Damian Sendler: Anesthesiologists and perioperative physicians had no idea in early 2020 how much their work lives would change. After COVID-19’s first peak, anesthesiologists were already experiencing significant difficulties in terms of their overall well-being and culture. Burnout among our specialty’s doctors could rise as a result of a lack of qualified workers, financial difficulties in balancing clinical, educational, and research demands, changes in hospital-based and private practice groups, coverage of subspecialty cases, relocations outside of operating rooms, and an increase in the number of hours worked. It was inevitable that the anesthesiology workforce would be adversely affected when the pandemic arrived.
Damian Jacob Sendler: The anesthesiologists’ response to the pandemic has been heroic. Workers scrambled for protective gear in the wake of an outbreak of SARS-CoV-2 in the workplace, which had been linked to occupational exposures. Despite the limited availability of COVID-19 testing, anesthesiology leaders collaborated to develop triage algorithms that allowed patients to proceed with surgery. For example, anesthesiologists have devised protocols and pathways for directing workers to critical care wards and hospital intubation teams, respectively. Weekends and post-call days were used to schedule donning and doffing training sessions. Patients with COVID-19, as well as anesthesiologists, were quickly enrolled in clinical trials for treatment and care. We organized webinars with colleagues in Europe and China to share information on postoperative care for patients with COVID-19. Innovators such as anesthesiologists developed transesophageal probe covers and infectious particle capture devices to reduce the spread of the SARS-CoV-2 virus.
Dr. Sendler: The pandemic’s impact on anesthesiologists was not the only source of stress for them. Meanwhile, personal lives were also being upended. There was a sudden shortage of childcare and a new responsibility to supervise virtual learning platforms for those with school-aged children. Due to mandated stay-at-home measures, many traditional childcare options (family members, nannies, and daycare) were rendered ineffective. Psychological and emotional strain was exacerbated by an increase in sick leave, COVID-19-related illness among anesthesiologists and financial strain as a result of temporarily cancelled elective cases.
The impact of the COVID-19 pandemic on the well-being of anesthesiologists is examined in detail in this article. Discuss the importance of recognizing threats to our health and resilience as well as the value of adopting strategies to promote wellness in our work environments. Well-being is essential to the culture of our workplaces, and it can only be achieved through a combination of top-down leadership and peer support.
You’ve probably heard the term “burnout” and used it in various contexts in discussions about work–life balance if you’re a doctor practicing in 2021. It is critical to determine what burnout is and how it affects the health care workforce. It was in the 1980s when Maslach and his colleagues first defined burnout as a psychological exhaustion experienced by health care workers, and the term has since been widely used to describe this phenomenon. Maslach and colleagues first proposed the three-symptom model of burnout in the 1950s.
In the context of health care, burnout is a personal expression of these three characteristics and is linked to workplace stress [2]. Burnout literature and metrics that analyze the prevalence of burnout amongst health care workers typically measure a combination of these three attributes in varying degrees. Chronic workplace stress that is not effectively managed can lead to burnout, according to the WHO’s International Classification of Diseases (ICD) (ICD-11).
According to a recent meta-analysis, it has been determined whether or not burnout falls on the spectrum of clinical depression and whether or not there is a correlation between burnout and clinical depression. A meta-analysis by Bianchi and colleagues [5] of 92 published articles on burnout and depression found that it was difficult to draw a distinction between the two. Chronic work stress causes burnout, but depression is not always linked to one’s job. In contrast, some studies have found that “end-stage” burnout exhibits symptoms that are similar to those of clinical depression [5]. Symptoms may overlap between the two diagnoses because of a lack of clear distinction between the two, but one must be careful to distinguish clear differences in etiology. As a result, it is important to treat each person’s burnout as unique.
Burnout manifests differently in men and women, according to research. Using the largest meta-analysis of 183 studies, Purvanova and Muros described the prevalence and slight differences in how men and women display burnout [6]. Their findings contradict the widely held belief that women are more susceptible to burnout than men. However, they found that men and women display the burnout triad slightly differently. Emotional exhaustion was more common among women, while depersonalization was more common among men in the studies. To avoid institutional decisions being influenced by gender stereotypes and burnout, it’s crucial to understand the differences between men and women, according to Purvanova and Muros [6].
According to annual surveys by Medscape, peer-reviewed research studies, and individual institution metrics, physician burnout is widespread in the United States (US) doctor workforce. Using the Maslach Burnout Survey, which is widely regarded as the gold standard for measuring burnout in the medical field, Shanafelt and colleagues [7] published the largest national study of 7288 US physicians from all specialties in 2012 and compared it to the general US workforce population. Professional burnout among doctors was higher (379.9% vs. 27.8%) than among nonphysicians, according to this study. In contrast to other professions where a graduate degree (master’s, doctorate) protects against burnout, the opposite is true in medicine, according to the researchers. Physicians with MD/DO degrees were more likely than the general population to report burnout [7]. As the first to show that physicians working in high-stress and especially frontline environments (emergency medicine, neurology, surgery, and anesthesiology) were more likely to experience burnout than those working in less-acute care specialties, this study is significant (dermatology, occupational health, pathology, and pediatrics).
More than half of all anesthesiologists have experienced burnout at some point in their careers, according to peer-reviewed studies (14 to 65 percent). In our specialty, whether the true prevalence is between 14% and 66% [12], the fact remains that it has reached a critical mass of at-risk physicians who are vital to the health of an aging surgical population in the middle of an international pandemic.
The prevalence of burnout (syndrome) was reported to be 13.8% in the largest published survey study in anesthesiology to date; however, 59% of respondents had a high risk of burnout. There was a low participation rate (13.6 percent) despite the survey having a high total number of responses (3,898).
Emotional exhaustion, stress, moral injury (the challenge of simultaneously knowing what patients need but being unable to provide it because of constraints that are out of our control), post-traumatic stress disorder, and mentation are just some of the many mental health risks that health care workers face in the COVID-19 pandemic. Anesthesiologists, who may have to work alone for 24 to 48 hours at a time (without being able to contact friends, family, or coworkers for days on end), are not exempt from the increased stress that has been brought on by COVID-19. Anesthesiologists are at risk of burnout, regardless of whether they work in the COVID-19 critical care wards, care for patients with unknown COVID-19 status, or work in the operating rooms with a limited workforce.
In most cases, the causes of burnout can be traced back to a combination of both organizational and personal factors. Individual risk factors are scarce, but many organizational risk factors have been discovered. [13] The six domains of these variables are: work load/control/reward/community/fairness/values. Burnout in physicians is often caused, in part, by a lack of control over their work environment and a lack of efficiency in how they spend their time. Medical errors, malpractice suits, and a physician’s approach to dealing with patient death and illness are all potential hazards, as are factors such as specialty choice, practice location, and work–life balance [14].
Anesthesiologists, like other physicians, are subject to the same influences. It is not uncommon for anesthesiologists, who practice in a high-stress medical field, to have to deal with a variety of unanticipated and sometimes life-threatening clinical scenarios. According to Afonso and colleagues, the strongest link between burnout and burnout syndrome was a feeling of not having enough support at work (OR: 6.7). There was also an independent link between a high risk of burnout and working more than or equal to 40 hours per week (2.2), feeling unsupported at home (2.1), and having difficulty finding qualified staff (2.1), as well as being underrepresented in the workplace (2.2), not having a confidant at work (1.6), and being under the age of 50 (1.5).
Nyssen and colleagues examined the levels, causes, and moderating factors associated with stress and burnout in Belgian physician anesthesiologists using a self-report questionnaire. They discovered that anesthesiologists’ stress levels were comparable to those of the general working population, but that they were more emotionally exhausted (particularly in anesthesiologists younger than 30 year old). A lack of control over (1) time management (long hours, planning nonclinical tasks like lectures, research), (2) work planning (difficulty in getting days off in advance, frequent schedule changes during a given work day), and (3) risks were cited as stress sources by respondents [15]. A link exists between high workload and burnout, such as working more than 70 hours per week and having a lot of call obligations (weekends, nights, and holiday shifts) [16].
Academic anesthesiologists, including those in leadership positions, are well aware of burnout. A survey of anesthesiology department chairs and directors of anesthesia residency programs was conducted by De Oliveira and his colleagues in 2011. More than half of the department chairs in two studies with high response rates showed signs of high or moderate burnout. [17] Low job satisfaction and lack of support from a spouse were both independent factors that contributed to high levels of burnout. Half of the program directors who took part in the survey said they were concerned about burnout. They found that lack of spousal support and compliance with regulations were significant predictors of burnout. Academia’s academic faculty face an additional challenge in dealing with the many competing demands on their time (clinical care, education, research, administration, and compliance). Each faculty member’s level of satisfaction with a given task varies. Career discord and burnout can result from an individual’s inability to focus on the areas of their work that are most meaningful to them. Finally, burnout in anesthesiology is associated with factors such as being younger, female, married, with children, having a weak family support system, and consuming alcohol.
Patients’ care and burnout were examined by Shanafelt and colleagues in a university-based internal medicine training program. Forgoing diagnostic tests in favor of early patient discharge and failing to consider the social or personal impact of a patient’s illness were among the subpar patient care practices reported by trainees as being subpar. More than twice as many burned-out residents (53 percent vs. 21 percent, P.004) reported subpar patient care practices and attitudes as those who were not burned out [22].
Physician burnout has far-reaching consequences that are not just felt by the physician. As a result of physicians’ exhaustion, patients may suffer. Patients and doctors who had been admitted to the hospital in the previous year were surveyed by Haslbelsen and Rathert. Depersonalized physician burnout was linked to longer patient recovery times and lower patient satisfaction after controlling for other factors [23]. A psychiatrist used the Maslach Burnout Inventory to survey emergency physicians in an academic emergency department as part of a prospective study [24]. A triage nurse determined the appropriate waiting times based on the severity of the patient’s condition. Waiting times increased as a result of increased burnout among emergency physicians, according to the study.
Physician burnout has been linked to a higher rate of medical errors, which in turn has been linked to a higher rate of medical errors. Many more people die each year as a result of hospital medical errors than are killed in car accidents or by breast cancer, and research shows that this has a direct effect on patients’ health [25].
Among 7905 surgeons, 8.9 percent said they had made a major medical error in the last three months. A study found that surgeons with higher levels of burnout and depression were more likely to report a self-perceived recent major medical error. A fifth-year study of Mayo Clinic internal medicine residents found a link between higher levels of burnout and residents’ perceptions of medical errors [27]. There were 139 participants in the study who made at least one error during the study period and had higher levels of burnout and emotional exhaustion than those who did not make any errors. Additional research has shown that reporting an error within the next three months is associated with higher burnout levels across all domains. Another study examined the level of burnout among 6695 US physicians. According to the findings [28], burnout was linked to self-reported medical errors regardless of age, gender, workload, or specialization.
Despite the fact that studies have shown a link between physician burnout and medical errors, the cause and effect are still unknown. Patient errors can exacerbate physician burnout, and physician burnout can exacerbate patient errors. People who are burned out may also be more critical of themselves and more likely to report medical mistakes. This research shows that burnout is bad for everyone involved in healthcare, including the people who are providing it.
Physician burnout has financial ramifications that must be considered as well. Using validated measures of physician burnout, Hamidi and colleagues [29] conducted a wellness survey with 472 physicians at a single institution. They looked at the link between employee self-reports of burnout and plans to leave and actual turnover using long-term data. Physicians who had burnout had a higher (OR: 2.68) likelihood of leaving their institution within two years than those who had not experienced burnout, even after adjusting for surgical specialty, work hours, sleep-related impairments, anxiety, and depression. 21 percent of those with burnout symptoms left 2 years later, compared to just 10 percent of those without burnout symptoms. Estimated economic losses to physicians due to burnout ranged from $15 million to $55 million over a two-year period. Physician turnover was not correlated with specialty, hours worked, sleep-related impairments, or anxiety.
Researchers at the Mayo Clinic found that burnout was strongly linked to future reductions in full-time equivalents (FTEs) [30] by analyzing administrative records. In addition to recruiting and training replacements, a reduction in FTE can have detrimental effects such as increasing the workload of other physicians, furthering a cycle of burnout, as these studies show that burnout can lead to physicians reducing their FTE or leaving the workforce altogether.
Damian Jacob Markiewicz Sendler: Physician burnout has been linked to a host of negative outcomes for the individual. The depersonalization domain of burnout was found to be associated with an increased risk of reported motor vehicle accidents in a prospective longitudinal cohort study of 340 internal medicine residents for more than five years [27]. Adjustments for fatigue and depression were made. Alcohol and drug abuse are also linked to physician burnout. A survey of more than 25,000 practicing surgeons by Oreskovich and colleagues found that more than 15 percent of them met the criteria for alcohol abuse or dependence. As a result, burnt-out surgeons (OR: 1.25, P.01) were more likely to develop alcohol abuse or dependence.
There is a link between physician burnout and poor mental health. Dyrbye found that physicians and their coworkers who had recently experienced work–home conflicts were more likely to experience burnout in a study of burnout, quality of life, depression, and these types of conflicts [32]. They were more likely to be depressed, contemplate divorce, or be dissatisfied with their partner [30]. Physicians with work–home conflict also had lower quality of life and were more likely to screen positive for depression. If you’re a medical resident, you’re more likely to have suicidal thoughts than if you’re not, according to a recent Dutch study of medical residents. [33] Burnout has a wide range of effects, including anxiety, depression, interpersonal conflict, and even suicide.
During the COVID-19 pandemic, anesthesiologists played a crucial role in health care due to their unique set of skills, such as airway and ventilator management and critical care and resuscitation expertise. As a result of this elevated role, the specialty has faced unexpected challenges that may lead to burnout.
Anesthesiologists were under a lot of pressure because of the potential shortage of PPE and the increased exposure to COVID-19. As a result, physicians’ families and loved ones were in danger of contracting the SARS-CoV-2 virus, which exacerbated their anxiety. As a precaution, some anesthesiologists avoided contact with their families. Others stayed in a hotel or even sent their children to be looked after by their grandparents while they were away. Concern over who would care for their children if they contracted COVID-19 on the front lines led one dual physician family, anesthesia and critical care, to send their children to live in Singapore. For 109 days [34], they had not seen their children. Many anesthesiologists were also concerned about the availability of reliable childcare as many schools were closed and quarantined following exposures. Men and women weren’t equally burdened by this responsibility. Even before the pandemic, women were already caring for their children at a rate that was nearly two times greater than that of men. The COVID-19 pandemic threw a wrench into an already shaky foundation. 40 percent of mothers added three or more additional hours of caregiving a day to their schedule, compared to 27 percent of fathers, according to a study co-authored by McKinsey and LeanIn.org, the 2020 Women in Workplace study.
As a result of COVID-19’s highly contagious nature, anesthesiologists were psychologically affected by the lack of information about the disease’s spread and limited testing. Most anesthesiologists were unable to work remotely because of the hands-on nature of their practice, unlike other medical specialties. There are numerous studies that support the negative psychological impact. In March and April 2020, anesthesia and ICU physicians in Cairo’s university hospitals participated in a cross-sectional survey to gather information about their mental health. The survey found that 66% of anesthesia and intensive care physicians treating patients with suspected or confirmed COVID-19 had a high level of psychological stress [37]. Providers’ greatest concerns were related to their own health, concerns about infecting other people, as well as PPE shortages. Patients with COVID-19 were found to have significantly higher rates of depression (OR: 1.5, P.01), insomnia (OR: 2.97, P.001), distress (OR: 1.6, P.001), and anxiety (OR: 1.6, P.001) in frontline Chinese health care workers [38]. During the COVID-19 outbreak, more than a third of medical staff reported experiencing insomnia, according to another survey [39].
Damian Sendler
About half of those surveyed by The University of Pennsylvania Anesthesia Department thought they were at risk for contracting COVID-19 while on the job. Interestingly, the pandemic-related anxiety they witnessed in their coworkers only exacerbated their own anxiety. They concluded that anxiety had a direct impact on emotional exhaustion, which in turn contributed to burnout.
Damien Sendler: COVID-19 has also had a significant impact on academics. Burnout is on the rise in higher education, according to a study by Fidelity and the Chronicle of Higher Education. Nearly 70% of faculty members in the United States reported feeling stressed in 2020, compared to just over a third in 2019. (32 percent ). Nearly three out of four people surveyed reported a decrease in work–life balance during the pandemic [40].
In spite of the fact that anesthesiologists spent less time in the operating room, they were frequently relocated to critical care units and faced unpredictable and irregular working hours.
Many anesthesia practices had significant financial consequences due to decreased elective case volumes. Furloughs or reductions in staffing caused a decrease in compensation for private practice groups where anesthesia reimbursement is directly linked to compensation. A challenge for anesthesia leadership in practices where some employees were furloughed was determining who, and what type of provider (C.R.N.A., anesthesiologist) [41]. Patients’ demand for anesthesiologists working in outpatient pain clinics and ambulatory surgery centers has dropped significantly. By providing some financial assistance to small businesses, the Coronavirus Aid, Relief, and Economic Security Act has mitigated some of the effects. Many people, however, remain concerned about financial uncertainty because there is no clear end in sight.
Physician burnout is difficult to detect and quantify for a variety of reasons. Numerous tools exist to assist in objectively capturing data on burnout, as individuals may lack insight into their own level of exhaustion. Physician burnout can be defined and detected in a variety of ways, which can affect how it is identified. Finding the right survey tool and then deciphering the results can be a daunting task. Poorly validated or incorrectly interpreted data can undermine the gains made through interventions. In terms of the burden they place on respondents, organizations, the degree to which the data can be actionable, the sensitivity to affect change, the psychometric support and applicability, survey tools differ [43]. Here, we’ll take a look at some of the most common survey tools. Physician burnout can be measured using the Maslach Burnout Inventory – Human Services Survey (MBI-HSS). Subscales are used to identify emotional exhaustion, depersonalization, and decreased personal achievement. A total of 22 items were asked of participants in each domain, and they were asked to rate the frequency with which they felt the emotions described in the questions. Validation of the MBI-HSS is strong because it is the most widely used tool. Emotional exhaustion and depersonalization have been shown to have a strong correlation with survey scores [12,44]. Using it costs money, and the analysis is time-consuming. The Physician Worklife Survey (mini-Z) (PWLS) is a single-item measure of burnout [45]. Respondents are asked to rate their level of self-described burnout on a five-point scale in this completely free survey. Respondents are less burdened because of the question’s straightforward nature (“Overall based on your definition of burnout, how would you rate your level of burnout?”). The MBI emotional exhaustion subscale has been validated to correlate with single-item, self-defined surveys, but another study found that the PWLS missed half of the high-burnout clinicians when compared to the MBI [42,46].
Stress-induced burnout differs significantly from the condition known as burnout. Physicians who are under a lot of stress tend to be hyperactive, engaged, and always on the go, with little time to stop and engage in meaningful social interactions. Burnout is a stage on the stress continuum that can occur as a result of inadequate stress coping mechanisms. In both ourselves and our co-workers, it is important to distinguish between stress and burnout. A burned-out physician, in contrast to a stressed-out one, may appear or act withdrawn, has lost faith in systems, and may appear hyper-engaged. People who are burned out may be less productive in places where they once excelled because they have lost hope, have a great deal of apathy for any change or relief, or they are afraid of contracting a disease. COVID-19.
Damian Jacob Sendler
It is possible to intervene in burnout on a more nimble and community-focused level than at the institutional level by forming smaller groups of providers (e.g. those who share shift assignments or a departmental division). Team interventions aimed at preventing burnout include those aimed at distributing work more evenly and encouraging peer support among team members. Successive pandemic teams freed clinicians from non-clinical duties in order to focus on the disproportionate impact of clinical work. Work hours can be limited to recognize the difficulty of balancing the need to staff a busy unit with the need to give team members adequate time off. “Battle buddy” is a peer support system developed by the United States Army and successfully adopted by a number of medical facilities [52]. Employees are encouraged to select a “battle buddy” and check in with that person on a regular basis about their well-being or any specific concerns.
Burnout cannot be prevented solely by employing personal resilience strategies, as many top-level executives have come to understand. Shanafelt and colleagues categorized the institutional approaches to wellness as responses specifically tailored to health care workers’ needs: the need to be heard, protected, prepared, supported, and cared for [53]. Importantly, the availability of hospital leaders in work areas and the provision of channels for workforce feedback, such as listening groups, town halls, suggestion boxes and the availability of hospitals, ensures that health care workers are part of the decision-making process. COVID-19-related stress and additional burnout can be alleviated by providing adequate PPE, rapid access to occupational health care, and information and resources aimed at protecting employees’ family members. This is a good place to start. Health care workers who have a higher risk of exposure to infectious diseases are especially concerned about practical accommodations that can reduce their exposure. To wrap things up, institutions can help support health care providers by creating an environment that values collaboration and acknowledges the unique challenges and opportunities presented by the pandemic. Developing diagnostics, treatments and directions requires rapid team training. The rapidly expanding body of knowledge and its implications for clinical practice should be kept up to date as often as possible, and institutions should strive to do so.
Situational (primary) and personal factors contribute to burnout, which necessitates a variety of recovery strategies. There must be a combination of educational, practice changes, and skill-building constructs in order for these strategies to work.
In order to reduce workload and increase participation in decision-making, effective interventions directed at the organization must alter the scheduling process. Changes in policies and practices to improve teamwork and evaluation are also effective strategies. As a result, physicians may experience decreased job demand and increased job control. Burnout can be prevented with proactive and reactive interventions for physicians who are experiencing difficulties, as well as measures of well-being conducted on a regular basis and the development of an organizational framework (e.g., a professional fulfillment model). Physician-directed interventions typically include courses on mindfulness or cognitive behavioral techniques that help improve job competence and improve communication and coping strategies in the workplace, as well.
It was discovered in a meta-analysis of interventions to reduce physician burnout by Panagioti and colleagues that organizational interventions (such as shift scheduling changes, workload reductions, and multidisciplinary meetings to improve teamwork and leadership) had better treatment outcomes than physician-directed interventions [55]. Interventions aimed at more experienced doctors were more effective than those aimed at less experienced doctors, regardless of stage in their career.
Leadership must embrace a commitment to a well culture, which can reduce burnout, distress, and depression. Well-being is a business and professional necessity. Medical malpractice claims can be reduced and patient care improved if burnout is reduced. Reducing burnout can have a positive impact on any department or practice. Surveys of anesthesiology residents and first-year graduates by Sun and colleagues [57] found that the well-being of physician anesthesiologists was influenced by their perceptions of institutional support, work–life balance, social support strength, workload, and student debt.
Seven steps are recommended by the American Medical Association for establishing and maintaining a well culture: (1) establish wellness as a quality indicator, (2) start a wellness committee and choose a wellness champion, (3) distribute an annual wellness survey, (4) meet regularly with leaders & employees, (5) initiate selected interventions, and (6) repeat the survey within a year to re-evaluate wellness. (7) seek answers with Other proven methods for creating a well culture include allowing faculty members to take on small projects that interest them in order to increase their sense of ownership, establishing clear expectations, and thanking them. Another effective strategy for preventing burnout is to form a workplace community [58]. In the event of a traumatic and stressful clinical outcome (such as a patient’s death in the operating room), this type of systemic support can be provided (pandemic).