SPECIAL ARTICLE
Stress and Burnout Among Surgeons
Understanding and Managing the Syndrome and Avoiding
the Adverse Consequences
Charles M. Balch, MD; Julie A. Freischlag, MD; Tait D. Shanafelt, MD
T
raining for and practicing surgery are stressful endeavors.1-4 Studies5-11 involving national samples of surgeons from surgical subspecialty societies and graduates of surgical training programs suggest that burnout rates among surgeons range from 30% to
38%. These statistics indicate that a substantial number of our colleagues are struggling with personal and professional distress at a level that should be of concern to all surgeons.
Surgeons work hard, work long hours, deal
regularly with life-and-death situations
with their patients, and make substantial
personal sacrifices to practice in their field.
These attributes of surgical practice, along
with the rigors and length of training for
this profession, attract individuals of a particular character and determination. These
individuals share an unwritten but understood code of rules, norms, and expectations. This code includes coming in early
and staying late, working nights and weekends, performing a high volume of procedures, meeting multiple simultaneous
deadlines, never complaining, and keeping emotions or personal problems from
interfering with work. These are hallmarks of dedicated professionals that
should be celebrated and rewarded. However, there is a fine line separating dedication from overwork; if unchecked, overwork could lead to counterproductive,
unhealthy, or even self-destructive behavior that may affect patient care. Studies5-11 show that a substantial proportion
of surgeons experience distress or burnout, conditions that can have negative repercussions for themselves, their families, their colleagues, and their patients.
The goals of this review are to (1) increase awareness of the symptoms, causes,
and consequences of surgeon distress and
burnout, (2) encourage surgeons to be proactive in their personal health habits,
Author Affiliations: Department of Surgery, Johns Hopkins Medical Institution,
Baltimore, Maryland (Drs Balch and Freischlag); and Department of Medicine,
Mayo Clinic, Rochester, Minnesota (Dr Shanafelt).
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(3) prompt leaders of surgery departments
and training programs to incorporate a
supportive workplace environment, and
(4) stimulate research in these areas.
STRESS AMONG SURGEONS
Distress among surgeons can have serious manifestations, including anxiety, depression, divorce or broken relationships, alcoholism, substance abuse, and
suicide. Unfortunately, many of these
problems are more prevalent among surgeons and physicians compared with those
who practice some other professions. Current estimates are that approximately 15%
of all physicians will be impaired at some
time in their careers and will be unable to
meet professional responsibilities because of mental illness, alcoholism, or drug
dependency.12 Although many surgeons
may believe they are more resilient than
their colleagues in other specialties, the
traits that define the surgeon (eg, commitment, self-sacrifice, singularity of focus) and the surgical workplace environment may place surgeons at particular risk
for overwork and for imbalance between
personal and professional life.
DEPRESSION AND SUICIDE
In a prospective study of more than 1300
male physicians from The Johns Hopkins
University, the lifetime prevalence of clinically significant depression was 12.8%.13
In a study of 4500 female physicians in the
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treated for alcoholism or drug dependence appear to have
favorable outcomes,25 although potential ramifications for
licensing and hospital privileges may deter some physicians from seeking assistance.
Causes
Suicide
Unintentional injuries
Cerebrovascular disease
DIVORCE AMONG PHYSICIANS AND SURGEONS
Diabetes mellitus
Cancer
Heart disease
HIV or AIDS
Liver disease
Chronic obstructive
pulmonary disease
Pneumonia or influenza
60 70 80 90 100 110 120 130 140 150 160 170 180 190
Mortality Ratio
Figure. Mean incidence of suicide among male physicians compared with
other male professionals. HIV indicates human immunodeficiency virus.
Error bars indicate SEM. Data are from Frank et al.17 Reprinted with
permission from Center et al.18
Women Physicians’ Health Study, the prevalence was
19.5%.14,15 In another study,16 20% of nearly 2000 survey respondents who are full-time academic physicians
and basic science faculty members had significant levels
of depressive symptoms, with higher levels in younger
faculty members. Although the lifetime rates of depression among physicians appear to be similar to those of
the general population, suicide is a disproportionately high
cause of mortality in physicians.17 Compared with other
professionals, a male physician’s proportionate mortality ratio from suicide is nearly 1.5- to 3.8-fold higher
(Figure).17 The discrepancy is even greater among female physicians, who have a 3.7- to 4.5-fold increased
risk of death from suicide.18,19
Unfortunately, the culture of medicine usually accords a low priority to physician mental health despite
evidence of a high rate of untreated mood disorders and
an increased burden of suicide. Too often, depression remains unrecognized or untreated until a physician’s personal distress compromises his or her capacity to care
for patients. For physicians seeking help, there is often
a punitive response, including discrimination in medical licensing, hospital privileges, and professional advancement. Thus, although physicians may have more
ready access to medical care for treatment for depression, they face daunting regulatory and workplace barriers that may dissuade them from seeking help.18
ALCOHOL AND SUBSTANCE ABUSE
Physician impairment by substance abuse represents a
significant challenge with potential grave consequences
for patients and society. Although data are sparse, the
prevalence of alcohol and illicit drug abuse among physicians is probably similar to that of the general population.20-24 Problematic alcohol use (ie, symptoms of alcohol dependence or having had ⱖ6 drinks on 1 occasion
in the last year) was reported by 6.8% of surgeons in a
recent study7 of members of the Society of Surgical Oncology, with a similar frequency reported in a separate
study6 of 110 surgical residency graduates from the University of Wisconsin–Madison. Most physicians who are
One large, prospective study26 of 1118 married physicians
found that the cumulative incidence of divorce after 30 years
of marriage was 29%. Specialty choice was independently
associated with the risk of divorce, with the highest divorce rates among surgeons (33% after 30 years) and psychiatrists (50% after 30 years).26 Higher levels of anger and
getting married before medical school graduation were also
associated with higher divorce rates.26 Surgeons continued to have a higher divorce rate (relative risk of 1.7 compared with internal medicine physicians) on multivariate
analysis controlling for other factors.26 Several studies27-30
of physicians and their spouses suggest that the ways in
which couples treat each other, communication styles, differences in the need for intimacy, and the degree of workrelated stress are more important factors for marital satisfaction than the number of hours worked by physicians.
BURNOUT: WHAT IS IT?
Although most surgeons are aware of major depression and
anxiety disorders, they may be less familiar with the specific symptoms associated with burnout or the consequences of those symptoms. Burnout is a form of personal
distress that appears in a markedly more common fashion
among physicians compared with depression, substance
abuse, and suicide. As a clinical syndrome, burnout is characterized by emotional exhaustion, depersonalization, and
a decreased sense of personal accomplishment.31-34 It is a
syndrome that primarily affects individuals such as physicians, nurses, and social workers, whose work involves
constant demands and intense interactions with people who
have great physical and emotional needs.
Two common symptoms of burnout are treating patients and colleagues as objects rather than human beings
and feeling emotionally depleted. Symptoms of burnout also
include physical exhaustion, poor judgment, cynicism, guilt,
feelings of ineffectiveness, and a sense of depersonalization in relationships with coworkers or patients.34,35
CONSEQUENCES OF SURGEON BURNOUT
Burnout can affect physicians’ satisfaction with their work
and the quality of medical care they provide 34,36-39
(Table 1). Increasing evidence suggests that physician
burnout can adversely affect patient safety and quality
of patient care and contribute to medical errors.34,36-39 Studies36,37 suggest a dose-response relationship between the
magnitude of burnout and measures of suboptimal patient care. In addition to its potential effect on patient
safety, physician burnout should also be of concern to
health care organizations because workers who are less
satisfied tend to be less productive and eventually may
decide to quit for a different practice opportunity or take
early retirement.3,5 Medical errors and patient lack of satisfaction with medical care provided by burned-out
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physicians also increase the threat of malpractice litigation; hence, physician burnout also poses substantial risk
to the economic well-being of health care organizations.40,41 These findings underscore the importance of
burnout to physician leaders and practice administrators who are responsible for the workplace environment. Work-related burnout can spill over into personal life and contribute to broken relationships, substance
abuse, and other types of distress. Burnout has also been
associated with poor health, including headaches, sleep
disturbances, hypertension, anxiety, alcoholism, and myocardial infarction.32-35,42
Table 1. Consequences of Physician Stress and Burnout
Professional
Poor judgment in patient care decision making
Hostility toward patients
Medical errors
Adverse patient events
Diminished commitment and dedication to productive, safe,
and optimal patient care
Difficult relationships with coworkers
Disengagement
Personal
Depression
Anxiety
Sleep disturbances and fatigue
Broken relationships
Alcohol and drug addictions
Marital dysfunction and divorce
Early retirement
Suicide
INCIDENCE OF STRESS AND BURNOUT
AMONG SURGICAL SPECIALTIES
General Surgeons
In a large study5 of 582 surgeons who trained at the University of Michigan–Ann Arbor, 32% showed high levels of emotional exhaustion, 13% showed high levels of
depersonalization, and 4% showed evidence of a low sense
of personal accomplishment. Notably, younger surgeons were more susceptible to burnout than their older
colleagues (P ⬍ .01). Burnout was not found to be related to caseload, practice setting, or percentage of patients insured by a health maintenance organization. In
contrast, etiologic factors associated with burnout were
a sense that work was “overwhelming”; a perceived imbalance among career, family, and personal growth; perceptions that one’s career is unrewarding; and lack of autonomy. More important, burnout was strongly associated
with a desire to pursue early retirement.5
These issues are not unique to US surgeons. An Australian study9 of 126 surgeons indicated that burnout levels were significantly higher for surgeons than for the normative population, with 47.6% of the sample reporting
high burnout levels. Younger surgeons reported significantly higher burnout levels, regardless of career stage.
Burnout correlated significantly with early retirement
and/or intentions for retraining and was inversely related to overall emotional intelligence levels. Another
study10 of 501 colorectal and vascular surgeons in the
United Kingdom showed that 32% had high burnout on
at least 1 subscale of the Maslach Burnout Inventory. Surgeons who planned to take early retirement or wished
to retire as soon as they could afford to do so were more
likely to have psychiatric morbidity and/or burnout.
Surgical Oncologists
In the recently published survey7 of 549 members of the
Society of Surgical Oncology, 28% of respondents met the
criteria for burnout. In addition, approximately 30% of study
participants screened positive for depression. Given the sensitivity (96%) and specificity (57%) of the screening instrument used,41,43 this finding implies that approximately 10% of respondents would have met the criteria for
major depressive disorder at the time of the survey if they
had undergone a full psychiatric assessment. Burnout was
more common among respondents 50 years or younger
(31% vs 22%; P=.03) and women (37% vs 26%; P=.03).
Burnout was strongly associated with both potentially problematic alcohol use (12.4% burned out vs 4.6% not burned
out; P=.001) and lower career satisfaction. No differences
were found between private practice physicians and academic physicians in frequency of burnout, symptoms of
depression, potentially problematic alcohol or other drug
use, or mental or physical quality of life.7
Transplantation Surgeons
Bertges and colleagues8 conducted a survey of 209 actively practicing transplantation surgeons. Burnout was
present in 38% of respondents. Several significant predictors of emotional exhaustion were identified and included questioning one’s career choice, giving up outside activities, and perceiving oneself as having limited
control over the provision of medical services. In contrast, surgeons who reported greater professional growth
opportunities, institutional support, and a sense of being
appreciated by their patients experienced a high sense
of personal accomplishment. Prioritizing goals to reflect both personal and professional values was associated with both lower emotional exhaustion and a higher
sense of personal accomplishment.8
Head and Neck Surgeons
Johnson and colleagues11 conducted a survey of 395 members of the American Society of Head and Neck Surgery and
the Society of Head and Neck Surgeons in 1993. A total of
34% who responded believed they were “burned out.” Most
respondents replied that they enjoyed their work, but the
stress of extended work hours, dealing with seriously ill patients, and the increased need to deal with governmental and
economic issues were their sources of greatest concern.
WHAT ARE THE CAUSES OF BURNOUT?
One of the tragic paradoxes of burnout is that those most
susceptible appear to be the most dedicated, conscientious, responsible, and motivated. Individuals with these
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Table 3. Steps to Promote Personal Well-Being48
Table 2. Partial List of Contributing Causes
to Physician Burnout
Identify personal and professional values and priorities
Reflect on personal values and priorities
Strive to achieve balance between personal and professional life
Make a list of personal values and priorities; rank in order
of importance
Make a list of professional values and priorities; rank in order
of priorities
Integrate these 2 lists
Identify areas where personal and professional goals may
be incompatible
Based on priorities, determine how conflicts should be managed
Enhance areas of work that are most personally meaningful
Identify areas of work that are most meaningful to you (patient
care, patient education, medical education, participation
in clinical trials, research, administration)
Find out how you can reshape your practice to increase your focus
in this area/these areas
Decide whether improving your skills in a specific area would
decrease your stress at work or whether seeking additional
training in this or other areas would be helpful for you
Identify opportunities to reflect with colleagues about stressful
and rewarding aspects of practice
Periodically reassess what you enjoy most about your work
Identify and nurture personal wellness strategies of importance to you
Protect and nurture your relationships
Nurture religion and spirituality practices
Develop hobbies and use vacations to pursue nonmedical interests
Ensure adequate sleep, exercise, and nutrition
Define and protect time for personal reflection at least once a month
Obtain a personal primary care physician and seek regular
medical care
Length of training and delayed gratification
Limited control over the provision of medical services
Long working hours and enormous workloads
Imbalance between career and family
Feeling isolated or loss of time to connect with colleagues
Financial issues (salary, budgets, managed care, etc)
Grief and guilt about patient death or unsatisfactory outcome
Insufficient protected research time and funding
Sex- and age-related issues
Inefficient and/or hostile workplace environment
Setting unrealistic goals or having them imposed on oneself
traits are often idealistic and have perfectionist qualities that
may lead them to submerse themselves in their work and
devote themselves to it until they have nothing left to give.
Thus, commitment to patients, attention to detail, and recognizing the responsibility associated with patients’ trust—
the very traits that define a good surgeon—also place surgeons with these qualities at greater risk for burnout.4,44
A number of studies32-35,42 have explored the potential causes of physician burnout. These studies32-35 suggest that a lack of autonomy, difficulty balancing personal and professional life, excessive administrative tasks,
and high patient volume are the greatest sources of stress.
The way these and other work characteristics affect a given
individual is complex and depends on his or her personal responsibilities (eg, relationships, age of children,
other interests), personality, health, and enthusiasm for
work. Recognizing these variables, there nevertheless appears to be some common themes among physicians and
surgeons who experience burnout. A partial list of potential contributing causes is given in Table 2.
Long hours and lack of control over one’s schedule during medical school, residency, and fellowship may also inculcate surgeons (and physicians from other medical specialties) with a set of habits that are counterproductive to
achieving a balanced and full life once training is completed.36,42,45 During this time, a coping strategy that puts
personal life on hold appears to foster a mentality of delayed gratification (ie, “things will get better when I finish
residency”) that many physicians carry with them into practice.4,33,42 Once developed, many physicians maintain this
strategy of delayed gratification after completing a residency or fellowship and rather than reclaiming their personal life, they find themselves delaying this task ever farther into the future (eg, until after establishing their practice
or becoming an associate professor). In fact, many physicians appear to believe they cannot simultaneously have a
fulfilling personal and professional life, so they put their
personal life on hold until retirement.4,33
Although the total number of hours worked by surgeons has not been found to be an independent predictor of burnout in most studies, most surgeons work more
than 60 hours per week.7,11 For example, 89% of surgical oncologists profiled in the study by Kuerer et al7
worked more than 50 hours per week, whereas 60% and
24% work more than 60 hours and 70 hours, respectively. This finding is in contrast with the average US
workweek of 34.5 hours as reported by the US Bureau
of Labor.46 Thus, the nearly uniformly long hours worked
by surgeons may limit the ability to evaluate the relationship between hours worked and burnout.
WELLNESS
Although recovery from burnout is possible, prevention is
a better strategy. Physicians who actively nurture and protect their personal and professional well-being on all levels—
physical, emotional, psychological, and spiritual—are more
likely to prevent burnout or at least to mitigate its consequences.4,35 The promotion of personal wellness needs to
occur throughout the professional life cycle of physicians,
from medical school through retirement. Promoting such
balance and well-being is a challenge that must be addressed
notonlybyindividualphysiciansbutalsobyourprofessional
organizations and in our workplace. Indeed, the leadership
of institutions, departments of surgery, and professional societies should encourage and identify workplace activities
and characteristics that encourage a balanced lifestyle. The
importance of mentorship cannot be underestimated.47,48
Bringing about personal growth and renewal involve
optimizing a sense of meaning at work and in personal
life. Strategies that may help increase wellness for individual surgeons include participating in research, continuing educational activities outside work, paying particular attention to important personal relationships and
spiritual practices, recognizing the importance of one’s
work, cultivating personal interests outside work, and creating a balance between personal and professional
life4,7,32,34,42,48 (Table 3). Each of us has a unique com-
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Table 4. Areas of Future Research on Stress and Burnout
Among Surgeons
Determine why younger surgeons and women surgeons are
at increased risk for burnout
Know how to recognize the early signs and symptoms of burnout
in surgeons to allow earlier detection and appropriate intervention
Explore nonpunitive ways to assist surgeons dealing with burnout and
depression to restore individual surgeons to optimal performance
Identify practical personal interventions that can prevent
or mitigate burnout
Evaluate the ways in which physicians’ own health checkups provide
opportunities to promote health and work-life balance
Better understand the ways in which mentoring and counseling
surgeons early in their career can reduce burnout
Evaluate how various workplace characteristics (eg, hours worked
per week, surgical caseload) relate to quality of life and burnout
among American surgeons
Evaluate how various demographic characteristics (sex, relationship
status, parental status, age) relate to quality of life and burnout
among American surgeons
bination of activities that can be self-renewing and energizing, which will change as we go through various
phases of our career and life. A new way of thinking about
work is required: viewing it not merely as a domain of
energy expenditure but also as a potential source of energy renewal (eg, facing and overcoming challenges, deriving meaning in work).
NEED FOR MORE RESEARCH
A limited amount of information exists about the relationship between demographic characteristics and burnout among physicians and surgeons. There also has been
a limited investment of financial resources in understanding the surgeon’s workplace environment (especially outside professional and safety issues) and how to
improve it. Physician depression and suicide, devastating consequences of physician stress, have received scant
research attention. Additional research in these areas is
needed to elucidate evidence-based interventions at both
the individual and organizational levels that would benefit the individual surgeon and indirectly affect patient
safety (Table 4).
Although stress and burnout are at the negative end
of the quality-of-life continuum, satisfaction and wellbeing are at the positive end. Similar to burnout, little
is known about the characteristics associated with the
achievement of personal satisfaction in the practice of
surgery. Factors that may reduce satisfaction with
career choice among surgeons include the aforementioned challenges that are unique to caring for seriously ill patients and a number of changes that have
emerged in the practice environment in recent years,
including increased workload, increased governmental
oversight, decreased insurance reimbursement,
decreased autonomy, and the complex demands of
office management.4,7,38,49 Despite the significant stress
experienced by some surgeons, others appear to thrive
and achieve a high degree of satisfaction with their
work and overall quality of life. The personal and professional characteristics associated with achieving per-
sonal satisfaction in the practice of each surgical specialty are not fully known.7
CONCLUSIONS
Physicians pursue the arduous task of becoming surgeons
to change the lives of individuals facing serious health problems, to experience the joy of facilitating healing, and to
help support those patients for whom medicine does not
yet have curative treatments. Despite its virtues, a career
in surgery brings significant challenges that can lead to substantial personal distress for the individual surgeon and his
or her family. Each surgeon should continuously map a career pathway that integrates personal and professional goals
with the outcome of maintaining value, balance, and personal satisfaction throughout his or her professional career. Being proactive in avoiding burnout is preferable to
reacting to burnout after it has damaged one’s professional life or personal wellness.
There is no single formula for achieving a satisfying
professional career. Each of us will have to deal with stressful times in our personal and professional lives; we must
cultivate habits of personal renewal, emotional selfawareness, and connection with colleagues and support
systems and must find genuine meaning in work to combat these challenges. As surgeons, we also need to set an
example of good health. To provide the best care for our
patients, we need to be alert, interested in our work, and
ready to provide for the patient’s needs, which means doing everything we can to stay as healthy as we want our
patients to be. Maintaining these values and healthy habits is the work of a lifetime.
Accepted for Publication: June 9, 2008.
Correspondence: Charles M. Balch, MD, Department of
Surgery, The Johns Hopkins University, 600 N Wolfe St,
Osler 624, Baltimore, MD 21287 (balchch@jhmi.edu).
Author Contributions: Study concept and design: Balch,
Freischlag, and Shanafelt. Drafting of the manuscript: Balch
and Shanafelt. Critical revision of the manuscript for important intellectual content: Freischlag and Shanafelt. Administrative, technical, and material support: Balch. Study
supervision: Balch and Freischlag.
Financial Disclosure: None reported.
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