Burnout: have we been suffering in silence?

Fardod O'KellyThe desire to feel infallible has remained integral to a surgeon’s career for decades. The need to be calm under stress, to operate under the toughest of conditions, to deal with other people’s emotions has been part and parcel of the job. Most doctors can relate to stories of colleagues/bosses who were difficult to deal with. Those who would quickly fly off the handle when something unexpected happened, had started to lose their passion for their job or even resorted to alcohol/drugs in order to deal with stressful situations.

There are a few different scenarios that can arise in a situation like this. Do you ignore it, tell yourself it’s none of your business, or that it’s a lost cause? Do you assume that that they’re suffering from depression or that maybe it’s a family/home matter? Or, could these symptoms be a sign of burnout? When did we as surgeons decide that we were immune to burnout? Is this simply a concoction of surgeons abnormally in touch with their emotions, or is it possible that in our own arrogance and ignorance of our own ability, this is a condition that has remained undetected for generations.

What is absolutely clear is that as surgeons, we are very susceptible to the effects and symptoms of burnout, and in fact the numbers are surprising. Depression, suicidal thoughts, substance misuse, family disharmony in any other individual would be taken extremely seriously by occupational health or mental health services, so why are they brushed over in surgery? Furthermore, why are we the main culprits? Research into the world of surgical burnout is increasing rapidly. It would appear that urologists are particularly prone to burnout, with high levels of emotional exhaustion and depersonalisation. Interestingly, many of the factors that lead to burnout in urologists have nothing to do with any of the things that we’ve been trained for, and instead include things like administrative workload and resource management. There is an increasing realisation that occupational health and human resources need to take a proactive role in detection and treatment of burnout, but the first step requires us to realise that something is amiss, and to accept that things need to change. Is it now time to take care of the caretakers?

Have you suffered from burnout? Have you worked with colleagues who suffered burnout that wasn’t recognised? Share your experiences below.

Read Fardod O’Kelly’s article: The ‘burnout complex’ in surgical practice

Comments (16) Add yours ↓
  1. Ioannis Urologist

    This a huge problem especially when the individual is in a leading position. The worst and most dangerous situation is that frequently they are not or do not want to be aware. It happens to us where I work. The problem is how to deal with it because the individual does not seem to understand even if he suffers and others are suffering.

    November 23, 2016 Reply
  2. Kieran O'Flynn President, BAUS

    Congratulations Fardod; this is an important and timely article, particlarly at a time when the NHS and Irish Health Service are under severe strain with mounting expectations, limited resources and an overstreched workforce. It is vitally important that urologists have a job plan that is fair with achievable goals. Avoid taking on extra roles that are not properly resourced! I encourage you to read the job planning guidance on the BAUS website.


    November 27, 2016 Reply
    • Robyn Webber Consultant urological surgeon

      I e mailed my colleagues about the job planning guide the day it was released and we intend to make full use of it. A particularly helpful section (which ties in with what I have said below) is the one on advice re clinic numbers. Thank you to Kieran and to BAUS!

      November 28, 2016 Reply
  3. Roger Kirby President RSM Urology Section

    One sure fire antidote to burnout is to join us on our RSM Winter Meeting in Northstar California Jan 27th- Feb 4th. Check out http://www.rsmlaketahoe.org.uk. But hurry as there are very few places left!

    November 28, 2016 Reply
    • Robyn Webber Consultant urological surgeon

      I’d be delighted to Roger. However my husband has managed to break his leg without getting anywhere near the ski slopes and will still be in plaster in January 🙁

      November 28, 2016 Reply
  4. Roland Morley Consultant Urologist

    BAUS recently reviewed and did a survey on burnout and found it was prevalent amongst urologists , perhaps because they take on too much !

    However, the GMC needs to take a driving role in ensuring that many activities we do are resources particularly at national level ! The speciality associations can help with this .

    November 28, 2016 Reply
  5. Robyn Webber Consultant urological surgeion

    Fardod’s article is timely and insightful. I agree with Roland that we may all be taking on too much, I am not sure whether this is just a personal failing on the part of urologists, or whether other surgical specialties re similarly affected. Part of the issue for urologists I suspect is that many of us work in subspecialties where we see large numbers of patients, often with limited time, and during that time have to not only assess each patient correctly, but also ensure that the patient feels valued and listened to. So, we have this pressure to deal with along with the many other co existing pressures – for some (like me) that involves running a service, and Ioannis makes an important point above regarding this. Plus of course there are the pressures of dealing with administrative work, keeping oneself up to date, being on call (often without junior support these days), taking part in national activities and finding time for one’s family we well. These competing pressures can make an individual feel energised and excited about their work, or have the complete opposite effect – which is when burn out can occur. My view is that we perhaps all need to slow down a little …

    November 28, 2016 Reply
    • Robyn Webber Consultant urological surgeon

      Just realised I can’t spell surgeon. Perhaps I need to slow down when I am typing. Apologies.

      November 28, 2016 Reply
  6. Louise de Winter Chief Executive

    This is a really interesting article Fardod. I was struck by the comments about leadership qualities having an impact on the wellbeing and satisfaction of physicians. A lot of stress and burnout symptoms can be attributed to individuals feeling that they are no longer in control of their own workload, eg. increasing administrative burdens, lack of staff. The Urology Foundation’s Taking the Lead course looks to address some of the issues facing consultants in the modern day NHS, including developing leadership qualities, time management skills, building resilience, etc. Part of developing leadership qualities is also a skill of recognising one’s own vulnerabilities and acknowledging when help might be needed.
    Delegates to our Taking the Lead course have the highest praise for it and find it extremely helpful. I’d encourage anyone to check it out here: http://theurologyfoundation.org/professionals/75-medical-education-programmes/295-taking-the-lead and let us know if you are interested in applying for a place at a future course.

    November 28, 2016 Reply
  7. Mike Kirby Professor

    PHE have recognised this as an important issue & produced a helpful document:
    Interventions to prevent burnout in high risk individuals: evidence review

    Key findings Interventions designed to reduce symptoms and impact on burnout and workrelated stress were conducted more often at an individual or small-group level than at an organisational level. Individual level interventions that can reduce burnout include staff training, workshops and cognitive-behavioural programmes.

    Changing aspects of the organisation’s culture and working practices might be considered alongside individual level interventions to more effectively prevent burnout. Changes to workload or working practices appear to reduce stressors and factors that can lead to burnout. There is some evidence to suggest that organisational interventions produce longer-lasting effects than individual approaches.

    This evidence review supports the wider literature which argues that organisational interventions in the workplace may be more effective than individual interventions alone. This might involve combining proactive preventative approaches focused at the organisational environment and secondary management approaches directed at individuals. Combining individual and organisational level approaches includes a system change that adopts a participatory environment, promotes open communication, manager and peer support, a culture of learning and successful participation of employees in planning and implementation of programmes.
    Interventions to prevent or treat burnout and work-related stress
    Because of the similarities between work-related stress and burnout, the lack of a valid differential diagnosis for burnout and the inconsistent use of the term burnout, evidence on both burnout and work-related stress is included in this evidence review. However, the evidence that specifically relates to burnout is highlighted.

    Burnout interventions often focus on individual-centred solutions. These may help individuals alleviate exhaustion, but research suggests they are likely to be relatively ineffective if the workplace allows these employees much less control over stressors than in other domains of their lives.
    Research has found that situational and organisational factors play a bigger role in burnout and work-related stress than individual factors.

    Both the Marmot Review and the National Institute for Health and Care Excellence recommend a strategic and coordinated approach to preventing burnout. They highlight various situational and organisational factors that play a larger role in preventing burnout than individual level factors:

    • job autonomy • job security • staff engagement • culture of participation, equality and fairness • opportunities for promoting employees’ mental wellbeing • opportunities for flexible working • strengthened role of line managers

    This evidence review explores how individual and workplace interventions can prevent burnout and work-related stress. Worth a read

    November 28, 2016 Reply
  8. Christian Brown Consultant

    I have just read the BAUS guide to job planning on my way home (8pm). It’s a fantastic guide to what we should be doing and hopefully our Trust will take on board the recommendations. Not a day goes by when we are all asked to do more with less resource. We agree, why? We do it for our patients and colleagues to help. Medicine has relied on this good will for decades and now I’m sad to say good will is limited and if we continue to say yes to everything we will all burnout and that’s a disaster for the profession and most of all our patients. Solution – unknown. In my view the NHS needs a shake up, the demands of the users is different to 1948 and so maybe the structure should be as well?

    November 28, 2016 Reply
  9. Duncan Summerton Consultant urologist

    A very timely and excellent topic to air – thank you, As noted above the latest BAUS job planning document informs us how we should/could work and Kieran has put a tremedous amount of work into this.
    I agree with many points above that the major stresses are often not clinical, but administative or organisational.
    Another issue is that at the same time that we are losing clinical autonomy and the abiltity to treat our patients as we would wish to (shared waiting lists, weekend initiatives, patients being moved around as units of activity to be seen by the first available practitioner) we have not lost any of the responsibility when it goes wrong. Therefore we are being held responsible for a system which we have not really helped to shape and keeping that system safe for our patients is often stressful.
    As Christian and Robyn point out , we do this for the very best intentions but perhaps it is time that we realise that “more haste = less speed” often applies.

    November 29, 2016 Reply
  10. Culley Carson Professor

    Physician burnout is an important and widely discussed topic in the US. Indeed, research on the subject has been published in the Mayo Clinic Proceedings. A recent survey at our medical center suggested that more than 70% of residents in training were significantly depressed and that faculty surgeons and physician s were likewise depressed and burned out. The answer seems to be early retirement (I can identify with that!), reduction of output or seeking positions that do not involve patient care. The causes appear to be many and include: government requirements, electronic medical records, medical malpractice, declining reimbursement. In a recent letter in the Mayo Clinic Proceedings, the authors stated that the burnout issue and loss of manpower was equivalent to the yearly graduation from 7 US medical schools (Shanafelt, TD, et al. Mayo Clin Proc 91:1667-8,2016).

    The solutions are complex and not soon to appear. There needs to be a return to the camaraderie, professionalism and decreased government intrusion for a start. Perhaps the US new secretary of Health and Human Services, Tom Price who is an orthopedic surgeon will give us hope. For too long, the profession of medicine has been governed by lawyers and administrators. Only if we can take back our place in determining policy will we be able to fight this pervasive burnout.

    November 30, 2016 Reply
  11. Fardod O'Kelly Senior Specialist Registrar

    Many thanks for the support as well as all the erudite comments. Many of you have experienced stressors and burnout at times in your careers, with many of the outward signs, symptoms and behaviours un-recognized or even ignored. I sincerely hope that this article and blog will facilitate a voice for those who currently need help, or may need help at some point in the future. I very much look forward to working with many of you going forward on this project.

    January 20, 2017 Reply
  12. Roger Kirby Professor of Urology

    Almost two out of three young hospital doctors say their physical or mental health is being damaged because pressures on the NHS are putting them under intolerable strain.

    Many are so relentlessly busy that they go through entire shifts without eating or drinking, while others suffer stress, burnout, exhaustion and sleeping problems. Relationships with family and friends are also deteriorating as a result of the struggle to cope with the fast-rising demand for care.

    A survey of the working lives of 2,300 trainee anaesthetists has found that six out of seven – 85% – are at risk of becoming burned out, despite only being in their 20s and 30s. Respondents identified long hours, fears about patient safety, the disruption of working night shifts and long commutes to their hospital as key reasons for their growing fatigue and disillusionment.
    A survey by the Royal College of Anaesthetists (RCoA) found that 64% of trainees in that speciality below the level of consultant felt their job had affected their physical health and 61% their mental health. Anaesthetists play a key role in both adult and children’s intensive care units and pain management, as well as in all surgery.

    February 11, 2017 Reply
  13. Roger Kirby Professor of Urology

    High levels of “grit” or resilience are associated with lower levels of burnout in UK doctors, researchers have found.[1]

    The correlation was found among different groups of doctors, with consultants recording significantly higher levels of grit than trainees.

    But it was not present among GPs who, as a group, had the highest levels of burnout.

    The authors said that the nature of burnout in GPs could be different from that of other colleagues and that when burnout levels are very high the “protective role that grit can play could be lost.”

    The UK study, led by researchers from NHS organisations in London including St George’s University Hospital, was published in the Postgraduate Medical Journal.[1]

    Researchers surveyed 548 doctors from different specialties and stages of training, including consultants, GPs, higher specialist trainees, and junior specialist trainees. Grit was described as the ability to persevere during difficulties, being self motivated to achieve success, and maintain a sustained effort over an extended period.

    The authors said that an understanding of a person’s level of grit may be used to identify doctors at greater risk of burnout. “Interventions to improve grit through resilience training should be examined,” they said.

    Burnout is characterised by exhaustion and disengagement from work, but not everyone who is subjected to long-standing stress related to work will develop it.

    Few published studies to date have looked at how burnout relates to individuals’ levels of grit or resilience.

    The researchers found that “overall, there was weak negative correlation between grit and burnout, demonstrating that high grit scores were associated (although weakly) with low burnout scores.” But when GPs were analysed separately, there was “no significant correlation between grit and burnout.”

    The researchers found hospital consultants had “significantly higher” grit scores than trainees.

    They said it was unclear whether this association was because those with lower levels of grit had left their profession, the acquisition of resilience during training, or a natural process with increasing age.

    But it was likely the relation between grit and burnout was “not unidirectional,” they said. Having greater job satisfaction, and thus lower burnout levels, may lead to greater perseverance and higher grit levels through positive reinforcement, according to the study.

    GPs’ grit scores were lower than consultants but comparable to the other groups. Although the GPs were, on average, younger than consultants, the difference remained after controlling for age.

    The researchers said that secondary care doctors’ longer training time might allow more resilience to develop, or different personality traits could affect those drawn to hospital or general practice.

    They said it remained to be seen whether grit could predict success in medical training.

    “Further research is needed to understand how grit levels change during a doctor’s career, why GPs experience higher levels of burnout, and why the relationship between grit and burnout is not seen in this group,” they said.

    1. Halliday L, Walker A, Vig S, Hines J, Brecknell J. Grit and burnout in UK doctors: a cross-sectional study across specialties and stages of training. Postgrad Med J 2017;93:389-94. [Link] [Link] .

    July 14, 2017 Reply

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