Burnout has come to be defined as a workplace syndrome from chronic exposure to job-related stress. It is the constellation of emotional exhaustion, depersonalization and reduced personal accomplishment. More than half of physicians report at least one of these symptoms. The consequences of burnout are not just detrimental to physicians themselves, but also the people around them. Loss in productivity, high-risk behavior, disregard for safety procedures, more referrals, additional diagnostic tests and poor care are among the manifestations of physician burnout. Additionally, substance abuse, family breakups, poor health, depression and even suicide may also be extreme consequences of burnout. Burnout does not have to manifest by these catastrophic events; it can show up in small ways. Some of the subtler indicators of burnout include anger, aggression, nastiness, snide comments and disrespect for other physicians and health care professionals.
Historically, neurosurgery has been a high-stress medical specialty. As a result, there has been a heightened awareness of the issue over the past several years. Manuscripts addressing burnout in neurosurgery started to appear in 2011, with the many more written in the past three years. Joseph C. Maroon, MD, FAANS, 
was one of the first neurosurgeons who talked openly about the negative effects a neurosurgeon’s lifestyle has on the body and mind, his challenges and the changes he made. Dr. Maroon argues that a balanced life is needed to thrive as a neurosurgeon. Gary R. Simonds, MD, FAANS and Wayne M. Sotile, PhD, are well-known spokespersons on physician wellness and resilience, having co-authored “The Thriving Physician: How to Avoid Burnout by Choosing Resilience Throughout Your Medical Career” and “Thriving in Healthcare: A Positive Approach to Reclaim Balance and Avoid Burnout in Your Busy Life.” They argue that being a neurosurgeon is difficult and challenging and that we need to train and prepare ourselves. Dr. Simonds states, “Everybody involved in health care are like elite athletes — they’re expected to perform their best every day.” Every day is “game day” for a neurosurgeon. This concept of perpetual peak performance is, on the one hand, completely unrealistic, but on the other hand, expected by society. An elite athlete doesn’t just walk onto the field and do that. They spend a great deal of time in preparation and injury prevention. Of course, they only have to perform once a week.
The concept of preparation for injury prevention is important for neurosurgeons. While much focus has been dedicated to the syndrome of burnout, there is another emerging concept important to the chronic stress of physicians: moral injury. Burnout should be considered an end-organ failure — it is a failure of our resilience. Moral injury is what causes that failure. The term moral injury first was used to describe soldiers’ responses to their actions in war. Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.” Physicians may find it increasingly difficult to provide the care we want for our patients. This might occur due to misaligned priorities and barriers to delivering optimal, efficient care. As health care professionals, we are accountable to our patients, to ourselves and to our employers, but also beholden to payors for reimbursement for the care rendered. The goals of these various stakeholders are often divergent, leaving physicians feeling of lack of efficacy and frustration. The result may be considered a moral injury that results in the collapse of our resilience and leads to burnout.
This problem is bigger than us, and changes need to happen not only within health delivery organizations but also at the legislative level. We need leaders who recognize that caring for their physicians results in thoughtful, compassionate care for patients, which ultimately is good business. As Wendy Dean, MD and Simon G. Talbot, MD said in STAT News, “We need leadership that has the courage to confront and minimize those competing demands. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions.”
We also need self-compassion. As sensible as self-compassion sounds, physicians have difficulty with the idea as it sounds like self-pity or self-indulgence. Instead of mercilessly judging and criticizing oneself for various inadequacies or shortcomings, self-compassion means you are kind and understanding with yourself when confronted with personal failings. Take the time to visit this website on self-compassion.
If you want to know more about the concept of moral injury, listen to Zubin Damania, MD (ZDoggMD) — he says it best.
Editor’s note: We hope that you will share what you learn from our posts. We invite you to be part of the conversation on Twitter by following @Neurosurgery and using the hashtag #PhysicianBurnout.
Martina Stippler, MD, FAANS, FACS
Beth Israel Deaconess Medical Center
Boston, Mass.