Is the well-being message getting through?

Anaesthesia provides a rewarding, challenging and satisfying career path. Nevertheless, burnout in the medical profession and in anaesthesia in particular appears to be endemic. Research indicates that up to 60% of doctors are affected. ¹ Searching Medline using the terms ‘anaesthesiology’ and ‘burnout’ yields 114 results, while the terms ‘physician’ and ‘burnout’ yield more than 2000. So, what are the issues, and how can the problem be solved?

The causes of burnout and stress are extensive, from organisational factors such as excessive workload, long hours and limited control over working conditions to theatre inefficiencies, delays and overruns, and even the tedium of paperwork and data entry, particularly during the introduction of electronic medical records. ¹ Patients are increasingly elderly with complex co-morbidities. Anaesthetists may experience conflict, fatigue and inadequate facilities for rest and recovery, and there is the ever-present risk of critical events, errors and omissions, and communication difficulties.

After an adverse event, those involved may also suffer from the second-victim phenomenon. ^{2 , 3}

The personal and professional consequences of burnout and stress include disenchantment, depression, alcohol or other substance abuse, the risk of suicide, shorter life span and suboptimal clinical performance. The latter may further result in unprofessional conduct and unfavourable patient outcomes. The desire to teach may be reduced and the effectiveness as teachers and role models is affected. ^{1 ,4–12}

Solutions to some of these problems may seem obvious, and some are more complex. Yet, despite the moral and ethical case for organisations to act, and mounting evidence in the literature supporting interventions, there is inertia when it comes to implementation.^13–18

A systematic approach to the structure, organisation and culture of health care is needed. ¹ Administrators have a duty to ensure the safe and effective delivery of medical care. A toxic work environment and dissatisfied staff are an enormous impediment to this. The focus of institutional and departmental attention needs to shift so that workloads are manageable, staffing is adequate and resources are used efficiently.

Shanafelt and Noseworthy of the Mayo Clinic have identified nine organisational strategies to promote physician well-being, from identifying the problem using robust data and analysis, to finding engaged leaders, through to developing and implementing targeted interventions. ¹⁹ This is underpinned by cultivating community in the workplace which is achieved by providing facilities and time for open discussion of success and failures, providing rewards and incentives aimed at self-care rather than productivity, introducing flexible hours and prioritising work–life balance, and providing the resources needed for self-care such as positive psychology exercises and mindfulness.

The Long Lives Healthy Workplaces toolkit funded by the Australian Society of Anaesthetists (ASA) has been designed to provide solutions and pathways to deal with wellness and mental-health issues within individual departments. This toolkit, developed by Everymind ²⁰ along with the Wellbeing Special Interest Group (SIG) of the Australian and New Zealand College of Anaesthetists (ANZCA), is now being promoted across Australia and New Zealand by the ASA and ANZCA. It aims to improve the training and work environment to reduce risk, increase well-being and reduce stigma, recognise and support those impacted by mental ill-health and suicide, and improve leadership, co-ordination and data collection. Yet, despite this toolkit being available and promoted, in a recent ANZCA survey of department heads, less than half of respondents were aware of its existence (pers. commun.).

Programmes to address the impact of stress, burnout and the second-victim phenomenon directly are highly desirable. In this issue of the journal, Slykerman et al. describe one such initiative. ²¹ They have developed and implemented a peer-support programme which provides automatic follow-up of staff members involved in critical incidents, identifies those at immediate and ongoing risk of psychological distress, encourages individuals experiencing difficulties to seek and receive help, and promotes a departmental culture of support. In their paper, the authors have identified key elements to manage individuals in need of assistance. One is the use of trained personnel from within the department who can strongly identify with the issues at hand, combined with the back-up of psychological referral services. Another is a mechanism to overcome the reluctance of individuals to seek help because of presumed stigma or fear of workplace repercussions, and lack of confidence in current employee-assistance arrangements. The success of a programme such as this is dependent on the goodwill of committed individuals, the support of administration, a co-ordinated approach and appropriate training. As well as assisting individuals at risk, it can stimulate a culture of support and collegiality within a department or institution, as described by Shanafelt. ¹⁹ Could the very presence of a programme such as this result in greater awareness of problems, and thus potentially reduce the likelihood of their occurrence? Could it similarly help to prevent conflict, bullying and discrimination? And if programmes such as this are successful, could they be extended to include our surgical colleagues and the wider hospital community, potentially using the expertise of the trained individuals from within anaesthesia?

In anaesthesia, there are many sources of information and assistance. The Wellbeing SIG has a wealth of experience and resources aimed at anaesthetist well-being. Its documents cover critical-incident support, mentoring, bullying and discrimination, personal health, depression and anxiety, medico-legal issues and finance issues amongst many others. We encourage all our colleagues to make use of these valuable resources.

Conclusion

The issues of burnout, stress and their consequences to doctors’ well-being and to patient care need to be more actively addressed. Programmes and resources exist and are readily available. It is up to governments, institutions and individuals to implement the structures and programmes required to deal with these ongoing problems. Slykerman et al. are to be congratulated for developing a programme in their institution to help achieve this aim, and they have set an example we would all do well to follow.

The standard you walk past is the standard you accept.

David Hurley, former Chief, Australian Defence Force