On the Neurosurgery Blog, you will see us cross-posting or linking to articles from other places that are timely and of importance to our readership. We wanted to bring attention to two recent articles highlighting the prevalence of suicide among physicians, particularly surgeons. Read More
From time to time on Neurosurgery Blog, you will see us cross-posting to items from other places that we believe will interest our readers. Today’s post originally appeared in Journal of the American Medical Association (JAMA) on Sept. 1. Neurosurgeon Anthony M. DiGiorgio, DO, MHA, FAANS, Jesse M. Ehrenfeld, MD, MPH and Brian J. Miller, MD, MBA, MPH discuss the impacts and causes of burnout, which affects up to two thirds of physicians.
Although the causes are multifactorial, the authors state that one of the key causes for clinician frustration is quality metrics. Administrative burdens from poorly designed systems and ineffective regulatory policies are central to clinician frustration. Improving these metrics could reduce clinician burnout, with studies indicating that physicians spend less than 15% of their day in direct patient contact. “A living system of quality metrics with a ceiling on their quantity, as well as a metric life cycle with continuous assessment and improvement, would significantly reduce burdens on clinicians and administrators alike” according to DiGiorgio et al.
Click here to read the full article in JAMA.
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From time to time on Neurosurgery Blog, you will see us cross-posting or linking to items from other places that we believe will be of interest to our readers. Today’s post originally appeared in The American Spectator on Jan. 3. In the op-ed, neurosurgeon Richard Menger, MD, MPA, FAANS and nurses Jessica Murfee, RN, BSN and Erin Roberts, RN, BSN, discuss health care provider burnout from the cumbersome prior authorization process required by insurance companies to perform surgery agreed upon by patient and surgeon.
The time-consuming prior authorization process disregards the patient-physician relationship. It also causes burnout for health care workers, and “Most of the time, it’s an administrative clarification issue, but calling into the insurance abyss is like dialing into a time warp.”
See 2021 AMA prior authorization physician survey
A survey from the American Medical Association noted that, on average, offices spend 13 hours per week on prior authorizations. The article states, “If a higher-level evaluation is needed, either myself or my physician assistant or nurse practitioner will have to get on the line and debate the merits of a neurosurgery with some other type of health representative who is acting on behalf of the insurance company.”
The piece concludes with the authors asking Congress to take action and pass legislation to streamline prior authorization in Medicare Advantage. The Improving Seniors Timely Access to Care Act would require enhanced transparency and streamline authorization in the Medicare Advantage program.
Click here to read the full article.
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and using the hashtag #FixPriorAuth.
For the past decade, Neurosurgery Blog: More Than Brain Surgery has investigated and reported on how health care policy affects patients, physicians and medical practices. Posts have discussed the state of neurosurgical sub-specialties and promoted key health care policy and advocacy initiatives to ensure patients’ timely access to care, improve neurosurgical practice and foster continued advancement of neurological surgery.
Its health policy reporting efforts include multiple topic months and guest blog posts from key thought leaders and members of the neurosurgical community. To mark the 500th post, we combed through the Neurosurgery Blog archives to highlight our most popular blog posts and focus series that showcase the current state of neurological surgery.
The Neurosurgery Blog’s 10 top posts:
The Neurosurgery Blog’s top focus series:
of the founding of Women in Neurosurgery (WINS), bringing with it an exciting time for the WINS community and neurosurgery. To celebrate the 30th anniversary of WINS, Neurosurgery Blog published a series of articles highlighting the section’s goals — to educate, inspire and encourage women neurosurgeons to realize their professional and personal goals.
The COVID-19 pandemic has significantly impacted neurosurgical practices across the country. To highlight the effects of the pandemic on neurosurgery, Neurosurgery Blog published a series of articles on the impact of COVID-19.
. Misinformation regarding spine care in the U.S. is a significant hindrance to understanding the critical issues surrounding the care of patients with spinal conditions.
published a series on Military Faces of Neurosurgery. Throughout history, neurosurgeons have served our country with distinction and grace. Read how former AANS president Roberto C. Heros, MD, FAANS(L), volunteered for the ill-fated Bay of Pigs invasion. Remember the horrors of the Vietnam War, as seen through the eyes of Patrick J. Kelly, MD, FAANS(L), while he was stationed in Da Nang during the bloodiest year of that conflict.
To explore and highlight the rising prevalence of burnout among clinicians in recent years, the Neurosurgery Blog published articles bringing physician wellness to the forefront of the profession and offering strategies to reduce physician burnout.
ice for neurosurgical residents. Click here to watch the series.Thanks for following Neurosurgery Blog, and stay tuned for great content in the coming decade!
Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by using the hashtag #Neurosurgery and following @Neurosurgery.
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.
High rates of clinician burnout in the U.S. are detrimental to the quality of care being provided and harmful to individuals in the workforce. A report “Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being” by the National Academy of Medicine takes a systemic approach to address burnout that focuses on the structure, organization and culture of health care.
Mounting system pressures have contributed to overwhelming job demands and insufficient job resources for clinicians, causing physical, psychological, and emotional stress, including burnout. Burnout is a syndrome characterized by high emotional exhaustion, high depersonalization and a low sense of personal accomplishment from work.
The report calls upon leaders in health care organizations, health professions’ educational institutions, government 
and industry to prioritize improvements to prevent and mitigate clinician burnout. Research shows the prevalence of burnout is around 35–54% for U.S. nurses and physicians and 45–60% for medical students and residents. Supporting professional well-being is essential to the delivery of high-quality care and to clinicians, patients and families.
To read the full National Academy of Medicine article, click here.
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.
Zubin Damania, MD (ZDoggMD) graciously sat down for an interview with the Neurosurgery Blog for the Physician Burnout focus series. He spoke with Kurt A, Yaeger, MD, neurosurgery resident at Mount Sinai Hospital in N.Y., and chatted about neurosurgery and moral injury/burnout.
Dr. Yaeger: Thanks for taking the time to chat with me for the Neurosurgery Blog. As a resident, a lot of your messages really resonate, especially reframing the phrase “burnout” to “moral injury.” Can you tell me about your motivation behind that?
ZDogg: Wendy Dean, MD and Simon G. Talbot, MD, wrote a piece for STAT News, which discussed how physicians aren’t suffering from burning out, they’re suffering from “moral injury.” It resonated with me because I realized that’s really what it is: it’s this conflict that we want to do the right thing. Physicians are very resilient, and yet we fail to be happy and succeed, not for lack of resilience, but because of the system in general. I wanted to draw attention to the fact that there’s a lot of victim shaming and a lot of over-simplification.
Especially as a surgeon, there’s a culture of “suck it up” and “what doesn’t kill you makes you stronger.” It’s part of the culture of medicine to be like that: if you can’t hack it, you can go someplace else. One of my biggest pet peeves are administrators that say, “Ah, you guys should get a massage, some essential oils, and we’ll hire a wellness officer who isn’t a doctor…” Directly in response to the video I made, some PhD wrote in Medical Economics, saying it was “burnout” and not “moral injury.” His title was, get this, the “director of provider well-being.” I thought, there’s so much wrong with that. First of all, you’re not a physician. Second, doctors tend to bristle at the term “provider” because it is an administrative commodification of all health care professionals. So, this is an ongoing problem and why I chose to focus on the terminology.
Dr. Yaeger: Do you think subspecialists like neurosurgeons are more or less prone to moral injury?
ZDogg: I don’t want to speak for my surgical colleagues, but because I have a platform where many medical professionals follow along, I get the sense that everyone is suffering in their own way. It may be that a surgeon’s kind of suffering is that they want to operate, and they want support from a primary care team. Yet they find themselves having to deal with everything because the system is so fragmented, there’s poor communication, everyone is siloed, and nobody has walked in each other’s shoes. Surgeons may feel like they’re patching up the failures of preventative medicine, which creates moral injury. They still have to chart. They have the pressures of trying to run a business and be successful financially. All this while doing good for patients. Thus, I think it’s more universal, though surgeons may compartmentalize a little bit more.
Dr. Yaeger: Do you think the evolution of technology in health care is enhancing the provider experience, or is it making them less productive and less able to spend time with patients?
ZDogg: So, I’m a big fan of technology in general. My whole platform is built on technology that didn’t exist when I was a kid — but as soon as it did exist, I was able to do the things I’ve always wanted to do. So, I’m a believer in that. The problem is, having been to some of these health IT (information technology) conferences like HIMMS (Healthcare Information and Management Systems Society), usually, it’s just a bunch of buzzwords and a bunch of people trying to capitalize on some concept — like building an app that counts steps and then pays you. But the truth is that without actually adding value to the physician’s day, those things are bound to fail. So EHRs (electronic health records) added value to administrators and hospital systems and insurance companies by capturing all this data that they couldn’t see before, but it doesn’t add much for patient care and just adds more to the plates of physicians. I think a lot of technology is seen as doing that currently, but it doesn’t have to be that way.
A good example is a company called Suki, whose creator I interviewed on my show. It’s a startup using artificial intelligence and natural language processing to automate clinical note documentation. Right now, it’s software that has to be invited into the exam room by a doctor. Doctors have to say, “this is something I want to assist me.” Suki designed its technology to take stuff off the doctors’ plates and make their lives easier. I think that’s the technology that’s going to help us.
Finally, I hate the terms telehealth and telemedicine, but some new companies do virtual, text-based primary care. Well, that’s an interesting way to rethink the practice of primary care because most people want the convenience to communicate with the physician the way they communicate with their kids. So, there is a lot of hope, but the parallel to EHRs is that you get the technology wrong, and it creates more work, and that’s the last thing we want.
Dr. Yaeger: What can we do, as professionals in neurosurgery, to lead the charge against moral injury?
ZDogg: Neurosurgeons are highly respected, even among other physicians. They’re are perceived as the apex of diligence with a complex skill set and work-intensive profession. What we haven’t seen yet — because you’re all so busy — is the leadership neurosurgeons can show in helping to reorganize medicine around principles we all care about. I call it the Health 3.0 Movement, where medicine is team-based. Neurosurgeons can be leaders in this — and have the gravitas to do it — so getting involved in organizations such as the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS), and getting engaged in social media, can actually make a difference.
Dr. Yaeger: How can neurosurgical department leaders, such as the chairs and program directors, emphasize the wellness of residents without sacrificing education?
ZDogg: What a great question. What I’ve noticed is that the “elders” in medicine — the Gen Xers and Baby Boomers — like myself, notice young people are coming in and saying, “I’m going to clock in and clock out and hit my work hours. If a particular task doesn’t fit my learning, I’m not going to do it.” The elders notice a general erosion in work ethic, some of which may be a “fragilization” of Millennials and Gen Z with over-parenting, social media — but it’s not their fault. It’s been documented. They’re more anxious and more suicidal because we’ve turned them into fragile creatures rather than anti-fragile, where they get strength from adversity. So I think the first step is for program directors to be open.
It’s hard in neurosurgery because you have to be that focused and that diligent. What that means to me is that we need the leaders to have a little bit of emotional intelligence. To say, yes, there is some suffering here, and to recognize that. But then really, still holding those expectations and saying to trainees, “If this really is a calling, you will put in the effort. If we see that you put in the effort and passion, we will do our best on our end to make work-life integration happen.” Because it’s really not work-life balance, it’s just life. You’re trying to create something that’s sustainable, with a purpose and a calling. You have to show your mentors that this is a calling for you, and your mentors need to return the favor by helping to make this better together. It’s a partnership.
There’s a term, “communalization of pain.” Sometimes you see it in the military. We in medicine tend to suffer in silence, alone. There is a perceived isolation here that creates more moral injury. But, if you have other colleagues who say, “Yes, we are also suffering,” there are ways to communalize the suffering, and it’s healing for everyone. It’s validating that your suffering was witnessed. You’re not just doing it silently. Part of my platform is to help communalize the experience. The reason why our moral injury video had so many views is because it communalizes pain and reminds us that it’s not so much “I’m crazy” as “THIS is crazy.” Residency program directors can help to communalize pain by acknowledging suffering.
Dr. Yaeger: Well, thank you very much for your time. It’s been a great conversation.
ZDogg: It’s been great talking to you, thanks for the opportunity!
ZDoggMD (Zubin Damania, MD) is an internist from the University of California San Francisco (UCSF)/Stanford University and founder of Turntable Health, who speaks out against the dysfunctional U.S. health care system. He has taken to social media to campaign against physician burnout — or moral injury — using the term he prefers. ZDogg was the keynote speaker at the 2019 AANS Annual Meeting. Visit his website for more information.
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.
Kurt A. Yaeger, MD
Mount Sinai Medical Center
New York, N.Y.
The prevalence of physician distress has been well documented in recent years, and data suggests that 44% of U.S. physicians experience symptoms of burnout.
A recent study titled, “Resilience and Burnout Among Physicians and the General US Working Population,” published in JAMA Network Open — a journal of the American Medical Association (AMA) — evaluated resilience among physicians and how it compared with resilience among other U.S. workers. The study also measured burnout symptoms to analyze the association between resilience and burnout among physicians.
Researchers surveyed 5,445 U.S. physicians and 5,198 U.S. workers. Results revealed significantly higher mean resilience scores among physicians than the general working population. The findings suggest that, although maintaining and strengthening resilience is important, physicians overall do not have a deficit in resilience.
Even among the most resilient physicians, burnout rates were substantial, and 29% of physicians with the highest possible resilience score still experienced burnout. This study demonstrates that solutions such as including efforts to address system issues in the clinical care environment are needed to reduce burnout and promote physician well-being.
To read the full JAMA Network Open article, click here.
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.
I chose to be a neurosurgeon because I sought a life bringing healing to those with neurological diseases. After completing my training with a tremendous sense of pride, I was prepared to have an impact on patients and families in their time of greatest need and hopelessness. I ended each day with the knowledge that I had given my all. Like many others, I ignored fatigue and underestimated the accumulated trauma of occasions where I gave all I had, but the patient’s disease won. My blessings were my family, my resolve and my mission.
Eleven years ago, in an unanticipated instant, my resolve was gone and replaced by fear, hopelessness, and a sense of inadequacy. I lacked the skills to process emotions I had never acknowledged. I could not turn for support to loved ones lest I lose their respect. I was trapped. I was one of the grim statistics — a burned out and depressed physician. The administrative, clinical and personal stressors had whittled away my physical and mental reserves.
Every year almost 400 physicians die by suicide. Simply reading that sentence should be enough to give anyone who has dedicated their lives to helping and saving others cause for concern.
Two recent articles on burnout of U.S. neurosurgeons and neurosurgical residents found the burnout rate was 56.7% for neurosurgeons and 67% for residents. However, paradoxically 81.2% of neurosurgeons and 81% of residents say they are satisfied with their careers. Some of the factors associated with burnout for neurosurgeons included anxiety over future earnings and the ability to achieve work-life balance outside the hospital. For residents, the key factors were hostile faculty and social stressors outside work, such as debt.
Our work in neurosurgery involves the brain health of our patients, and integral to maintaining their brain health is taking care of ourselves while sustaining a work-life balance. A lot has changed in neurosurgical training and technology in recent decades. Now is the time to challenge the status quo. We need to raise awareness about physician wellness and remove the stigma and the tendency to keep physician burnout a secret. Burnout can lead to anxiety, depression, suicidal thoughts, marital and family stress, anger issues, addiction and substance abuse — any of which can lead to dissatisfaction and, ultimately, physicians ending their marriages, their careers and their lives.
Consider the following statistics:
We can, and should, do better. If we recognize and reduce the stressors that lead to burnout, we can create a supportive environment for physicians that fosters our own physical and mental well-being. This will allow us to provide the best quality care for our patients.
I know recovery is possible. I recovered through ultra-running, friendships, and other coping strategies. Acknowledging insecurities is vital, but it’s how we deal with them that is key. We should show compassion and kindness to ourselves and the members of the teams we lead.
My efforts over the past four years have been to help colleagues focus on wellness strategies and overcoming burnout. I have shared my story countless times with colleagues, medical students and staff. I do this to destigmatize burnout and let those facing pain in silence know they are not alone. I have also taken the empathy resultant from my pain and turned it into a career focused on healing for the vulnerable. In June 2018, I was recruited by Michigan State University (MSU) to help develop a safer and healthier campus following the trial and sentencing of former U.S. gymnastics and sports medicine physician, Larry G. Nassar, D.O., who went to prison for criminal acts of sexual assault. I help to develop strategic initiatives and programs to increase efficiency, safety, compliance and quality practices across all MSU’s health care services to ensure best practices and exemplary care in a learning and healing environment.
We also formed a wellness and patient experience committee. We developed a faculty peer support program to foster an environment that promotes healthy work-life balance, the continued physical and emotional development of our colleagues, role-modeling of professional and healthy behaviors, and compassionate recognition of unhealthy behaviors. Under the leadership of Claudia Finkelstein, MD, our peer support program offers a safe way for physicians impacted by adverse events, medical errors, litigation or other workplace stressors to talk about their experience and emotions with someone who has empathy from having “been there.” The goal is to ensure all physicians understand stress management and burnout prevention, and to make resources available to help.
We must all listen, learn and heal with each other to achieve a healthier, more peaceful and purposeful life with optimum performance in body, mind and spirit. We must remember we are never alone. And we must find hope even in the darkest moments for the lessons learned can give us insights on how to bring light to others.
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.
Anthony M. Avellino, MD, MBA
Michigan State University
East Lansing, Mich.
As the husband of a physician, I like to say that issues affecting health care workers aren’t just dinner tables issues — they’re breakfast, lunch and dinner table issues. This has never been truer than it is during the current coronavirus crisis.
When the greater Chicago area was overrun with COVID-19 patients this past spring, my wife, an anesthesiologist, was among those on the front lines placing intensive care unit (ICU) patients on ventilators. She did so while wearing a welder’s mask that she purchased from a hardware store because there was simply not enough personal protective equipment (PPE) to go around. Our children and I could not have been prouder of her bravery, but we worried about her constant exposure to the virus and the pressures of being a frontline health care worker during a pandemic.
Although case numbers have come down in our area, the virus is far from quashed, and any amount of progress feels fragile. For many who served in hot spots like New York City in the early days of the pandemic — and those in areas currently experiencing surges, like Miami and Houston — navigating the emotional toll of being on the front lines has proven to be among the pandemic’s greatest challenges.
As with so many other areas of policy, the COVID-19 crisis has forced us to confront the ways we have failed as a nation to look out for the well-being of our health care workforce. Too many have struggled in silence for decades; now, they have been called to respond to a once-in-a-century public health crisis without an emotional safety net. It is for these reasons that I introduced the bipartisan Coronavirus Health Care Worker Wellness Act (H.R. 7255), along with my colleagues Reps. John Katko (R-N.Y.) and Frederica Wilson (D-Fla.). This legislation seeks to accomplish two goals:
Studies and events of the past several months have confirmed that many health care workers are indeed struggling with their mental health as a direct result of COVID-19. Consider the following:
As dire as the current situation is, the unfortunate truth is that burnout and mental health challenges were common among health care professionals long before the world had ever heard of SARS-CoV-2 — something that likely comes as no surprise to members of the neurosurgery community.
COVID-19 will, unfortunately, be with us for an extended period. Frontline workers needed our support back in March — not just with our words, but with Congressional action — and we failed to provide it. We simply cannot overlook this situation any longer, nor can we continue to ignore the importance of the long-term job satisfaction of our nation’s health care workforce. We must pass the Coronavirus Health Care Worker Wellness Act as soon as possible.
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.
U.S. Congressman Raja Krishnamoorthi (IL-8)
