How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents?
Concerning 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.
(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?
Two 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.
Nine 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).
We 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.
Institutions 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.
Verret CI
，Nguyen J
，Verret C
，Albert TJ
，Fufa DT
... -
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Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.
APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce.
Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email.
144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted.
In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.
Martin AE
，McEvoy CS
，Lumpkins K
，Scholz S
，DeRoss AL
，Emami C
，Phillips MR
，Qureshi F
，Gray BW
，Safford SD
，Healey PJ
，Alaish SM
，Dunn SP
... -
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Building a sustainable rural physician workforce.
CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia.
Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants.
Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians.
Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8).
Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas.
In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19.
Individual and collective descriptors of professional identity.
We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation.
Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality.
A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters.
Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location.
Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors.
Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action.
We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles.
Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles.
These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce.
Ostini R
，McGrail MR
，Kondalsamy-Chennakesavan S
，Hill P
，O'Sullivan B
，Selvey LA
，Eley DS
，Adegbija O
，Boyle FM
，Dettrick Z
，Jennaway M
，Strasser S
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ResearchGate
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