ANESTHESIOLOGIST BURNOUT

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Regarding anesthesiologist burnout: What if I told you 50% of physician anesthesiology trainees suffer burnout, and those trainees average $220,000 in educational debt by the age of 32? 

The term “burnout” was coined in the 1970s by American psychologist Herbert Freudenberger, who used the term to describe the consequences of severe stress and high ideals in helping professions such as doctors and nurses, who sacrifice themselves for others.

The symptoms of physician burnout are recognized as: 

  • Exhaustion
  • Emotional detachment, i.e. feeling alone in the world
  • Self-doubt
  • Feeling helpless, trapped, and defeated
  • Increasingly cynical and negative outlook
  • Decreased satisfaction and sense of accomplishment

Our specialty’s premiere journal Anesthesiology recently published a study by Dr. H. Sun titled, “Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates.” The study reported that “Based on survey data from 2013 to 2016, the prevalence of burnout, distress, and depression in anesthesiology residents and first-year graduates was 51%, 32%, and 12%, respectively. More hours worked and student debt were associated with a higher risk of distress and depression, but not burnout. Perceived institutional and social support and work-life balance were associated with a lower risk of burnout, distress, and depression.”

I completed two residencies in the 1980s at Stanford University Hospital, the first in internal medicine and the second in anesthesiology. The internal medicine residency required 100-hour weeks of service. I worked 30-hour shifts in the hospital every third night on most rotations, without a day off afterwards. The anesthesia residency was 80 hours per week with in-hospital night call.

Were residents burned out in the 1980s? I believe they were, but no one was publishing data on burnout then. Fellow residents I knew committed suicide, became addicted to fentanyl and overdosed, or dropped out of their residencies. We had a battlefield mentality—everyone was stressed, but we marched onward with the goal of finishing our training and entering the early career years. The plot of a popular 1970s medical novel, The House of God by Samuel Shem, involved a cohort of Boston medical interns who had burnout symptoms, and began to cynically dislike their patients and their own lives. In the end these young doctors dropped out of their internal medicine residencies to join cushier specialties such as radiology, dermatology, pathology, ophthalmology, and (gasp) anesthesiology. 

Now we learn that anesthesiology residents have a 50% incidence of burnout. In the Sun study the mean physician age was 32 years, the mean number of hours worked per week was 61, the mean number of night calls/night shifts per month was 5, and 37% of the doctors were females. Females were more likely than males to suffer from burnout (54% vs. 49%, P = 0.002). Seventy-eight percent of the respondents reported having student loan debt, with a median amount of $220,000. 

In 1980 I graduated from the University of Chicago School of Medicine with $23,000 in student debt. In 1984 the average debt for students who graduated from a private medical school was $27,000. Per Consumer Price Index data, $1 in 1980 equaled $3.11 in 2019. Adjusting for inflation, the average student debt from 1984 calculates to $83,970 in 2019 dollars, or roughly 40% of what today’s students are borrowing.  

Among medical specialties studied, anesthesiology has a higher rate of burnout (approximately 48%) than the all-physician average (46%).  Anesthesiology ranks seventh on the list of burnout by specialty, with emergency medicine, internal medicine, neurology, and family medicine having the four highest rates.  

Medical school application rates remain high. In 2019 there were 849,678 applications to U.S. medical schools, and 21,622 students matriculated. The average student applied to 16 schools. It’s terrific that bright students are still interested in becoming physicians. Are they driving themselves toward the twin brick walls of physician burnout and six-figure educational debt? Yes, many of them are.  

The current political healthcare debate includes the prospect of Medicare for All. How would Medicare for All affect anesthesiology? Medicare pays anesthesiologists approximately 20% of what commercial insurance pays anesthesiologists. If Medicare for All ever becomes a reality, those young anesthesiologists who already own $220,000 in student debt will see their income plummet. Paying off their debt will take significantly longer, adding stress to an already stressed young physician’s life. 

If you’re a patient reading this, you might wonder how all this might affect you. Consider this: we all want our doctors to be emotionally and physically healthy. We all want our caretakers to be content, well-reimbursed, non-burned out professionals rather than stressed-out MDs in chronic debt. 

What can be done about physician burnout? Per the Sun article, “Perceived institutional and social support and work-life balance were associated with a lower risk of burnout, distress, and depression,” and “those who believed they maintained an appropriate balance between personal and professional lives and who were satisfied with the level, accessibility, and acceptability of workplace resources were much less likely to suffer from burnout, distress, and depression.” Stanford Medical Center recently hired Tait Shanafelt MD as their first Chief Wellness Officer, in an effort to provide programs with a supportive medical center environment for Stanford physicians. 

I still recommend a career path toward medical school for motivated and qualified students, with these reservations: 

1. It’s important that your medical school and your residency training program have intact resources to support psychologically stressed/burned out/depressed enrollees; and 

2. You need to carefully examine your projected economic stress, i.e. the debt you will incur in your medical training vis-à-vis your expected income in the medical specialty you hope to enter.   

Anticipate psychological stress and debt in your medical training. You’ll need to be well informed and supported in your journey to become a physician in 21st Century America.

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The most popular posts for laypeople on The Anesthesia Consultant include:
How Long Will It Take To Wake Up From General Anesthesia?
Why Did Take Me So Long To Wake From General Anesthesia?
Will I Have a Breathing Tube During Anesthesia?
What Are the Common Anesthesia Medications?
How Safe is Anesthesia in the 21st Century?
Will I Be Nauseated After General Anesthesia?
What Are the Anesthesia Risks For Children?
The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:
10 Trends for the Future of Anesthesia
Should You Cancel Anesthesia for a Potassium Level of 3.6?
12 Important Things to Know as You Near the End of Your Anesthesia Training
Should You Cancel Surgery For a Blood Pressure = 178/108?
Advice For Passing the Anesthesia Oral Board Exams
What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?


LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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IS ANESTHESIA A CUSHY SPECIALTY?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Is anesthesia worthy of the House of God‘s assessment that it’s a cushy medical specialty? My answer, after thirty years of anesthesia practice, is … it depends.

Cover image of The House of God

Samuel Shem’s classic novel/satire of medicine, The House of God (published in 1978, more than two million copies sold), follows protagonist Dr. Roy Basch as he struggles through his year as an internal medicine intern. A second physician recommends Basch switch careers to one of six no-patient-contact specialties: Rays, Gas, Path, Derm, Eyes, or Psych. These names translate to radiology, anesthesia, pathology, dermatology, ophthalmology, and psychiatry. These specialties are touted as lower stress choices with superior lifestyles, where time with sick patients is minimized and the physician is more likely to be happy.

Is this true? Is anesthesia worthy of Samuel Shem’s assessment that it’s a cushy specialty?

My answer, after thirty years of anesthesia practice, is … it depends.

Let’s examine each of the six specialties regarding their perceived advantages:

• Radiology involves a career of peering at digital images of X-rays, MRIs, CT scans, or ultrasound studies. Patient contact is minimal. Because many of these tests are ordered in emergency rooms at all hours of the night, on-call radiologists work long hours and endure sleepless nights. As well, the subspecialty of Invasive Radiology has become a hands-on field that requires as much patient contact as most surgical specialties.
• Pathology involves a career of peering through a microscope, running a clinical lab to determine blood and urine chemistry results, or performing autopsies. Most of pathology requires zero contact with living patients. Most pathology work is done in daylight hours, and loss of sleep is unusual.
• Dermatology involves a career of seeing a multitude of patients (think 80 – 100 per day) in a busy clinic practice. Patient volume and patient contact are high. Each clinic visit is brief because only the specific skin lesions in question are fair game for physician-patient interrogation. Hospitalized patients are uncommon, there are few emergencies, and loss of sleep is unusual.
• Ophthalmology involves an office practice of examining the vision and eyes of patients, as well as an operating room practice of performing cataract, retinal, or corneal surgeries. Other than an occasional eye trauma surgery at a late hour, loss of sleep for ophthalmologists is unusual.
• Psychiatry involves an outpatient practice of verbal therapy and/or prescribing oral medications (e.g. antidepressants, anti-anxiety, or attention deficit hyperactivity disorder meds). Inpatient psychiatry is usually limited to patients with severe depression and psychotic diseases. Most emergencies are limited to patients with after-hours suicidal ideation or attempts. Loss of sleep is unusual.
• Anesthesiology involves providing unconsciousness and medical management to patients during all types of surgical interventions. Surgeries occur at all hours of the day and night. Loss of sleep is common, and job stress during select cases can be extreme. Let’s examine lifestyle issues of anesthesia practice in more detail:

An anesthesiologist and his or her awake surgical patient are only together for only 15 minutes prior to induction of anesthesia, during which time they exchange information on medical history and informed consent. This brief duration doesn’t exactly qualify for The House of God’s no-patient-contact list, but anesthesia does qualify as very-little-awake-patient contact. Minimal time with conscious patients appeals to physicians who don’t relish prolonged face-to-face patient interaction.

An image of your anesthesiologist playing tennis or golf and then waltzing into the operating room at leisure to do a simple surgery is mistaken. The presence of an anesthesiologist is imperative for nearly every emergency procedure. All emergency medical care follows the guideline of A-B-C, or Airway-Breathing-Circulation, and anesthesiologists are airway specialists nonpareil. Emergency room attendings and head and neck surgeons have certain airway skills, but no other specialty has the depth of airway expertise that anesthesiologists own. An anesthesiologist provides care for 500–1000 patients per year, and every one of these patients requires acute management of the airway to assure safe oxygenation and breathing.

Trauma surgery, childbirth, acute surgical disease from the emergency room, and organ transplant surgery are as common at night as in the daytime. An on-call anesthesiologist at a busy community hospital may arrive at 6:30 a.m., do seven or eight surgical anesthetics which last until dusk, and then remain in the hospital all night to perform several epidural anesthetics on laboring women, anesthetize an 80-year-old woman for surgery to relieve a bowel obstruction, and replace an endotracheal tube in a struggling patient in the intensive care unit as the sun comes up the following day. An on-call anesthesiologist at a university hospital may arrive at 6:30 a.m. and attend to a complex liver-transplant surgery which lasts 20 hours and concludes at 3 a.m. A cushy specialty? Hardly.

A lifestyle advantage for anesthesiologists is that we can work hard and play hard. It’s possible for an anesthesiologist to take weeks or months off at a time if their employer or anesthesia group approves. There’s no chronic patient care/patient follow up, no clinic overhead, and no clinic employee overhead. For these reasons an anesthesiologist can schedule multiple weeks without work or income more easily than a clinic doctor can. For these reasons it’s also possible for an anesthesiologist to work part time, i.e. two or three days each week. This scheduling flexibility is an excellent lifestyle advantage, and for this reason my answer to whether anesthesia is a cushy specialty is … it depends.

Some anesthesiologists choose to spend their career outside the operating room. Some specialize in pain management and see patients in outpatient pain clinics—selected patients are taken to the operating room non-urgently to receive pain-injection procedures such as epidural steroid injections, nerve blocks, or pain pump insertions. A small number of anesthesiologists run preoperative assessment clinics where they assess the medical status of patients prior to surgery. A small number of anesthesiologists supervise intensive care units and manage critically patients who require ventilators, cardio-active medications, and anesthesia sedation infusions.

I’d like to leave you with one image imprinted in your mind—that of an anesthesiologist toiling over an ill patient at 2 a.m. in a hospital. The patient may have survived a car crash, suffered a ruptured appendix, be delivering twin babies, or be the recipient of a lung transplant. Wherever there’s a sick patient who needs acute supervised unconsciousness, there’s an anesthesiologist present. In words John Steinbeck wrote at the conclusion of The Grapes of Wrath, Tom Joad tells his mother,

“I’ll be all around in the dark – I’ll be everywhere.
Wherever you can look – wherever there’s a fight, so hungry people can eat, I’ll be there.
Wherever there’s a cop beatin’ up a guy, I’ll be there.
I’ll be in the way guys yell when they’re mad.
I’ll be in the way kids laugh when they’re hungry and they know supper’s ready, and when the people are eatin’ the stuff they raise and livin’ in the houses they build – I’ll be there, too.”

This prompts me to pen parallel text regarding my specialty, entitled
Tom Joad the Anesthesiologist:

I’ll be all around in the dark—I’ll be everywhere.
Wherever you can look—wherever there’s a motorcycle accident, a Cesarean section, a heart transplant, I’ll be there.
Wherever there’s a cop dragging a knifed-up gang member into the E.R., I’ll be there.
I’ll be there when the surgeon screams and when the new mother laughs,
When the 100-year-old gets his hernia mended and when the 4-year-old gets his tonsils out—I’ll be there, too.
Ma, it’s just what I do.
It’s what we all do.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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