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April 15, 2020

Service to Others May Be the Answer to Physician Burnout

Author Affiliations
  • 1Walter Reed Department of Surgery, Uniformed Services University, Bethesda, Maryland
JAMA Surg. 2020;155(6):463-464. doi:10.1001/jamasurg.2020.0046

There is a crescendo of attention focused on compassion training in health care. Importantly, this is not just about meeting the needs of patients, but also about learning how compassion can bring personal joy. Some of these concepts can be conceptualized as seva: a service that is performed without any expectation of result or award for performing it. Such services can be performed to benefit other human beings or society. “Seva is an ancient Sanskrit term, which originally referred to the service performed by members of the community.”1 A more recent interpretation of the word is “dedication to others.”

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    6 Comments for this article
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    reaction to burnout
    Thomas Walsh |
    interesting proposal. physician burnout is sadly a very serious issue. however, your proposal treats the symptoms rather than the cause of the problem. what we need is true respect, accompanied by a dramatic decrease in interference, from non-clinical coworkers. physicians are among the most highly trained people in our society and most highly respected members of our society. the most recent COVID crisis has sadly proven that we rank among the most valuable resource in any society. we need to be treated with respect and collegiality each day at work. I promise that we will ten see much less problem from physician burnout.
    thanks for your thoughts in the article
    CONFLICT OF INTEREST: None Reported
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    It’s BS, not burn out.
    Michael Plunkett, AB MD MBA | Practice/teaching
    Totally disagree. And I’ve been playing this game for 48 years.

    Medical students and all physicians, by their very nature, are altruistic. But, in today’s world with all its regulations, documentation, compliance, etc. etc. etc. it’s easy to burn out. In fact it’s the natural response. Who wouldn’t burn out?

    In “the day“ you used to look in the ear, make a diagnosis of otitis media, prescribe amoxicillin, and then see if the patient got better.

    Today you have to click 1000 boxes in your EMR, make sure you list whether it’s
    left ear or right ear, (As if the amoxicillin cares which ear it is) click another bunch of boxes and electronically send the prescription to it turns out to be the wrong pharmacy because they switched yesterday. And then you get to do it all over again. And then your EMR wants you to click the right box to see whether they using chewing tobacco or not.

    I really liked being a doctor. I’m not really enjoying being a provider. And, going forward, no one in their right mind is going to be doing this. Our bright young people will find other occupations where they are valued and appreciated.

    CONFLICT OF INTEREST: None Reported
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    Seva Service & COVID19
    Lynne Baines, Ph.D. | Oxford University
    This commentary could not be more timely as doctors and allied healthcare providers work with COVID19 patients. Under increased stress, they are living in fear of their own lives, while oftentimes separated from support networks of family and friends. We can only hope for their own well-being and that of their patients, that their instinctive altruism and psychological first aid skills, are as highly developed as their medical intervention. For this is a deadly and largely unknown virus. There are daily reports of front line healthcare providers overcoming their own fears trying to save the lives of their patients, only to contract the virus and die themselves. This could be viewed as a seva service, but without the joy. However, for those who survive, once the pandemic has subsided and they have debriefed, they can take comfort in knowing that their performance has unquestionably benefited other human beings and society as a whole.
    CONFLICT OF INTEREST: None Reported
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    PHYSICIAN BURNOUT IN LOW AND MIDDLE INCOME COUNTRIES IS ALSO A PROBLEM
    Lynne Baines, Ph.D | Uniformed Services University
    Jindal has rightly pointed out increased emphasis and inclusion of global surgery in medical school and residency curriculums to facilitate “dedication to others” (seva), which will give meaning, purpose of profession, and balance in life . It has been shown that bidirectional learning experiences fostered by global surgery electives will generate compassion and also improve care delivered in both high-income and low-income countries.
    However, care should be exercised in selection of the host country as physician burnout in low and middle countries (LMIC) has also reached a crisis point. Chemali et al. investigated the burden of burnout among
    healthcare providers in the Middle East, through a systematic review which found 138 articles that met inclusion criteria. The Maslach Burnout Inventory was the most common tool to measure burnout, which ranged from between 40 and 60%. Dhusia et al. questioned 300 resident doctors working in public sector hospitals across Mumbai, India, by the "Copenhagen Burnout Inventory". They found that the residents worked 88 h/week and 56.66% (n = 170) showed scores of burnout. Zang et al. carried out a cross-sectional survey across 30 provinces comprising 3016 Chinese doctors, of which 2617 completed valid questionnaires and found that the overall prevalence of burnout symptoms was 85.79%. They concluded that burnout symptoms among Chinese doctors were associated with age, professional title, and long working hours.
    I suggest that enthusiasm for Global Health and Surgery electives from high income countries should be tempered by consideration of burnout in healthcare workers in LMICs. Furthermore, benefits to LMIC healthcare workers and institutions should be clearly defined.
    REFERENCES
    Jindal RM. Service to Others May Be the Answer to Physician Burnout [published online ahead of print, 2020 Apr 15]. JAMA Surg. 2020;10.1001/jamasurg.2020.0046. doi:10.1001/jamasurg.2020.0046

    Chemali Z, Ezzeddine FL, Gelaye B, et al. Burnout among healthcare providers in the complex environment of the Middle East: a systematic review. BMC Public Health. 2019;19(1):1337. Published 2019 Oct 22. doi:10.1186/s12889-019-7713-1

    Dhusia AH, Dhaimade PA, Jain AA, Shemna SS, Dubey PN. Prevalence of Occupational Burnout among Resident Doctors Working in Public Sector Hospitals in Mumbai. Indian J Community Med. 2019;44(4):352‐356. doi:10.4103/ijcm.IJCM_78_19

    Zhang S, Wang J, Xie F, et al. A cross-sectional study of job burnout, psychological attachment, and the career calling of Chinese doctors. BMC Health Serv Res. 2020;20(1):193. Published 2020 Mar 12. doi:10.1186/s12913-020-4996-y
    CONFLICT OF INTEREST: None Reported
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    Increase Research On Physician Burnout In Medical Schools
    john lyndsay, MBBS, MD | Apollo Hospital International Limited
    Dear Editor

    There is considerable literature on physician burnout, however, there is relatively little research on the etiology in pre-clinical stage of medical school. To devise coping mechanisms as a practicing physician, it is important to understand the beginnings of physician burnout.

    Thompson et al. (1) studied depression and burnout along with specific coping strategies used during stressful times, and perceptions of social support in a cross-sectional study of students at the University of North Dakota School of Medicine and Health Sciences. They found that 17% had moderate to severe depression, and 49% had burnout. Of
    depressed respondents, 81% were undiagnosed. A significantly greater risk of depression was associated with inadequate support from family and friends, fellow medical students, and the leadership. Greater use of approach-oriented coping strategies than avoidant-oriented strategies was associated with significantly decreased risk of burnout and was inversely correlated with depression.
    Whinning (2) has suggested that emphasis on the positive, as opposed to exclusively the negative, aspects of the medical school experience may be effective. MacArthur et al. (3) utilized the metaphor of the Coping Reservoir Model as a theoretical and analytical framework for understanding medical student well-being by identify the 'depleting' and 'replenishing' inputs that are deposited into students' coping reservoirs. The study consisted of 105 medical students' reflective writings using a data analytic process consistent with an interpretive description approach, engaging in a hierarchical 3-step coding process to identify the main replenishing inputs deposited into students' coping reservoirs. The prolonged stress of medical school is made "worth it" in hopes that it will "get better" with more meaningful patient interaction in the future.

    In addition to research, academic leadership needs to be innovative and eventually standardized curriculum for medical student wellness, which may prevent physician burnout in the future. An example is the Vanderbilt Medical Student (VMS) Wellness Program to promote student health and well-being program consisting of three core components: The Advisory College Program, The Student Wellness Committee, and VMS LIVE. Preliminary data indicated that student response was highly satisfactory, as evidenced by their positive feedback (4).

    REFERENCES

    1. Thompson G, McBride RB, Hosford CC, Halaas G. Resilience among medical students: The Role of Coping Style and Social Support. Teach Learn Med 2016; 28(2):174‐182.

    2. Winning J. The use of an object: exploring physician burnout through object relations theory [published online ahead of print, 2020 May 28]. Med Humanit 2020; medhum-2019-011752. doi:10.1136/medhum-2019-011752.

    3. MacArthur KR, Sikorski J. A qualitative analysis of the coping reservoir model of pre-clinical medical student well-being: human connection as making it 'worth it'. BMC Med Educ 2020; 20(1):157. Published 2020 May 19. doi:10.1186/s12909-020-02067-8.

    4. Drolet BC, Rodgers S. A comprehensive medical student wellness program - design and implementation at Vanderbilt School of Medicine. Acad Med 2010; 85(1):103‐110.
    CONFLICT OF INTEREST: None Reported
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    GLOBAL SURGERY AND SEVA MAY PREVENT SURGERY RESIDENT ATTRITION AND PHYSICIAN SUICIDE
    Rahul Jindal, MD, PhD | Fulbright Scholar
    Jindal’s concept of introducing Global Surgery and seva in medical school and General Surgery residency curricula should be explored as a modality to prevent attrition and decrease suicidal thoughts and physician suicide.

    Ellis et al. (1) surveyed 7,409 residents, 930 (12.6%) reported considering leaving residency over the last year. Consideration of other specialties (47.0%) was more likely if dissatisfied with being a surgeon. Residents were more likely to consider leaving medicine (49.7%) if female or dissatisfied with a surgical career. Would Global Surgery electives early in residency decrease attrition rate?

    Another hypothesis which needs to be tested
    is introduction of Global Surgery at intern stage in decreasing suicidal thoughts, generally attributed to burnout. Hu et al. (2) in a cross-sectional national survey of general surgery residents administered with the 2018 American Board of Surgery In-Training Examination assessed mistreatment, burnout, and suicidal thoughts during the past year. Among 7409 residents (99.3% of the eligible residents) from all 262 surgical residency programs, reported weekly burnout symptoms by 38.5% of residents, and 4.5% reported having had suicidal thoughts during the past year. Residents who reported exposure to discrimination, abuse, or harassment were more likely than residents with no reported mistreatment exposures to have symptoms of burnout and suicidal thoughts.

    COVID-19 pandemic will certainly have severe psychological and social effects at multiple levels – societal and in health care workers. Studies have shown that the pandemic is associated with distress, anxiety, fear of contagion, depression, and insomnia in the general population and in health care professionals (3). In addition to psychotherapeutic measures to reduce suicides during and after the COVID-19 crisis, a focused period of Global Surgery may reduce burnout, and as a corollary, decrease stress, anxiety, loneliness and suicidal thoughts in “at risk” health care providers.

    References
    1. Ellis RJ, Holmstrom AL, Hewitt DB, et al. A comprehensive national survey on thoughts of leaving residency, alternative career paths, and reasons for staying in general surgery training. Am J Surg 2020; 219(2):227-232.
    doi:10.1016/j.amjsurg.2019.10.040

    2. Hu YY, Ellis RJ, Hewitt DB, et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N Engl J Med 2019; 381(18):1741-1752. doi:10.1056/NEJMsa1903759

    3. Sher L. The impact of the COVID-19 pandemic on suicide rates [published online ahead of print, 2020 Jun 15]. QJM 2020;hcaa202. doi:10.1093/qjmed/hcaa202
    CONFLICT OF INTEREST: None Reported
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