Burnout in Anesthesiology Providers: Shedding Light on a Global Problem.

Abstract

See Article, p 310 As anesthesiologists, we are regularly entrusted with the lives of others. But do we pay enough attention to our own wellbeing? We are trained to react appropriately to numerous clinical challenges, are expected to be attentive, exhibit professionalism in spite of additional workload, and provide the safest patient care possible at all times. At the same time, as highly specialized professionals, we are experiencing the burden of accelerated technological and scientific development and frequent changes in professional and regulatory standards. In the health care systems of developed countries, anesthesiologists have achieved great professional recognition, becoming essential members of interdisciplinary teams charged with diagnostic, perioperative, and therapeutic patient management, as well as taking part in joint scientific projects. Generally, anesthesiologists in low- and middle-income countries (LMICs) have the same responsibilities, but they are confronted with higher workload due to shortages in manpower and other resources. All of these competing factors can contribute to psychophysical exhaustion, chronic or accumulated stress, and unresolved problematic interpersonal relations. In addition, due to significantly lower annual income, LMIC anesthesiologists face difficulties in providing for even basic needs of their families. Currently, the World Federation of Societies of Anaesthesiologists (WFSA), together with national member societies, is focusing on the professional wellbeing and burnout of its members. There has been a plethora of published data about burnout syndrome among anesthesiologists. A critical view is needed in interpretation of the results, keeping in mind differences in methodology. Caution must be used in generalizing due to noncomparable data, different study designs (qualitative versus quantitative), limitations of cross-sectional design, poorly defined study populations, instruments used, and differences in cut-offs for the same scales or quantification of total burnout. This is why it is difficult to estimate the prevalence of overall burnout, no matter which professional group is studied. Nevertheless, anesthesiologists are frequently considered to rank among the health professionals most often affected by burnout. Fatigued and exhausted anesthesiologists are prone to compromise in the handling and monitoring of patients, which may affect the interpretation of parameters and result in erroneous decisions.1,2 The need for constant alertness, combined with decreased personal physical and cognitive power, can lead to impaired judgment, late and inadequate responses to clinical changes, poor communication, and faulty record keeping. Thus, a better understanding of the causes and consequences of burnout in anesthesiologists can be used to improve patient safety in the operating room, in the intensive care unit, and in all other areas of anesthesiology practice.2,3 UNDERSTANDING THE CONCEPT OF BURNOUT Since first being defined in the 1980s, a number of models and instruments have been proposed to more accurately measure or better define the burnout syndrome.4 The first burnout measure that was based on comprehensive psychometric research was the Maslach Burnout Inventory (MBI), which remains the most frequently used instrument. According to Cristina Maslach, burnout is a psychological syndrome emerging as a response to chronic interpersonal stressors on the job. The 3 key dimensions of this response are overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment.5 Today, we have reached the latest, “semiempirical” phase, with a new approach focused on pathogenesis, quantification, diagnosis, and finally treatment.6 DATA FROM LMICs While research in burnout has traditionally derived from developed economies, several studies from LMICs have recently been published.7,8 In this issue of Anesthesia & Analgesia, in their article “A cross-sectional survey to determine the prevalence of burnout syndrome among anesthesia providers in Zambian hospitals,” Bould et al9 report on the prevalence of different dimensions of burnout syndrome among anesthesia providers from public and private hospitals in Zambia, including physicians and nonphysicians. This first survey conducted in Zambia on this extremely important public health topic raises awareness of possible consequences for the entire health care system, including patients and providers. The authors address the associated sociodemographic and occupational factors leading to burnout with a nationwide survey using the MBI as an instrument which assess 3 domains of burnout: emotional exhaustion, depersonalization, and personal accomplishment. They found that more than half of the anesthesia providers in Zambia meet the criteria for burnout, with the risk being highest in nonphysician anesthesia providers. The authors achieved a very high response rate. If similar research questions are to be investigated in other countries or regions, we would recommend using a method of stepwise multivariate logistic regression, to extend the bivariant model of the study at hand, which corresponds with burnout predictors. Furthermore, a variable like “vacation days used” may show an even stronger association with burnout if it were treated as an integer numeric in other setups. The authors did well with dichotomizing this variable because roughly half of their study participants had not taken any holidays in the past year. We strongly recommend continuation of the assessment of burnout among anesthesia providers in Zambia. Keeping in mind the huge differences in burnout prevalence among 2 subpopulations of anesthesia providers there, future analyses should explore the possible predictors of burnout for each subpopulation. This knowledge could inform policy makers for addressing this issue in the Zambian health care system. Similarly, researchers from Pakistan reported very recently that 39% of academic anesthesiologists in Pakistan said that they experience emotional exhaustion, 68.4% reported depersonalization, and 50.3% reported a reduction in personal achievements―the major factors of burnout.7 Holding a job in a field other than the primary career choice was identified as a major risk factor in a multivariable analysis. The disturbingly high levels of burnout, especially in the dimension of depersonalization, should be addressed in the entire anesthesiology population in Pakistan in the future. First results on burnout from these 2 studies, and the knowledge acquired, give us insight into a serious issue in anesthesiology populations within countries where the problem had not been previously recognized. A Chinese survey revealed similar findings for the Beijing–Tianjin–Hebei region.8 And data from developing African countries such as Malawi include reports of high intraoperative mortality rates.10 These findings should be explored more fully in connection with possible staff burnout, with possible contributing factors being nonavailable equipment and shortages in trained staff.11 It is notable that there are 1000 times fewer appropriately trained anesthesia providers in some LMICs compared with most high-income countries (HICs).12 THE ROAD FORWARD The challenges associated with extremely limited resources and devastating clinical burden will continue globally, potentially even being accentuated in LMICs.13 Innovative approaches are urgently needed. For example, through professional development programs supported by the WFSA and the Australian Society of Anaesthetists, the Mongolian Society of Anesthesiologists (MSA) significantly improved training in Mongolia by developing leadership in acute care.14 Similarly, the recent evolution of anesthesiology in the Pacific region has highlighted that leadership development in teachers and trainees alike is key to advancing our specialty.15 Kudsk-Iversen et al13 recently emphasized that—as in the developed world—we must focus on building a network of resilient professionals to fight burnout and abandonment of professional practice in LMICs. It is time to highlight the global burden of burnout among anesthesiologists and to embrace nontechnical dimensions including the crucial dimensions “self-management” and “self-development” in our technical specialty.16 Although the challenges may differ between various settings and countries, evidence from both LMICs and HICs demonstrates that emotional intelligence is key to coping with burnout in our profession and can be both learned and enhanced.17 Developing qualities such as empathy, motivation, self-awareness, and self-regulation18 will help anesthesiologists serve as key players in acute care. That will consequently lead to safer surgery, obstetrics, and interventions as defined by the Lancet Commission on Global Surgery (LCGS).19 With safe surgical care as a critical dimension of global health, one of the solutions for achieving health, welfare, and economic development envisioned by the LCGS19 defines a 2-hour response period for safely managing Bellwether procedures (emergency laparotomies, treatment of open fractures, and cesarean delivery) in first-level hospitals worldwide.12,19,20 Accordingly, a suitably trained and resilient anesthesia workforce must be available globally.21 The WFSA is supporting sustainable training, recognizing that anesthesiologists are key leaders in enabling the LCGS goals, even in extremely resource-deprived settings.15 We strongly support all future attempts by authors to explore the alarming issue of burnout among anesthesia providers to facilitate wider recognition of the problem. Raising awareness of the causes, symptoms, and consequences of burnout in health professionals is vital. Our community must support the building of resilience in both urban and rural settings and an efficient distribution to guarantee the envisioned 2-hour period to safe surgical care. The measures may be different in various settings, but the goal—a healthy workforce—is shared by everyone. DISCLOSURES Name: Miodrag S. Milenovic, MD, PhD. Contribution: This author helped write the article. Conflicts of Interest: None. Name: Bojana R. Matejic, MD, PhD. Contribution: This author helped write the article. Conflicts of Interest: None. Name: Dusica M. Simic, MD, PhD. Contribution: This author helped write the article. Conflicts of Interest: None. Name: Markus M. Luedi, MD, MBA. Contribution: This author helped write the article. Conflicts of Interest: M. M. Luedi is on the editorial board of Anesthesia & Analgesia. This manuscript was handled by: Angela Enright, MB, FRCPC.