Although burnout affects physicians in all medical disciplines, orthopaedic surgeons can be particularly at risk, with prevalence rates up to 60% higher than their general surgeon counterparts [1]. Previous columns have catalogued the direct effects of burnout including depression, substance abuse, decreased work performance, and the potential for damaging relationships with loved ones [1, 9, 13, 15]. The high rates of burnout have been related to excessive administrative tasks [14], loss of autonomy to choose treatment strategies, feelings of insignificance, and the sense that patients are treated as litigation risks, as opposed to opportunities to deliver compassionate healing to a person in need [15]. We have highlighted some means of counteracting this trend, including the practice of mindfulness, taming the scourge of perfection, and focusing on maintaining intimate relationships. A less commonly cited antidote to emotional exhaustion, however, is delivering care abroad.
When considering the benefits of delivering orthopaedic care to low- and middle-income countries [7], we tend to focus on the benefits delivered to those international sites [2]. In addition to those benefits, we have found through our own personal experiences that spending time abroad can improve the mental health of the delivering surgeons themselves. Each author has volunteered in developing countries including India (JDK), Nicaragua (JDK, DJD), and Haiti (JF).
Volunteering abroad to practice surgery can serve as a healthy and sustainable method for US surgeons to stave off burnout by reigniting the passion to help others and by reconnecting surgeons with their patients. Participating in international surgical trips to developing areas offers autonomy, opportunities to make larger impacts on communities, an escape from excessive administrative tasks, and a return to patient-focused practice. In this context, practicing abroad may be an underutilized approach for surgeons who want to avoid burnout.
Less Resources, More Autonomy
Ideally, the surgeon traveling abroad knows precisely what resources are available before the trip begins. Naturally, surgeons volunteer their time and expertise to low- and middle-income countries because their country’s healthcare conditions are often dire. Without consistent resources, the abroad surgeon must learn to improvise his or her treatment strategy in a setting where equipment may be scarce. Although counterintuitive, the lack of resources in developing countries gives surgeons greater autonomy and builds pure surgical skill. Surgeons volunteering abroad must rely on their knowledge of basic fracture principles to create fixation constructs best suited for the fracture in front of them. This forces surgeons to think more constructively about their surgical approaches, and can reinforce understanding of basic orthopaedic principles. In some cases, closed reduction techniques will have to suffice and artful molding of plaster may accomplish more than the surgeon may have thought possible.
The freedom to improvise can truly be an unexpected bonus and could even reinvigorate a physician’s desire to practice. While volunteering in Nicaragua, a coauthor of this column (DD) and his team created a depth gauge out of a 25-gauge needle in order to treat a patient with a both bone forearm fracture. The same patient had purchased his own plates and screws for the procedure, requiring the surgical team to use bolt cutters for trimming the screws to the appropriate length.
While abroad, new diseases are experienced, novel approaches are learned, and creativity blossoms. I (JDK) can recall performing a fracture fixation without a radiograph and calling upon visual spatial skills that otherwise laid dormant inside of me during my own trip abroad to Nicaragua.
Make an Impact on the Community
Orthopaedic surgeons battling burnout can feel expendable or underappreciated at their institution. Have you ever asked, “Is that all there is?” One of the benefits of volunteering abroad is that even one surgeon can have a dramatic impact on the well-being of the surrounding community. According to a report on global surgery, 5 billion people have no access to surgical care, 143 million emergent surgeries are needed per year to meet global demand, and 5 million deaths per year are attributed to trauma—more deaths than caused by HIV, TB, and malaria combined [11, 12]. Research suggests that there is a disproportionate need abroad for musculoskeletal surgical care. In the US, there are five orthopaedic surgeons per 100,000 persons, whereas many countries have less than one orthopaedic surgeon per million people [5, 6]. To put this in perspective, in 2012 there were 10 orthopaedic surgeons in Haiti, a country of 10 million; those surgeons practiced in only three locations. A large majority of Haitian patients serviced at a single surgical center came from within 20 km of the hospital [10]—not because they chose to go to a different facility, but because there was simply no transportation infrastructure to get those patients to the hospital.
With adequate planning and collaboration, the US orthopaedic surgeon can realize many rewarding international trips. The fulfillment one gains by playing an important role within a community is immeasurable, and certainly can dissipate feeling that one is expendable.
Patients are the Priority
One recent study reports that an orthopaedic surgeon spends approximately 50% of his or her time on paperwork, and less than 30% of their time on patient care [14]. Traveling abroad affords a respite from the paperwork that inevitably piles up on the average surgeon’s desk. Undoubtedly, excessive administrative tasks drains one’s soul and decreases time for energy-sustaining patient care. The opportunity to spend more time with patients without the need to spend countless hours dealing with electronic records, documentation, and compliance concerns greatly relieves stress and helps form stronger bonds with patients [8].
Working on the patient/doctor relationship is nearly impossible when the physician has only carved out 10 or less per visit for each patient [3]. In fact, there is a prevailing sentiment in the United States that physicians view patients as litigation risks, which works to alienate the physician from those in his or her care [4]. Therefore, the freedom to treat patients as humans and not as “potential plaintiffs” is a refreshing experience. When traveling, it is astounding to see, despite differences in language, culture, and geographic location, how similar people tend to be. To anyone who has travelled extensively, it becomes apparent that we are indeed all part of one “world family.” The pictures emerging from Syria today of bloodied children being pulled from bombed buildings or from recently gassed towns only highlight the solemn moral obligation to render help to our brothers and sisters in lands less developed and privileged than ours. We believe the fulfillment surgeons derive from helping those in need can directly help sidestep the onset of burnout.
Tomorrow, Try This
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1.
Speak to colleagues who have engaged in service trips on a regular basis.
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2.
Read about others who have expended considerable time and energy abroad and appreciate the fulfillment they experience.
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3.
After learning about the conditions that beset our overseas colleagues, and if you are interested in addressing the orthopaedic needs of a developing country, research sustainable and responsible affiliate organizations who may facilitate a 7-day trip abroad.
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A note from the Editor-in-Chief:
I am pleased to present the next installment of “Your Best Life,” a quarterly column written by John D. Kelly, IV MD. Dr. Kelly is a Professor of Clinical Orthopaedic Surgery at the University of Pennsylvania. His column explores the many ways that busy professionals—surgeons and scientists—might find peace, happiness, and balance both at work and in their personal lives.
The authors certify that neither they, nor any members of their immediate families, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of Clinical Orthopaedics and Related Research ® or The Association of Bone and Joint Surgeons®.
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Friedman, J., Donegan, D.J. & Kelly, J.D. Your Best Life: Resiliency Builder: Delivering Orthopaedic Care Abroad. Clin Orthop Relat Res 475, 2168–2171 (2017). https://doi.org/10.1007/s11999-017-5446-y
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DOI: https://doi.org/10.1007/s11999-017-5446-y