Out of the Straitjacket
Michael S. Weinstein, MD, MBE
Review written by Jeffrey M. Smith, MD, FACS, Director of San Diego Orthopaedic Trauma Fellowship, and founder of SurgeonMastersSM
To start, Dr. Weinstein’s story is relayed in the third person, making the reader think he is describing a colleague. Then Dr. Weinstein reveals to the reader that the very dramatic events are in fact about HIM!
He explains the context of his situation going through residency that ultimately resulted in his profound depression and burnout:
“My training occurred before work-hour regulations were created. Every-third-night call was the norm; every-other-night was common. On one rotation, we were ‘rewarded’ with being the operative resident on post-call days, which extended our shift to nearly 36 hours. On my trauma rotation, we took 48-hour shifts alternating with 48 hours off, to maximize the consecutive hours we could spend with family or friends.”
In general, research has shown that resiliency is a significant contributor to wellness and burnout prevention. The “old school” strategies for surgical training often centered on the methods of negative resilience training, such as long hours, sleep deprivation, pimping, and shaming. The evidence on risk factors for burnout is limited, and we should be careful in evaluating these factors, especially as it pertains to in-training or in practice.
Interestingly, burnout rates in residents have increased even after the implementation of work-hour restrictions. In a discussion paper for the National Academy of Medicine from June 2017, we can learn some of the current best available evidence. Much is still unknown, and the authors of the discussion paper encourage ongoing research in this area.
A Stark Description of Burnout
- Discussion Point:
My theory is that negative and positive resilience training each play a role, and that many more positive strategies need to be utilized to create sustainable success as a surgeon.
In describing his experience, Dr. Weinstein offers a stark description of the burnout he faced:
“My work lost meaning; I was just going through the motions. I thought everything I tried to accomplish was a failure. I had trouble relating to patients and felt the urge to avoid encounters altogether. I cared less and less about anything I was doing. I didn’t know it then, but I had long experienced classic signs of burnout: emotional exhaustion, depersonalization, and low perceived personal achievement. But the burnout had been waxing and waning for 22 years; now I was in the worst episode of major depression of my life.”
First of all, burnout is not a bad thing nor a sign of weakness. Burnout is an occupational hazard secondary to emotional, mental and even physical injury. Some aspects of burnout are preventable through methods that address injury prevention or through full healing and recovery. Other aspects of burnout are not preventable, and proper management is needed to minimize permanent injury and maximize recovery.
Mental Health and Illness
- Discussion point:
My recommendation for addressing burnout is to start somewhere. Find one or two healthy habits to implement and start now. Commonly, burnout is the result of too many or unrealistic expectations; adding also requires removing one or two unhealthy habits.
Between 300 and 400 physicians commit suicide every year. Personally, I know of too many in my career. While these rare events are the most tragic, burnout is independently associated with a 200% increased likelihood of suicidal ideation. Dr. Weinstein recounts:
“I remember the pain, early in residency, of witnessing a young man who had lost both his arms in an electrical incident, but my recollection of the countless limbs I subsequently removed is vague or nonexistent.” At another point in his story, he states, “I didn’t know what to do with these feelings. I didn’t believe anyone around me had similar thoughts. I didn’t know how to talk to my co-residents or faculty about medical mistakes and the accompanying self-flagellation. I don’t remember anyone talking about such issues back then.”
Recovery is Probable
- Discussion point:
Beyond the fact that physicians are human and can be vulnerable to any physical and mental illness as well as alcohol and substance abuse, the factors that contribute to this increased risk include:
- post-traumatic stress
- secrecy or culture of silence
- stigma or shaming
- punishment or fear of loss of licensure, privileges or the ability to practice
Although awareness is growing, our current training and practice culture has made very little progress. Dr. Weinstein has taken the steps in the right direction to break the silence and invite others to talk about the subject, to decrease the stigma or shame, and to demonstrate that we can return to provide excellent, safe and compassionate care to our patients:
“I have been back at work in the same capacities as before. I find daily joy in interactions with patients, their families, colleagues, trainees, and our health care team. ... I am concerned for future generations of clinicians unless we change how we teach and practice medicine. We need to devote time and resources to promoting self-care. Too many physicians leave practice prematurely. Too many physicians take their own lives.”
This is an unfortunately all too common situation in which many over-burdened physicians find themselves. Dr. Weinstein found recovery from depression through the support of his family, expert-guided trial and error drug therapies, and cognitive behavioral therapy including mindfulness practices.
Helping a Colleague or Team Member
- Discussion point:
A list of best practices and resources are growing for the treatment and prevention of burnout as well. Recovery from repetitive physical injury or overuse requires time, energy, focus, unloading and specific exercises. Recovery from repetitive mental and emotional injury and overuse does as well. Here are three resources dedicated to combating burnout:
- AMA STEPS Forward - AMA Practice Improvement Strategies
- National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience
- SurgeonMasters - Wellness and Burnout Prevention Education and Coaching
The Reciprocity of Roles and Relationships, one of my 8 PRACTICEs methodology, is consistent with Dr. Weinstein’s story, where even the provision of assistance requires a give and take.
“I’ve subsequently learned that my colleagues were quite concerned about me but found me unreceptive to attempts to help. I was trying to get help in many ways, but nothing seemed to work.”
Many programs are evolving that address managing potentially traumatic events with teams that offer as much support to the healthcare teams including the surgeons to minimize the injuries that can lead to post-traumatic stress disorder. While others may disagree, my impression is that providing voluntary options that avoid the perception of punishment allows the surgeon to maintain as much control as possible and minimize the mental and emotional injury.
- Discussion point:
As far as I know, all of us experience phases of burnout or at least emotional and mental stress or injury. Thoughts and emotions such as stress, anxiety, and anger are normal, and when they should raise concern is not necessarily easy to determine.
In most cases, earlier intervention or assistance is better. Each of us can be aware that we are ALL at risk. The responsibility falls on ALL of us as colleagues to take the following steps:
- Notice the potentially concerning event or behavior
- Interpret the event as an opportunity to show compassion
- Assume personal responsibility
- Know or learn how to assist yourself and others
- Implement assistance without punishment