and work life between groups. Simple linear regression models were used to report correlations between subscales. Stratified analyses were used to identify which group demonstrated higher correlations. All open comments were analyzed and coded to fully understand which areas of work life were problematic and how they were perceived in our population.ResultsNine percent (7 of 80) of attending surgeons, 6% (1 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of depersonalization on the Maslach Burnout Inventory (p < 0.001). Mean depersonalization scores were higher (worse) in residents followed by attending surgeons, then fellows (10 ± 6, 5 ± 5, 4 ± 4 respectively; p < 0.001). Sixteen percent (13 of 80) of attending surgeons, 31% (5 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of emotional exhaustion (p = 0.07). Mean emotional exhaustion scores were highest (worse) in residents followed by attending surgeons then fellows (21 ± 12, 17 ± 10, 16 ± 14 respectively; p = 0.11). Workload was the most problematic work life area across all stages of orthopaedic career. Scores in the Areas of Worklife Survey were the lowest (worse) in the workload domain for all subgroups: residents (2.6 ± 0.4), fellows (3.0 ± 0.6), and attending surgeons (2.8 ± 0.7); p = 0.08. Five problematic work life categories were found through open comment analysis: workload, resources, interactions, environment, and self-care. Workload was similarly the most concerning to participants. Specific workload issues identified included administrative load (limited job control, excessive tasks and expectations), technology (electronic medical platform, email overload), workflow (operating room time, patient load distribution), and conflicts between personal, clinical, and academic roles. Overall, worsening emotional exhaustion and depersonalization were most strongly associated with increasing workload (r = - 0.50; p < 0.001; and r = - 0.32; p < 0.001, respectively) and decreasing job control (r = - 0.50; p < 0.001, and r = - 0.41; p < 0.001, respectively). Specifically, in residents, worsening emotional exhaustion and depersonalization most strongly correlated with increasing workload (r = - 0.65; p < 0.001; and r = - 0.53; p < 0.001, respectively) and decreasing job control (r = - 0.49; p = 0.001; and r = - 0.51; p = 0.001, respectively). In attending surgeons, worsening emotional exhaustion was most strongly correlated with increasing workload (r = - 0.50; p < 0.001), and decreasing job control (r = - 0.44; p < 0.001). Among attending surgeons, worsening depersonalization was only correlated with increasing workload (r = - 0.23; p = 0.04). Among orthopaedic fellows, worsening emotional exhaustion and depersonalization were most strongly correlated with decreasing sense of fairness (r = - 0.76; p = 0.001; and r = - 0.87; p < 0.001, respectively), and poorer sense of community (r = - 0.72; p = 0.002; and r = - 0.65; p = 0.01, respectively).ConclusionsWe found higher levels of burnout among orthopaedic residents compared to attending surgeons and fellows. We detected strong distinct correlations between emotional exhaustion, depersonalization, and areas of work life across stages of orthopaedic career. Burnout was most strongly associated with workload and job control in orthopaedic residents and attending surgeons and with fairness and community in orthopaedic fellows.Clinical RelevanceInstitutions wishing to better understand burnout may use this approach to identify specific work life drivers of burnout, and determine possible interventions targeted to orthopaedic surgeons at each stage of career. Based on our institutional experience, leadership should investigate strategies to decrease workload by increasing administrative support and improving workflow; improve sense of autonomy by consulting physicians in decision-making; and seek to improve the sense of control in residents and sense of community in fellows.     

Burnout among American surgeons

BACKGROUND: The long-term consequences of stress on the surgeon are unknown. One manifestation of stress is burnout. The purpose of this study was to measure the prevalence of burnout in actively practicing American surgeons. METHODS: The Maslach Burnout Inventory and a questionnaire of our own design were sent to 1706 graduates of various University of Michigan surgical residencies (1222) and members of the Midwest Surgical Association (484). The response rate was 44%. Responses from 582 actively practicing surgeons were the sample used for analysis. RESULTS: Thirty-two percent of actively practicing surgeons showed "high" levels of emotional exhaustion, 13% showed "high" levels of depersonalization, and 4% showed evidence for low personal accomplishment. Younger surgeons were more susceptible to burnout (r = -0.28, P <.01). Burnout was not related to caseload, practice setting, or percent of patients insured by a health maintenance organization. Important etiologic factors were a sense that work was "overwhelming" (r = 0.61, P <.01), a perceived imbalance between career, family, and personal growth (r = -0.56), P <.01), perceptions that career was unrewarding (r = -0.42, P <.01), and lack of autonomy or decision involvement (r = -0.39, P <.01). A strong association was noted between burnout elements and a desire to retire early (r = 0.50, P <.01). CONCLUSIONS: Burnout is an important problem for actively practicing American surgeons. These data could be used to modify existing surgical training curricula or as an aid to surgical leadership when negotiating about the surgical work environment.     

A national study of burnout among American transplant surgeons

This study examines burnout in a national sample of transplant surgeons. Data analyses were conducted on a sample of 209 actively practicing transplant surgeons. Measures included the Maslach Burnout Inventory, a demographic survey, and the Surgeon Coping Inventory. Burnout was reflected in 38% of surgeons scoring high on the Emotional Exhaustion dimension, whereas 27% showed high levels of Depersonalization, and 16% had low levels of Personal Accomplishment. Several significant predictors of emotional exhaustion were identified and included questioning one's career choice, giving up activities, and perceiving oneself as having limited control over the delivery of medical services (R2= 0.43). Those who perceived themselves as having a higher ability to control delivery of medical services and who felt more appreciated by patients had lower levels of depersonalization and were less likely to question their career choice (R2= 0.16). Surgeons with high personal accomplishment experienced greater professional growth opportunities, perceived their institution as supportive, felt more appreciated by patients, and were less likely to question their career (R2= 0.24). The prioritization of goals to reflect both professional and personal values accounted for a significant amount of the variance in predicting both emotional exhaustion and personal accomplishment in separate regression equations. Recommendations to decrease burnout would include greater institutional support, increased opportunities for professional growth, and greater surgeon control over important services to facilitate efficient work. Coping strategies to moderate stress and burnout are also beneficial and should include prioritizing goals to reflect both professional and personal values.     

Burnout in Australasian Younger Fellows

Background: Burnout is the state of prolonged physical, emotional and psychological exhaustion characteristic of individuals working in human service occupations. This study examines the prevalence of burnout among Younger Fellows of the Royal Australasian College of Surgeons and its relationship to demographic variables. Methods: In March 2008, a survey was sent via email to 1287 Younger Fellows. This included demographic questions, a measure of burnout (Copenhagen Burnout Inventory), and an estimate of social desirability (Marlowe–Crowne Social Desirability Scale – Form C). Results: Females exhibited higher levels of personal burnout (P < 0.001) and work‐related burnout (P < 0.025), but no significant difference in patient‐related burnout. Younger Fellows in hospitals with less than 50 beds reported significantly higher patient‐related burnout levels (mean burnout 37.0 versus 22.1 in the rest, P= 0.004). An equal work division between public and private practice resulted in higher work‐related burnout than concentration of work in one sector (P < 0.05). Younger Fellows working more than 60 hours per week reported significantly higher personal burnout than those who worked less than this (P < 0.05). There was no significant correlation between age, country of practice, surgical specialty and any of the burnout subscales. Conclusion: Female surgeons, surgeons that work in smaller hospitals, those that work more than 60 h per week, and those with practice division between the private and public sectors, are at a particularly high risk of burnout. Further enquiry into potentially remediable causes for the increased burnout in these groups is indicated.     

Barriers to minorities in the orthopaedic profession.

The rapidly growing population of the United States is becoming more diversified in its ethnicity. Conversely, the orthopaedic profession has not kept pace with this increase. Although 1/3 of the total population is comprised of Latinos, African Americans, and Native Americans, only 7% of all orthopaedic surgeons represent these minorities. There is a widespread need for minority orthopaedic surgeons who can communicate with and understand these patients to provide them with competent cultural care. Minority students face significant barriers, intrinsic and extrinsic, which impede them in choosing orthopaedics as a career. Recognizing that these barriers are rooted in the early years of education, solutions such as mentoring activities, good guidance counseling, and accessible role models should be advocated and adopted. Misconceptions on the part of the minority students, medical school admissions committees, and directors of orthopaedic residency training programs may lead to negative impressions and results. The purpose of this paper is to make the orthopaedic community aware of this disparity and the barriers that underrepresented minority students encounter. Hopefully an appropriate positive response by those who have the ability to make a difference will result, thus facilitating the pathway for the minority student to become an orthopaedic surgeon.     

Stress, burnout, and maladaptive coping: strategies for surgeon well-being

Practicing physicians and surgeons, medical and surgical residents, and medical students dedicate their lives to providing optimum patient care, but doing so places them at significant risk for personal and professional stress and, ultimately, burnout. Of great concern is the fact that unrecognized stress and unmanaged burnout are more prevalent among residents than previously believed. Research shows that stress without conflict resolution may lead to burnout, which can contribute to impaired technical performance, medical errors, physical and mental health problems, and even increase the risk of suicide. Therefore, it is crucial that surgeons, and the organizations that train and employ them, recognize the early signs of stress and burnout, adopt adaptive coping strategies, and maintain a culture wherein work-life balance and surgeon well-being are shared goals.     

Drivers of distress and well-being amongst pediatric surgeons

IntroductionAlthough pediatric surgeons have lower rates of burnout compared to other surgical subspecialists, they still struggle with work-home conflict, depersonalization, and emotional exhaustion. Prior surveys have measured career satisfaction and burnout, but none have identified factors that contribute to physician well-being or provided potential solutions.MethodsMembers of the American Pediatric Surgical Association were surveyed regarding sources of distress and institutional practices intended to promote well-being. Responses were analyzed using content analysis.ResultsThere was a 31.5% response rate to the survey. The most frequently cited sources of distress were administrative issues (45.2%), work/life balance (42.3%), personal issues (18.8%), and relationships with coworkers (17.9%). In open-ended questions, other sources of distress included poor leadership, loss of autonomy, lack of support and mentorship, and patient complications. Successful wellness strategies included relief from clinical burden, substantive wellness programming, surgeon inclusion in administrative decision making, support after adverse events, appropriate compensation and benefits, and opportunities for career development in research, teaching, and clinical care.ConclusionPediatric surgeons are affected by multiple sources of distress. Interventions that ameliorate stress in pediatric surgeons were identified and should be considered by local institutions and national organizations to promote well-being.Level of evidencen/a     

Preparing for the road ahead

SUMMARY:: The practice of orthopaedic trauma has been considered "a young person's game," but there are many before you who have maintained a fulfilling, successful, and long-lasting career in orthopaedic trauma. The keys to longevity are avoiding burnout and developing a supportive team of practice partners, mentors, and other colleagues. It is important to develop and continually refine a series of "5-year plans" to make sure that you are progressing toward your goals. Develop a specialized niche in 1 or 2 areas that fills an open gap in your community and in which you can really flourish. Finally, it is critical to maintain your skills in a trauma-related discipline that can be built into an elective practice that provides referrals, fills the gaps when trauma slows, and is something that you enjoy.     

How to negotiate with your hospital

SUMMARY:: The orthopaedic trauma market place and career track have changed considerably over the last 10 years. There is an increasing demand from community hospitals for orthopaedic trauma. Understanding how to assess the practice opportunity and engage prospective employers is key to developing a successful and sustainable program and career. The article reviews the market place changes and how to approach negotiations. Lessons from other aspects of life and business are highlighted.     

Burnout and Professional Fulfillment in Early and Early-Mid-Career Breast Surgeons

Annals of Surgical Oncology - Prior work has shown that burnout among breast surgeons is prevalent and highest in those earlier in their clinical practice career. Therefore, we sought to better...     

Burnout in surgeons: a ticking time bomb?

Burnout refers to a syndrome of depersonalisation, emotional exhaustion and feelings of reduced achievement. Early studies suggested 40% of surgeons are affected by burnout. However, a post-pandemic GMC report demonstrates a significant increase in its incidence. Burnout is associated with direct adverse clinical outcomes, personal suffering and increased work-force attrition. There are several individual and organizational factors that contribute to burnout and, despite it being well recognized, its prevalence in healthcare is continuing to increase. We examine the reasons why surgeons may be particularly vulnerable to this syndrome, both as individuals and from the environment in which they practise. We discuss why burnout is so important in the current climate, review potential protective strategies and outline why this is imperative for the future of surgery.     

Career Satisfaction, Practice Patterns and Burnout among Surgical Oncologists: Report on the Quality of Life of Members of the Society of Surgical Oncology

Background Studies show that 30–50% of medical oncologists experience burnout, but little is known about burnout among surgical oncologists. We hypothesized that wide variation in burnout and career satisfaction exist among surgical oncologists. Patients and Methods In April 2006, members of the Society of Surgical Oncology (SSO) were sent an anonymous, cross-sectional survey evaluating demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL). Burnout and QOL were measured using validated instruments. Results Of the 1519 surgical oncologists surveyed, 549 (36%) responded. More than 50% of respondents worked more than 60 hours per week while 24% performed more than 10 surgical cases per week. Among the respondents, 72% were academic surgical oncologists and 26% spent at least 25% of their time to research. Seventy-nine percent stated that they would become a surgical oncologist again given the choice. Overall, 28% of respondents had burnout. Burnout was more common among respondents age 50 years or younger (31% vs 22%; P = .029) and women (37% vs 26%; P = .031). Factors associated with a higher risk of burnout on multivariate analysis were devoting less than 25% of time to research, had lower physical QOL, and were age 50 years or younger. Burnout was associated with lower satisfaction with career choice. Conclusions Although surgical oncologists indicated a high level of career satisfaction, nearly a third experienced burnout. Factors associated with burnout in this study may inform efforts by program directors and SSO members to promote personal health and retain the best surgeons in the field of surgical oncology. Additional research is needed to inform evidenced-based interventions at both the individual and organizational level to reduce burnout.     

Thromboprophylaxis following cast immobilisation for lower limb injuries--survey of current practice in United Kingdom

The risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is well documented in patients following cast immobilisation for injuries of lower extremities. There are no generally accepted approaches to preventing this complication and hence there remains substantial practice variation amongst surgeons regarding the use of anticoagulation measures. The present survey was conducted to investigate the current chemothromboprophylaxis practice among UK orthopaedic departments for patients immobilised with plasters for lower extremity injuries and establish any variations in practice. A telephone questionnaire survey was conducted on junior doctors (Senior House Officers and Registrars) in orthopaedic departments of 70 randomly selected hospitals in United Kingdom. This survey assessed the thromboprophylaxis practice for lower limb injuries in plaster casts. Our results show substantial variation amongst British orthopaedic surgeons in the use of chemothromboprophylaxis measures. Sixty-two percent of the departments do not use any DVT prophylaxis in this group of trauma. Furthermore, only 11.4% of the departments performed risk stratification on their patients. Ninety-nine percent of the respondents were unaware of any existing guidelines in this regard. Although the incidence of DVT in patients in plaster for lower extremity injuries is low compared to the Hip/Knee arthroplasty group, this is not insignificant. Both over and under treatment with thromboprophylaxis can have implications in terms of side effects and costs. One possible solution is to use risk stratification to identify individuals who are likely to benefit from prophylaxis. There is a substantial variation and inconsistency in practice among orthopaedic departments in United Kingdom due to a lack of clinical guidelines in this group of trauma and it remains underused even in high-risk group.     

Are Surgeons Capable of Introspection?

The traditional action-oriented surgical personality, although essential in the service of solving emergent operative dilemmas, may serve as a barrier to introspection. Certainly, challenges of the twenty-first century practice environment, including time constraints, also distract from self-reflection. Without engaging in moments of introspection, surgeons risk not only abandoning dying patients in their time of need, but leave the surgeons themselves at risk for burnout and its consequences. The increase in the number of women surgeons, as well as the less heroic image of surgeons performing laparoscopic operations, may reorient traditional extroverted behavior toward a persona of professional grace.     

Editorial Commentary: Returning to High-Impact Sports After Hip Arthroscopy: Are We Shooting Ourselves in the Hip?

There is a clear consensus in the literature that professional athletes exhibit high rates of return to sport following hip arthroscopy. As orthopaedic surgeons, we are well equipped to guide athletes back to the field after intra-articular hip injuries. However, returning to high-impact sports and playing through the pain can have implications on long-term health. Literature suggests that former elite athletes are at greater risk for reinjury and developing hip osteoarthritis compared with non-athletes. While it is incumbent upon us as orthopaedic surgeons to inform and advise our patients regarding the long-term consequences of return to sport after a hip injury, we recognize and enthusiastically support the passion that many athletes feel for the game and the vast benefits that they can derive from returning to the sport they love.     

Wound Closure Following Intervention for Closed Orthopedic Trauma

The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.     

The impact of the COVID-19 pandemic on wellness among vascular surgeons

The coronavirus disease 2019 (COVID-19) pandemic has placed significant strain on the health and welfare of all health care professionals, including vascular surgeons. This review summarizes the implications of the pandemic on the health and wellness of surgeons and trainees, with a particular focus on those in vascular surgery (VS). A literature review was completed using common resource databases. We provide a brief history of burnout in VS and explore burnout and wellness in VS during this unprecedented pandemic. We then offer recommendations to address mental health needs by the VS workforce and highlight opportunities to address the gaps in the literature. The impact of COVID-19 on the professional and personal lives of surgeons and trainees in VS is notable. More than half of vascular surgeons reported some degree of anxiety. Factors associated with anxiety and burnout include COVID-19 exposure, moral injury, practice changes, and financial impacts. Trainees appeared to have more active coping strategies with dampened rates of anxiety compared to those in practice. Women appear to be disproportionately affected by the pandemic, with higher rates of anxiety and burnout. Groups underrepresented in medicine seemed to have more resilience when it came to burnout, but struggled with other inequities in the health care environment, such as structural racism and isolation. Strategies for addressing burnout include mindfulness practices, exercise, and peer and institutional support. The COVID-19 pandemic has had a substantial mental health impact on the VS workforce globally, as shifts were made in patient care, surgical practice, and work–home life concerns.     

Wound care practices after orthopaedic trauma surgery are highly variable and not evidence based

ObjectiveGiven the tremendous medical, social and financial costs of surgical site infections, the pressure to minimize these complications has been mounting. There remains a substantial gap in evidence-based practice for postoperative wound care after orthopaedic trauma surgery. The purpose of this study is to determine what standards are currently in practice for postoperative wound management.MethodsA 16-question web-based survey was published on the Orthopaedic Trauma Association website and disseminated to members through the association's quarterly email. The survey gathered data on postoperative wound care practices; specifically, when wound checks are performed, and when providers allow patients to get the incisions wet.Results102 Orthopaedic surgeons completed the survey. Ninety-one percent were trauma fellowship trained, and 95% worked at either a Level I (76%) or Level II (19%) trauma center. There were over 100 different proposed protocols captured by the survey. The majority of surgeons (54%) perform a wound check within the first three days after surgery. Additionally, half of surgeons (50%) do not permit patients to get their incisions wet until sutures and staples are removed.ConclusionWound care routines following surgical management of orthopaedic trauma injuries are highly variable. Diverse protocols are performed at the discretion of the treating surgeon without scientific basis. This study defines immense variability in one aspect of peri-operative care that could play an important role in surgical site infections and provides a foundation for future studies to explore the potential influence of standardized wound care routines on post-operative infections and wound healing.