How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents?

BACKGROUND: Concerning levels of burnout have been reported among orthopaedic surgeons and residents. Defined as emotional exhaustion and depersonalization, physician burnout is associated with decreased productivity, increased medical errors, and increased risk of suicidal ideation. At the center of burnout research, person-centered approaches focusing on individual characteristics and coping strategies have largely been ineffective in solving this critical issue. They have failed to capture and address important institutional and organizational factors contributing to physician burnout. Similarly, little is known about the relationship between burnout and the working environments in which orthopaedic physicians practice, and on how orthopaedic surgeons at different career stages experience and perceive factors relevant to burnout. QUESTIONS/PURPOSES: (1) How does burnout differ among orthopaedic attending surgeons, fellows, and residents? (2) What specific areas of work life are problematic at each of these career stages? (3) What specific areas of work life correlate most strongly with burnout at each of these career stages? METHODS: Two hundred orthopaedic surgeons (residents, fellows, and attending physicians) at a single institution were invited to complete an electronic survey. Seventy-four percent (148 of 200) of them responded; specifically, 43 of 46 residents evenly distributed among training years, 18 of 36 fellows, and 87 of 118 attending physicians. Eighty-three percent (123 of 148) were men and 17% (25 of 148) were women. Two validated questionnaires were used. The Maslach Burnout Inventory was used to assess burnout, measuring emotional exhaustion and depersonalization. The Areas of Worklife Survey was used to measure congruency between participants and their work environment in six domains: workload, control, reward, community, fairness, and values. Participants were invited to openly share their experiences and suggest ways to improve burnout and specific work life domains. The main outcome measures were Maslach Burnout Inventory subdomains of emotional exhaustion and depersonalization, and Areas of Worklife Survey subdomains of workload, control, reward, community, fairness and values. We compared outcome measures of burnout and work life between groups. Simple linear regression models were used to report correlations between subscales. Stratified analyses were used to identify which group demonstrated higher correlations. All open comments were analyzed and coded to fully understand which areas of work life were problematic and how they were perceived in our population. RESULTS: Nine percent (7 of 80) of attending surgeons, 6% (1 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of depersonalization on the Maslach Burnout Inventory (p < 0.001). Mean depersonalization scores were higher (worse) in residents followed by attending surgeons, then fellows (10 ± 6, 5 ± 5, 4 ± 4 respectively; p < 0.001). Sixteen percent (13 of 80) of attending surgeons, 31% (5 of 16) of fellows, and 34% (14 of 41) of residents reported high levels of emotional exhaustion (p = 0.07). Mean emotional exhaustion scores were highest (worse) in residents followed by attending surgeons then fellows (21 ± 12, 17 ± 10, 16 ± 14 respectively; p = 0.11). Workload was the most problematic work life area across all stages of orthopaedic career. Scores in the Areas of Worklife Survey were the lowest (worse) in the workload domain for all subgroups: residents (2.6 ± 0.4), fellows (3.0 ± 0.6), and attending surgeons (2.8 ± 0.7); p = 0.08. Five problematic work life categories were found through open comment analysis: workload, resources, interactions, environment, and self-care. Workload was similarly the most concerning to participants. Specific workload issues identified included administrative load (limited job control, excessive tasks and expectations), technology (electronic medical platform, email overload), workflow (operating room time, patient load distribution), and conflicts between personal, clinical, and academic roles. Overall, worsening emotional exhaustion and depersonalization were most strongly associated with increasing workload (r = - 0.50; p < 0.001; and r = - 0.32; p < 0.001, respectively) and decreasing job control (r = - 0.50; p < 0.001, and r = - 0.41; p < 0.001, respectively). Specifically, in residents, worsening emotional exhaustion and depersonalization most strongly correlated with increasing workload (r = - 0.65; p < 0.001; and r = - 0.53; p < 0.001, respectively) and decreasing job control (r = - 0.49; p = 0.001; and r = - 0.51; p = 0.001, respectively). In attending surgeons, worsening emotional exhaustion was most strongly correlated with increasing workload (r = - 0.50; p < 0.001), and decreasing job control (r = - 0.44; p < 0.001). Among attending surgeons, worsening depersonalization was only correlated with increasing workload (r = - 0.23; p = 0.04). Among orthopaedic fellows, worsening emotional exhaustion and depersonalization were most strongly correlated with decreasing sense of fairness (r = - 0.76; p = 0.001; and r = - 0.87; p < 0.001, respectively), and poorer sense of community (r = - 0.72; p = 0.002; and r = - 0.65; p = 0.01, respectively). CONCLUSIONS: We found higher levels of burnout among orthopaedic residents compared to attending surgeons and fellows. We detected strong distinct correlations between emotional exhaustion, depersonalization, and areas of work life across stages of orthopaedic career. Burnout was most strongly associated with workload and job control in orthopaedic residents and attending surgeons and with fairness and community in orthopaedic fellows. CLINICAL RELEVANCE: Institutions wishing to better understand burnout may use this approach to identify specific work life drivers of burnout, and determine possible interventions targeted to orthopaedic surgeons at each stage of career. Based on our institutional experience, leadership should investigate strategies to decrease workload by increasing administrative support and improving workflow; improve sense of autonomy by consulting physicians in decision-making; and seek to improve the sense of control in residents and sense of community in fellows.

Standardized Perioperative Patient Education Decreases Opioid Use after Hand Surgery: A Randomized Controlled Trial.

BACKGROUND: Despite the growing hand surgery literature on postoperative opioid use, there is little research focused on patient-centered interventions. The purpose of this randomized controlled trial was to create a standardized patient education program regarding postoperative pain management after hand surgery and to determine whether that education program would decrease postoperative opioid use. METHODS: Patients scheduled to undergo ambulatory hand surgery were recruited and randomized to standardized pain management education or standard of care. All patients received a webinar with instructions for study participation, whereas the education group received an additional 10 minutes of education on postoperative pain management. All patients completed a postoperative daily log documenting opioid consumption. The total number of opioid pills consumed was compared between groups. The authors constructed a linear regression model to determine risk factors for postoperative opioid use after surgery. RESULTS: A total of 267 patients were enrolled in the study. One hundred ninety-one patients completed the study (standardized education, n = 93; control group, n = 97). Patients in the standardized education group were more likely to take no opioid medication (42 percent versus 25 percent; p = 0.01) and took significantly fewer opioid pills (median, two) than those in the control group (median, five) (p < 0.001). Standardized education predicted decreased postoperative opioid pill consumption, whereas higher number of pills prescribed and a history of psychiatric illness were risk factors for increasing opioid use. CONCLUSION: Perioperative patient education and limitation of postoperative opioid prescription sizes reduced postoperative opioid use following ambulatory hand surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Current Fixation Options for Elbow, Forearm, Wrist, and Hand Fractures.

The universal goals of upper limb fracture management are to restore anatomic alignment, establish stable fracture fixation (while preserving blood supply), and allow for early mobilization of the elbow, wrist, and digits. However, the indications for operative management and fixation constructs are specific to each fracture type. This article systematically reviews current classifications and treatment options for adult fractures of the distal humerus, radius, ulna, scaphoid, metacarpals, and phalanges. For each anatomic location, we discuss the salient imaging features to guide management decisions (conservative versus internal and/or external fixation). Specifically, we emphasize the amount of displacement, angulation, comminution, and/or intra-articular involvement typically guiding operative management for each fracture type. Through this understanding of the surgical indications, rationale behind different fixation options, and common complications, the radiologist can better support the orthopaedic surgeon via more informed fracture reporting.