Surgeons: Take a Break

In this 24/7-work world, it seems we're working all the time. Everyone I talk to says the same thing. It's relentless.  For surgeons, there are added concerns; the exceedingly long shifts have a potential impact on patient care stemming from a physician's psychological trouble spots: burnout, depression, career dissatisfaction, and problems at home.

An extensive study from Johns Hopkins University School of Medicine and Mayo Clinic that surveyed more than 7,000 physicians shows a strong connection between increased hours and nighttime work, and a detrimental psychological impact on surgeons.

It's not surprising. And one answer seems to be pretty simple: reduce work hours.

But it never is simple, is it? Forced reduction in work hours may not be the solution for the busiest surgeons, according to authors of the study, published in the November issue of the Journal of the American College of Surgeons. For one thing, surgeons don't like punching a time clock, they say.

In fact, the authors don't suggest many restrictions on work hours—perhaps, tweaking them a bit, and usually on terms of the physicians, themselves.  The best solution: identify the burnout potential before it becomes a full-fledged fire of concern.

In the study, a survey of surgeons working 80 hours per week, 50% met the criteria for burnout; 39% were screened positively for depression, and 11% said they made a significant medical error the previous three months. Moreover, one in five surgeons who worked more than 80 hours a week said he or she would not become a surgeon if they had a chance to do life's planning all over again.

Despite the survey suggestions linking workload to stress, Charles M. Balch, MD, professor of surgery at the Johns Hopkins University School of Medicine, says he doesn't particularly advocate restrictions on work hours. "There is no evidence that reducing hours would make all doctors more satisfied, or lead to better patient care," Balch says in a statement.

The survey shows that two-thirds of surgeons say they did not want limits put on their hours, including those who work more than 80 hours a week, or are on call more than three nights a week.

"If hours were regulated," he says, "the reality is that people would have to punch time clocks and I don't think surgeons necessarily want their workload monitored."

Co-author Julie Ann Freischlag, MD, senior investigator for the study, and head of the department of surgery at Johns Hopkins University School of Medicine, tells me, however, that while physicians may not want their workload monitored, there should be some flexibility, perhaps reduced work hours reflected in working arrangements with other physicians.

"Different kinds of physicians choose their specialties for all different sorts of reasons," Freischlag says. "Most people find surgeons tend to be aggressive; how much they do. It's just sort of their nature. They tend to move around a lot, don't sit in an office."

Long work hours, indeed, "do not correlate with burnout," Freischlag says. "Physicians like being busy. They like what they do. But sometimes when things go awry and things are conflicted—something is happening at home or work, and they want to be both places at the same time"—and the stress occurs, not unlike the rest of us.

But in the physician workplace, there is an increasing need for "self-regulation" of doctors' hours, particularly surgeons, to offset potential depression or burnout, she says.  "There's got to be this realization—yes, it's ok for time off."

"You need time off," Freischlag, 55, says. "The new generation knows they should have time off. When I came up, there were 110-hour workweeks. Now they know they need time away from the office; they are smarter and know how to pace themselves."

More attention should be made to "earlier identification of surgeons at higher risk for burnout problems," according to Balch. The survey showed that surgeons who were on salary were more likely to favor restrictions in work hours than those whose pay was based entirely on billing.

Surgeons are learning, over time, to work better cooperatively, and to stay away from the office, and know they can be replaced on certain days, Freischlag says. She adds that that's the way she practices, and she has learned to fit in her home life with her busy practice, among other things.

Freischlag has been editor of the Archives of Surgery and has served on several editorial boards. She also has published more than 150 transcripts, abstracts and book chapters.

 "If I'm not there, a partner can make up for me or a nurse practitioner," Freischlag says. "It works well. It is the shifting sands of how we practice."

"Part of it is the aging process," Freischlag says of making adjustments in her practice. "You don't need to prove to others. And, you get tired. It's the nature of things; how you set up your life and balance it.  I think it's the nature of things; how you want to set up your life and the balance in it."

 "I'm in and out of town, I take vacations, [that's] one of the reasons I'm still a surgeon," says the mother of three.

And then Freischlag laughs. "Sometimes I don't do a very good job (of the relaxation), and there's too much on your plate."