Having taken the SVS “burnout” survey, I felt that it really never got into the “whys” of what was making individuals burn out. It dealt more with the consequences of the whys rather than the whys themselves, and it is these whys that must be addressed to assist in the prevention of burnout. I would like to comment on my experience of some, certainly not all, of the possible whys related to both inherent stressors and “administrator induced stressors” encountered in my 42-year vascular surgery practice that can easily cause burnout.
I believe there are several major areas that need to be evaluated to understand the causes of burnout because the complexities of today’s practice environment demand a different approach to the practice of vascular surgery for the well-being of the vascular surgeon. These complexities include the emotional baggage inherent in a practice, practice structure, unpredictable time management issues of running a practice, and hospital administration’s decisions creating unintended consequences for the vascular surgeon.
By its very nature, vascular surgery is a difficult field with many inherent stressors, endovascular innovations not withstanding. The initial emotional stressors may well be those of dealing with elderly patients with multiple severe comorbidities, poor outcomes, and the ensuing consequences. With the aging of the population, these stressors will only increase, yet compensation to treat these feeble patients has yet to rise to a level commensurate with the risk factors and complications the surgeon must deal with. Over time this will take its toll on some.
Which practice pattern one chooses to utilize – solo, group, or employed – also plays an important part. The presence or absence of appropriate help and backup for difficult cases, call coverage, and partnership financial packages can be either very stress producing or stress relieving. Are practice responsibilities and finances equally split so as to achieve a reasonable lifestyle, or is there a hierarchy of work and financial gain by which some must shoulder more of the burden for less pay than others? This is the beginning of the income versus lifestyle conflict and becomes a seriously stressful trap when one is short sighted and does not go for the long term. In our practice, we rotate the work and split the gain equally in return for the most valuable commodity of all: free time.
Time management is of paramount importance in completing a schedule, yet the paradox of the vascular world is its inherent unpredictability. There are difficult, time-consuming cases; unexpected, recurrent vascular problems in the same patient; urgent consults needing treatment within a few days; and the inevitable emergency room call for immediate treatment, day or night, for an embolism, vascular trauma, or ruptured aneurysm – not to mention the hospital committees or other responsibilities in the everyday life of a vascular surgeon.
One’s schedule requires dedicated time and attention yet the urgent/emergent issues interrupting one’s daily schedule ensures that the only predictability is unpredictability. This is a source of burnout. My experience over the years has been that about 25% of our practice load comes on an urgent to emergent basis, often causing considerable scheduling problems both in the operating room and at the office – again, issues that can cause tremendous stress for many. Without a large group, these constant stressors become difficult to shoulder.
Then there are the hospital-induced stressors caused by poorly conceived administrative decrees. One example is when emergency rooms need vascular services but no contracts are offered to secure these services, in which physicians are merely expected to provide 24/7 services. Once a physician has been called in for a case in the middle of the night, the stress of carrying on the next day becomes greater for that physician unless a system is in place for designated calls, which some larger groups have worked out.
Another example is the tendency to grant interventional privileges to those incapable of treating their operative complications without any consideration for who would reimburse those who come in after and how. Why is it assumed that vascular surgeons would/should take time out of their practice to answer the call without any additional compensation? If the compensation from these service lines is so lucrative, then compensation in the form of contracts needs to be offered to those who can provide the necessary services to treat the inevitable complications. This will in some way help compensate for time lost in the vascular surgeons’ practices.
The contracts should reflect the value to an institution vascular surgeons bring for their presence, including ED coverage for most if not all of the service lines, such as cardiology, radiology, orthopedics, gynecology, and general surgery. This also includes issues arising from the house staff inserting lines and from subsequent renal failure, as well as for angio-access patients who need immediate vascular backup to treat the vascular complications encountered.
In addition, these contracts should acknowledge the revenue generated by the presence of a vascular service line. With the burnout rate and unpredictable lifestyle, one would be concerned that vascular surgeons could be on the endangered species list; and given the current shortage of vascular surgeons, don’t our numbers reflect this concern?
There are no easy solutions because the field is a difficult one and is undercompensated for the risks assumed and services provided, which makes it an unattractive specialty, especially in today’s lifestyle-conscious generation. The vascular specialty is embattled, and the human toll extracted in the field speaks for itself. The rewards must improve to make things more appealing, and this will lead to an increase in the number of vascular surgeons, and more will join in groups to mitigate the effects of the stressors of the field. Until then, vascular surgeons need to demand that they receive fair compensation for their availability and the coverage they provide, which allows many other departments and specialties to function. This reality must be acknowledged and compensated.
Carlo A. Dall’Olmo, MD
Michigan Vascular Center