Health Professional Wellbeing

Aim

To determine the incidence of burnout among American surgeons and evaluate personal and professional characteristics associated with surgeon burnout.

Method

Members of the American College of Surgeons (ACS) were sent an anonymous, cross-sectional survey in June 2008. The survey evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life (QOL).  Burnout was measured using the Maslach Burnout Inventory (MBI), Symptoms of depression were identified using the 2-item Primary Care Evaluation of Mental Disorders (PRIME MD). Mental and physical QOL were measured using the Medical Outcomes Study Short Form (SF-12).  Additional questions were developed to explore demographic factors and professional characteristics.

Results

Overall, 32% had high emotional exhaustion, 26% demonstrated high depersonalization, and 13% had a low sense of personal accomplishment. 40% of respondents had either a high emotional exhaustion score and/or a high depersonalization score and were considered burned out. Approximately 30% of study participants screened positive for depression.  10–15% of respondents would have met the criteria for major depressive disorder. 28% of surgeons had a mental QOL score one half standard deviation below the population norm and 11% had a physical QOL score one half standard deviation below the population norm.

71% of the study participants indicated that they would become a physician again, 74% would become a surgeon again if they could revisit their career and specialty choice. 51% of surgeons indicated they would recommend their children pursue a career as a physician/ surgeon and 36% felt their work schedule left enough time for personal/family life.

Conclusion

Burnout among American surgeons is common but most were content with their career and specialty choice. Additional research is needed to identify individual, organizational, and societal interventions that preserve and promote the mental health of American surgeons.

Comment

A full 40% of participants in this study met the criteria for burnout. Interestingly 71% of participants indicated that they would become a physician again and 74% a surgeon if they could revisit their career. At the same time only 51% of physicians would recommend a similar profession for their own children and a meagre 36% felt their work schedule left enough time for persona/family life. Would a physician accept similar levels of stress in a patient? There seems to be a dichotomy between the levels of stress that physicians expose themselves to and what they would themselves see as acceptable levels of stress in their patients.

Writer Kabir Sattarshetty, Masters Student

Supervisor Dr Ramesh Manocha.

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Confronting Physician depression and suicide

The American Foundation for Suicide Prevention planning group invited 15 experts with expertise in physician health, medical education, licensing and credentialing issues, public health, disability law, substance abuse, depression, and suicidology to evaluate the state of knowledge about physician depression and suicide and barriers to treatment. The consensus statement articulated the following common concerns.

Current State

Depression is as common in physicians as in the general population however they are higher in medical students and residents. In physicians the female rate of suicide is higher than in the general population.

Risks

90% of physicians who die by suicide have a mental disorders and/or a substance abuse disorder

Many have untreated mood disorders and there is an increased burden of suicide.

Barriers

Physician reluctance to admit health vulnerabilities or seek help.

Practicing physicians with psychiatric disorders often encounter overt or covert discrimination.

Recommendations

Physicians should establish a regular source of health care and seek help for mood disorders.

Provide information about state and federal protections for confidentiality of medical records and legal protections for physicians and others with disabilities.

New research is needed. Most of the literature is out dated and contains significant methodological problems.

Comment

It is clear physicians often neglect their own mental health and this appears to contribute to reduced recognition of the significance of mental illness in their patients.  Depression is among the most common condition in primary care patients. And physicians do not adequately detect or treat 40% to 60% of cases. Physicians are more likely to recognize and treat depression and suicide in patients if they are able to first confront it within themselves and their peers. This consensus statement suggests it is high time to transform professional attitudes and change institutional policies to encourage physicians to seek help.

Writer Kabir Sattarshetty, Masters Student

Supervisor Dr Ramesh Manocha.

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Aim

An Australian field study evaluated the feasibility, acceptability and effectiveness of wellbeing seminar designed to train GPs in a set of evidence based meditation skills.

Method

The seminar was held on Saturday afternoon. Following a lecture on healthy lifestyles, they received 1.5 hrs of instruction in basic and intermediate meditation skills. GPs then had the option of doing 2 weeks of structured home practice. Professional development points were granted by the RACGP for the event. The main measures were The K10 Psychological Distress Scale (K10), a visual analogue scale (VAS), and a Diary card to assess compliance. The K10 questionnaire was completed at the beginning of the seminar at the end of the 2-week home practice period. The participants rated their subjective experience of mental silence using the VAS.

Results
299 GPs attended. 111 GPs completed the 2 week home-based and provided pre/post K10 data. At the end of the 2 week home based program, one-quarter (25.1%) of the at risk participants had improved sufficiently to shift into the low risk category. The Diary Cards showed an improvement in the achievement of mental silence by 40%.

Conclusions
The K10 baseline scores indicated higher levels of psychological distress among GPs as compared to the rest of the population. The pre/post scores showed that highly distressed GPs improved significantly. Overall, meditation has practical potential as a mental health promotion and primary prevention strategy for health professionals.

Comment

Meditation it seems is something Health Professionals are enthusiastic about. A survey of Australian GPs in 2000 found that almost 80% of respondents had recommended meditation to patients at some time in the course of their practice.

The question is should they practice what they preach? A pertinent question considering the high stress levels in the profession and their own confidence in suggesting meditation to others. A recent field study went in the direction of answering this question by evaluating the feasibility, acceptability and effectiveness of an initiative to train GPs in a set of evidence based meditation skills.

Writer Kabir Sattarshetty, Masters Student

Supervisor Dr Ramesh Manocha.

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An American study by Robins Et al. of health care professionals in a children’s hospital found that 39% of staff were of a moderate to extreme risk of compassion fatigue, and 21% were of a moderate to high risk of burnout.

The study of 314 health care professionals additionally found that doctors reported higher levels of burn out than other professions and, more years spent working in child care was associated with higher burnout. The study also found an association between the time spent working in child care and compassion fatigue.

The study suggests decreased patient interaction may be the mechanism through which the physicians develop greater levels of burnout than other professions, and concluded that paediatric healthcare professionals are at greater risk of burnout, and similar risk of compassion fatigue, than trauma workers.

The study can be found at elsevier.com.

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Pirrotta (2000) conducted a survey of Australian GPs and  found that almost 80% of respondents had recommended meditation to patients at some time during the course of their practice, even though less than 35% had any formal training or education in the field. This reflects, on the one hand, the growing legitimacy of what was once regarded as a fringe concept and on the other, the paucity of quality education in the field. More recent surveys about the status of meditation in the perception of general practitioners have produced revealing results. For instance, a survey of GPs reported by Cohen et al. in 2005 found that:

• 82% regarded meditation as moderately or highly effective with low risk for harm, whereas only 3% regarded it as occasionally or frequently harmful,
• 23% were either self taught or had only attended an introductory workshop on meditation, while a mere 3% had formal training such as part of a certificate, diploma or degree,
• 51% said they would like to receive some form of training or had already done so over the previous 12 months for personal use,
• 40% affirmed that they had either used it over the previous 12 months or would consider using it in their practice
• 65% said they would actively encourage any patient who raised the topic to practice meditation,
• 9% had suggested the use of meditation at least once per week or more, while 56% had suggested it at least once per month.

While there is no hard data, it seems reasonable to assume that endorsement of meditation practice by a good proportion of physicians is likely to be seen as tacit approval by consumers.

Dr Ramesh Manocha

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A German survey of medical staff working in radiology by Sehlen Et al. (2009) found that the nurses reported the highest level of job stress followed closely by physicians. The survey of 82 physicians and 113 nurses found that the greatest stressor for physicians was reported to be excessive paperwork. Physicians and nurses both reported “structural conditions”, including underpayment and telephone ringing, also had a major impact on their job stress. Physicians also reported having the highest level of job satisfaction.

The authors comment that the results emphasise the importance of nurses and physicians developing a work/life balance and strategies for promoting personal wellness.

The study can be found at the Radiation Oncology journal.

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In order to develop an understanding of the potential efficacy of meditation as an stress management intervention (SMI) directed at stress and especially work stress, I reviewed the evidence in the peer-reviewed literature. Computer databases, including MEDLINE, PsycINFO, CINAHL, EMBASE, Current Contents and Biological Reports were consulted. I also searched the Internet, hardcopy reports and other sources of “grey literature”. Search terms included “stress”, “work”, “occupational”, “job”, “strain”, “meditation”, “stress management”, “psychotherapy”, “behaviour therapy”, “relaxation” and combinations of these terms. Of the 12 controlled studies found, 8 were described as RCTs and 4 as NRTs. The NRTs all compared meditation to either a waiting list or non-intervention control group, so it is not surprising that they all reported substantial positive effects of meditation. Such a design cannot however exclude the impact of non-specific effects such as placebo and spontaneous improvement and so were excluded from my review.

Of the 8 studies describing themselves as RCTs, those of Winzelberg and Peters clearly reported using a strategy that cannot be described as acceptable random allocation. Moreover, Peters used self-report questionnaires that had not been validated. They were re-classified as NRTs and excluded from this review.

The remaining 6 RCTs involved comparison with a number of different controls. Two used more than one control, simultaneously giving rise to 8 comparisons. The authors universally concluded that meditation was effective as an SMI.

Dr Ramesh Manocha

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A study of ophthalmologists in Quebec by Viviers Et al. found that over 35% of the 133 ophthalmologists reported high levels of burnout. over 45% of the ophthalmologists reported having problems reconciling work and personal life.

The study, which was published in the Canadian journal of Ophthalmology, found that the three main occupational stressors were the rise in demand for services, the shortage of ophthalmologists and a high work load.

The study concedes a range of limitations including its cross-sectional nature. The study recommends ophthalmologists work to gain greater control over their participation in the workplace.

The full study can be found at pubs.nrc-cnrc.gc.ca.

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A Dutch study by Zantinge et al. exploring the impact of burnout on the quality of health care delivered by GPs found that burnt-out GPs have, contrary to expectations, longer consolations with patients.

The study explored three facets of burnout - emotional exhaustion, depersonalisation and reduced accomplishments. It found that GPs with emotional exhaustion or depersonalisation additionally show more communication in their consultations (such as increased eye contact and greater explanation of diagnoses); while GPs with feelings of reduced accomplishment or competency have reduced communication and fewer patient-centred consultations.

The study offered two explanations for the results. The study first proposed that doctors who are suffering psychological problems may be more empathetic towards patients suffering from similar problems. The study also suggested that burnt-out GPs may take longer in their consultations because they are less efficient.

The study can be found at www.biomedcentral.com.

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A systematic review by Mukherjee et al. (2009) explored burnout in paediatric oncology staff. Of the 10 studies included in the analysis none directly measured the extent of burnout in the staff, and only one measured distress, reporting a lower level of distress then the general population.

The systematic review reported a number of factors associate with increased burnout and distress in the staff including coping style, duration of relationship of patients, and care settings.

Sources of stress in paediatric oncology staff included observing patient suffering, caring for a dying patient, death, supporting parents of patients, delivery of inadequate care, workload, lack of resources, insufficient managerial support and poor relationship with colleagues.

The study highlighted a number of major limitations including an extremely limited quantity of research, poor quality of research, and a large range of staff types within the area of research. The studies examined were also reported a number of limitations including  small sample sizes and limited research sites.

The study can be found at interscience.wiley.com.

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