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Table of Contents    
GUEST COMMENTARY
Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 1572-1574

Generational tensions are a distraction from addressing the burnout crisis in Neurosurgery


Department of Neurosurgery, Medical University of South Carolina, Charleston, USA

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Alejandro M Spiotta
Department of Neurosurgery, Medical University of South Carolina, 96 Jonathan Lucas Street, 301 CSB, Charleston, SC 29425
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.246283

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How to cite this article:
Spiotta AM, Patel S. Generational tensions are a distraction from addressing the burnout crisis in Neurosurgery. Neurol India 2018;66:1572-4

How to cite this URL:
Spiotta AM, Patel S. Generational tensions are a distraction from addressing the burnout crisis in Neurosurgery. Neurol India [serial online] 2018 [cited 2018 Dec 14];66:1572-4. Available from: http://www.neurologyindia.com/text.asp?2018/66/6/1572/246283




Physician burnout, which is associated with depression, is currently at crisis levels across all specialties. Burnout is a state of chronic stress leading to physical and emotional exhaustion, detachment, cynicism, and depersonalization. It is associated with a reduced sense of personal accomplishment and job satisfaction that can also negatively impact one's personal life. Physicians and medical students have higher rates of burnout and depression than the general population,[1],[2] providing evidence that a higher education level, current and future income potential, and work hour restrictions are not protective against burnout. Suicide is currently the leading cause of death among male resident physicians and second leading cause among their female counterparts.[1] Crucially, burnout does not solely threaten the physicians’ health, it also endangers patients and leads to suboptimal outcomes.[3],[4],[5]

The rise of physician burnout has taken place in the context of duty hour work reform initially implemented in 2005, which leads many to place the blame entirely on intrinsic properties of the generation itself and not acknowledge or address other factors that contribute heavily. The duty hour regulations, although now fully established among training programs, are not yet fully accepted in the minds of many and continue to be a point of contempt among some in established medicine. This is perhaps most true among neurosurgeons, and many privately will never forgive the incoming generation for their ‘sin’ of embarking on neurosurgery training in the era of duty hour regulation. There may be nothing the new generation can do to redeem themselves in the eyes of some. Why such animosity and resentment? Neurosurgeons are among professionals who take the most pride in their craft, and rightly so - few individuals can claim to match the years of training and sacrifice required to acquire the knowledge, temperament, judgement and necessary surgical skills to become a successful neurosurgeon. As such, neurosurgeons should and must demand only the very highest standards from individuals seeking entry into our profession. Another consideration is the phenomenon of cognitive dissonance. For those who ‘bought in’ 110% into the training system of old, survived and gave up everything to exist in that learning environment, to now acknowledge that there are more efficient methods of training to be a neurosurgeon within the confines of an eighty hour work week, that there is ‘scut’ that is noneducational and should be delegated to other providers, and the notion of physician wellness and that a healthy (physically and emotionally) trainee may become a better doctor and surgeon to their patients, only serves to diminish their own experience and sacrifice.

While Generation Xers are currently in their mid-career point and on the rise in Neurosurgery, the long-established guardians of Neurosurgery are predominantly from the Baby Boomer generation. Born to the “Greatest Generation” who grew up during the Great Depression and triumphed against clear evil in World War II, the Baby Boomers are now the second largest segment of our population (now behind Millennials). There may be no other generational divide in any other setting that causes as much visceral tension as the Baby Boomer-Millennial conflict in Neurosurgery. While stereotypes have their obvious limitations when applied to populations, the traits and tendencies commonly observed for the various generations can provide a framework for a discussion of differences and sources of disharmony in a more objective, non-emotional manner.

Millennials are a product of the environment that they grew up in, including parenting style, social media, terrorism, mortgage crisis, high layoffs and unemployment rates, political scandals and the rapid and seamless integration of technology into everyday life.[1],[2] Their approach to work and careers, in general, is antithetical to the spirit of Neurosurgery, and by sharp contrast, the Baby Boomer approach is sine qua non Neurosurgery through and through [Table 1]. Consider, for instance, the approach to work. For a Baby Boomer, one pays their dues and waits patiently for their hard work to be recognized. Work is a career and a large part of what defines them as an individual and putting in long hours is a source of pride. For many millennials, work is a means to an end, not to interfere with more important matters such as maintaining their family and friend networks. They do not give the same deference to authority, appreciate a flat corporate structure and value instant gratification. Given such stark contrasts, it is an easy trap to blame the burnout crisis squarely on the shoulders of the weaker, coddled, ‘snow flake’ Millennial. Some may declare: “They are not cutout for Neurosurgery. They don't have the dedication, discipline or self-sacrifice required. They should just be happy to not have to work the long hours we endured…etc.” Unfortunately, the problem of burnout is not that simple. While this may be true to a certain extent (to what degree as yet unclear as Millennials are just beginning to graduate from Neurosurgery training programs), there are a variety of external influences which cannot be ignored and must be addressed. Burnout is not a syndrome of the ‘weak-minded,’ as both neurosurgeons and neurosurgeons-to-be are not immune; burnout rates have been reported to be as high as 67% among neurosurgery residents[6],[7] and 56.7% among practicing neurosurgeons.[8]
Table 1: Attitudes and philosophical perspectives on career, workplace environment and work-life balance contrasted between Baby Boomers and Millennials

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Thus, if it is not simply that the current generation of young physician graduates and physicians in training are simply not cut out for hard work and devotion to the profession, then what is the root of the cause of the burnout crisis? Is it simply as a result of increased awareness? The answer is that the current environment in which we take care of patients has fundamentally changed in profound and sinister ways.

Burnout can occur when you are working toward goals that do not resonate with you, you lack social support, when you do not feel in control of how you carry out your duties at work, and when you feel unappreciated. As such, burnout is not simply a result of long work hours, but rather the kind of work being done and the level of respect and appreciation felt for the care being provided. Gone are the days of giants who worked countless hours, never leaving the hospital. While those experiences were brutal, it was also a source of pride for those who survived the rite of passage, they were able to follow patients along the continuum of care leading to a greater sense of patient ownership, and their sacrifice was acknowledged by other providers in the hospital setting. Although an 80 hour work week is still twice the norm, duty hour regulation has eliminated any possible empathy from the public and hospital support personnel. Residents now must negotiate a heavily scrutinized and compartmentalized work structure approximating shift work. This is of particular relevance, as over the past hundred years of the American residency system, the sustaining factors for residents have consistently been patient relationships, mentorship, and the camaraderie of the team.[3]

Residents are also faced with orders of magnitude higher administrative burdens, litigation exposure and a highly punitive anti-physician culture prevalent within hospital administration that devalues the contribution and expertise of the physician. Cumbersome electronic medical records and painstaking documentation requirements pull the physician further and further from the patient bedside. Management protocols to be followed blindly (‘cookbook’ medicine) do not allow focusing on individualized patient care and further devalue the contribution of the physician. The current ‘write-up’ culture in a hospital makes the physician feel as if they inhabit the lowest rung of hierarchy. To add insult to injury, the administration has succeeded in dwindling the worth of a physician down to the three letters, “relative value unit [RVU]”.[9] Diminishing reimbursements, bundling of Current Procedural Terminology (CPT) codes [a medical code set maintained by the American Medical Association through the CPT Editorial Panel] and other rule changes, create an unfair work system for the physician, who is often blamed for the changes and is expected to make up for financial shortcomings by working harder and longer. Perhaps most disheartening is the fact that some patients with access to search engines can surf the web for ten minutes, read unverified sources and truly believe that they have more knowledge and expertise than their treating physician. Armed with this readily available knowledge at their fingertips, some may be emboldened to challenge their physician.

Neurosurgery has been, and always will remain, a leader among other specialties in medicine. Look no further than how organized Neurosurgery took to arms when the Institute of Medicine proposed curtailing training hours further to fifty or sixty hours a week. All other surgical specialties followed our lead. We should all be very proud to see how our leaders stepped up to the plate and that is part of what makes Neurosurgery great. We should carefully select from among the next generation, those who truly have the devotion to patient care and the craft of Neurosurgery required to succeed and lead a long and satisfying career. Close mentoring will also be required to instill some of the Baby Boomer principles of hard work, patience and the satisfaction from devotion to a worthy career.[10] However, we should not lose sight that the enemy of Neurosurgery is not the Millennial, but rather the layers of administration, bureaucracy and hospital systems that systematically devalue our role as physicians and drive a wedge between us and our patients. It is imperative that Neurosurgery lead the charge against the factors herein described which are contributing to the burnout crisis. Other specialties will follow our lead.



 
  References Top

1.
Spiotta AM, Kalhorn S, Patel S. Millennials in Neurosurgery: Is there Hope? Neurosurgery 2018;83:E71-E3. Available from: http://dx.doi.org/10.1093/neuros/nyy228.  Back to cited text no. 1
    
2.
Spiotta AM. Pursuing wellness in neurosurgery: Resiliency. Neurosurgery 2018. doi: 10.1093/neuros/nyy113.  Back to cited text no. 2
    
3.
Ludmerer KM. Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. New York, NY: Oxford University Press 2014.  Back to cited text no. 3
    
4.
Felton J. Burnout as a clinical entity—its importance in health care workers. Occup Med 1998,48:237-50.  Back to cited text no. 4
    
5.
Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Internal Med 2002;136:358-67.  Back to cited text no. 5
    
6.
Attenello FJ, Buchanan IA, Wen T, Donoho DA, McCartney S, Cen SY, et al. Factors associated with burnout among US neurosurgery residents: A nationwide survey. J Neurosurg 2018. doi: 10.3171/2017.9.JNS17996.  Back to cited text no. 6
    
7.
Shakir HJ, McPheeters MJ, Shallwani H, Pittari JE, Reynolds RM. The prevalence of burnout among US neurosurgery residents. Neurosurgery. 2018;83:582-90.  Back to cited text no. 7
    
8.
McAbee JH, Ragel BT, McCartney S, Jones GM, Michael LM 2nd, DeCuypere M, et al. Factors associated with career satisfaction and burnout among US neurosurgeons: Results of a nationwide survey. J Neurosurg 2015;123:161-73.  Back to cited text no. 8
    
9.
Beck DE, Margolin Da. Physician coding and reimbursement. Ochsner J 2007;7:8-15.  Back to cited text no. 9
    
10.
Available fom: http://www.wmfc.org/uploads/GenerationalDifferencesChart.pdf. [Last accessed on 2018 Oct 15].  Back to cited text no. 10
    



 
 
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