Embracing Failure: Nurturing Learning and Well-Being in Anesthesiology and Perioperative Medicine.

Failure, ubiquitous in life and medical practice, offers myriad opportunities for learning and growth alongside challenges to overall well-being. In this article, we explore the nature of failure, it's sources and impacts in perioperative medicine, and the specific challenges it brings to trainee well-being. With a deeper understanding of the societal, psychological and cognitive determinants and effects of failure, we propose solutions in order to harness the opportunities inherent in failures to create brave and supportive learning environments conducive to both education and well-being.

U.S. Attending Anesthesiologist Burnout in the Postpandemic Era.

BACKGROUND: Anesthesiologists are experiencing unprecedented levels of workplace stress and staffing shortages. This analysis aims to assess how U.S. attending anesthesiologist burnout changed since the onset of the COVID-19 pandemic and target well-being efforts. METHODS: The authors surveyed the American Society of Anesthesiologists' U.S. attending anesthesiologist members in November 2022. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey with additional questions relating to workplace and demographic factors. Burnout was categorized as high risk for burnout (exhibiting emotional exhaustion and/or depersonalization) or burnout syndrome (demonstrating all three burnout dimensions concurrently). The association of burnout with U.S. attending anesthesiologist retention plans was analyzed, and associated factors were identified. RESULTS: Of 24,680 individuals contacted, 2,698 (10.9%) completed the survey, with 67.7% (1,827 of 2,698) at high risk for burnout and 18.9% (510 of 2,698) with burnout syndrome. Most (78.4%, n = 2,115) respondents have experienced recent staffing shortages, and many (36.0%, n = 970) were likely to leave their job within the next 2 yr. Those likely to leave their job in the next 2 yr had higher prevalence of high risk for burnout (78.5% [760 of 970] vs. 55.7% [651 of 1,169], P < 0.001) and burnout syndrome (24.3% [236 of 970] vs. 13.3% [156 of 1,169], P < 0.001) compared to those unlikely to leave. On multivariable analysis, perceived lack of support at work (odds ratio, 9.2; 95% CI, 7.0 to 12.1), and staffing shortages (odds ratio, 1.96; 95% CI, 1.57 to 2.43) were most strongly associated with high risk for burnout. Perceived lack of support at work (odds ratio, 6.3; 95% CI, 3.81 to 10.4) was the factor most strongly associated with burnout syndrome. CONCLUSIONS: Burnout is more prevalent in anesthesiology since early 2020, with workplace factors of perceived support and staffing being the predominant associated variables. Interventions focused on the drivers of burnout are needed to improve well-being among U.S. attending anesthesiologists.

Barriers to recovery for medical professionals: Assessing financial support through a survey of Physician Health Programs.

BACKGROUND AND OBJECTIVES: There is increasing focus on physician burnout, psychiatric problems, and substance use disorders. Costs of recovery for physicians enrolled in Physician Health Programs (PHPs) remain unexamined with little known regarding funding resources. We sought to elucidate perceived costs of recovery from impairing conditions and highlight resources for financial strain. METHODS: This survey study was distributed by the Federation of State Physician Health Organizations via e-mail to 50 PHPs in 2021. Questions assessed perceptions of costs and ability to pay for recommended evaluation, treatment, and monitoring. Questions also assessed limitation of engagement due to financial concerns, and availability of financial resources. RESULTS: Complete responses were received from 40 of 50 eligible PHPs. The majority (78%) of responding PHPs assessed ability to pay at initial intake evaluation. There is notable financial strain on physicians, particularly those earliest in training, to pay for services. DISCUSSION AND CONCLUSIONS: PHPs are vital to physicians, especially physicians-in-training, as "safe haven programs." Methods to financially assist through PHPs included fee deferrals, sliding scale fees, and fee forgiveness. Health insurance, medical schools, and hospitals were able to provide additional assistance. SCIENTIFIC SIGNIFICANCE: Because burnout, mental health, and substance use disorders are high stakes amongst physicians, it is critical that access to PHPs is available, destigmatized, and affordable. Our paper focuses specifically on the financial cost of recovery, the financial burden placed on PHP participants, a topic lacking in the literature, and highlights remedies and vulnerable populations.

The Wicked Problem of Physician Well-Being.

The collective threat to physician well-being is a complex issue with no clear solution. Even before the coronavirus disease 2019 pandemic, physicians suffered from widespread burnout and moral injury, with negative consequences for patient care, physician health, and the health care system. Initial clinician well-being efforts leaned heavily on individual-focused interventions. However, workplace culture and environment are key factors that affect burnout, and therefore clinician well-being efforts require both individual-focused and systems-level interventions. A sustainable culture of support in medicine is necessary to foster physician well-being.

Burnout, Mental Health, and Workplace Discrimination in Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, and Asexual Anesthesiologists.

Increasing attention is being paid to both anesthesiologist well-being and commitments to diversity, equity, and inclusion. Sexual minorities (ie, members of the lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual [LGBTQIA] communities) face many challenges in society and the workplace, including mental health conditions, discrimination, and increased risk for burnout. In this review, we outline the current state of mental health conditions and burnout in sexual minority individuals, discrimination and harassment faced both in society and the workplace, and steps that workplaces can take to become more inclusive and welcoming.

Trends in Pediatric MRI sedation/anesthesia at a tertiary medical center over time.

BACKGROUND: Each year, hundreds of thousands of children require sedation/anesthesia to facilitate MRI scans. Anesthetic techniques for accomplishing sedation/anesthesia vary widely between institutions and providers, with unclear implications for patient safety. AIMS: We sought to establish trends in anesthetic practice for pediatric MRI sedation/anesthesia across a 7-year period and determine rates of adverse events, considering technique used, age, and ASA physical classification status (ASA-PS). METHODS: Using established data resources, we analyzed 24 052 anesthetics performed by anesthesiologists for MRI scans between 5/1/2013 and 12/31/2019 on patients less than 18 years old, focusing on medications used, trends of use, and associated adverse events. Adverse events (hypoxia, hypotension, bradycardia) were defined by deviation from age norms and accessed via the electronic anesthetic record database. The Cochran-Armitage test was used to assess trends over time in categorical data, and one-way ANOVA was used to analyze continuous data. Multivariable logistic regression analysis was implemented to determine the independent associations between anesthetic technique and adverse events while adjusting for age, ASA-PS, and weight. RESULTS: The most significant trends noted were a decrease in "propofol-only" anesthetic techniques and an increase in propofol and dexmedetomidine combination techniques. Mild desaturation (80-89% SpO2 ) occurred in 4.22% of cases with more significant hypoxia much rarer (0.44% of cases having desaturation <70% SpO2 ). Bradycardia occurred in 2.39% of cases and hypotension in 1.75% of cases. Major adverse events were rare. CONCLUSIONS: We provide the largest report of the nature of MRI sedation/anesthesia as practiced by anesthesiologists in a large children's hospital. We demonstrate that, even in a large system, anesthetic techniques are pliable and shift significantly over time. Our data also support a high level of safety within our system, despite a case mix likely higher in risk than those in most of the previously published studies.

Burnout Rate and Risk Factors among Anesthesiologists in the United States.

BACKGROUND: Physician burnout, widespread across medicine, is linked to poorer physician quality of life and reduced quality of care. Data on prevalence of and risk factors for burnout among anesthesiologists are limited. The objective of the current study was to improve understanding of burnout in anesthesiologists, identify workplace and personal factors associated with burnout among anesthesiologists, and quantify their strength of association. METHODS: During March 2020, the authors surveyed member anesthesiologists of the American Society of Anesthesiologists. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey. Additional survey questions queried workplace and personal factors. The primary research question was to assess rates of high risk for burnout (scores of at least 27 on the emotional exhaustion subscale and/or at least 10 on the depersonalization subscale of the Maslach Burnout Inventory Human Services Survey) and burnout syndrome (demonstrating all three burnout dimensions, consistent with the World Health Organization definition). The secondary research question was to identify associated risk factors. RESULTS: Of 28,677 anesthesiologists contacted, 13.6% (3,898) completed the survey; 59.2% (2,307 of 3,898) were at high risk of burnout, and 13.8% (539 of 3,898) met criteria for burnout syndrome. On multivariable analysis, perceived lack of support at work (odds ratio, 6.7; 95% CI, 5.3 to 8.5); working greater than or equal to 40 h/week (odds ratio, 2.22; 95% CI, 1.80 to 2.75); lesbian, gay, bisexual, transgender/transsexual, queer/questioning, intersex, and asexual status (odds ratio, 2.21; 95% CI, 1.35 to 3.63); and perceived staffing shortages (odds ratio, 2.06; 95% CI, 1.76 to 2.42) were independently associated with high risk for burnout. Perceived lack of support at work (odds ratio, 10.0; 95% CI, 5.4 to 18.3) and home (odds ratio, 2.13; 95% CI, 1.69 to 2.69) were most strongly associated with burnout syndrome. CONCLUSIONS: The prevalence of burnout among anesthesiologists is high, with workplace factors weighing heavily. The authors identified risk factors for burnout, especially perceived support in the workplace, where focused interventions may be effective in reducing burnout.

It's the Culture!-How systemic and societal constructs impact well-being.

Pediatric anesthesiologists practice within a culture, a system, and a society. In this article, we provide an overview of the influence these have on the well-being or the unwellness of pediatric anesthesiologists. The scope of these issues is broad and far-reaching; thus, our goal has been to highlight those areas which would be likely to have the largest impact on well-being if addressed fully by society, institutions, and leaders in our field. We discuss the burnout-promoting aspects of medical education and training. We survey occupational factors, such as the high-stake pediatric anesthesia environment, occupational health hazards, time pressure, and the reduction in physician autonomy. We then describe societal barriers, such as the marginalization of certain populations, the US system of malpractice litigation, the stigma surrounding psychiatric care, and some of the issues related to physician reimbursement in the United States. We conclude that in order to move forward, improving physician wellness must be a focus of society, of the medical system as a whole, and of individual departments and leaders in pediatric anesthesia.

Physician Well-Being in Practice.

Despite a recent surge of interest in physician well-being, the discussion remains diffuse and often scattered. Lingering questions of what wellness entails, how it is personally applicable, and what can be done, remain pervasive. In this review, we focus on policy-level, institutional and personal factors that are both obstacles to wellness and interventions for potential remedy. We outline clear obstacles to physician wellness that include dehumanization in medicine, environments and cultures of negativity, barriers to wellness resources, and the effect of second victim syndrome. This is followed by proven and proposed interventions to support physicians in need and foster cultures of sustained well-being from policy, institutional, and personal levels. These include medical liability and licensure policy, peer support constructs, electronic health record optimization, and personal wellness strategies. Where sufficient data exists, we highlight areas specific to anesthesiology. Overall, we offer a pragmatic framework for addressing this critical concern at every level.

Educational Perspectives: Anesthesia 101: What the Neonatologist Needs to Know About Anesthesiology.

As the complexity of medicine increases, so too do the challenges with multidisciplinary communication and coordinated patient care. Anesthesiology represents a field for which there is no required study for medical students, pediatric residents, or neonatal-perinatal medicine fellows in the United States, so a neonatologist may have never received any formal training in anesthesiology (and vice versa for pediatric anesthesiologists in neonatology). In this review, we address frequently asked questions of neonatologists to anesthesiologists to better frame common issues. These topics include thermal regulation, fluid management, airway management, and the field of regional anesthesiology. Finally, collaborative efforts between the surgical and medical fields, such as the American College of Surgeons Children's Surgery Verification Quality Improvement Program, and the American Academy of Pediatrics NICU Verification Program, are ongoing and robust; these programs represent important opportunities to significantly improve the perioperative care of infants. Our hope is that this summary can serve as a primer and reference for those caring for neonatal patients during any perioperative period, including seasoned neonatologists and those early in their training. It is our further desire that this review will lead to improved communication and collegiality between the specialties.

Neurotoxicity of Anesthesia in Children: Prevention and Treatment.

PURPOSE OF REVIEW: The purpose of this review is to summarize the current evidence regarding the impact of the exposure to anesthetic and sedative agents on neurodevelopment during the period of rapid brain growth in the first 3 years of life. Though much of the definitive data demonstrating anesthesia-induced neurotoxicity has come from studies in young animals, the focus of this review is on emerging human data. RECENT FINDINGS: In 2016, the first prospective trials investigating the neurodevelopmental impact of early anesthetic exposure (GAS and PANDA studies) were published, both showing no significant impact on IQ from a single brief anesthetic. More recent population cohort analyses have shown varying, but minimal, impacts from early anesthetic exposure on academic performance and IQ, much smaller than that of maternal education and other environmental factors. Animal and human data document that post-anesthetic neurotoxicity is a genuine phenomenon, but its long-term clinical significance is uncertain. Most experts would agree that a single, brief anesthetic likely has no significant impact on neurodevelopment, but it is yet to be determined whether longer exposures or multiple anesthetics are associated with subsequent learning issues. Future research is aimed at determining the mechanisms of neuronal injury from exposure to anesthetic and sedative agents, adjunctive medications that may prevent or ameliorate this injury, and therapeutic approaches such as early intervention that can enhance recovery. While these studies are underway, it is recommended that exposure to anesthetic and sedative agents be minimized in young children and consideration be given to alternative methods of immobilization for nonpainful procedures such as radiologic imaging.

Peer support in anesthesia: turning war stories into wellness.

PURPOSE OF REVIEW: Peer support, a method of providing for the well being of healthcare providers following adverse or stressful events, is garnering increased attention in light of the increased prevalence and awareness of burnout, depression and suicidality in physicians. In this review, we will summarize the evolution of the 'second victim,' explore methods of support and examine how new regulatory requirements are changing the peer support landscape. RECENT FINDINGS: As peer support and the second victim are investigated more, themes are emerging regarding the natural history of recovery. As these are delineated, more targeted peer support models are being developed. One major change in 2017 is the institution of new Accreditation Council for Graduate Medical Education's Common Program Requirements, now including topics targeted on well being. SUMMARY: Effective and accessible peer support is developing in many departments nationwide and can only be expected to continue, given new regulatory requirements. As these programs develop, and research on their effect continues, best practices will likely emerge.

Anaesthetic considerations for surgery in newborns.

Almost 30 years ago, the American Academy of Pediatrics Committee on Fetus and Newborn coauthored a policy statement strongly advocating for the use of anaesthesia in all neonates stating 'local or systemic pharmacologic agents now available permit relatively safe administration of anesthesia or analgesia to neonates undergoing surgical procedures and that such administration is indicated according to the usual guidelines for the administration of anesthesia to high-risk, potentially unstable patients'. With current techniques and advanced monitoring, preterm and full-term infants routinely undergo surgical procedures under general anaesthesia to repair congenital defects that were lethal in years past. Recent research in immature animal models, however, has shown evidence of enhanced neuroapoptosis and other signs of neurotoxicity with all of the currently used anaesthetic agents. There is also increasing concern about the potential adverse effects of perioperative hypotension and hypocapnia on neurocognitive development in infants. This review outlines the most recent animal and human evidence regarding the effects of general anaesthesia and anaesthetic-related haemodynamic changes on the developing brain of newborns.

National Survey of US academic anesthesiology chairs on clinician wellness.

STUDY OBJECTIVE: The prevalence of anesthesiology department wellness programs is unknown. A database of wellness programs is needed as a resource for departments attempting to respond to the Accreditation Council for Graduate Medical Education Anesthesiology Milestones Project. The purpose of this study was to survey academic anesthesiology chairs on wellness issues, characterize initiatives, and establish wellness contacts for a Wellness Initiative Database (WID). DESIGN: An Internet-based survey instrument was distributed to academic anesthesiology department chairs in the United States. SETTING: On-line. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS: Analysis for continuous variables used standard means, modes, and averages for individual responses; 95% confidence intervals for proportions were calculated by Wilson's method. MAIN RESULTS: Seventy-five (56.4%) responses (of a potential 133 programs) were obtained. Forty-one (of 71 responders; 57.8%) expressed interest in participating in a WID, and 33 (44%) provided contact information. Most (74.7%) had recently referred staff for counseling or wellness resources, yet many (79.5% and 67.1%, respectively) had never surveyed their department's interest in wellness resources. Thirty-four percent had a wellness resources repository. Of 22 wellness topics, 8 garnered >60% strong interest from respondents: Addiction Counseling, Sleep Hygiene, Peer Support Program, Stress Management, Conflict Management, Burnout Counseling, Time Management, and Dealing with Adverse Events Training. There was a statistically significant difference in interest between those willing to participate or not in the WID across most topics but no significant difference based on need for recent staff referral. CONCLUSIONS: The majority of chairs needed to recently refer a department member to wellness resources or counseling. Most were interested in participating in a WID, whereas a minority had gauged staff interest in wellness topics or had a wellness resource repository. Highest interest was in topics most related to function as an anesthesiologist. Those willing to participate in the database had statistically significant differences in interest across most wellness topics.

Assessing levels of support for residents following adverse outcomes: a national survey of anesthesia residency programs in the United States.

AIM: The impact of physician burnout is becoming apparent in the medical community, especially among anesthesiologists and young physicians. Anesthesia residents will experience emotionally charged adverse events during their training. The objective was to determine the prevalence, efficacy and utilization of support structures in place for residents following adverse events in order to develop a best-practices model of resident support. METHODS: We sent an anonymous internet-based survey to program directors (PDs) at all American College of Graduate Medical Education (ACGME)-approved Anesthesia Residency programs, with an optional secondary survey of residents. RESULTS: There was a 53% response rate among PDs with most reporting resource availability. The strongest support programs were the anesthesia support programs, morbidity and mortality (M&M) conference, and "individual meetings with department leadership." These results were mirrored in the responses of residents at the 32 programs who opted to participate in the secondary survey. Both also cited M&M conference as being highly utilized, but not efficacious. The strongest support programs had a low prevalence. CONCLUSIONS: These data suggest that a best-practices model of resident support entails establishing a department-based support program, facilitating comfortable meetings with departmental leadership and optimizing M&M conference.