Common symptoms of depression: Lost of interest in the things that were previously pleasurable Depressed and Sadness Hopelessness Other may Include: Anxiety Increased feeling of guilt Irritability Impatience Sleep disturbances Tearfulness Difficulty concentrating Appetite changes (loss/gain) Increased Isolation Somatic Pain Substance abuse

1. Burnout
among
surgeons
DR. SREEJOY PATNAIK
HON. PROFESSOR IMA AMS
SHANTI OMNI SUPER SPECIALITY
HOSPITAL
1

2. 2

3. 1. What are the Overall professions with the highest
to lowest rate of depression.
2. Why do physicians have higher rates of depression
than the general population?
3. Which physicians specialty has the highest suicide
rate? Others?
4. How do most physicians commit suicide?
5. Which gender of physicians has the higher suicide
rate?
Some Questions you may be thinking of.

4. •Nearly 1 million people
worldwide commit suicide
•10 million - 20 million people
attempt suicide every year
•Incidence of suicide in
India (as per a Lancet study)
is the highest in the world.
•20% of the total suicides of
the world occur in India.
•By 2010 the figure had
reached 187,000 (with 40%
adolescents).
4
•Doctors have the highest rate of
suicide among all the
professions i.e. is 2-4% as
against only about 1-2% among
general population
•suicide rate among male and
female doctors is the same.
•Male physicians have a
70% higher suicide rate
than males in other
professions;
•and female physicians
have a 400% higher rate
than females in other
professions

5. It is estimated that on
average
400 Physicians
commit suicide a year in the
United States!

6. Physician Suicide
Positive:
– Physicians worldwide have
a lower mortality risk from
cancer and heart disease
relative to the general
population
– Physicians have decreased
smoking and other common
risk factors for early
mortality
* Source: Gagné P, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested case control study. Depress Res Treat.
2011;2011:936327.
Negative:
•Physicians are reluctant to address
depression, a significant cause of morbidity
and mortality that disproportionately affects
them.
•Significantly higher risk of dying from
suicide than the general population
•Among Medical Students: after accidents,
suicide is the most common cause of death.
To Note:
Suicide is usually a result of UNTREATED or INADEQUATELY TREATED DEPRESSION,
connected with knowledge of and access to lethal means*

7. • Physicians have a
higher rate of
completion than the
general population
• 1.4 – 2.3 times higher
• Interestingly Female
physicians attempt
suicide less than Males
BUT same completion
rate as males
• So they are more likely
to complete a suicide
making them 2.5 – 4
times more than the
general population.*
* Sourcea: Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec
1999;156(12):1887-94.
Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec
2004;161(12):2295-302
Most common psychiatric
diagnosis among those
physicians that complete
suicide:
•Depression and Bipolar
Disorder
•Alcoholism and other
Substance Abuse
Most common means of
suicide by physicians
•Medication Overdose
and Firearms

8. Depression in Our Profession
• Depression is as common among
the medical profession as the
general population
– Males: 12%
– Females: 18%
in medical students (15 – 30%)
in interns and residents (30%)
• Preliminary study found that
residents who experienced
depression may be as much as 6
times more likely than
nonaffected controls to make
medication errors. Other studies
have confirmed the association of
depression with self-perceived
medication and other errors.
Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and
Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).
Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. Mar 1
2008;336(7642):488-91.
West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. Sep 23
2009;302(12):1294-300.
 Lifetime rates of depression in
women physicians were 39%
compared to 30% in age
matched women with PhD’s 
Higher than the General
Population.
 Lifetime rates of depression in
male physicians (13%) may be
similar to rates of depression in
men in the general population,
or they may be slightly elevated.
Concerns of underestimating the
prevalence secondary to limited
self reporting

9. What is
Depression?
• Common symptoms of
depression:
– Lost of interest in the things that
were previously pleasurable
– Depressed and Sadness
– Hopelessness
• Other may Include:
– Anxiety
– Increased feeling of guilt
– Irritability
– Impatience
– Sleep disturbances
– Tearfulness
– Difficulty concentrating
– Appetite changes (loss/gain)
– Increased Isolation
– Somatic Pain
– Substance abuse

10. 10

11. •Every day is a bad day.
•Caring about your work or home life
seems like a total waste of energy.
•exhausted all the time.
•The majority of your day is spent on
tasks you find either dull or
overwhelming.
•You feel like nothing you do makes a
difference or is appreciated
DO YOU FEEL LIKE
THIS OFTEN?
11

12. Stress??
12

13. 13

14. 14

15. Burnout (from English to burn
out, burn completely),
also called burnout syndrome,
was named by New York
psychoanalyst Herbert
Freudenberger
1970
15

16. 16
Burnout is a state of emotional,
mental, and physical exhaustion
caused by excessive and prolonged
stress.
It occurs when you feel
overwhelmed and unable to meet
constant demands. As the stress
continues, you begin to lose the
interest or motivation.
OR It is a chronic psychological
stress.
DEFINITION

17. • emotional and physical
exhaustion
• as a direct result of excessive study or
work related
stress
• can cause significant physical, emotional,
psychological, and spiritual damage to
people.
17
“Burnout is a syndrome made up
of emotional exhaustion,
depersonalization, and reduced
personal accomplishment “
(Beck1995)
“An emotional condition marked
by tiredness, loss of interest, or
frustration that interferes with job
performance. Burnout is usually
regarded as the result of
prolonged stress.”
(Medical Dictionary)
“a progressive loss of idealism , energy and
patterns experienced by people in the
helping professions as a result of working
conditions ’’
Jerry Edelwich and Archie Brodsky (1980

18. Gillespie distinguished two types of Burn out
18
• Characterized by
the maintenance of
assertive behaviour
• It relates to the factors
organizations or external
elements to the
profession
Active
Burn
out
• Dominated by feelings of
withdrawal and apathy.
• It has to do with internal
psychosocial factors.
Passive
Burn
out

19. Why are
we at a
higher
risk??
19

20. Being a Doctor is No Easy Task
20
•Practice of medicine is
stressful
•Physicians must interact
with intense emotional
aspects of life
•Physicians are called on
to cope and adapt with
stress characteristic of
their job

21. 21

22. Are YOU in the
Danger
Zone……..What You
Can DO about it?
Numerous global
studies involving
nearly every medical
and surgical specialty
indicate that
approximately 1 of
every 3 physicians is
experiencing burnout
at any given time”
22
Tait Shanafelt MD JAMA. 2009;302(12): 1338-1340 (physician burnout.
HIGH Job Stress and LOW
Personal Autonomy leads to
higher chances of BURNOUT!
Increase prevalence among
medical students, residents,
and physicians.

23. 23

24. Surgeons – The Heavyweights of the
Medical Profession 24

25. General Surgeons
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
An Australian studyof 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
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.
25
Surgical Oncologists
549 members of the Society of Surgical
Oncology, 28% of respondents met the
criteria for burnout. In addition,
approximately30%of study participants
screened positive for depression
Transplantation Surgeons
Bertges and colleagues8 conducted a
survey of 209 actively practicing
transplantation surgeons. Burnout was
present in 38% of respondents
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%whoresponded believed they
were“burned out

26. Burnout, The Greatest Threat to
Surgeons’ Quality of Life 26

27. BURNOUT SIMPLIFIED…
27

28. The Concept
of Burnout
• Burnout is a reaction to
chronic, job-related stress.
• “A literal collapse of the
human spirit” (Storlie
1979).
• “The loss of concern for
the people with whom one
is working”(Maslach 1976).
• “psychological withdrawal
from work in response to
excessive stress and
dissatisfaction” (Cherniss
1980).

29. Maslasch and Jackson, configured IT as a
three-dimensional syndrome
• absence or lack of
energy, enthusiasm
and a sense
of scarcity of
resources.
emotional and
physical exhaustion
• treating customers ,
colleagues and
the organization as
objects.
depersonalization
and dehumanization • a tendency of
workers to assess
themselves
negatively.
reduction of personal
fulfilment
29

30. Understanding
Burnout
• One of the most useful metaphors
to understand Physician Burnout is
a Bank Account. In this Bank is a
store of your Energy.
• In my experience, that energy
comes in three “flavors”
1.PHYSICAL ENERGY – your basic “get
up and go”
2.EMOTIONAL ENERGY –emotionally
available and compassionate
3.SPIRITUAL ENERGY –Purpose in your
work … Your “WHY”
30
The 3 Energetic
Bank Accounts

31. Understanding Burnout – The 3
Energetic Bank Accounts
• Every Single Day you work … there
is a withdrawal from this
Physical/Emotional/Spiritual
Energetic Bank Account.
• The amount of the withdrawal is
different from person to person
and day to day.
• Your job –Keep Your Energetic
Bank account in a Positive
Balance.
• Your life outside of medicine, your
health and your relationships
depend on it.
When your batteries run out,
the machine stops.
31
PHYSICIAN BURNOUT IS JUST
ANOTHER NAME FOR
A NEGATIVE BALANCE IN THESE
ACCOUNTS
•Work drains you beyond
your energetic, emotional and
spiritual reserves.
•You are unable to recharge
your account.
• You are overdrawn and it
hurts. You can feel it and your
colleagues and family can see
and feel it as well.
• In most cases you are a last
person to recognize your own
physical burnout.

32. When it comes to
Surgeon burnout …
they can operate for
a very long time on
a negative balance
in the accounts.
32

33. SURGEON Burnout – The Three
Symptoms
33
• you are dog-tired on one or more of the three levels –
Energy, Emotion, SpiritEXHAUSTION
• you have lost your ability to care, empathize, and
connect with your patients, staff and co-workers. You
may even blame, shame or demonize the very people
you are charged to care for – and feel guilty about it.
CYNICISM
•you may begin to doubt that your work really makes
any difference or question the quality of what you do
(this is a late and inconsistent symptom that is nearly
absent in men)
DOUBT

34. Stages
of burnout
34

35. FREUDENBERGER

36. DEGREES OF BURNOUT
third degree
major physical and psychological breakdown
second degree
accelerated physical and emotional deterioration
first degree
failure to keep up and gradual loss of reality

37. • 3 STAGE TRANSACTIONAL MODEL OF BURNOUT:
• STAGE 1: demands exceeding emotional resources
• -STAGE 2: attempts to balance between demands and
resources
• -STAGE 3: maladaptive coping mechanisms develop
Maladaptive coping mechanisms
Responses
Physical Emotional
Adaptive coping
mechanisms
balance restored responses resolved

38. What is a balanced life? Is this you?
Imbalanced: Physicians and Residents Life
Work
Health
Personal
Household
Recreation
Spiritual
Exercise
Friends
Family
Partner

39. Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal
Medicine, Aug. 20, 2012

40. Does Burnout Lead to Depression or Is It The
Other Way Around?
• Actually it can go both ways.
• Lets look at in terms of the Conservation of
Resources (COR) theory which is based on the
presence of downward spirals.
– Deficiency of resources in one area, which leads to
the exhaustion of resources in other areas.
– Depression  Lack of energy  Accelerated job
burnout
OR
– Overburdened at work  Physical and mental
exhaustion  Accelerate symptoms of depression

41. 43

42. CAUSES OF BURNOUT
•work-related causes Lifestyle causes Personality traits
•little or no control over your work
•Lack of recognition or rewards
•Unclear or overly demanding job
expectations
•monotonous or unchallenging work
•unorganized or high-pressure
environment
•constant noise & business
• critical ill patients
•crisis of patients and family's
(Cooper, 2001) Grief and guilt about
patient death or unsatisfactory
outcome
•Working too much, without
enough time for relaxing and
socializing
•Being expected to be too many
things to too many people
•Taking on too many
responsibilities, without enough
help
•Not getting enough sleep
•Lack of close, supportive
relationships
•Perfectionist tendencies; nothing is
ever good enough
•Pessimistic view of yourself and
the world, low self esteem, need for
approval
•The need to be in control;
reluctance(unwillingness) to
delegate to others
•High-achieving, Type A personality
•Setting unrealistic goals or having
them imposed on oneself
44

43. Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575

44. 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 co workers
• Disengagement
Personal
• Depression
• Anxiety
• Sleep disturbances
and fatigue
• Broken
relationships
• Alcohol and drug
addictions
• Marital
dysfunction and
divorce
• Early retirement
• Suicide 46

45. SOLUTION
47

46. 48

47. Assessing signs and
symptoms and consulting
doctor for confirmation
Various questionnaires
can be used for self-
assessment (“Maslach
Burnout Inventory”
(MBI))
49
DIAGNOSIS

48. AFFECTIVE SIGNALS
Depressed mood
Changing mood
Tearfulness
Emotional
exhaustion
Tension and
Anxiety
COGNITIVE SIGNALS
sense of failure
hopelessness,
powerlessness
poor self esteem
guilt
inability to concentrate
Increasingly
cynical(pessimistic) and
negative outlook
Decreased satisfaction and
sense of accomplishment
PHYSICAL SIGNALS
headache
nausea
dizziness ,muscle pain
ulcer
Feeling tired and drained
(exhausted) most of the
time (chronic fatigue)
Lowered immunity,
feeling sick a lot
Change in appetite or
sleep habits
BEHAVIOURAL SIGNALS
hyperactivity
increased
consumption of
tobacco, beverages
abandonment of
recreational activities
Isolating yourself
from others
Withdrawing from
responsibilities
Turnover
Skipping work or
coming in late and
leaving early
Absenteeism
Taking longer to get
things done
Taking out your
frustrations on others
MOTIVATIONAL SIGNALS
resignation
disappointment
boredom 50

49. SCALE MASLACH
51

50. Burnout Syndrome: What is it? --
-Assesment
Christina Maslach ( an American
social psychologist & Prof. at
university of California) developed
the most widely instrument for
assessing burnout namely MBI.
Source: Maslach Burnout Inventory. The leading measure of burnout. Christina Maslach, Susan E. Jackson, Michael P. Leiter, Wilmar B.
Schaufeli, & Richard L. Schwab
Maslach has coined BURNOUT as a 3D
SYNDROME which measures 3 main areas:
•Exhaustion.
•Cynicism or Depersonalization
•Inefficacy

51. 1. I feel emotionally drained from my work.
2. I feel tired at the end of the workday.
3. I feel tired when I wake up in the morning and have
to go to work
4. I understand easily as patients feel.
5. I believe I treat some patients as if they were
impersonal objects.
6. Work all day with many people is an effort.
7. Treatment of patients problems very effectively.
8. I feel "burned" by my work.
9. I think my work positively influenced the lives of
people.
10. I have become insensitive to people since I exercise
this profession.
11. I am concerned that this work hardening me
emotionally.
12. I am very active.
13. I feel frustrated in my work.
14. I think I'm working too.
15. I do not really care what happens to my patients.
16. Work directly with people gives me stress .
17. I can easily create a atmosphere relaxed with my
patients.
18. I feel stimulated after working with my patients.
19. I got many useful things in my profession.
20. I am finished.
21. In my work I try emotional problems calmly.
22. I feel that patients blame me for any of your
problems
There are three defined sub-scales, as
described below:
1. Sub-scale of emotional exhaustion . It
consists of 9 questions. : 1, 2, 3, 6, 8, 13, 14,
16, 20
Rate the experience of being emotionally
exhausted by the demands of the
job.Maximum score 54
2. Sub-scale of depersonalization . It consists
of 5 items. : 5, 10, 11, 15, 22
Rate the degree to which each
recognizes attitudesof coldness and
detachment. Maximum score 30
3. Sub -scale of personal fulfillment . It
consists of 8 items. 4, 7, 9, 12, 17, 18, 19, 21.
Assesses feelings of self efficacyand self-
fulfillment at work. Maximum score 48
0 = Never
1 = A few times a year or less
2 = Once a month or less
3 = A few times a month or less
4 = Once a week
5 = A few times a week
6 = Everyday 53

52. A high degree of burnout is reflected by high scores
on the EE and DP subscales and a low score on the
PA subscale.
54

53. MANAGEMENT APPROACHES
55
Depressive
symptoms
BURNOUT
Depressive
symptoms
psychotherapy
pharmacotherapy
+
psychotherapy

54. 56
•PERSON OR ORGANISATIONAL APPROACHES
1. PERSON DIRECTED
2. ORGANISATIONAL APPROACHES
•PSYCHOTHERAPEUTIC APPROACHES
1. ETIOLOGICAL INTERVENTIONS
2. SYMPTOMATIC INTERVENTIONS
•COPING STRATEGIES
1. ACTIVE COGNITIVE COPING
2. ACTIVE BEHAVIOURAL COPING
3. COPING BY AVOIDANCE
PSYCHOTHERAPY

55. 57
PERSON DIRECTED
psychotherapy
counselling
adaptive skill training
communicative skill training
social support
exercises for relaxation
ORGANISATIONAL APPROACHES
training supervisors and managers
changing organisational practices
training for better coping and stress
management techniques
change shift work system and introducing
vacations
counselling and exercises
1.PERSON OR ORGANISATIONAL APPROACHES
PERSON DIRECTED
ORGANISATIONAL DIRECTED
COMBINED

56. 2.PSYCHOTHERAPEUTIC
APPROACHES
• experimental group therapy
• group analytic therapy
58
B)SYMPTOMATIC INTERVENTIONS
Proper medications
physical relaxation techniques for
fatigue
behavioral training for frustration
social support
identifying interesting areas and
motivating
A)ETIOLOGICAL
INTERVENTIONS
cognitive restructuring
self control training
training of active coping
rational training for
frustration

57. COPING STRATEGIES
objectives
coping oriented to problem
coping oriented to emotion
COPING METHODS
ACTIVE COGNITIVE COPING
(management by assessing
potential stressful events)
ACTIVE BEHAVIOURAL
COPING
(observable efforts
managing stressful
conditions)
COPING BY AVOIDANCE
( avoiding stressful
conditions and problematic
situations)

58. Coz..
Prevention is
always better
than cure
60

59. HOW TO COPE UP YOURSELF?
1.RELAXATION
2.CULTIVATE RICH NON-WORK LIFE
3. UNPLUG
4. SLEEP
5. GET ORGANISED
6.STAY ATTUNED
7.KNOW WHEN IT’S U & WHEN IT’S THEM
61
•Notice self burnout and
realistic recognition
•Exercise: A study* show that
Physical Exercise DOES
decrease burnout and
depression.
•Supportive help and talking
with others about issues and
stressors
•Professional resources
•Forming firm Boundaries so to
avoid increased stress and
problems
•Using Humor and Laughter
•Finding Non-Medical Hobbies
•Working in various clinical
settings or changing up clinical
duties periodically
DECREASING BURNOUT
* Source: Toker, S., & Biron, M. (2012, January 9). Job Burnout and Depression: Unraveling Their Temporal Relationship and Considering the Role
of Physical Activity. Journal of Applied Psychology.

60. 62
•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

61. Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575

62. Start the day with a relaxing ritual
Adopt healthy eating, exercising, and
sleeping habits. .
Set boundaries..
Take a daily break from technology.
Nourish your creative side.
Learn how to manage stress..
64

63. My thoughtsMY RESPONSIBILITY
• Learn to recognize burnout syndrome,
depression, & suicidality in yourselves and
educate medical students and residents to
do so as well.
• Better identify those physicians at high
risk of suicide.
• Conclude the need to establish regular
source of health care and seek help for
mood disorders, substance abuse, and/or
suicidality.
• Assessment of Competence
• Provision for Physical/Mental Rest and
Recreation
• officially organising Stress Busting
Activities
• Programme of Prevention of Depression
and Suicide among medical professional
OUR RESPONSIBILITY
• Organizing Well and On Time
• Breaking Down Responsibilities
• Set Reasonable Goals and Stick to Them
• Maintain Good Health and Respect
Personal Needs
• “Go Dark” with a Social-Media Shutdown
• No self medications
65
M
Y
T
H
O
U
G
H
T
S

64. 66

65. 67
Everyda

66. Arch Surg. 2009;144(4):371-376. doi:10.1001/archsurg.2008.575

67. REMEMBER NOT TO FORGET
SAYING WHO YOU ARE
WHILE BECOMING
WHO YOU WANT TO BE 69

68. 70