EDITORIAL

 

Physician wellness in South Africa - 'Where are we going? And if we get there, will there be a place to park?'

 

 

Marais LC

MBChB, FC Orth SA, MMed(Ortho), PhD; Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa

Correspondence

 

 

 

In 2009, a survey of 7 905 surgeons in America noted that 40% had signs of burnout, 30% depression, 20% a mental quality of life score >0.5 SD below the population mean, and 7% suicidal ideation.¹ Professional burnout is a syndrome characterised by loss of enthusiasm for work, depersonalisation and a low sense of personal accomplishment.² The hallmarks include emotional and physical exhaustion, as well as feelings of cynicism, guilt and ineffectiveness. Sounding familiar? I am not surprised.

Forty-five per cent of physicians in the US were reported to have burnout symptoms in 2012.² Physicians were also significantly more likely to have burnout and a dissatisfaction with work-life balance than the general population. Furthermore, while a higher level of education had a protective effect in the general population, the opposite is true for physicians.³ And things may be getting worse. Shanafelt and co-workers repeated the survey in 2015, reporting a burnout rate of close to 55% and a reduction in job satisfaction from 49% to 41% across all specialities.⁴

How did orthopaedics fare? Not great, with a burnout rate of 60%. This was the fifth highest behind Emergency Medicine, Urology, Family Medicine and Radiology.⁴

Burnout has consequences on several levels. The personal costs are significant. It adversely affects relationships and results in an increase in alcohol use, depression and cognitive impairment.^2,5-7 The Medscape National Physician Burnout & Suicide Report of 2020 reported that 23% of respondents have either thought about or attempted suicide (and a further 9% preferred not to answer).⁸ On an occupational level, it results in decreased effectiveness at work, it erodes professionalism and increases staff turnover, absenteeism, presenteeism (being at work when one should be off sick) and early retirement.^9,10 It also impacts patient care with a decrease in quality of care and patient satisfaction, an increase in medical errors and erosion of the doctor-patient relationship.^9,10 At an organisational level, the cost to the healthcare system cannot be disregarded. In the US it is estimated that the annual national costs associated with burnout is in the region of about $4.6 billion.¹¹ It was recently described as 'a global crisis' by The Lancet.¹²

There are numerous factors that play a role in the development of burnout. Personal factors that contribute include female sex, being a racial minority or being from Generation X.^8,10 Financial concerns and work-family conflict add to this burden, while time for hobbies, high self-efficacy, parenthood and strong familial support systems have a protective effect.¹⁰ The second major category is work environment-related factors, such as excessive workload, long working hours, stress in workplace relationships, loss of autonomy, lack of a sense of community and insufficient reimbursement.¹⁰ Other negative factors in this sphere include too many bureaucratic tasks, increased computerisation and government regulations.⁸ The third group of factors relate to the physician's career. Negative factors include being a registrar, regret about career choice, competition with colleagues and anxiety about competence. Job satisfaction and being later in your career may have a positive effect¹⁰ - except if you are in a leadership position, in which case there is an increased risk of burnout, particularly in the emotional exhaustion and depersonalisation sub-scales.¹³

The statistics are alarming and there is certainly cause for concern. It would be reasonable to expect that funders, organisations, hospitals or healthcare system managers would therefore take heed and implement preventative and curative strategies. However, in South Africa there seems to be a great vacuum in this space. While universities and the Department of Health have employee wellness programmes, I am not aware of a programme dedicated to physicians. Private hospitals and private healthcare funders surely have a great deal to benefit by ensuring that their doctors are fully effective. Yet, an internet search and discussion with my private counterparts failed to provide any information of a physician wellness programme offered by these organisations.

Thus, it seems we might be on our own with this one. The problem is that only about 13% of clinicians seek professional help.⁸ In fact the top coping mechanism in the 2020 Medline survey was: 'Isolate myself from others'.⁸ We are in a vicious cycle. If I see my colleagues suffering in silence and simply getting on with the work, who am I to complain? And I certainly don't want to be seen as the physician suggesting that I may not always be able to place the needs of my patient or student first. It is therefore understandable that surgeons with burnout often isolate themselves and internalise their struggles.

The problem is that many of the physician wellness programmes currently implemented in other countries, such as mindfulness training, volunteer days and social events, are not addressing the underlaying cause and have been described as simply 'putting the proverbial lipstick on a pig'.¹⁴ Drozdowicz suggests that the problem should be addressed at its roots with widespread healthcare system reform on multiple levels.¹⁴ What action then needs to be taken? The consensus study report by the National Academy of Medicine in the US provides some more comprehensive guidelines.¹⁵ In brief the goals are to create a positive work and learning environment, reduce the administrative burden placed on clinicians, enable technology solutions to support clinicians, provide support for clinicians and learners, and invest in research.

So where are we going here in South Africa in terms of the prevention and management of burnout? And once we have the necessary programmes in place, do we have adequate knowledge and resources to deal with the problem? The South African Orthopaedic Association (SAOA) has undertaken to engage with this issue. As a stepping-stone, the Association has initiated research to characterise both the extent and the cause of the problem among orthopaedic surgeons and trainees. It is crucial that our community participates. It seems that if we do not start looking after ourselves, our colleagues and our trainees, no-one else will.

 

References

1. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction amongst American surgeons. Annals Surg. 2009;250(3):463-70.         [ Links ]

2. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-85.         [ Links ]

3. Shanafelt TD, Sinsky C, Dyrbye LN, et al. Burnout among physicians compared with individuals with a professional degree in a field outside of medicine. Mayo Clin Proc. 2019;94(3):549-51.         [ Links ]

4. Shanafelt TD, Hasan O, Derbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general population between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-603.         [ Links ]

5. Jackson ER, Shanafelt TD, Hasan O, et al. Burnout and alcohol abuse/dependence among US medical students. Acad Med. 2016;91 (9):1251-56.         [ Links ]

6. Haskins J, Carson JG, Chang CH, et al. The suicide prevention, depression awareness, and clinical engagement program for faculty and residents at the University of California, Davis health system. Acad Psychiatry. 2016;40(1):23-29.         [ Links ]

7. Sandström A, Rhodin IN, Lundberg M, Olsson T, Nyberg L. Impaired cognitive performance in patients with chronic burnout syndrome. Biol Psychol. 2005;69(3):271-79.         [ Links ]

8. Medscape National Physician Burnout, Depression & Suicide Report 2020. Available from: https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460#1. (Date accessed: 5 March 2020)        [ Links ]

9. Ames SE, Cowan JB, Kenter K, et al. Burnout in orthopaedic surgeons: a challenge for leaders, learners, and colleagues. J Bone Joint Surg. 2017;99:e78(1-6).         [ Links ]

10. Hui RWH, Leung KC, Ge S, et al. Burnout in orthopaedic surgeons: A systematic review. J Clin Orth Traum. 2019;10:S47-52.         [ Links ]

11. Shanafelt TD, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Int Med. 2017. doi:10.1001/jamainternmed.2017.4340        [ Links ]

12. Editorial: Physician burnout: a global crisis. Lancet 2019;394:93.         [ Links ]

13. Saleh KJ, Quick JC, Conaway M, et al. The prevalence and severity of burnout among academic orthopaedic departmental leaders. J Bone Joint Surg Am. 2007;89(4):896-903.         [ Links ]

14. Drozdowicz L. Physician wellness programs are lipstick on a pig. 2017. Available from: https://www.kevinmd.com/blog/2017/11/physician-wellness-programs-lipstick-pig.html (Date accessed: 6 March 2020).         [ Links ]

15. National Academies of Sciences, Engineering, and Medicine. Taking action against clinician burnout: a systems approach to professional well-being. Washington, DC: The National Academies Press, 2019. https://doi.org/10.17226/25521        [ Links ]

 

 

Correspondence:
Marais LC
maraisl@ukzn.ac.za