I was 48 years old, and 5 weeks after quintuple coronary artery bypass wondering whether I would I have the strength to return to work in a week. My first day back would be my busiest since I transitioned to academia 6 months ago after 16 years in private practice. There was a backlog of patients who needed to be seen. Could I do it? Of course I could. I was a surgeon, and I was tough. All surgical trainees of my vintage know that asking for help is a sign of weakness. I emailed the division chief but reframed the paradigm: “I’m a little weak, and I need a little help.”
The medical profession has typically attracted individuals with certain personality and character traits: motivated, focused, and driven. This singular intensity, however, can cause challenges. Burnout—physician frustration with daily administrative requirements—in surgery has been well documented,1 but my earliest recollection of burnout comes from sports. In 1983, Dick Vermiel, legendary coach of the Philadelphia Eagles, abruptly resigned. After 6 years on the sidelines, he had a winning record and a Super Bowl appearance on his impressive resume. Vermiel admitted he was his own worst enemy, sleeping on a cot in his office several nights a week. ''I'm far too intense, far too emotional.…I'm emotionally burned out,'' he said. His distress was palpable as he repeated the phrase over and over during the press conference. ''I don't mean I'm about to go off my rocker, but I'm burned out.'' I don’t ever recall hearing the term burnout during training or even during my first few years in practice, but Vermiel’s typical week sounds a lot like parts of residency.2
After residency, I transitioned to a small private practice. The community was perfect for my family. Surgically, I was performing cases I enjoyed. Hospital call was 1:3, but everybody covered their own patients...all the time; however, this arrangement was unsustainable. Why couldn’t we cover each other on call? I proposed a more team-oriented system that would benefit everyone. But as a junior partner, not the head coach, my colleagues were resistant to change.
Early on, I was involved in a devastating complication after a routine procedure resulting in permanent harm to a patient. I prayed for that patient every day, but I knew the individual’s long-term prognosis was poor. I will never suffer what that family suffered, but I suffered. There was finger-pointing, cancellation of my malpractice insurance, and legal depositions with minimal hospital support.
Previous studies have diagnosed acute traumatic stress (using validated diagnostic criteria) in one-third of surgeons a month after a major surgical complication.3 When a major complication occurred for the first time after residency, the emotional consequences were greater.4,5 Every time the pager went off, my heart would beat out of my chest fearing the worst-case scenario. I had all the risk factors for and checked all the boxes as a second victim,6 but no one noticed. Support is often readily available for those who experience trauma and loss in other parts of their lives, but surgeons are supposed to be innately resilient. I clung to outdated mantras: “Don’t complain,” “Don’t explain,” and “Asking for help is a sign of weakness.” My only option was to get back on the horse, and I did. I may not have been clinically depressed, but I was in pain. I confided in a few of my former residency colleagues, but I still felt like a failure.
Time passed.
I managed the emotional scars and soldiered on. Then, one of my partners relocated. Recruiting a replacement to our community practice would be challenging and costly. Ultimately, we chose not to replace him. We would adjust staffing and work to meet clinical needs with the resources we had. We were routinely averaging in the 90th percentile for yearly work relative value units. The quarterly bonus checks temporarily eased the burnout progression, but the ever-increasing workload and continued call demands were killing me.
I began reading about physician burnout and encore careers and deleted every hospital email regarding physician engagement. I didn’t care, and I felt the system didn’t care either. I was not abusing alcohol, getting divorced, or experiencing suicidal thoughts. My complication rates did not go up. I still cared about my patients, but the culture and call schedule led to greater frustration. I may have been home when I was on call but was rarely mentally present. I was a different person when the pager went off. Every Sunday, I dreaded returning to work. Although I was gladly ready to give up compensation for balance, there was resistance to recruiting additional clinicians. I tried all the suggestions to address the burnout: meditation, reading, exercise, vacations, starting a side business. I hired a scribe to help with the electronic health record. However, there were only so many variables I could control.
The hospital ultimately bought our practice. When my contract was up for renewal, I applied for a position at the nearby academic medical center. My family would not have to move. The compensation would be less, but I didn’t care. Call demands would be less, and there would be residents to teach and assist with patient care. Most importantly, I would be part of a team of talented colleagues, all of whom worked to support each other.
The transition was harder than I anticipated, and I noticed a tingling sensation in my chest with exercise. I was hoping it was stress or anxiety. My cardiologist scheduled further testing, which was easy to do on my academic day. In my prior job, I probably would have delayed testing due to having to reschedule a half day of patients from an already overbooked practice.
The stress test demonstrated multiple areas of reversible ischemia with a coronary artery calcium score of 2777. Cardiac catheterization confirmed multivessel disease. My family history was not favorable, but I ate well and exercised regularly. My blood pressure and cholesterol were normal. As I reflect now, I realize I was likely destined for a cardiac bypass at some point given my genetics. I cannot help but wonder about the extent the burnout contributed to the plaque buildup. Statistically, I also recognized I may need another revascularization procedure in the future. Change was critical for me.
“Are you sure you’re ready?” asked my division chief. “How many patients do you think you could see? Take that number and undershoot it.” Asking for help was such a foreign concept, and I felt so relieved. As a physician and a patient, I needed help not only from my treating physicians but also from my supervising physicians. A culture of caring and compassion is critical not only for patient care but also for physician well-being. We all need help now and then, but we need to eliminate the associated barriers. We need to build cultures that acknowledge these vulnerabilities and offer support.
The toll of surgical complications can be high, and clinical success will always require resilience. Improving outcomes and preventing complications is critical, but that does not address the adverse emotional effect on surgeons. In a recent survey of surgeons, 90% of all respondents had experienced an adverse event and felt anxiety, guilt, sadness, shame, anger, or embarrassment within the past year.7 These results led to a confidential outreach program for at-risk surgeons to meet with a trained peer supporter. Most were relieved to have someone to talk to. Discussions often shifted from negative to positive, ending on notes of rejuvenation and resiliency.6 If only I had access to such a program so many years ago.
Medicine is a calling to help and heal others, but we must also learn to help and heal ourselves before burnout builds and plaque accumulates. I am back at full strength now and grateful my call for help was answered. I am no longer hesitant to ask for help. This is a sign of courage and strength, not weakness.
We need to pay attention to our symptoms (mental and physical) and have them evaluated. We need to take care of ourselves, recognize when we feel unhappy or overworked, and examine why. Some issues can be controlled, others cannot.
I thought I had lost the passion for my craft as burnout and the bypass drained it out of me. However, in a culture that cares about me as a physician and as a person, I feel I have been given a second chance. There is precedent. In 1997, 15 years after expressing burnout, Dick Vermiel returned to coaching. Three years later he hoisted the Lombardi trophy as coach of the Super Bowl XXXIV champion St Louis Rams. I should only be so lucky to achieve that level of success. If I do get there, it won’t be without asking for a little help.
Corresponding Author: Jayson S. Greenberg, Department of Otolaryngology–Head and Neck Surgery, University of Michigan, 1904 Taubman Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5312 (jaysongr@med.umich.edu).
Conflict of Interest Disclosures: None reported.
Additional Contributions: I thank Gurjit Sandhu, PhD, Department of Surgery, University of Michigan, for her feedback on the manuscript and for encouraging me to share my story. She was not compensated for these contributions.