3:13 a.m. and wide awake. Dr. David Rothenberger tries to go back to sleep, but thoughts about Kaitlyn keep flooding his mind. A busy day ahead, he tries to fall back to sleep, but cannot. Going to his study, he sits in the dark and thinks. Spiraling thoughts about his own experiences, as a young physician and during his four-decade career as a surgeon and leader, flood his mind: memories of when, as a fourth-year medical student, he was told to go stand in the corner of the operating room and shut up, after he pointed out that a faculty surgeon had inadvertently contaminated some tubing…memories of being grilled and humiliated during a weekly morbidity and mortality conference, after a serious error occurred in the operating room when a faculty surgeon took an instrument from him because that surgeon had to “get moving.”  The despair in Kaitlyn’s letter to her parents is heart-wrenching. Kaitlyn took her own life during her third year of medical school. Each year, 400 physicians take their own lives. Rothenberger asks himself what he can do to make sure it doesn’t happen to those he works with daily.

— adapted from Breaking the Culture of Silence on Physician Suicide, published online by the National Academy of Medicine (NAM)

Action needed

“Our profession is in the midst of a crisis — a crisis of epic proportions  yet most in our profession do not yet acknowledge its existence, let alone the obligation to address it,” says David Rothenberger, MD.

The data are clear: Burnout is experienced by 1 in 3 physicians at any given time, and an estimated 400 U.S. physicians commit suicide annually.

Alarmingly, medical students have an equal, or even higher, risk of burnout, depression, substance abuse and suicide.

An American College of Surgeons (ACS) survey found that, of 7,905 physicians, a shocking 40 percent of them met the diagnostic criteria for burnout, 30 percent screened positive for depression, 28 percent had a mental quality of life (QOL) score below the population norm, and 6.4 percent reported suicide ideation.

Code of silence

As the recent past chair of the Department of Surgery, Rothenberger made it his mission to educate the profession about the growing problem of burnout.

That sleepless night, after reading the suicide letters written by Kaitlyn and other physicians (compiled in Pamela Wilbe’s book, Physician Suicide Letter – Answered), Rothenberger asked himself how many Kaitlyns are there among us within our department? Our medical school? Our profession?

Seeking to bring the problem of burnout out from the shadows, Rothenberger coauthored a discussion paper, Breaking the Culture of Silence on Physician Suicide, published online by the National Academy of Medicine (NAM). He and his three coauthors wrote from their own different perspectives (nursing, medical training and the clergy), each reflecting on the suicide of Kaitlyn and subsequently her mother.

“Our intent was to make an emotional appeal that no one in medicine could ignore,” says Rothenberger. “We reasoned that if NAM would get involved, it could do the same thing for the issues of burnout and well-being as it had previously done to address and improve safety in medicine, through its landmark reports To Err Is Human (2000), Crossing the Quality Chasm (2001), and Priority Areas for National Action: Transforming Health Care Quality (2003).”

To Err Is Human sought to increase awareness about deaths caused by preventable medical errors. The report provided a comprehensive strategy to change what was broken to reduce preventable errors. After initial pushback and finger-pointing, compelling data in subsequent reports eventually resulted in dramatic, systemic changes.

Rothenberger sees a similar level of inaction surrounding physician burnout. An unwritten code of silence tells medical students, residents, fellows and junior faculty members to keep their mouths shut, no matter how negative the culture is, no matter how exhausted or demeaned they are.

Consequences of burnout

According to Tait Shanafelt, MD, who has written and lectured extensively on the subject, the rate of burnout in the general workforce has held steady at 28 percent. In stark contrast, the rate in the physician workforce in 2011 was 45 percent and grew to 54 percent in 2014.

Burnout often results in drug and alcohol abuse, disruptive behavior, broken relationships, conflicts and ultimately withdrawal.

Ignoring the problem will continue to have lasting consequences, explains Rothenberger, not only for burned-out physicians but also for their patients, their colleagues and their families. Burnout can lead to less empathy for everyone, poor quality of care, unsatisfactory patient outcomes, decreased adherence to protocols and standards, and medical errors.

Burnout can hurt the entire health care organization, harming its reputation, increasing its malpractice risks, damaging its financial performance, and increasing staff dissatisfaction and turnover.

Causes of burnout

Physician burnout is largely a systems issue. The rapid rise in its prevalence is due, in part, to the unintended net result of multiple, highly disruptive changes in a short period that have made the medical work environment so challenging.

The physician-patient relationship has eroded in recent years. Medicine has quickly moved from a high-touch, low-tech, fairly autonomous profession to a low-touch, high-tech, frustratingly micromanaged job, says Rothenberger.

In the Physician Worklife Study, which began in 1996, Mark Linzer, MD, documented that physician satisfaction is not derived from financial gain, but rather from patient relationships. He reported that the drivers of burnout in primary care included lack of control over work conditions and decision-making; time pressure linked with “productivity”; an inefficient and chaotic work environment, with MDs burdened with clerical tasks; and a lack of alignment between health care providers and leadership.

Rothenberger points to an Annals of Internal Medicine article written by Christine Sinsky, MD, which suggested that 80 percent of physician burnout is due to the workplace environment. As she noted, for every hour physicians have direct face-to-face time with patients, nearly two additional hours are spent on electronic health records and desk work within the official workday. Outside office hours, physicians spend another one to two hours of personal time each night doing additional computer and other clerical work. 

In a 2016 lecture at the ACS Clinical Congress, Delos (Toby) Cosgrove III, MD, the former CEO of the Cleveland Clinic, attributed the burnout crisis to transitions within the medical profession occurring at an unsustainable rate. The focus of medical care has moved from volume (fee for service) to value (cost and quality); subjective outcomes have been replaced by Big Data, and physicians are no longer just providing individual health care but are also responsible for population health. Moreover, medical knowledge now doubles every 73 days, whereas previously it doubled every 150 years.

Rothenberger says that, with all these changes, it’s no surprise that physicians are experiencing burnout at unprecedented rates.

Going forward

When Rothenberger was invited to speak at the ACS Clinical Congress as the Herand Abcarian Lecturer in 2014, he wasn’t sure how his colleagues would react to the topic of burnout.

“I thought no one would show up; or, those who showed up would throw tomatoes at me,” he says. Instead, the large lecture hall was filled to capacity. Afterward, nearly 100 physicians spoke to him or emailed him, sharing their own personal struggles with burnout. He is encouraged that change might be on the horizon.

Most promising is the ongoing NAM effort. On July 14, 2017, it held the first public meeting, in Washington, DC, of the more than 20 organizations comprising the Action Collaborative on Clinician Well-Being and Resilience.

“I firmly believe that, as the Collaborative's committees identify priority areas for national action, even clearer solutions to the problem of physician burnout will be forthcoming,” says Rothenberger, who participated in that inaugural meeting. Victor Dzau, president of NAM, welcomed the audience of several hundred people and then confessed he had not understood why well-being and resilience should be a concern to NAM – until he read Breaking the Culture of Silence on Physician Suicide, the discussion paper that Rothenberger coauthored. Dzau urged everyone to read it. And people are doing just that; in fact, it was NAM's fourth-most frequently downloaded publication in 2016.

Rothenberger is encouraged by the actions of NAM to take on the problem. “I am sure many other factors led to its decision to address this issue, but it was nice to learn that our strategy had an influence on their leaders and that they have now committed major resources and energy to this problem for the next two years,” he says.

Partial solutions, based on evidence, are already being studied and applied, emphasizes Rothenberger. As he outlined in a recent article, “Physician Burnout and Well-Being: A Systematic Review and Framework for Action,” two of the most highly effective strategies include aligning personal and organizational values enabling physicians to devote 20 percent of their work activities to the part of their medical practice that is especially meaningful to them.

Rothenberger will continue to publish seminal papers on physician burnout and to lecture on the subject. He has already given grand rounds for several departments in the Medical School. “I am especially encouraged that Dean Tolar has a similar commitment to achieving wellbeing across our entire organization,” says Rothenberger.

Upcoming lecture: December 7 at 5 p.m.

The upcoming 10th Annual Rothenberger Lecture (free and open to the public) will take place at 5 p.m. on Thursday, December 7, 2017, in the Coffman Union Theater. 

Caprice Christian Greenberg, MD, MPH, of the University of Wisconsin, will deliver a talk titled “Sticky Floors and Glass Ceilings” regarding gender equity in medicine. Her presidential address to the Association for Academic Surgery, in February 2017, has stimulated discussions across the U.S. surgical world.