Original Research


A Comprehensive Umbrella Review for Understanding Burnout in Orthopaedic Surgery

Maike van Niekerk, PhD1; Kali Tileston, MD1; Maryse Bouchard, MD2; Melissa A. Christino, MD3; Rachel Goldstein, MD4; George Gantsoudes, MD5; Cordelia Carter, MD6; Alfred Atanda, MD7

1Stanford School of Medicine, Pediatric Orthopaedic Surgery, Stanford, CA; 2The Hospital for Sick Children, Division of Orthopaedic Surgery, Toronto, ON; 3Boston Children’s Hospital, Department of Orthopedic Surgery, Boston, MA; 4Children’s Hospital Los Angeles, Los Angeles, CA; 5Inova Fairfax Hospital, Department of Orthopedic Surgery, Falls Church, VA; 6NYU Langone’s Hassenfeld Children’s Hospital, Center for Young Athletes, New York, NY; 7Nemours Children’s Health, Department of Orthopedic Surgery, Wilmington, DE

Correspondence: Maike van Niekerk, PhD, Stanford School of Medicine, Pediatric Orthopaedic Surgery, Stanford University, 453 Quarry Rd., Stanford, CA 94305. E-mail: [email protected]

Received: November 20, 2022; Accepted: January 9, 2023; Published: February 1, 2023

DOI: 10.55275/JPOSNA-2023-619

Volume 5, Number 1, February 2023

Abstract

Background: Burnout is characterized by depersonalization, emotional exhaustion, and low personal achievement. Occupational demands can lead to burnout in orthopaedic surgeons, negatively impacting patients and surgeons alike. A high-level overview of burnout is lacking; we therefore aimed to conduct an umbrella review (i.e., review of reviews) summarizing evidence on burnout in orthopaedic surgery, focusing on its rates, associations, prevention, and management.

Methods: We searched Ovid Medline, Ovid PsycINFO, EBSCO CINAHL, and CENTRAL from database inception to 16 July 2022, using the terms “orthopaedic surgery,” “burnout,” and “review.” Quality assessments were conducted using the PASS checklist. An article was considered for inclusion if it was a review, summarized evidence on burnout in orthopaedic surgery, and had a full text available to allow for data extraction. We present the results of our review using narrative syntheses.

Results: We included eight systematic reviews and eight narrative reviews. We found burnout to be common among orthopaedic surgeons, although reviews reported variable rates, thereby precluding definitive conclusions. Residents were found to be particularly at risk of experiencing burnout, with estimates of one in two being affected. Burnout was found to be positively associated with several personal-related factors, including identifying as a female or as a racial minority, experiencing work-life imbalances, and not having spousal support. It was also associated with work-related factors, including working long hours, having stressful work relationships, and experiencing anxiety about one’s clinical competence. Literature on interventions for preventing and managing burnout was limited, although there was some evidence supporting work-hour restrictions for residents.

Conclusions: Although burnout is detrimental for orthopaedic surgeons and their patients, high-quality literature in this field is scarce. Future efforts should be dedicated to conducting large-scale, prospective studies to examine burnout rates and associations as well as interventional studies to prevent and manage burnout.

Level of Evidence: Level IV

Key Concepts

  • Burnout is a work-related syndrome that negatively impacts orthopaedic surgeons and their patients.
  • Burnout is common in orthopaedic surgeons, though rates vary considerably between studies, making definitive conclusions difficult to draw.
  • Orthopaedic surgery residents are particularly at risk of experiencing burnout, with estimates of one in two being affected.
  • Burnout is positively associated with several personal- and work-related factors.
  • Research on interventions for preventing and managing burnout is limited and requires additional inquiry.

Introduction

Burnout is a work-related syndrome characterized by depersonalization, emotional exhaustion, and low personal achievement, secondary to chronic workplace stressors.1,2 Depersonalization can be understood as feeling mentally distant or cynical about one’s job; emotional exhaustion as feeling overextended and progressively worn out, both physically and mentally; and low personal achievement as feeling less competent in one’s job.3,4

Burnout affects physicians at an alarming rate—with documented estimates of more than half experiencing it—and has harmful effects on physicians and patients alike.4,5 Orthopaedic surgeons may be particularly vulnerable to developing burnout due to their heavy workloads, long work hours, and challenging training programs.6 Clinically significant burnout is most commonly defined as high depersonalization and/or high emotional exhaustion, with low personal achievement not being an obligatory criterion.68

Previous reviews of burnout have often been limited in their ability to provide a high-level overview in orthopaedics, specifically, as they only focused on a specific aspect of burnout, such as its rates, associations, or interventions, without assessment of these three in conjunction, and/or reported on orthopaedic surgery as a subgroup in their analyses. An overview summarizing these reviews’ collective results offers a comprehensive understanding of the field as well as highlights areas for further investigation and improvement. It thereby serves as a valuable resource for healthcare policymakers, orthopaedic surgeons, and researchers aiming to improve physician well-being and patient outcomes.

We therefore aimed to conduct an umbrella review (i.e., review of reviews) summarizing evidence on burnout in orthopaedic surgery, focusing on its rates, associations, prevention, and management.

Materials and Methods

We conducted an umbrella review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.9,10 We identified relevant literature (without any language or publication date restrictions) by searching Ovid Medline, Ovid PsycINFO, EBSCO CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) from database inception to July 2022. Searches were run for a combination of “orthopaedic surgery,” “burnout,” and “review” using standardized subject and free-text terms, including synonyms and alternative spellings (search strategy described in Appendix 1). Additionally, we contacted authors of relevant conference abstracts found through our electronic database search to locate associated publications, conducted manual searches of the reference lists of included reviews for relevant literature, and consulted experts on wellness in orthopaedics to obtain grey literature.

We included articles meeting the following selection criteria:

  1. the study was a review (“systematic” or “narrative,” defined below);
  2. the review aimed to summarize evidence of burnout in orthopaedic surgery (or had a clear subgroup on orthopaedic surgeons); and
  3. the full text was available to allow for data extraction.

We use the term “orthopaedic surgeons” as an all-encompassing term that includes trainees and practicing physicians. Later in this paper, we explicitly state orthopaedic “residents” or “attendings” when information on these subgroups was provided by reviews.

Identified articles were imported into Covidence, an electronic software platform for managing reviews. One reviewer (MvN) screened articles’ titles and abstracts to determine if they met selection criteria, reviewed the full texts of all articles deemed to be potentially relevant, and extracted data from eligible articles.

We performed quality assessments of eligible “systematic reviews” using a newly developed quality measure for systematic reviews: the PASS checklist.11 PASS assesses if a review: was Planned with a clearly stated aim, considered All relevant literature, used methods for study Selection that were unbiased and transparent, and conducted Synthesis of data from included studies in an unbiased and informative way.11 We chose PASS over other available measures, as it was designed for clinicians and healthcare policymakers.11 We defined “systematic reviews” as those with clear objectives, pre-defined selection criteria, explicit methods, and systematic presentations of findings; this definition was informed by the one proposed by The Cochrane Collaboration.12 We did not conduct quality assessments of reviews that did not meet these criteria, which we describe as “narrative reviews,” as narrative reviews do not aim to summarize all of the literature on a topic and are, therefore, inherently prone to bias.13

We extracted the following information from systematic reviews: authors, aim(s), selection criteria, database(s) searched, quality assessment(s), method(s) of data analysis, number of relevant primary studies included as well as their characteristics (such as authors, publication dates, and sample sizes), and finding(s). We extracted the following from narrative reviews: authors, aim(s), and finding(s). We resolved queries regarding article inclusion, data extraction, and quality assessments through consensus discussions between all review authors.

Umbrella reviews use reviews as their units of analysis.14 Because of this, data were extracted from reviews themselves, rather than from the primary studies included in the reviews.14 We present the findings of our umbrella review using narrative synthesis. We did not conduct meta-analyses, as several reviews included overlapping primary studies.

Results

Overview

We identified 727 articles in our initial database search as well as an additional two articles through supplemental searches. We screened the titles and abstracts of 604 articles (after removing duplicate articles) and performed full-text review of 137 articles. We deemed 16 reviews to be relevant for inclusion, of which eight were systematic reviews6,8,1520 and eight were narrative reviews (Figure 1).3,2127

Figure 1. Study methodology for umbrella review.

jposna2023619_fig1.jpg

Systematic Reviews

Systematic reviews were conducted between 2013 and 2021,6,8,1520 with the majority being conducted in the past five years (Table 1, Appendix 2). Only two reviews focused specifically on burnout in orthopaedic surgery;6,15 the remainder reported on orthopaedic surgery as a subgroup, for example, when summarizing the literature on burnout in surgeons or residents more broadly.8,1620 Additionally, 75% of reviews focused on a specific subsample of orthopaedic surgeons: three were resident-specific8,17,19 and three were region-specific16,18,20 (two on the United States16,20 and one on the Eastern Mediterranean Region [EMR]18). Rates of burnout in orthopaedic surgery were summarized in all but one review.6,8,15,16,1820 Literature on its associations and interventions were summarized in two6,15 and three reviews, respectively (Table 2, Appendix 2).6,15,17

Reviews included a total of 19 independent primary studies on burnout in orthopaedic surgery, although only a few studies were typically included in each review (median: 2.5 studies; range: 1 to 12 studies) (Table 2, Appendix 2). About half of the primary studies were included in more than one review and conducted in the United States. Reviews frequently excluded primary studies that (a) did not measure burnout using the Maslach Burnout Inventory (MBI)8,16,18,19 or (b) were not published in English.6,16,17,19,20 About half the reviews conducted quality assessments,8,1719 with only one using it to inform study inclusion.8

Narrative Reviews

Narrative reviews were conducted between 2016 and 2022;3,2127 we present the results of these reviews in Appendix 3. We highlight the results of the systematic reviews in the subsequent sections because, unlike narrative reviews, they aim to present all of the available literature on a topic.

Rates of Burnout

We found seven systematic reviews that reported on the rates of burnout in orthopaedic surgery (Table 1).6,8,15,16,1820

Table 1. Rates of Burnout in Orthopaedic Surgery Reported by Systematic Reviews Included in Umbrella Review

Systematic Review Number of Studies Total Sample Size Rates of Burnout
High Depersonalization (measure) High Emotional Exhaustion (measure) Low Personal Achievement (measure) Overall Clinically Significant Burnout (measure)
Arora (2013) 8 1,906* Range: 25% to 65%* (MBI) Range: 28% to 51%* (MBI) Range: 4% to 25%* (MBI) Range: 50% to 60% (MBI)
Bartholomew (2018) (U.S. only) 3 700 Pooled Mean (SD) Score: 9.3 (6.0) (MBI) (high DP is > 12) Pooled Mean (SD) Score: 20.8 (10.9) (MBI) (high EE is > 30) Pooled Mean (SD) Score: 40.4 (5.7) (MBI) (low PA is < 33)
Doraiswamy (2021) (EMR only) 2 244* Range: 39.44% to 40.20%* (MBI-HSS) Pooled Prevalence: 39.75% (95% CI, 33.80% to 46.03%, I2=0%) (MBI-HSS) Range: 34.31% to 50%* (MBI-HSS) Pooled Prevalence: 42.45% (95% CI, 31.96% to 53.68%, I2=66.2%) (MBI-HSS) Range: 11.76% to 39.44%* (MBI-HSS) Pooled Prevalence: 23.15% (95% CI, 8.99% to 47.90%, I2=90.4%) (MBI-HSS) Range: 19% to 57% (MBI-HSS) Pooled Prevalence: 38.7% (95% CI, 15.58% to 68.36%, I2=78.2%, n=149) (MBI-HSS)
Hui (2019) 9 1,753* Range: 11.4% to 59.4% (NR) Range: 16.2% to 50.7% (NR) Range: 4% to 43% (NR) Range: 16.2% to 85.1%* (NR)
Clear Subgroup: Residents Only
Low (2019) 2 435 Range: 53% to 56%* (MBI) Pooled Prevalence: 55.63% (95% CI, 50.93% to 60.28%, I2= 96.3%) (MBI)
Rodrigues (2018) 2 78 Range: 35.3% to 37.0%* (MBI) Pooled Prevalence: 36% (95% CI, 25% to 47%, I2=0%) (MBI) Range: 29.6% to 45.1%* (MBI) Pooled Prevalence: 38% (95% CI, 23% to 53%, I2=47.4%) (MBI) Range: 26.0% to 33.3%* (MBI) Pooled Prevalence§: 30.8% (CI and I2 NR) (MBI) Range: 40.7% to 52.9%* (MBI) Pooled Prevalence: 49% (95% CI, 37% to 60%, I2=7.0%) (MBI)

Note: Quantitative data could not be suitably extracted from Pulcrano (2016) for table.

Acronyms: CI = Confidence Interval; DP = Depersonalization; EE = Emotional Exhaustion; EMR = Eastern Mediterranean Region; MBI = Maslach Burnout Inventory; MBI-HSS = Maslach Burnout Inventory – Human Services Survey; NR = Not Reported; PA = Personal Achievement; SD = Standard Deviation; US = United States.

* Calculated using data from paper.

Not all studies reported rates of burnout, some provided qualitative descriptions.

Arora (2013), Hui (2019), and Pulcrano (2016) described burnout in residents versus attendings, noting residents were at higher risk.

§ Discrepancies in results were noted between the manuscript’s table, figure, and text; data extracted from table.

Two reviews summarized literature on the rates of burnout in orthopaedic surgery broadly, that is, did not solely report region- or resident-specific data.6,15 Both reported wide ranges, making it difficult to meaningfully interpret their results. On the whole, findings indicate that between around 10% to 65% experience high depersonalization, 15% to 50% experience high emotional exhaustion, and 15% to 85% may be classified as burnt out. A smaller number of individuals are likely to have low levels of personal achievement, but this number is still considerable (between around 5% to 45%). The heterogeneity in rates reported by studies may have been secondary to including participants at different career stages; we therefore discuss disaggregated data on residents and attendings below.

It is notable that only one review calculated pooled prevalence estimates for burnout in orthopaedic surgery; this review summarized literature conducted in the EMR.18 Reviewers estimated that just under half of participants (around 40%) had high depersonalization, high emotional exhaustion, and/or overall clinically significant burnout, and one-quarter had low levels of personal achievement.18 On the other review, burnout percentages were not reported; instead, the mean MBI score across studies conducted in the United States was calculated.16 Reviewers estimated that orthopaedic surgeons had average scores that were below the cut off for high depersonalization, high emotional exhaustion, and low levels of personal achievement, suggesting low burnout.16

Orthopaedic Surgery Residents Versus Attendings

Five reviews discussed levels of burnout in residents,6,8,15,19,20 two of which calculated pooled prevalence estimates (Table 1).8,19 Both reviews included two primary studies in their analyses, one of which was included in both (Tables 2 and 3, Appendix 2).8,19 They similarly estimated that around one in two residents experienced burnout.8,19 One of the reviews conducted further analyses, estimating that around one in three residents had high depersonalization, high emotional exhaustion, and/or low personal achievement.8 Three of these five reviews discussed levels of burnout in attendings (i.e., practicing surgeons, faculty, chiefs) as well.6,15,20 Reviewers noted high levels of emotional exhaustion and depersonalization and relatively preserved levels of personal achievement, suggesting that personal achievement increases with seniority.6,15 All three highlighted that residents are more susceptible to burnout than attendings.6,15,20

Orthopaedic Surgeons Versus Other Specialties

Four reviews compared levels of burnout between medical specialties (Table 4, Appendix 2).8,16,18,19 All focused on specific subgroups of physicians, such as residents,8,19 physicians in the EMR,18 and surgeons in the United States.16

Compared with pooled estimates for all specialties, orthopaedic surgeons tended to have similar or lower rates of high depersonalization, high emotional exhaustion, and low personal achievement.8,18 Rates of overall clinically significant burnout were noted to be slightly higher in orthopaedic surgery residents, affecting around one in two residents, compared with 35% to 51% of residents broadly; however, differences between specialties was not found to be statistically significant.8,19

Between reviews, notably high rates of depersonalization were found in cardiology and intensive care; emotional exhaustion in cardiology, dermatology, neurology, otolaryngology, and radiology; low personal achievement in anesthesiology, emergency medicine, intensive care, and plastic surgery; and overall clinically significant burnout in internal medicine and general surgery.8,18,19 Family medicine and pediatrics had comparatively lower rates of burnout.8,18,19

Orthopaedic Surgeons in Different Countries

Two reviews observed differences in rates of burnout between countries.6,19 In both reviews, countries in Asia and North America were found to have higher burnout rates than those in Europe.6,19 One review, however, noted that these differences were statistically insignificant.19 It was speculated that burnout rates may be higher in countries with long work hours, educational pressures, limited autonomy, and professional uncertainty (such as those in Asia and North America).6,19 Comparatively, European countries may have lower risk of burnout due to regulations, such as their work-hour limitations of 48 hours a week and demonstrated adherence to these limits.19

Factors Associated with Burnout

We found two systematic reviews that reported on the associations of burnout in orthopaedic surgery (Table 2).6,15 One review included only one primary study;15 the other reviewed this as well as eight others.6

Table 2. Personal- and Work-Related Factors Associated with Burnout In Orthopaedic Surgery Reported by Systematic Reviews Included in Umbrella Review

Negatively Associated with Burnout (“Protective”) Positively Associated with Burnout (“Risk”)
Personal-Related Factors High self-efficacy (burnout) Female (EE)
Work-life balance (low PA) Work-life conflict†, ‡ (EE)
Time for hobbies (high EE) Harassment & discrimination (burnout)
Satisfaction from talking to friends & family†, ‡ (low PA) Racial minority status (EE)
Good marital relationship†, ‡ (low PA) Lack of spousal support (EE)
Personal time with one’s spouse†, ‡ (high EE) Poor marital relationship (EE)
Spouse working long hours (low PA) Significant other in active military duty (burnout)
Parenthood†, ‡ (high DP, low PA, burnout) Financial concerns†, ‡ (EE) & anticipation of debt (DP)
Greater number of children (high DP) Alcohol & drug use†, ‡ (DP)
Having a father who is a physician (EE)
Good relationship with one’s mother†, ‡ (high DP)
Work-Related Factors Standard work hours (residents) (low PA) Excessive work/long work hours†, ‡ (high DP, burnout)
Long work hours (faculty) (high DP) Nights on-call per week (burnout)
Perceived support from colleagues†, ‡ (high EE, low PA) Sleep deprivation (high DP, high EE, low PA)
Satisfaction from talking with colleagues†, ‡ (high EE, low PA) Stressful workplace relationships†, ‡ (high DP, high EE)
Job satisfaction (burnout) Perception of work as stressful†, ‡ (high EE)
≥ 10 years of post-residency experience (high DP, high EE) Regrets in choosing a medical career (high EE, low PA)
Good quality mentorship (high DP, high EE, low PA) Current resident status (high DP, high EE, low PA)
  • Senior resident mentor (high EE)
Working in large residency program (high DP, high EE)
  • Faculty mentor (low PA)
Anxiety about clinical competence†, ‡ (high EE)
Frequent contacts with mentors (high EE, low PA) Worry about competition from other orthopaedic surgeons†, ‡ (high EE)
Research duties on top of clinical duties (burnout) Credentialing (high EE)
Tenure & promotion (high EE)
Increasing overhead, department, and hospital budget deficits (high EE)
Staff dismissal (high EE)

Acronyms: DP = Depersonalization; EE = Emotional Exhaustion; PA = Personal Achievement.

Hui (2019) included nine studies. Arora (2013) included one study. Reviews included overlapping study.

Personal-Related Factors

Many non-work related factors were found to be linked to burnout. Identifying as a female and as a racial minority, for example, were each associated with higher levels of emotional exhaustion.6 Both groups likely experience greater levels of harassment and discrimination, which were factors also positively associated with burnout.6 Burnout was also associated with financial concerns as well as alcohol and drug use.6,15

It is worth noting the mounting evidence of the role of family factors in burnout. Unsurprisingly, work-life conflict, lack of spousal support, and having a significant other in active military duty were positively associated with burnout.6,15 Conversely, opposing factors (including work-life balance, perceived support from family, good marital quality, and personal time with one’s spouse) appeared protective. Furthermore, orthopaedic surgeons who were parents as well as those whose spouses worked longer hours, were found to have higher levels of personal achievement.6,15

Work-Related Factors

A number of work-related factors were also found to contribute to burnout. Among these factors were sleep deprivation, long work hours, nights on-call, and stressful relationships with colleagues.6,15 In contrast, supportive environments (such as those with supportive relationships among colleagues and mentorship opportunities) were negatively associated with burnout.6,15 Job satisfaction and research duties on top of clinical duties contributed to lower burnout among orthopaedic surgeons while feelings of regret for choosing a career in medicine were associated with higher emotional exhaustion and lower personal achievement.6

Orthopaedic Surgery Residents Versus Attendings

Factors associated with burnout likely vary by level of seniority.6,15 Although being a resident was associated with greater burnout (especially in larger residency programs), surgeons with a minimum of 10 years post-residency experience had lower levels of depersonalization and emotional exhaustion.6 In contrast to residents, faculty appeared to be uniquely burdened by the threat of competition from the increasing numbers of orthopaedic surgeons.6,15 Interestingly, there was evidence to suggest that faculty who worked longer hours experienced lower levels of depersonalization.15 It was also found that senior surgeons in administrative positions faced distinctive challenges related to credentialing, tenure and promotion, budget deficits, and staff dismissals.6 Although a surgeon’s level of seniority may play a role in burnout, it is noteworthy that several factors appear to be universally related to burnout, such as having anxiety about one’s clinical competence, experiencing work-life imbalances, and having stressful relationships at work.

Interventions to Prevent or Manage Burnout

Three systematic reviews aimed to summarize literature on interventions to prevent or manage burnout in orthopaedic surgery.6,15,17 Two of these reviews reported finding no studies.6,15 The third review described a pre- and post-study evaluating changes in burnout rates following the implementation of the 2003 ACGME (Accreditation Council for Graduate Medical Education) work-hour restrictions in the United States.17 Following the implementation of these restrictions, orthopaedic surgery residents were found to have improved personal achievement scores, but faculty burnout rates did not change.17

It is worth noting that the majority of narrative reviews also suggested useful strategies for improving wellness and addressing burnout in the profession, though most suggestions were not based on orthopaedic literature. One of these reviews proposed using a top-down approach to addressing burnout, highlighting the importance of buy-in from all stakeholders (Figure 2).27 We summarize the remainder of strategies in Appendix 3 and wrote a dedicated paper describing these further and proposing new ones based on expert opinion.

Figure 2. Top-down model to addressing burnout in orthopaedic surgery.

Figure reproduced with permission from: Jennings JM, Gold PA, Nellans K, Boraiah S. Orthopaedic surgeons have a high prevalence of burnout, depression, and suicide: Review of factors which contribute or reduce further harm. J Am Acad Orthop Surg. 2022;30(5):e528-e535.

jposna2023619_fig2.jpg

Quality Assessments

We summarize the results of our quality assessments in Table 3. All reviews had clearly stated aims, detailed search strategies, as well as clear selection criteria. However, about half did not clearly describe how studies were selected for inclusion in their review or the characteristics of the primary studies they included. Moreover, half did not perform quality assessments of included studies and therefore also did not adequately discuss the possible effects of study quality on their findings.

Table 3. PASS Quality Assessments of Systematic Reviews Included in Umbrella Review

Arora (2013) Bartholomew (2018) Busireddy (2017) Doraiswamy (2021) Hui (2019) Low (2019) Pulcrano (2016) Rodrigues (2018)
P – Planned with a clearly stated aim Review aim specified the population & outcome(s) being studied Yes Yes Yes Yes Yes Yes Yes Yes
A – All the relevant literature was considered Detailed, replicable search strategy Yes Yes Yes Yes Yes Yes Yes Yes
S – Selection of included studies was unbiased and transparent Clearly defined selection criteria Yes Yes Yes Yes Yes Yes Yes Yes
Study selection done by ≥ 2 independent reviewers with a procedure for dealing with disagreements No/Unclear Yes Yes No/Unclear Yes Yes No/Unclear Yes
Clear description of how studies were selected for inclusion‡ No/Unclear No/Unclear No/Unclear Yes Yes Yes No/Unclear Yes
S – Synthesis of data from included studies was unbiased and informative Data extraction done by ≥ 2 independent reviewers with a procedure for dealing with disagreements No/Unclear Yes No/Unclear No/Unclear No/Unclear Yes No/Unclear Yes
Quality assessments done for each included study No/Unclear No/Unclear Yes Yes No/Unclear Yes No/Unclear Yes
Clear description of the sample characteristics, procedures for assessing conditions, and outcome for each included study No/Unclear No/Unclear§ Yes Yes No/Unclear Yes No/Unclear No/Unclear
Method for synthesizing data from included studies was clear, acknowledging possible effects of heterogeneity & study quality# No/Unclear No/Unclear Yes Yes No/Unclear Yes No/Unclear Yes

Removed specification of prevalence from measure to be more widely applicable for this umbrella review. Rated as no/unclear if no PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram with reasons for exclusion of full texts (or similar description in text). §Did not report MBI (Maslach Burnout Inventory) values for individual studies despite conducting mean aggregate estimates across studies. Discrepancy noted between manuscript, table, and figure in reporting of personal achievement outcome. #Rated as no/unclear if no quality assessment done.

Discussion

This umbrella review summarized reviews of burnout in orthopaedic surgery. We identified eight systematic reviews;6,8,1520 all but one summarized literature on rates of burnout,6,8,15,16,1820 and a minority described its associations or interventions.6,15,17 There were only two reviews that exclusively summarized evidence on orthopaedic surgery,6,15 while the remainder discussed orthopaedic surgery as a subgroup in their analyses.8,1620 We also found eight narrative reviews on the topic.3,2127

Although literature revealed high rates of burnout in orthopaedic surgery, the wide range of estimates preclude definitive conclusions on its prevalence. Evidence suggests residents may be particularly susceptible to burnout: just under half were estimated to have high depersonalization, high emotional exhaustion, and clinically significant burnout, and one-quarter to have low personal achievement. Compared with other specialties, orthopaedic surgeons had similar or lower levels of high depersonalization, high emotional exhaustion, and low personal achievement, with slightly higher (though statistically insignificant) levels of clinically significant burnout amongst residents.

Burnout was found to be associated with a variety of personal- and work-related factors. Personal factors positively associated with burnout included: identifying as a female or a racial minority; experiencing harassment, discrimination, or financial concerns; using alcohol and drugs; and experiencing negative family factors (including work-life imbalances and lack of spousal support). Conversely, good marital status and parenthood appeared protective. Stressful workplaces (including those where surgeons work long hours, are constantly on-call, and have stressful relationships with colleagues) contributed to burnout. On the other hand, supportive environments, job satisfaction, and research duties were negatively associated with burnout. Orthopaedic surgeons at different stages of their career were found to experience unique burnout associations.

Interventions for preventing or managing burnout in orthopaedic surgery are sparse. While there is some evidence that work-hour restrictions improve residents’ outcomes, a consensus across reviewers was the need for additional research on individual- and institutional-level interventions to address burnout.

Rates of Burnout

Although research suggests burnout is common in orthopaedic surgery it is unclear why estimates are so variable. Much like our review, a review of burnout in physicians of all specialties similarly reported substantially variable estimates ranging from 0% to 80.5%.28 Its authors attributed the heterogeneity to the lack of consensus on how burnout is measured and operationalized in the literature, noting at least 142 definitions.28 Without negating the importance of burnout in medicine, reviewers called into question the validity of frequently cited prevalence estimates (such as 50% of physicians experiencing burnout) considering the heterogeneity between studies.28 Researchers found significant differences in rates of burnout when applying different definitions, with studies applying standard cut-off scores reporting significantly higher rates than those that did not.18 Even amongst studies that applied similar definitions, substantial heterogeneity was found between them.18 Researchers attributed this to study-related factors as well as differences in health systems, types of training, and salaries.18 To meaningfully quantify burnout, we advocate for more consistent reporting of burnout as other review authors have stated.28 In the absence of an agreed-upon definition, researchers may consider (a) reporting burnout as a continuous outcome and/or (b) reporting multiple estimates using a range of cut-off scores until consensus is achieved.28

Factors Associated with Burnout

Despite our inclusion of only two reviews summarizing evidence of burnout in orthopaedic surgery,6,15 many more reviews have included orthopaedic literature in analyses of burnout among physicians, surgeons, or residents generally. Most of these were excluded due to the lack of an explicit subgroup of orthopaedic surgeons in their results.7,2932 By and large, similar associations of burnout were noted by these reviews. Interestingly, one review highlighted evidence that certain personality traits (such as extraversion, agreeableness, conscientiousness, and grit) are associated with less burnout among surgeons.29

Unlike most reviews in our umbrella review, others have summarized evidence on the effects of burnout on patient outcomes. In one such review, researchers examined the relationship between surgeon burnout, patient safety, and professionalism.5 They found burnout was associated with increased odds of medical mistakes (2.5-fold increase) and poorer professionalism (such as loss of temper and poorer empathy).5 It is worth noting that the only study that attempted to investigate burnout exclusively in orthopaedic surgeons found that those with greater emotional exhaustion lost their tempers more frequently.6 According to reviewers, their findings mirrored those of reviews on physicians and healthcare providers generally and that associations are likely bidirectional.5

Interventions to Prevent or Manage Burnout

Given that one point increases in depersonalization and emotional exhaustion have been associated with 11% and 5% increases in medical error rates, respectively,33 it is important that we intervene. Despite there being limited literature on interventions targeting burnout in orthopaedic surgery, we can use insights from reviews on interventions for physicians in general to inform how to address burnout in orthopaedics. High-quality reviews have found evidence to support both individual- and institutional-level interventions.34,35

A number of individual-level interventions, such as mindfulness, stress management, and small group discussions, have been found to reduce levels of depersonalization and emotional exhaustion.34 It should be noted, however, that pooled analyses of these interventions failed to demonstrate significant reductions in rates of overall clinically significant burnout, high depersonalization, or high emotional exhaustion.34

It is therefore clear that burnout cannot be addressed at the individual-level alone: institutional changes are needed as well.4 In fact, institutional-level interventions have been demonstrated to be more effective than individual-level interventions in improving outcomes, further highlighting their importance.35 In a review of institutional-level interventions for physician burnout, the most promising results were found for interventions that improved workflows and teamwork (such as using scribes or medical assistants to assist with electronic health record documentation, implementing team-based care models, and improving communication between physicians).36 Despite there being evidence to support work-hour restrictions, particularly for residents,17,34 researchers have pointed out the variability of this evidence and cautioned against implementing such restrictions as the sole means of addressing burnout, particularly if institutional factors are not addressed to reduce workload in a manner that reflects reductions in work hours.16,31,36,37 For residents, adapting burdensome work schedules, increasing autonomy and recognition, and defining clear role divisions may be particularly helpful.17

Future Clinical and Research Recommendations

Numerous clinical and research recommendations were made in the systematic reviews included in our umbrella review, collectively summarized below:

  • The profession must acknowledge burnout as well as its harmful effects;
  • Institutions should implement early detection programs; and
  • Institutions and professional societies – such as the Pediatric Orthopaedic Society of North America (POSNA) – must provide guidance on ways to improve surgeon well-being and pioneer evidence-based programs for preventative and therapeutic strategies.

These studies also highlighted the importance of developing a unified definition for burnout and measuring it using a validated, standardized measure to allow for cross-study comparisons. Several research recommendations were also made, including conducting (a) large, multi-center prospective studies examining burnout rates and associations that allow for multivariate analyses and stratification by level of training, and (b) interventional studies that address burnout in orthopaedics with long follow-up periods.

Strengths and Limitations of the Current Manuscript

This umbrella review has several strengths which include (a) using a comprehensive search strategy to find all relevant published literature; (b) searching for grey literature; (c) not applying language or publication date restrictions; and (d) conducting quality assessments of all included reviews. Additionally, umbrella reviews are useful because they provide a comprehensive overview of key literature in a field, which allows busy clinicians and policymakers to quickly gain a broad understanding of the state of research in an area without having to read multiple individual systematic reviews and primary studies. This saves time and allows for more efficient decision-making.

It also has several limitations, including (a) one researcher performing study selection, data extraction, and quality assessments; (b) inclusion of reviews deemed to be of relatively low quality; (c) inability to conduct statistical analyses due to overlapping primary studies and heterogeneity; and (d) limited evidence on interventions for preventing or managing burnout in orthopaedics. It is also important to note that umbrella reviews have the inherent limitation that they summarize only published systematic reviews. For this reason, recent primary studies may be overlooked if they have not already been included in a systematic review. Many of the primary studies included in the systematic reviews also had important limitations, including (a) having small sample sizes; (b) being conducted in single centers (mainly in the United States); (c) being cross-sectional and conducting bivariate analyses of associations; (d) having low response rates; and (e) using various burnout definitions.

Conclusion/Call to Action

One of the reviews included in our umbrella review compared orthopaedic surgeons to canaries in a coal mine: surgeons (like canaries) are strong and resilient, but if the workplace (coal mine) becomes too toxic for them to function, institutions must take this as a warning sign and respond accordingly.23 We therefore put forth a call to action to address burnout in orthopaedic surgery through clinical and research efforts, particularly on the institutional level. Future efforts should be dedicated to developing a unified definition of burnout; conducting large-scale, prospective studies to examine burnout rates and associations; and conducting interventional studies to prevent and manage burnout.

Additional Links

Acknowledgement

The authors wish to recognize and acknowledge the valuable contributions of all past and present members of the POSNA Wellness Committee, which will continue its efforts to optimize the professional well-being of its members.

Disclaimer

The authors have no conflicts of interest to report.

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Appendix 1

1.0 Search Strategy

1.1 Database 1: Ovid Medline

Search terms 1 Physicians/
2 Physician*.ti.
3 Attending*.ti.
4 Doctor*.ti.
5 Surgeon*.ti.
6 Intern*.ti.
7 Residen*.ti.
8 Orthopedics/
9 Orthop*.ti.
10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11 Burnout, professional/
12 Burnout*.ti.
13 Exhaust*.ti.
14 Depersonali*.ti.
15 MBI.ti.
16 MasLach Burnout Inventory.ti.
17 11 or 12 or 13 or 14 or 15 or 16
18 Review.pt.
19 Review*.ti,ab.
20 Overview*.ti,ab.
21 Meta-analy*.ti,ab.
22 Metaanaly*.ti,ab.
23 18 or 19 or 20 or 21 or 22
24 10 and 17 and 23
Publication date restrictions None (database inception to 16 July 2022)
Language restrictions None

1.2 Database 2: Ovid PsycINFO

Search terms 1 Physicians/
2 Physician*.ti.
3 Attending*.ti.
4 Doctor*.ti.
5 Surgeon*.ti.
6 Intern*.ti.
7 Residen*.ti.
8 Orthopedic/
9 Orthop*.ti.
10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11 Burnout/
12 Burnout*.ti.
13 Exhaust*.ti.
14 Depersonali*.ti.
15 MBI.ti.
16 MasLach Burnout Inventory.ti.
17 11 or 12 or 13 or 14 or 15 or 16
18 Review*.ti,ab.
19 Overview*.ti,ab.
20 Meta-analy*.ti,ab.
21 Metaanaly*.ti,ab.
22 18 or 19 or 20 or 21
23 10 and 17 and 22
Publication date restrictions None (database inception to 16 July 2022)
Language restrictions None

1.3 Database 3: EBSCO CINAHL

Search terms S1 (MH “Physicians”)
S2 TI (physician* or attending* or doctor* or surgeon* or intern* or resident*)
S3 (MH “Orthopedic Surgery”)
S4 TI (orthop*)
S5 (MH “Burnout, Professional”)
S6 TI (burnout* OR exhaust* OR depersonali* OR MBI OR “MasLach Burnout Inventory”)
S7 (MH “Systematic Review”)
S8 TI (review* OR overview* OR meta-analy* OR metaanaly*) OR AB (review* OR overview* OR meta-analy* OR metaanaly*)
S9 S1 OR S2 OR S3 OR S4
S10 S5 OR S6
S11 S7 OR S8
S12 S9 AND S10 AND S11
Publication date restrictions None (database inception to 16 July 2022)
Language restrictions None

1.4 Database 4: Cochrane Central Register of Controlled Trials (CENTRAL)

Search terms #1 MeSH descriptor: [Physicians] explode all trees
#2 (Physician*):ti
#3 (Attending*):ti
#4 (Doctor*):ti
#5 (Surgeon*):ti
#6 (Intern*):ti
#7 (Residen*):ti
#8 MeSH descriptor: [Orthopedics] explode all trees
#9 (Orthop*):ti
#10 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9
#11 MeSH descriptor: [Burnout, Professional] explode all trees
#12 (Burnout*):ti
#13 (Exhaust*):ti
#14 (Depersonali*):ti
#15 (MBI):ti
#16 (MasLach Burnout Inventory):ti
#17 #11 or #12 or #13 or #14 or #15 or #16
#18 MeSH descriptor: [Systematic Review] explode all trees
#19 MeSH descriptor: [Meta-Analysis] explode all trees
#20 (Review*):ti,ab,kw
#21 (Overview*):ti,ab,kw
#22 (Meta-analy*):ti,ab,kw
#23 (Metaanaly*):ti,ab,kw
#24 (Meta analy*):ti,ab,kw
#25 #18 or #19 or #20 or #21 or #22 or #23 or #24
#26 #10 and #17 and #25
Publication date restrictions None (database inception to 16 July 2022)
Language restrictions None

Appendix 2

Table 1. Characteristics of Systematic Reviews on Burnout in Orthopaedic Surgeons Included in Umbrella Review

Systematic Review Aim(s) Selection Criteria Database(s) Searched Population(s) of Interest Studies of Burnout in Orthopaedic Surgeons
Number of Studies Outcome(s) of Interest Quality Assessment(s) Method(s) of Analyzing
Arora
(2013)

Burnout in orthopaedic surgeons: A review
To summarize available literature on burnout among orthopaedic surgeons and provide recommendations for future work in the field.
  1. Measured burnout
  2. Used validated burnout measure
  3. Participants were primarily orthopaedic surgeons
Database(s): EMBASE,
MedLine, Google Scholar (supplemental)

Dates: Database inception to ‘present’
Orthopaedic Surgeons 8 studies
(all orthopaedic)
Rates
(8 studies)

Associations
(1 study)

Interventions
(0 studies)
None Narrative synthesis
Bartholomew
(2018)

Meta-analysis of surgeon burnout syndrome and specialty differences
To quantify the presence of burnout syndrome among surgeons and to compare scores on burnout subscales among different specialties.
  1. Participants were surgeons (residents or attendings)
  2. Reported specialty-specific data
  3. Used MBI to measure burnout
  4. Conducted in the United States
  5. Written in English
  6. Excluded if participants were medical students or other health professionals
Database(s): EMBASE, MedLine, PsycINFO

Dates:
January 1980 to July 2015
Surgeons (United States) Subgroup

16 studies
(3 orthopaedic)
Rates
(3 studies)
None Narrative synthesis

Meta-analysis of mean subscale scores
Busireddy
(2017)

Efficacy of interventions to reduce resident physician burnout: A systematic review
To summarize current evidence and systematically review various interventions and their effect on burnout rates among residents.
  1. Peer-reviewed
  2. Participants were residents
  3. Studied efficacy of burnout intervention with follow-up results
  4. Written in English
  5. Excluded if abstract only, review article, editorial, or letter
Database(s): EMBASE, PubMed, WOS

Dates: Database inception to unclear end date
Residents Subgroup

19 studies
(1 orthopaedic)
Interventions
(1 study)
Newcastle-Ottawa Scale for cohort studies & Jadad scale for RCTs

(orthopaedic study had Newcastle-Ottawa score of 4 [low quality])
Narrative synthesis for orthopaedic subgroup
Doraiswamy
(2021)

Physician burnout in the Eastern Mediterranean Region: Influence of gender and related factors – Systematic review and meta-analysis
To synthesize available evidence on the prevalence of physician burnout and its relationship to gender, physician specialties, and age, in the World Health Organization Eastern Mediterranean Region (EMR).
  1. Participants (or a clear subgroup) were physicians from the EMR
  2. Measured burnout prevalence
  3. Used MBI-HSS to measure burnout
  4. Cross-sectional, case-control, or cohort study design
  5. English, Arabic, or French abstract
  6. Excluded if experimental, interventional, qualitative study, or review
Database(s):
EMBASE,
Google Scholar,
PsycINFO,
PubMed

Al Manhal
(supplemental)

Dates:
Database inception to June 2020
Physicians (EMR) Subgroup

78 studies
(2 orthopaedic)
Rates
(2 studies)
National Heath, Lung, and Blood Institute (NHLBI)-Recommended Quality Assessment Tools

(2 orthopaedic studies rated as poor quality)
Narrative synthesis

Meta-analysis using random effects model (studies with n ≥ 20)

Heterogeneity I2 statistic
Hui
(2019)

Burnout in orthopaedic surgeons: A systematic review
To summarize and discuss the evidence of the prevalence, determinants, outcomes, and management of burnout in orthopaedic surgeons.
  1. Peer-reviewed
  2. Measured burnout
  3. Used validated burnout measure
  4. Participants were orthopaedic surgeons
  5. Written in English
Database(s): PubMed

Dates: Database inception to March 2018
Orthopaedic Surgeons 14 articles of 12 studies
(all orthopaedic)
Rates
(9 studies)

Associations
(9 studies)

Interventions
(0 studies)
None Narrative synthesis
Low
(2019)

Prevalence of burnout in medical and surgical residents: A meta-analysis
To quantitatively summarize the global prevalence rates of burnout among residents, by specialty, and its contributing factors.
  1. Cohort or cross-sectional study design
  2. Measured prevalence of burnout
  3. Participants were medical residents
  4. Used MBI to measure burnout
  5. Written in English
  6. Excluded if: participants were senior physicians, chiropractors, or medical students; missing or unavailable data; or review, commentary, or editorial
Database(s):
EMBASE,
PsycINFO,
PubMed, WOS

Dates:
Database inception to March 2018
Residents Subgroup

47 studies
(2 orthopaedic)
Rates
(2 studies)
National Institutes of Health’s Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies
(NIH-QAT)

(no quality score calculated)
Narrative synthesis

Meta-analysis using random effects

Heterogeneity I2 statistic
Pulcrano
(2016)

Quality of life and burnout rates across surgical specialties: A systematic review
To systematically review the literature across multiple surgical specialties and provide a comprehensive understanding of quality of life (QoL) and burnout among all surgeons, to delineate variation in rates of burnout and poor QoL, and to elucidate factors that are commonly implicated in these outcomes.
  1. Participants were surgical specialists practicing in the United States
  2. Used questionnaire(s) with ≥ 1 QoL question
  3. Written in English
  4. Excluded if participants were medical students or non-surgical health care professionals
  5. Excluded reviews
Database(s):
EMBASE,
MedLine, PsycINFO

Dates:
January 1980 to June 2015
Surgeons (United States) Subgroup

41 studies
(6 orthopaedic)
Rates
(6 studies)
None Narrative synthesis
Rodrigues
(2018)

Burnout syndrome among medical residents: A systematic review and meta-analysis
To summarize the published studies and to estimate burnout syndrome prevalence among different medical resident specialties and point to medical specialties most affected by the syndrome.
  1. Cross-sectional study design
  2. Participants were medical residents
  3. Used 22-item MBI to measure burnout
  4. "Excellent" or "good" according to quality checklist (see column 9)
  5. Approved by ethics
  6. Excluded if: longitudinal or interventional study; not stratified by individual specialty; or focused on subgroup of residents (e.g., females only)
Database(s): EMBASE,
Google Scholar, PubMed,
Scopus, WOS

Dates:
January 1974 to March 2018
Residents Subgroup

26 studies
(2 orthopaedic)
Rates
(2 studies)
Agency for Healthcare Research and Quality (AHRQ) Methodology Checklist for Cross-sectional/Prevalence Study Methodology Checklist for Cross-sectional Study/Prevalence

(2 orthopaedic studies met quality criterion to be included in review)
Narrative synthesis

Meta-analysis using random effects

Heterogeneity I2 statistic

Acronyms: AHRQ = Agency for Healthcare Research and Quality; EMBASE = Excerpta Medica dataBASE; EMR = Eastern Mediterranean Region; MBI = Maslach Burnout Inventory; MBI-HSS = Maslach Burnout Inventory – Human Services Survey; MEDLINE = Online counterpart to MEDLARS (MEDical Literature Analysis and Retrieval System); NHLBI = National Heath, Lung, and Blood Institute; NIH-QAT = National Institutes of Health’s Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies; QoL = Quality of Life; RCTs = Randomized Controlled Trials; WOS = Web of Science.

† Stated inclusion of 10 papers in manuscript but cited nine references.

Table 2. Primary Studies on Burnout Rates, Associations, and Interventions in Orthopaedic Surgery Cited by Systematic Reviews Included in Umbrella Review

Primary Study Systematic Review Number of Times Cited
Arora
(2013)
Bartholomew
(2018)
Busireddy
(2017)
Doraiswamy
(2021)
Hui
(2019)
Low
(2019)
Pulcrano
(2016)
Rodrigues
(2018)
Rates (R) 8 studies 3 studies 2 studies 9 studies 2 studies 6 studies 2 studies
Associations (A) 1 study 9 studies
Interventions (I) 0 studies 1 study 0 studies
R A I
1 Alsheikh (2019) Saudi Arabia R 1 0 0
2 Arora (2014) Australia R R R 3 0 0
3 Barrack (2006) US I A 0 1 1
4 Balch (2011) US R R 2 0 0
5 Leigh (2002) US R 1 0 0
6 Lesić (2009) Serbia R R 2 0 0
7 Sadat-Ali (2005) Saudi Arabia R R R 3 0 0
8 Saleh (2007) US R R§ R A R 4 1 0
9 Saleh (2009) US R A 1 1 0
10 Salles (2014) US R 1 0 0
11 Sánchez-Madrid (2005) Spain R 1 0 0
12 Sargent (2004) US R A R A R 3 2 0
13 Sargent (2009) US R R R A R R 5 1 0
14 Sargent (2011) NR A 0 1 0
15 Shanafelt (2012) US R 1 0 0
16 Simons (2016) US R A R 2 1 0
17 van Vendeloo (2014) Netherlands R 1 0 0
18 van Wulfften Palthe (2016) NR A 0 1 0
19 Zheng (2018) China R A 1 1 0

Note: Hui (2019) categorized study by Barrack (2006) as being an association analysis, while Busireddy (2017) categorized it as interventional.

Acronyms: A = Associations; I = Interventions; NR = Not Reported; R = Rates, US = United States.

† See Table 3 for full references.

‡ Stated inclusion of 10 papers in manuscript but cited nine references.

§ Reported Saleh (2009) in manuscript but Saleh (2007) in reference list.

Table 3. Full References for Primary Studies on Burnout Rates, Associations, and Interventions in Orthopaedic Surgery Cited by Systematic Reviews Included in Umbrella Review

1 Alsheikh (2019) Alsheikh KA, Alhabradi FA, Almalik FF, Alsalim AA, Ahmed FE, Alhandi AA. Burnout syndrome among orthopedic surgery residents in Saudi Arabia: A multicenter study. Journal of Musculoskeletal Surgery and Research. 2019;3:184.
2 Arora (2014) Arora M, Diwan AD, Harris IA. Prevalence and factors of burnout among Australian orthopaedic trainees: A cross-sectional study. J Orthop Surg (Hong Kong). 2014 Dec;22(3):374-7. doi: 10.1177/230949901402200322.
3 Barrack (2006) Barrack RL, Miller LS, Sotile WM, Sotile MO, Rubash HE. Effect of duty hour standards on burnout among orthopaedic surgery residents. Clin Orthop Relat Res. 2006 Aug;449:134-7. doi: 10.1097/01.blo.0000224030.78108.58.
4 Balch (2011) Balch CM, Shanafelt TD, Sloan JA, Satele DV, Freischlag JA. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011 Oct;254(4):558-68. doi: 10.1097/SLA.0b013e318230097e.
5 Leigh (2002) Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med. 2002 Jul 22;162(14):1577-84. doi: 10.1001/archinte.
6 Lesić (2009) Lesić AR, Stefanovic NP, Perunicić I, Milenković P, Tosevski DL, Bumbasirević MZ. Burnout in Belgrade orthopaedic surgeons and general practitioners, a preliminary report. Acta Chir Iugosl. 2009;56(2):53-9. doi: 10.2298/aci0902053l.
7 Sadat-Ali (2005) Sadat-Ali M, Al-Habdan IM, Al-Dakheel DA, Shriyan D. Are orthopedic surgeons prone to burnout? Saudi Med J. 2005 Aug;26(8):1180-2.
8 Saleh (2007) Saleh KJ, Quick JC, Conaway M, Sime WE, Martin W, Hurwitz S, Einhorn TA. The prevalence and severity of burnout among academic orthopaedic departmental leaders. J Bone Joint Surg Am. 2007 Apr;89(4):896-903. doi: 10.2106/JBJS.F.00987.
9 Saleh (2009) Saleh KJ, Quick JC, Sime WE, Novicoff WM, Einhorn TA. Recognizing and preventing burnout among orthopaedic leaders. Clin Orthop Relat Res. 2009 Feb;467(2):558-65. doi: 10.1007/s11999-008-0622-8.
10 Salles (2014) Salles A, Cohen GL, Mueller CM. The relationship between grit and resident well-being. Am J Surg. 2014 Feb;207(2):251-4. doi: 10.1016/j.amjsurg.2013.09.006.
11 Sánchez-Madrid (2005) Sánchez-Madrid MA, Delgado-Martínez AD, Alcalde-Pérez D. Prevalence of burnout syndrome in orthopaedic surgeons in Spain. Archiv Ortp Traumatol. 2005;49:364–367.
12 Sargent (2004) Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2004 Jul;86(7):1579-86. doi: 10.2106/00004623-200407000-00032.
13 Sargent (2009) Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice. Part 1: Orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2009 Oct;91(10):2395-405. doi: 10.2106/JBJS.H.00665.
14 Sargent (2011) Sargent MC, Sotile W, Sotile MO, Rubash H, Vezeridis PS, Harmon L, Barrack RL. Managing stress in the orthopaedic family: avoiding burnout, achieving resilience. J Bone Joint Surg Am. 2011 Apr 20;93(8):e40. doi: 10.2106/JBJS.J.01252.
15 Shanafelt (2012) Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, West CP, Sloan J, Oreskovich MR. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012 Oct 8;172(18):1377-85. doi: 10.1001/archinternmed.2012.3199.
16 Simons (2016) Simons BS, Foltz PA, Chalupa RL, Hylden CM, Dowd TC, Johnson AE. Burnout in U.S. military orthopaedic residents and staff physicians. Mil Med. 2016 Aug;181(8):835-9. doi: 10.7205/MILMED-D-15-00325.
17 van Vendeloo (2014) van Vendeloo SN, Brand PL, Verheyen CC. Burnout and quality of life among orthopaedic trainees in a modern educational programme: Importance of the learning climate. Bone Joint J. 2014 Aug;96-B(8):1133-8. doi: 10.1302/0301-620X.96B8.33609.
18 van Wulfften Palthe (2016) van Wulfften Palthe OD, Neuhaus V, Janssen SJ, Guitton TG, Ring D; Science of Variation Group. Among musculoskeletal surgeons, job dissatisfaction is associated with burnout. Clin Orthop Relat Res. 2016 Aug;474(8):1857-63. doi: 10.1007/s11999-016-4848-6
19 Zheng (2018) Zheng H, Shao H, Zhou Y. Burnout among Chinese adult reconstructive surgeons: Incidence, risk factors, and relationship with intraoperative irritability. J Arthroplasty. 2018 Apr;33(4):1253-1257. doi: 10.1016/j.arth.2017.10.049.

Table 4. Subgroup Analyses Comparing Rates of Burnout in Orthopaedic Surgery Versus Other Specialties in Systematic Reviews Included in Umbrella Review

High Depersonalization
(%)
High Emotional Exhaustion (%) Low Personal Achievement (%) Overall Clinically Significant Burnout
(%)
Systematic Review Doraiswamy
(2021)
Rodrigues (2018) Doraiswamy (2021) Rodrigues (2018) Doraiswamy (2021) Rodrigues (2018) Doraiswamy (2021) Rodrigues (2018) Low (2019)
Population(s) of Interest Physicians (EMR) Residents Physicians (EMR) Residents Physicians (EMR) Residents Physicians (EMR) Residents Residents
Burnout Measure(s) MBI
Specialties of Interest Anesthesiology 50.96% 39.46% 46.21% 24.68% 41% 43.71%
Cardiology 72% 68% 10.5%
Dermatology 55.56% 76.54% 13.58% 51.89%
Emergency Medicine 32.26% 39% 59.26% 37% 32.59% 46.1% 36.57%
Family Medicine 24% 14% 35.97%
General Surgery 44.64% 50% 58.26% 55% 18.41% 22.3% 67.9% 46% 58.39%
Intensive Care 70.07% 37.74% 51.02% 58.29%
Internal Medicine 40.74% 45% 60.30% 37% 14.72% 62.3% 64.18% 30% 57.11%
Neurology 50.62% 85.19% 4.94% 18% 71.93%
Neurosurgery 52.02%
Obstetrics/Gynaecology 51% 37% 25.3% 40% 52.84%
Oncology 37.06% 57.53% 25.11% 18.11% 38.36%
Ophthalmology 37.92% 58.94% 42.13% 41.03%
Orthopaedic Surgery 39.75% 36% 42.45% 38% 23.15% 30.8% 38.7% 49% 55.63%
Otolaryngology 50.12% 53% 70.32% 47% 15.14% 26.5% 25.87% 27% 42.06%
Pediatrics 25% 23% 6.49% 29% 43.74%
Plastic Surgery 46.73% 25% 69.57% 13% 36.64% 46.1% 32.99% 29%
Psychiatry 42.05%
Radiation Oncology 27% 49% 13.3%
Radiology 45.26% 49% 64.74% 53% 5.79% 15% 77.16%
Overall 37.83% 43.6% 44.26% 38.9% 36.57% 28.05% 24.5% 35.1% 51.0%
Significant Difference? Yes NR Yes NR Yes NR No No No

Note: Reviews reported 95% confidence intervals and I2 statistics; not reported here for simplicity. Bartholomew (2018) compared mean MBI scores across studies conducted in the United States for orthopaedics, obstetrics/gynaecology, and otolaryngology: orthopaedics had significantly higher depersonalization, emotional exhaustion, and personal achievement scores when compared with otolaryngology & significantly lower emotional exhaustion than obstetrics/gynaecology.

Acronyms: EMR = Eastern Mediterranean Region; MBI = Maslach Burnout Inventory; NR = Not Reported.

† Discrepancies in results were noted between the manuscript’s table, figure, and text; data extracted from table.

‡ Surgical residents (53.27%) versus medical residents (50.13%); no significant difference.

Appendix 3

Table 1. Characteristics of Narrative Reviews on Burnout In Orthopaedic Surgeons Included in Umbrella Review

Narrative Review Aim(s) Summary
Ames
(2017)
Burnout in orthopaedic surgeons: A challenge for leaders, learners, and colleagues
  1. To review burnout in the medical profession.
  2. To demonstrate that burnout begins during medical education and affects all parts of a surgeon’s career.
  3. To explore suggestions and interventions to address issues inherent to prevent burnout, specifically in orthopaedic surgeons.
Aim 1: Review burnout in medical profession
  • Symptoms: Characterized by high depersonalization, high emotional exhaustion, and low personal achievement.
  • Prevalence: Higher than in general population; steadily increases during medical education and continues through physicians’ careers, affecting about one in two physicians; particularly common in orthopaedic surgery, emergency medicine, general internal medicine, and family medicine.
  • Associations: Higher staff turnover, absenteeism, and early retirement; lower quality of care and patient safety; greater medical errors. Also associated with substance abuse and depression.
  • Contributing factors: Work overload, lack of control, sense of unfairness, lack of community.
  • Burnout measure: 22-item MBI.
Aim 2: Demonstrate burnout begins during medical education and affects all parts of a surgeon’s career
  • Medical students: Burnout worsens during medical school; schools now required to have wellness programs.
  • Residents (highest risk group): Substantial risk for burnout, depression, and suicidal ideation, with higher levels than age-matched comparisons; ACGME has active interest in improving well-being; work-hour regulations have not improved rates.
  • Physicians: Early career physicians at higher risk than experienced peers; burnout notable irrespective of setting (urban or rural).
  • Chairs and program directors: Continue to experience burnout, with increases in proportion dissatisfied with career; related to excessive workload, budget deficits, tenure and promotion, and loss of key staff.
Aim 3: Suggestions and interventions to address burnout
  • No interventions found specifically for orthopaedics.
    • Mindfulness training found to improve burnout in trial of physicians.
    • Resilience training not found to be efficacious among residents.
  • General recommendations to address burnout in medical community:
    • Measuring well-being;
    • Offering education on burnout, substance abuse, and suicidal ideation;
    • Developing structured interventions to improve workflow and management; and
    • Building a culture of appreciation.
Daniels
(2016)

Orthopaedic surgeon burnout: Diagnosis, treatment, and prevention
  1. To describe burnout in orthopaedic surgery, including its effects and risk factors.
  2. To describe diagnosis of burnout.
  3. To describe the treatment and prevention of burnout.
Aim 1a: Describe burnout in orthopaedic surgeons
  • Symptoms: Characterized by high emotional exhaustion, high depersonalization, and low personal achievement.
  • Prevalence: Between 40% to 60%; more common than in many other subspecialties.
  • Distribution: Trainees, surgeons, and faculty leaders have different types of burnout:
    • Practicing surgeons: High levels of emotional exhaustion and depersonalization, with preserved personal achievement; less experienced have higher emotional exhaustion and depersonalization; faculty at larger programs more likely to be lonely and irritable.
    • Faculty leaders (chairs and chiefs): Similar pattern as surgeons with higher emotional exhaustion.
    • Residents: High levels of emotional exhaustion, very high depersonalization, and low personal achievement; work hour restrictions improve emotional exhaustion and personal achievement, with limited impact on depersonalization.
  • Countries have different rates of burnout:
    • Higher in United States; trainees elsewhere work fewer hours and report lower burnout, including depersonalization; work-hour restrictions in United States did not impact depersonalization score therefore unrelated work factors may influence depersonalization rates.
Aim 1b: Effects of burnout
  • Personal: Reduced quality of life; physical exhaustion; poor judgment; cynicism; impaired relationships with patients and colleagues; decreased productivity; poor mental and physical health outcomes (e.g., depression, alcohol and drug use, cardiovascular disease).
  • Institutional: Poorer performance; higher staff turnover and absenteeism; greater medical errors; lower compassion at work; greater sub-optimal patient care experiences.
Aim 1c: Risk factors for burnout
  • Faculty: Anxiety regarding clinical competence; concerns about growing number of orthopaedic surgeons; stressful relationships with staff, spouse, and family members; financial concerns; increased stress at work; increased conflict between work-home life; greater number of work hours; increased alcohol use.
  • Residents: Anxiety regarding clinical competence; stressful relationships with other staff; increased stress at work; increased conflict between work-home life; increased anticipation of debt.
  • Irritability and social withdrawal are early warning signs of burnout; families and colleagues should be aware of these to help with screening efforts.
Aim 2: Describe diagnosis of burnout
  • Measures: 22-item MBI. Reviewers recommend performing focused burnout screening efforts (e.g., on those with multiple risk factors or with symptoms) and adding screening to standard residency surveillance activities.
Aim 3: Describe treatment and prevention of burnout
  • Minimal evidence-based literature exists; cited below strategies for treatment and prevention of burnout:
Intervention Description Evidence
Mindfulness-based interventions Increased physical and emotional self-awareness, including via breathing and yoga. Cited two studies noting improvements in burnout symptoms across three domains of MBI among physicians of different specialties; neither had control group.
Counseling sessions and workshops Stress management and coping education; group discussions of burnout. Cited two studies noting improvements in emotional exhaustion and depersonalization among physicians and pediatric residents respectively; further research required.
Maximizing protective factors Protective factors include support at work and home; having a mentor; being part of a national specialty organization; separating personal and professional life; meditating, exercising, and hobbies; limiting alcohol intake; maintaining strong family relationships. Cited two studies finding consistent protective factors among orthopaedic surgeons.
Institutional adjustments Interventions focused on increasing physician autonomy, work efficacy, and satisfaction; encouraging participating in leadership opportunities; improving fairness; and streamlining workflow. Cited study noting improvements in burnout among physicians after institutions changes.
Goldstein & Weiss (2019)

The canary in the coal mine: Wellness among pediatric orthopaedic surgeons
To describe wellness among pediatric orthopaedic surgeons. Aim 1: To describe wellness among pediatric orthopaedic surgeons
  • Occupational burnout is a problem in pediatric orthopaedics.
  • POSNA created a task force in 2018 to address burnout among its members.
  • It administered a survey (nearly 50% response rate), confirming high prevalences of burnout:
Question Response
“I enjoy my work. I have symptoms of burnout.” 1 in 7 (15.38%)
“Occasionally I am under stress, and I don’t always have as much energy as I once did, but I don’t feel burned out.” 1 in 2 (46.85%)
“I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion.” 1 in 4 (26.92%)
“The symptoms of burnout that I’m experiencing won’t go away. I think my frustration at work a lot.” 1 in 10 (7.34%)
“I feel completely burned out and often wonder if I can go on. I am at the point where I may need some changes or may need to seek some sort of help.” 1 in 30 (3.50%)
  • POSNA has highest percentage of women among orthopaedic societies (around one in two in 2016).
  • Survey found female surgeons were more likely to report burnout than male surgeons; females also more likely to experience bullying, harassment, sexual harassment, pay disparity, and implicit bias against them.
  • Article compared orthopaedic surgeons to canaries in the coal mine, wherein canaries (like surgeons) are strong and resilient, but if the coal mines (workplaces) become too toxic, we must change the coal mine (workplace) rather than strengthen the canary (surgeon).
  • POSNA is therefore taking on both individual well-being efforts (“canary strengthening”) and institutional cultural changes (“coal mine changing”).
  • “Canary strengthening” interventions: normalize and promote self-care; implement mindfulness interventions (e.g., pediatric orthopaedic surgeons can take opportunities for mindful practice during natural pauses).
  • “Coal mine changing” interventions: future efforts should be directed here, for example in topics on: call ratios, scribes and advanced practitioner assistance, and trauma room access.
Talwalkar & Weiss (2020)

Wellness and drivers of burnout
To review relevant literature and work of the POSNA wellness committee. Brief supplementary article outlining work of the POSNA wellness committee as well as recommendations for approaching burnout, including “canary strengthening” interventions (e.g., mindfulness and self-care) and “coal mine changing” interventionists (e.g., addressing time spent documenting and stigmatization of mental health and treatment for physicians).
Jennings (2022)

Orthopaedic surgeons have a high prevalence of burnout, depression, and suicide: Review of factors which contribute or reduce further harm
To describe the issue of physician burnout and depression and make recommendations regarding necessary changes to counteract mental illness in orthopaedic surgeons.

Information on depression and suicide not summarized here; please see review.
Section 1: Burnout
  • Characterized by high depersonalization, high emotional exhaustion, and low personal achievement.
  • Rates in orthopaedic surgery range from 40% to 60%; particularly high in residents.
  • Workload, decreased job control, excessive charting, and verbal abuse are associated with burnout.
  • High burnout may lead to mental health concerns (e.g., suicide and depression).
Section 2: Barriers to seeking mental health treatment
  • Stigma; fear of punitive actions, such as loss of staffing privileges and negative effects on licensure; concerns around loss of confidentiality.
Section 3: Top-down approach to physician wellness
  • There must be buy-in from all parties.
Institutional level
  • The ACGME requires residency programs to promote mental health
  • Surgeon peer discussion groups (protected time/safe space to discuss work stressors)
  • Improve inefficiencies in electronic health record and ancillary staff
  • Update workplaces in partnership with surgeons
  • Eliminate unnecessary obligations (prioritize surgeon nonwork relationships)
  • Recognize gender differences, promote equality regardless of gender (protected time for childcare, maternity/paternity leave)
Professional assistance
  • Establish a Chief of Wellness Officer (CWO) to oversee counseling services
  • Build a Wellness Team (counseling, psychiatric, and coaching services)
  • Implement proactive counseling programs
  • One-on-one executive/wellness coaches (improve prioritization, boundary setting, self-compassion)
Individual practices
  • Increase self-awareness
  • Practice mindfulness (see table below)
Meditation or wellness applications “Waking Up”, “Headspace”, “UCLA Mindful”, “Calm”, “Insight Timer”, “Koa Health”, “Real”, “Smiling Mind”, “Mindfulness Coach”
Mindfulness practices Journaling, Yoga, Breathwork, Retreats with like-minded communities, Exercise routines, Hiking/walking
Section 4: Current research by orthopaedic societies
  • American Society for Surgery of the Hand:
    • Found around one in two hand surgeons reported burnout. Factors negatively associated with burnout: ≥ 65 years, working in outpatient setting, performing hand-specific surgeries only, low commute times, and performing ≤ 10 surgeries per month; sex and compensation did not have an effect.
  • POSNA:
    • Established a Mental Health and Wellness Charter in 2018.
Charter plans to redesign fellowship training (e.g., promote compassionate connection between patients and families, promote fellow autonomy); healthcare delivery (e.g., optimize care systems including electronic health record, documentation burdens, and reimbursement); and research prioritization (e.g., understand interventions that help improve surgeon health, culture, and clinical outcomes).
Smith (2021)

Physician wellbeing in orthopaedic surgery: Challenges and solutions
To define four main components of wellness (physical, mental, emotional, and spiritual) and offer potential solutions for readers on how to apply these to their own lives. Aim 1: Define four components of wellness and offer solutions for achieving each
  • Article focuses on wellness broadly, rather than specifically burnout, although the two are intertwined.
Component of Wellness Potential Solution
Physical wellness Physical activity
  • > 150 minutes of moderate-intensity or > 75 minutes of vigorous intensity aerobic exercise per week
  • Active additionally for 1 hour daily
  • Cross-training
  • Strengthening, stretching, and balance exercises
Sleep
  • Ideally 7 to 9 hours
  • Power naps 15 to 30 minutes in length
  • Avoid caffeine, alcohol, and nicotine before sleep
  • Minimize blue light before sleep
Eating habits
  • Reduce sodium, fat
  • Eat a balanced diet
  • Increase healthy options
  • Hydration: 2.7 liters per day for women; 37 liters per day for men
Acute/chronic musculoskeletal injuries
  • Achieve optimum patient table height
  • Surgeon posture: neck flexion ≤ 25 degrees, lumbar spine neutral flexion
  • Anti-fatigue mats
  • Intra-operative targeted stretch microbreaks
Mental wellness Visualization
  • Mentally rehearse complex scenarios beforehand, such as operations and difficult conversations
Meditation and mindfulness
  • Do deliberate exercises focused on senses, such as breaths, physical sensations, or repetition of words
Resiliency training
  • Obtain training focused on unlearning negative drivers of resilience
  • Learn strategies to adapt to stress, maintain positively, and become flexible with unknown
Emotional wellness Cognitive reframing
  • Cultivate an optimistic attitude by reframing challenges as opportunities
Self-compassion
  • Positive self-talk
  • Allowing self-acceptance
Peer support, community, and connection
  • Connect with colleagues to build supportive network
Spiritual wellness
  • Aligning values, beliefs, and purpose
Travers (2020)

Burnout in orthopaedic surgeons
  1. To define burnout.
  2. To describe the frequency of burnout and its risk factors.
  3. To describe how burnout impacts orthopaedic and trauma surgery specifically.
  4. To describe how burnout can be prevented and treated.
Aim 1: Define burnout
  • Concept introduced in 1961.
  • Characterized by high depersonalization, high emotional exhaustion, and low personal achievement.
  • Symptoms can be emotional, psychological, and physical:
    • Emotional (e.g., anxiety, sadness, irritability)
    • Cognitive (e.g., memory, attention, concentration problems)
    • Behavioral (e.g., withdrawal, reduced empathy, cynicism)
    • Motivational (e.g., progressive disengagement, reduced motivation)
    • Physical (e.g., trouble sleeping, headaches, back pain)
  • Six psychosocial risk factors:
Risk Factors Examples
Intensity and complexity of work
  • Work schedule constraints
  • Adequacy of means
Difficult work schedules
  • Work overload
  • Atypical work schedule
Significant emotional requirements
  • Tension with public
  • Being face-to-face with suffering of others
  • Difficulty controlling emotions
Lack of autonomy at work
  • Lack of task & time autonomy (e.g., having to do administrative tasks)
Deterioration in social interactions at work
  • Lack of support from colleagues and superiors
  • Internal violence
  • Lack of recognition at work
Conflicted values
  • Quality prevented
  • Useless work
Job and work insecurity
  • Socioeconomic insecurity
Aim 2: Describe frequency of burnout and its risk factors
  • About one in two surgeons experience burnout; often emotional exhaustion and depersonalization increase, but personal achievement remains intact.
  • Burnout affects all age groups, practice types, and countries; higher in women and residents.
  • Mean suicide rate is double that of general population.
  • Primary risk factors are physical and emotional overload, growing bureaucracy, and fear of being sued.
Aim 3: Describe how burnout impacts orthopaedic and trauma surgery specifically
  • Rates of burnout in orthopaedic surgery are between 30% and 40%, with over 50% in residents.
  • Orthopaedic surgeons noted the below challenges:
Operating room challenges
  • Administrative burdens with scheduling time slots
  • Growing bureaucracy
  • Conflictual relationships with operating room staff
Clinic challenges
  • Patient demands
  • Fatigue after consultations
  • Delays/cancellations
  • Malpractice lawsuits
Organizational challenges
  • Difficult relationships with administration
  • Not being consulted in decision-making
  • Financial charges being high
Other notable stressors
  • Apprehension about workload and seeing patients
  • Lack of pleasure seeing colleagues
  • Lack of desire going to work
  • Insufficient sleep
  • Unable to disconnect from work
  • Extreme fatigue at end of work shift
  • Anxiety over financial requirements
Aim 4: Describe how burnout can be prevents and treated
  • Paper outlined prevention strategies.
Detecting burnout
  • Individual detection: systematic analysis of clinical signs and susceptibility risk factors.
  • Group detection: assessment by occupational health team and using data on operating room performance (e.g., absenteeism, high turnover).
Addressing workload & schedule
  • Reduce work time
  • Engage in personal and recreational activities
Managing “difficult” patient encounters
  • Recognize only small proportion are “difficult”
  • Develop strategies to approach patients differently
Managing malpractice lawsuits
  • Implement strategies to reduce lawsuits
  • Acknowledge opportunities for improvement
  • Place lawsuits into perspective, recognize most patients are grateful for care
Managing administration conflicts
  • Develop strategies to adapt to different administration
  • For example: step back when necessary and define negotiation boundaries
Recapturing purpose and values of profession
  • Recapture purposes and values of profession by engaging in community efforts
Improving interprofessional communication
  • Debrief & share information in a timely manner with colleagues to decrease likelihood of negative interactions
Self-awareness
  • Recognize when things are not going well and tangible ways to address them
  • Personal (medication, relaxation, therapy) or group (e.g., stress management weekends) self-help strategies
  • Paper outlined treatment strategies:
    • Personal: Sick leave +/-non-pharmacological strategies (e.g., psychotherapy with psychologist; discussion with occupational health team)
    • Institutional: Analysis of workplace conditions by occupational health team
Walker & Goldstein
(2019)

Current concept review: Surgeon wellness and burnout
  1. To describe burnout.
  2. To describe the effects of burnout.
  3. To describe risk factors for burnout.
  4. To describe detection of burnout.
  5. To describe how to prevent and treat burnout.
Aim 1: Describe burnout
  • Characterized by high depersonalization, high emotional exhaustion, and low personal achievement.
  • Associated with negative personal and professional outcomes.
  • Prevalence of 40% to 60% in orthopaedics; more common in women.
  • Factors may differ between sexes due to gender roles, hierarchical structures, and power imbalances.
Aim 2: Describe the effects of burnout
  • Professional: medical errors, reduced patient satisfaction, reduced productivity, increased job turnover.
  • Personal: decreased fulfillment, conflict with colleagues, cynicism, substance use, physical and mental illness, suicidal ideation.
Aim 3: Describe risk factors for burnout
  • Residents particularly at risk for high emotional exhaustion, high depersonalization, and low personal achievement; attendings and faculty at risk for high emotional exhaustion and high depersonalization, with personal achievement preserved; surgeons with > 10 years’ experience have lower rates.
  • Factors associated include difficult relationships with other faculty; increased conflict between home and work life; greater number of work hours/call shifts; increased stress at work; anxiety over clinical competence; increased alcohol use.
  • Despite number of work hours being associated with burnout, rates did not uniformly improve after implementation of 80-hour work-week restrictions in United States.
Aim 4: Describe detection of burnout
  • Co-workers and family members should look for warning signs, which include failing relationships at work and home; withdrawal; exhaustion that does not respond to adequate rest; cynicism; lack of efficacy; desperation; internalization; overworking; increased alcohol use, disruptive or dangerous behaviors; changes in appetite or sleep habits; irritability; muscle spasms; back pain; headaches.
Aim 5: Describe how to prevent and treat burnout
  • Multi-faceted approach is required.
  • Individual-level interventions: mindfulness interventions
  • Institutional-level interventions: addressing stigma around seeking professional help; implementing practice management changes to increase physician autonomy, work efficiency, and satisfaction (e.g., customizable work options, group meetings to discuss concerns, streamlining workflow); clarifying guidelines for advancement and encouraging participation in leadership opportunities; offering mentorship and partnership opportunities
POSNA has taken large steps to combat burnout.

Acronyms: ACGME = Accreditation Council for Graduate Medical Education; MBI = Maslach Burnout Inventory; POSNA = Pediatric Orthopaedic Society of North America.