Burnout and Depression in the Orthopedic Resident: Prevalence and Protective Factors
Introduction: Burnout is characterized by emotional exhaustion, a low sense of personal accomplishment, and high levels of depersonalization. While burnout is increasing across all medical specialties, no studies have focused on orthopedic residents. This study examines the prevalence of burnout and depression among orthopedic residents and seeks to identify protective factors. Methods: A survey consisting of resident and program characteristics, the Patient Health Questionnaire-9 Depression form, and the Abbreviated Maslach Burnout Questionnaire was sent to 160 orthopedic residency program directors to distribute to their residents near the end of the 2018-2019 academic year. Regression analyses were then performed. Results: Among 179 orthopedic residents who responded, 78% suffered from moderate or severe emotional exhaustion, 62% had moderate or severe levels of depersonalization, and 23% had a low sense of personal accomplishment. 59% showed at least moderate signs of depression, with prevalence increasing with post-graduate year. Residents who did not match in the top third of their rank list and those who decided on orthopedics later in medical school had higher risks of becoming depressed. A useful mentorship program, adherence to ACGME duty hour limits, and protected research/elective time were associated with less burnout. Discussion: Burnout worsens throughout residency, and residency programs must teach the skills and behaviors necessary for an effective work-life balance. Institutional variables protective against burnout and depression must be implemented in order to maintain healthy residents. Level of Evidence: II; Prospective survey study. Keywords: Depression; Burnout; Orthopaedic residency training.
Employee happiness and wellness has garnered an increasing amount of attention over the last decade throughout a variety of professional communities, medicine included. Burnout is characterized by emotional exhaustion, low sense of personal accomplishment, high levels of depersonalization, and too often leads to suicide. In medicine, these behavioral changes can not only be personally detrimental, but may also negatively impact patient care . Physicians who report high levels of burnout are more likely to commit medical errors, flash out against others, and be less productive . Recent studies show that physicians have a high rate of burnout relative to the general working population (37.9% versus 27.8%) . Close to 50% of physicians reported at least one symptom of burnout. Additionally, investigations have shown that burnout starts prior to residency, with reported rates of 20% or higher in medical students . This significant burnout penetrance within the field of medicine should be a cause for concern.
Burnout and decreased work satisfaction are associated with depression and suicidal ideation. The physician suicide rate has been reported to be between 28 and 40 per 100,000, more than twice the rate reported for the general population (12.3 per 100,000) . Despite the incidence of physician burnout, depression, and suicide, research regarding the causative and protective variables has been sparse . Much of the research has been observational in nature, focusing on the levels of burnout and depression within different medical specialties and tracking the increasing frequency among physicians . There has been very little investigation into protection against burnout . Given that burnout and depression are deeply intertwined, one can neither assess nor modify one without addressing the other .Variables protective against burnout in urology residents were investigated. The authors noted both personal and institutional variables were valuable in fighting burnout. Two of these variables were the presence of structured mentorship programs and the availability of therapy . Another study indicated that when given the opportunity, residents are likely to seek therapy, however this resource is often not available in training programs .
Orthopedic surgeons are a subgroup of physicians who experience burnout more frequently than other physicians, with rates ranging from 60-70% . In addition, burnout is increasing in orthopedics faster than in other subspecialties . It is not surprising that surgical specialties might have higher rates of burnout given the longer length of residencies. Orthopedic surgery residency in particular is associated with a high call burden and a long, steep learning curve . Studies have shown that the levels of burnout increase as the necessity for call coverage increases . Given these associations, it is reasonable to surmise that orthopedic residents would be at higher risk of burnout and depression than residents in other specialties; however, there is little research focused specifically on orthopedics.This study aims to determine the prevalence of depression and burnout among orthopedic residents nationwide and to define potential protective mechanisms. It is hypothesized that there will be high prevalence of burnout and depression among all years of residency and that institutional characteristics will be associated with these levels of burnout and depression.
MATERIALS & METHODS
An email survey (available in Appendix) was sent to 160 orthopedic residency program directors to distribute among residents. Residents completed this survey anonymously through SurveyMonkey (SurveyMonkey Inc.; San Mateo, CA). Implied consent was obtained by completion of the survey. This survey was distributed near the end of the 2018-2019 academic year and closed prior to the start of the next academic year and closed prior to the start of the next academic year in order to avoid inconsistency among respondents. Institutional IRB approval for the study was obtained prior to survey distribution.
The survey was composed of 35 questions covering basic demographics, vacation time and frequency of family visits, as well as residency program characteristics, including work and research support such as availability of a useful mentorship program, dedicated research time, and the emphasis placed on research. The full Patient Health Questionnaire 9 (PHQ-9) Depression and the Abbreviated Maslach Burnout Questionnaire were utilized [14,15]. The PHQ-9 categorizes respondents into five levels of depression, from none/minimal to severe. The Abbreviated Maslach is a validated assessment tool that determines scores for emotional exhaustion, depersonalization, and personal accomplishment. These were the three areas of burnout studied in this investigation. Both the PHQ-9 and the Abbreviated Maslach have been extensively validated in previous studies.
Regarding depression, the PHQ-9 answers were scored according to the standardized guidelines. This score corresponded to one of five depression severity categories: minimal, mild, moderate, moderately severe, and severe depression. For this study, the minimal and mild depression categories were combined, as were the remaining categories, in order to dichotomize the outcome variables and allow a determination of the presence or absence of depression.Abbreviated Maslach scores for emotional exhaustion, depersonalization, and personal accomplishment determined burnout. The scores for each of these areas ranged from 0-18, with higher scores indicating greater emotional exhaustion, greater depersonalization, or greater sense of personal accomplishment (thought to be protective against burnout). As for depression, scores were dichotomized and grouped as present or absent. Residents with scores from 0-6 were considered to have none or minimal emotional exhaustion and depersonalization, whereas individuals with values from 7-18 were labeled as moderate or severe. For the personal accomplishment, the scoring was inverted and 0-12 was defined as present and 13-18 as absent.
All statistical analyses were performed using SPSS (SPSS 21.0 for Windows, SPSS Inc, Chicago, IL). Chi-squared and Fishers exact test were performed, as appropriate, on all independent categorical variables with respect to the dependent variables of depression and burnout. Binary logistic regression models were created for each of the three burnout variables and for depression. A P-value of <0.05 was defined as significant. Odds ratios were used to determine the degree of increased or decreased risk of burnout or depression due to those variables.
A total of 179 orthopedic surgery residents responded to the survey. Nineteen percent were female, 70% were PGY-3 level or lower, and 81% came from programs respondents classified as academic. The majority lived greater than 100 miles from their hometown (76%) and had no close family in the training city (72%). Eighty-seven percent visited family more than twice per year, and 80% took at least 2 vacations yearly, which may have been combined with family visits. Seventy-nine percent said that their programs placed an emphasis on research, and 73% had dedicated research or elective blocks. The largest percentage of respondents took primary call every fourth day (34%), and 30% of respondents said that they were not able to adhere to the ACGME duty hour maximums. More than half (59%) stated that their program did not create useful mentorship assignments or programs. Eighty-one percent said that they matched to a program that was in the top third on their rank list. A minority of respondents (35%) had chosen to specialize in orthopedics prior to medical school (Table 1).