480 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina

Practical RetinaIncorporating current trials and technology into clinical practice

Burnout in Ophthalmologyby Neha Siddiqui, MS; and Michael Tsipursky, MD

For this Practical Retina column, I requested Michael Tsipursky, MD, and Neha Siddiqui, MS, to share their expertise and experiences regarding

burnout in oph-thalmology. During the last decade we have seen an ac-celerating trend of burnout through-out medicine. Why is this?

To have this discussion, we first need to understand the causes of burn-out, which are ex-

tensive and increasing year over year. Factors such as isolation, increases in mundane tasks, increasing patient volumes, lack of intellectual stimula-tion, decreasing autonomy, reimburse-ment hassles, and most recently wear-ing personal protective equipment to see patients are just some examples. We need to develop a framework to create coping mechanisms as well as build solutions at the individual and institutional level to combat this concerning trend.

Another important aspect of burn-out is that we need to notice signs in our colleagues and trainees. Of-ten the signs are missed. Be aware of colleagues acting out of character or who seem very irritable. Rather than penalizing colleagues, please take a moment to inquire and listen to them. This is our duty and you may very well save their lives.

Dr. Tsipursky and Ms. Siddiqui generously share their extensive knowledge regarding burnout in oph-thalmology. They will dissect, ana-lyze, and summarize the salient issues surrounding this sensitive and vitally important topic. I am certain that the insights regarding burnout presented in this piece will prove to be very valuable for our community.

Burnout is a psychological state encompassing a combination of emotional exhaustion, depersonalization, and low feeling of personal accomplishment.1 It is especially prevalent in medicine, where work-related stressors tend to be more extreme, responsibilities are numerous, and one is surrounded by and constantly compared to successful peers.

Here, we provide an overview of burnout in ophthalmology and its causes, summarize a framework behind understanding burnout, outline methods to bring awareness to burn-out in fellow colleagues, and appraise both personal and policy-oriented suggestions to combat burnout.

Now considered a billable condition in the International Classification of Diseases, 10th edition (ICD-10) with code Z73.0, burn-out is officially defined as a “state of vital exhaustion.” It is widely prevalent in all medicine, with more than half of physicians

reporting at least one symptom of burnout when assessed with the Maslach Burnout Inventory.2 Ophthalmology as a field has some of the lower reported rates of burnout, but “low” is relative to other surgical specialties, and still much higher than the gen-eral population.3 Ophthalmologists report burnout at a high rate of 37%. Women in ophthalmology report an even higher rate at 43%, and middle-career physicians report higher burnout than those in early or late stages.4,5

Burnout is linked to mental health. A 2018 survey found that 46% of ophthalmologists felt burned out, depressed, or both.4 A recent study from Mayo Clinic found that 41% of physicians screened positive for depression.2 This mental state affects pro-ductivity and work environment, as nearly half with depression report expressing frustration in front of staff/peers, becoming easily exasperated with colleagues and patients, and being less engaged/friendly.4 There is concern over this affecting out-comes, as well, with burnt-out clinicians rating patient safety as a lower priority.6

Burnout not only affects psyche and productivity, but the literature also points to physical sequelae. A review by Salva-gioni et al. showed that burnout was a predictor of 12 physi-cal conditions including hypercholesterolemia, diabetes, cor-onary heart disease, severe injuries, and mortality below the age of 45 years.7 There is even bigger concern is that burnout

Neha Siddiqui

Michael Tsipursky

doi: 10.3928/23258160-20200831-01

Seenu M. Hariprasad Practical Retina

Co-Editor

Practical Retina

September 2020 · Vol. 51, No. 9 481

could lead to suicide. More than 400 physicians commit suicide every year, with the rate of com-pletion among women physicians being 2.27-times higher than the general female population, and men being 1.41-times greater than the general male population.8 This issue has dubbed burnout and suicide as a “public health crisis” among medical professionals.

In light of the recent COVID-19 pandemic, these mental health issues can be exacerbated due to high-er workload, anxiety due to uncertainty, increased

burden or a new workflow, leading to acute stress reactions, compassion fatigue, or fear of becoming sick oneself or spreading illness to loved ones. Al-ternatively, disruption of workflow and shifting of resources to “essential procedures only” results in the cancellation of many health maintenance ap-pointments and can hinder access to routine oph-thalmological care. This paired with the difficulty of completing ophthalmological exams via telemed-icine can lead to poor work satisfaction and long-term patient outcomes.9

Figure 1. The pyramid shows how each category of needs builds upon the previous. The culture in medicine is often not conducive to layers of this pyramid, and we should try to be aware of its pitfalls. Physical needs such as sleep and food are of high importance and are bases to all other success. Creating an environment where one has plenty of rest, exercise, and nourishment is paramount. Safety and security touch on the need to feel safe in work and home environment in terms of job security, household stability, and financial security. The need for love and belongingness can often be forgotten when professional obligations conflict with personal ones. Fostering relationships with friends, family, and colleagues is extremely important to balance. These require concerted effort but are cornerstones to personal well-being. Feelings of accomplishment and esteem are attainable during training as goals are reached, but during clinical practice this can be lost in daily routine. Setting goals and milestones and having mentors is important. A sense of accomplishment can come from helping improve or preserve patients’ vision. Others may feel accomplished by being active in professional organizations and within the hospital or practice. Academic endeavors (such as publications or recognition by the scientific community) can be motivators. Financial health is important, but purely financial metrics of success do not lead to long-lasting satisfaction. The path to self-actualization is a path of successes, failures, tribulations, and personal growth. A mindful approach to everyday, routine interactions with patients, staff, and colleagues will go a long way.

482 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina

Practical Retina

SOME CAUSES OF BURNOUT

Factors specific to ophthalmology that lead to in-creased feelings of burnout include:1. A feeling of isolation from the hospital. Often-

times, procedures and surgeries can be performed in-office or at surgical centers, and providers may feel disengaged from the patient, a disconnect from the care they provide and not feeling as part of the general patient care team approach.

2. Many ophthalmologists work in private prac-tice, and 58% are completely or partially self-employed.10 Managing a practice has its own stressors related to business, administration, and logistics. Some providers find these tasks mun-dane and may be more suited for the employed model where these tasks are often taken care of. However, in an employed position, the tradeoff is letting go of some autonomy.

3. For those who primarily focus on one procedure like cataract surgery or subspecialize, there is a concern of getting bored with the routineness of procedures. The perceived lack of intellectual stimulation can feel monotonous.

4. A lack of autonomy is a common stressor for phy-sicians — which medications they are “allowed” to prescribe (eg, which ones will be reimbursed by insurance), and how much time must be spent on administrative logistics such as charting, bill-ing, etc. As of 2018, a survey of ophthalmologists found that 48% of ophthalmologists spend 10 or more hours a week on administrative duties.10

5. As reimbursement rates decrease and corporate health care becomes more prevalent, the pres-sure to have high-volume surgery and clinic days increases. The average ophthalmologist now spends only 9 to 12 minutes with a patient.10 In the same survey, the top two cited challenges in practicing were “too many rules and regula-tions” and “difficulty getting reimbursement.” Financial pressures coupled with debt (a median of $185,000 for postgraduate year 1 ophthalmolo-gists in 2016), in turn, lead to a feeling of exhaus-tion that sets physicians up for burnout.11

6. The “rat race” feeling of keeping up with increas-ing patient volumes to keep up with financial goals or to help practice grow/succeed can have

Figure 2. Despite more than 40% of ophthalmologists reporting burnout, only 23% report seeking professional help for it. Image courtesy of Medscape.

Practical Retina

September 2020 · Vol. 51, No. 9 483

unhealthy consequences on personal and profes-sional life.

7. The physical criteria of a microsurgical specialty means that any tremor or vision problems could end a hard-earned career. Similarly, the physical toll of surgeries ranges from fatigue to neck and back problems.

8. An inability to provide ophthalmological care via telemedicine to allow for close follow-up and more favorable patient outcomes, and the relative deprioritization of ophthalmological care relative to other medical care.

9. Wearing of personal protective equipment (PPE), which can be uncomfortable, claustrophobic, and make it more difficult to connect with the patient for the lack of seeing full facial expressions.

Apathy and disengagement become common when practice becomes viewed as work rather than something that has a meaningful impact on patients’ health and vision. In a 2018 Medscape Ophthalmol-ogy survey, the top two cited reasons for ophthal-mology being rewarding were “relationships with patients” and “knowing that I’m making the world a better place.”10

FRAMEWORK FOR CREATING COPING MECHANISMS

According to Maslow’s hierarchy of needs, an individual must take care of certain needs before they can achieve “self-actualization,” the notion of reaching one’s full potential and benefitting society in the maximum possible way. These needs range from physical and physiological to self-esteem and belonging before an individual is finally able to transcend such concerns and focus on creativity (Figure 1).12

BUILDING SOLUTIONS

Policy-OrientedA shift in culture is what is truly necessary, and

this can only begin at the policy level. Leadership can shape expectations, provide resources, and formulate accommodating policies without compromising ex-cellence in performance and patient care.

Quality leadership. According to a study done by Mayo clinic, each point increase in leadership metric scores resulted in 3.3% decrease in odds of burnout and increase in likelihood of satisfaction by 9%.13 These leaders help physicians develop their careers, empower and inspire them to succeed at their job, and subsequently recognize their successes.

A supportive culture. Encouraging feedback from physicians, making positive comments, thanking people for their efforts, and highlighting others’ suc-

cess. Gratitude and a team-based mindset in leader-ship will trickle down to the culture of an institution.

Rehabilitation over retribution. When a mistake is made, the root cause analysis should focus on pre-vention, and protection, not punishment. When there is a poor surgical outcome, the physician is likely already distressed about the situation, and pointing out mistakes immediately will only serve to worsen the guilt. A more effective strategy is to respond em-pathetically and acknowledge the difficulty that the physician may be going through, and then request necessary information and schedule a meeting for a later time.

Mental health resources and accommodations. Evidence-based mindfulness and mental health pro-grams instituted at an academic center showed im-provements in all attributes studied, ranging from happiness to satisfaction to gratitude.14

Forming a formal, anonymous complaint and investigation system. This will allow physicians to report frustrations without fear of repercussions and allow for building a better system going forward.

Self-advocacy. Physicians often succumb to a high level of personal sacrifice to adequately serve their patients. Advocating for oneself can help achieve policies conducive to a better work-life balance.

Safe environments. Allowing for plentiful PPE and workflows that are safe, not overwhelming, and appropriate during the COVID-19 pandemic.

Individual Coping StrategiesFinancial independence. Saving early in the ca-

reer liberates one from succumbing to workload de-mands and thus better preserve autonomy.

Conscious recognition and reminder of one’s pri-orities and impact. Remembering how one is help-ing patients will give more meaning to practice than maximizing output.

Pursuing hobbies. Often, physicians make their career their identity, and when things do not go well, it feels like a lifetime of effort turned into failure. It is important to harbor interests outside of medicine to stay resilient through ups and downs.

Time for family/friends. Loneliness is an epi-demic in medicine. Building intimate relationships can also help improve self-esteem. This is especial-ly important in light of measures for social distanc-ing, and video calls with loved ones can help deter feelings of isolation when physically distancing from others.

Spirituality. Whether it be religion, meditation, philosophy, or even journaling, spirituality can help one reflect and feel connected and more at ease with what is out of their control.

484 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina

Practical Retina

Identifying larger goals. Finding intellectual stim-ulation or a “larger” goal, ideally one that keeps in touch with society or a larger community, will also help bring meaning and enthusiasm toward one’s practice. Research, mentoring, advocacy work, health policy, leadership, nonprofit work, etc., bring larger meaning to a career and give vigor and motivation to power through the mundane tasks of day-to-day work.

Prioritizing physiological needs. Simple things like eating breakfast and an adequate night’s sleep can give more energy and combat exhaustion and help focus.

Building a healthy lifestyle. Joining a gym might not be enough — sometimes an accountability bud-dy, trainer, or group fitness classes will better ensure commitment to a healthy lifestyle. Similarly, help-seeking for mental/physical health is a priority. Phy-sicians are notorious for skipping doctor’s appoint-ments (Figure 2).4

NOTICING BURNOUT IN COLLEAGUES

In many cases, the initial burnout signs are missed or misinterpreted. When someone begins acting out of character, it is important not to penalize that per-son, but rather, reach out in concern and inquire as to the best reasons on how to support them. Often, the first symptoms of burnout are irritability and fail-ing to complete responsibilities, and penalizing col-leagues in distress only further worsens their despair. Understanding stressors and mistakes and building a culture of support is essential. Furthermore, because of stigma associated with help-seeking and an expec-tation of self-sufficiency, physicians are reluctant to seek help. Befriending colleagues, inquiring about well-being, and constantly checking in will allow op-portunities for conversations that a person in need may not initiate themselves.

CONCLUSION

A career in ophthalmology is an ever-evolving process fraught with many professional and personal successes and pitfalls. Its endeavors require extreme precision and mental concentration and are ultimate-ly able to save or improve patient’s vision. To have a fulfilling career, one must pace oneself and have a mindful/intentional approach. The techniques pre-sented in this article serve as a starting point for com-batting burnout.

REFERENCES

1. Linzer M, Visser MR, Oort FJ, Smets EM, McMurray JE, de Haes HC; Society of General Internal Medicine (SGIM) Career Satis-faction Study Group (CSSG). Predicting and preventing physi-cian burnout: results from the United States and the Netherlands.

Am J Med. 2001;111(2):170-175. https://doi.org/10.1016/S0002-9343(01)00814-2 PMID:11498074

2. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-1613. https://doi.org/10.1016/j.mayocp.2015.08.023 PMID: 26653297

3. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471. PMID:19730177

4. Grisham S. Medscape Ophthalmologist Lifestyle Report 2018: Personal Happiness vs Work Burnout. Medscape. January 24, 2018. Accessed December 9, 2019. https://www.medscape.com/slideshow/2018-lifestyle-ophthalmologist-6009233

5. Dyrbye LN, Varkey P, Boone SL, Satele DV, Sloan JA, Shanafelt TD. Physician satisfaction and burnout at different career stages. Mayo Clin Proc. 2013;88(12):1358-1367. https://doi.org/10.1016/j.mayocp.2013.07.016 PMID:24290109

6. Annalena W, Meier LL, Tanja M. Emotional exhaustion and work-load predict clinician-rated and objective patient safety. Front Psychol. 2015;22;5:1573. https://doi.org/10.3389/fpsyg.2014.01573 PMID: 25657627

7. Salvagioni DAJ, Melanda FN, Mesas AE, González AD, Gabani FL, Andrade SM. Physical, psychological and occupational conse-quences of job burnout: A systematic review of prospective studies. PLoS One. 2017;12(10):e0185781. https://doi.org/10.1371/journal.pone.0185781 PMID:28977041

8. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psy-chiatry. 2004;161(12):2295-2302. https://doi.org/10.1176/appi.ajp.161.12.2295 PMID:15569903

9. Rathi S, Tsui E, Mehta N, Zahid S, Schuman JS. The Current State of Teleophthalmology in the United States. Ophthalmol-ogy. 2017;124(12):1729-1734. https://doi.org/10.1016/j.oph-tha.2017.05.026 PMID:28647202

10. Peckham C. Medscape Ophthalmologist Compensation Report 2018. April 28, 2018. Accessed December 9, 2019. https://www.medscape.com/slideshow/2018-compensation-ophthalmologist-6009664

11. Grischkan J, George BP, Chaiyachati K, Friedman AB, Dorsey ER, Asch DA. Distribution of Medical Education Debt by Specialty, 2010-2016. JAMA Intern Med. 2017;177(10):1532-1535. https://doi.org/10.1001/jamainternmed.2017.4023 PMID:28873133

12. McLeod S. Maslow’s hierarchy of needs. Simply Psychology. Accessed December 9, 2019. Updated March 20, 2020. https://www.simply-psychology.org/maslow.html

13. Shanafelt TD, Gorringe G, Menaker R, et al. Impact of orga-nizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432-440. https://doi.org/10.1016/j.mayocp.2015.01.012 PMID:25796117

14. Berkland BE, Werneburg BL, Jenkins SM, et al. A Worksite Wellness Intervention: Improving Happiness, Life Satisfaction, and Gratitude in Health Care Workers. Mayo Clin Proc Innov Qual Outcomes. 2017;1(3):203-210. https://doi.org/10.1016/j.mayocpiqo.2017.09.002 PMID:30225418

Neha Siddiqui, MS, can be reached at Carle-Illinois College of Medicine, 807 S Wright St, Champaign, IL 61820; email: neha5@illinois.edu.

Seenu M. Hariprasad, MD, can be reached at University of Chicago, Department of Ophthalmology and Visual Science, 5841 S. Maryland Ave., Room S-439, Chicago, IL 60637; email: retina@uchicago.edu.

Michael Tsipursky, MD, can be reached at Carle Hospital Eye Department, 3105 Fields S Dr, Champaign, IL 61822; email: mtsipursky@gmail.com.

Disclosures: Ms. Siddiqui and Dr. Tsipursky report no relevant financial disclosures. Dr. Hariprasad is a consultant or on the speakers bureau for Allergan, Novartis, Biogen, Graybug, EyePoint, Alimera Sciences, Spark, and Regeneron.