Wellbeing pp 157-171 | Cite as

Addressing External Factors

  • Hilary SanfeyEmail author
Part of the Success in Academic Surgery book series (SIAS)


The rapidly changing health care environment has profoundly affected clinician wellbeing, and the percentage of surgeons with one or more manifestations of burnout has been increasing along with an equivalent decrease in the proportion who report high job satisfaction. This chapter will focus on addressing the external factors that impact physician wellbeing.


Burnout Socio-cultural factors Organizational factors Regulatory factors Environmental factors 


  1. 1.
    Maslach C, Schaufeli W, Lieter M. Job burnout. Annu Rev Psychol. 2001;52(1):397–422.CrossRefGoogle Scholar
  2. 2.
    Balch CM, Freischlag JA, Shanafelt TD. Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences. Arch Surg. 2009;144(4):371–6.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Bittner JGT, Khan Z, Babu M, et al. Stress, burnout, and maladaptive coping: strategies for surgeon well-being. Bull Am Coll Surg. 2011;96(8):17–22.PubMedPubMedCentralGoogle Scholar
  4. 4.
    Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354–73.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Shanafelt TD, Balch CM, Dyrbye LN, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54–62.CrossRefGoogle Scholar
  6. 6.
    Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–13.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Van der Heijden F, Dillingh G, Bakker A, et al. Suicidal thoughts among medical residents with burnout. Arch Suicide Res. 2008;12(4):344–6.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Shanafelt TD, Dyrbye LN, West CP, et al. Potential impact of burnout on the US physician workforce. Mayo Clin Proc. 2016;91(11):1667–8.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Balch CM, Shanafelt TD, Sloan JA, et al. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann Surg. 2011;254(4):558–68.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463–71.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Dyrbye LN, Shanafelt TD, Balch CM, et al. Physicians married or partnered to physicians: a comparative study in the American College of Surgeons. J Am Coll Surg. 2010;211(5):663–71.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Dyrbye LN, Shanafelt TD, Balch C, et al. Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex. Arch Surg. 2011;146(2):211–7.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: a call to explore and address this under recognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, 2017 National Academy of Medicine, Washington, DC. Washington, DC: National Academy of Medicine. Accessed 1.12.19.
  14. 14.
    Shanafelt TD, Mungo M, Schmitgen J, et al. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. Mayo Clin Proc. 2016;91(4):422–31.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91(7):836–48.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    West CP, Dyrbye LN, Shanafelt T. Physician burnout, contributors, consequences and solutions. J Intern Med. 2018;283:516–29.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    DesRoches CM, Rao SR, Fromson JA, et al. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA. 2010;304(2):187–93.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Sanfey H, Fromson J, Mellinger J, et al. Surgeons in difficulty: an exploration of differences in assistance-seeking behaviors between male and female surgeons. J Am Coll Surg. 2015;221(2):621–7.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Sanfey H, Fromson J, Mellinger J, et al. Residents in distress: an exploration of assistance-seeking and reporting behaviors. AJS. 2015;210(4):678–84.CrossRefGoogle Scholar
  20. 20.
    Brigham T, Barden C, Legreid Dopp A, et al. A journey to construct an all-encompassing conceptual model of factors affecting clinician well-being and resilience. NAM Perspectives. Discussion Paper. Washington, DC: National Academy of Medicine; 2018. Accessed 1.14.19.Google Scholar
  21. 21.
    Rassolian M, Peterson LE, Fang B, et al. Workplace factors associated with burnout of family physicians. JAMA Intern Med. 2017;177(17):1036–7.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Lemaire JB, Wallace JE. Not all coping strategies are created equal: a mixed methods study exploring physicians’ self-reported coping strategies. BMC Health Serv Res. 2010;10(1):208.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Cousin G, Mast MS, Jaunin-Stalder N. When physician-expressed uncertainty leads to patient dissatisfaction: a gender study. Med Educ. 2013;47:923–31.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Linzer M, Harwood E. Gendered expectations: do they contribute to high burnout among female physicians? J Gen Intern Med. 2018;33(6):963–5.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Mast MS, Hall JA, Roter DL. Disentangling physician sex and physician communication style: their effects on patient satisfaction in a virtual medical visit. Patient Educ Couns. 2007;68:16–22.CrossRefGoogle Scholar
  26. 26.
    Mast MS, Hall JA, Cronauer CK, et al. Perceived dominance in physicians: are female physicians under scrutiny? Patient Educ Couns. 2011;83:174–9.CrossRefGoogle Scholar
  27. 27.
    Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714–21.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Medscape National Physician Burnout & Depression Report 2018. Accessed 1.12.19.
  29. 29.
    Shanafelt T, Kaups KL, Nelson H, et al. An interactive, individualized intervention to promote behavioral change to increase personal wellbeing in US surgeons. Ann Surg. 2014;259(1):82–8.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Shanafelt TD, Chung H, White H, et al. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol. 2006;24(24):4020–6.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Gelfand DV, Podnos YD, Carmichael J, et al. Effect of the 80-hour workweek on resident burnout. Arch Surg. 2004;139(9):933–40.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Goitein L, Shanafelt TD, Wipf JE, et al. The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165(22):2601–6.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243:864–75.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Rosen IM, Gimotty PA, Shea JA, et al. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med. 2006;81(1):82–5.CrossRefGoogle Scholar
  35. 35.
    Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995–1000.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296:1071–8.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Luu S, Patel P, St-Martin L, et al. Waking up the next morning: surgeons emotional reactions to adverse events. Med Educ. 2012;46:1179–88.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    DeCaporale-Ryan L, Sakran J, Grant SB, et al. The undiagnosed pandemic: burnout and depression within the surgical community. Curr Probl Surg. 2017;54(9):453–502.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Marmon LM, Heiss K. Improving surgeon wellness: the second victim syndrome and quality of care. In: Seminars in pediatric surgery. Elsevier; 2015.Google Scholar
  40. 40.
    Sakran JV, Kaafarani H, Mouawad NJ, et al. When things go wrong. Bull Am Coll Surg. 2011;96(8):13–6.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Plews-Ogan M, May N, Owens J, et al. Wisdom in medicine: what helps physicians after a medical error? Acad Med. 2016;91(2):233–41.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Carinci AJ, Christo PJ. Physician impairment: is recovery feasible. Pain Physician. 2009;12(3):487–91.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Linzer M, Levine R, Meltzer D, et al. 10 bold steps to prevent burnout in general internal medicine. J Gen Intern Med. 2013;29(1):18–20.PubMedCentralCrossRefGoogle Scholar
  44. 44.
    Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92(1):129–46. Scholar
  45. 45.
    National Academy of Medicine. Action collaborative on clinician well-being and resilience. Accessed 1.14.19.
  46. 46.
    Peckham C. Medscape survey lifestyle report 2016: Bias and burnout. 2016. Accessed 1.3.19.
  47. 47.
    Goroll AH. Eliminating the term primary care “provider”: consequences of language for the future of primary care. JAMA. 2016;315(17):1833–4.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Shanafelt TD, Goh J, Sinsky C. The business case for investing in physician well-being. JAMA Intern Med. 2017;177(12):1826–32.CrossRefGoogle Scholar
  49. 49.
    Helfrich CD, Simonetti JA, Clinton WL, et al. The association of team-specific workload and staffing with odds of burnout among VA primary care team members. J Gen Intern Med. 2017;32(7):760–6.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Shanafelt T, Dyrbye LN, West CP. Addressing physician burnout; the way forward. JAMA. 2017;317(9):901–2.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
  52. 52.
    Martin L. Good news: how to extinguish physician burnout. Advisory Board. Accessed 1.12.19.
  53. 53.
    Boothman RC, Imhoff SJ, Campbell DA Jr. Nurturing a culture of patient safety and achieving lower malpractice risk through disclosure: lessons learned and future directions. Front Health Serv Manag. 2012;28:13–28.CrossRefGoogle Scholar
  54. 54.
    Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153:213–21.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    CANDOR Quality AfHRa. Communication and Optimal Resolution (CANDOR) Toolkit. 2016. Accessed 1.14.19.
  56. 56.
    Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168–77.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Panagioti M, Panagopoulou E, Bower P, et al. Controlled interventions to reduce burnout in physicians a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195–205.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272–81.PubMedPubMedCentralCrossRefGoogle Scholar
  59. 59.
    Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. J Gen Intern Med. 2015;30(8):1105–11.PubMedPubMedCentralCrossRefGoogle Scholar
  60. 60.
    Swensen S, Kabcenell A, Shanafelt T. Physician-organization collaboration reduces physician burnout and promotes engagement: the Mayo Clinic experience. J Health Manag. 2016;61(2):105–27.Google Scholar
  61. 61.
  62. 62.
    Center for Professional Health, Vanderbilt University Medical Center. Accessed 1.13.19.
  63. 63.
    Salles A, Nandagopal K, Walton G. Belonging: a simple, brief intervention decreases burnout. J Am Coll Surg. 2013;217:S116.CrossRefGoogle Scholar
  64. 64.
    West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527–33.CrossRefGoogle Scholar
  65. 65.
    Linzer M, Visser MR, Oort FJ, et al. Society of General Internal Medicine (SGIM) Career Satisfaction Study Group. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. 2001;111(2):170–5.PubMedCrossRefPubMedCentralGoogle Scholar
  66. 66.
    Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358–67.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334–41.PubMedPubMedCentralCrossRefGoogle Scholar
  68. 68.
    Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443–51.PubMedPubMedCentralCrossRefGoogle Scholar
  69. 69.
    Dyrbye LN, Shanafelt TD, Werner L, et al. The impact of a required longitudinal stress management and resilience training course for first-year medical students. J Gen Intern Med. 2017;32(12):1309–14.PubMedPubMedCentralCrossRefGoogle Scholar
  70. 70.
    De Vibe M, Solhaug I, Tyssen R, et al. Mindfulness training for stress management: a randomised controlled study of medical and psychology students. BMC Med Educ. 2013;13:107.PubMedPubMedCentralCrossRefGoogle Scholar
  71. 71.
    Ishak W, Nikravesh R, Lederer S, et al. Burnout in medical students: a systematic review. Clin Teach. 2013;10(4):242–5.CrossRefGoogle Scholar
  72. 72.
    Slavin SJ, Chibnall JT. Finding the why, changing the how: improving the mental health of medical students, residents, and physicians. Acad Med. 2016;91(9):1194–6.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Warnecke E, Quinn S, Ogden K, et al. A randomised controlled trial of the effects of mindfulness practice on medical student stress levels. Med Educ. 2011;45(4):381–8.PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    Dyrbye LN, Moutier C, Durning SJ, et al. The problems program directors inherit: medical student distress at the time of graduation. Med Teach. 2011;33(9):756–8.PubMedCrossRefPubMedCentralGoogle Scholar
  75. 75.
    Mata DA, Ramos MA, Bansai N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA. 2015;314(22):2373–83.PubMedPubMedCentralCrossRefGoogle Scholar
  76. 76.
    Martini S, Arfken CL, Churchill A, et al. Burnout comparison among residents in different medical specialties. Acad Psychiatry. 2004;28(3):240–2.PubMedCrossRefPubMedCentralGoogle Scholar
  77. 77.
    Stoesser K, Cobb NM. Self-treatment and informal treatment for depression among resident physicians. Fam Med. 2013;46(10):797–801.Google Scholar
  78. 78.
    Hakanen JJ, Schaufeli WB. Do burnout and work engagement predict depressive symptoms and life satisfaction? A three-wave seven-year prospective study. J Affect Disord. 2012;141(2–3):415–24.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    Elmore LC, Jeffe DB, Jin L, et al. National Survey of Burnout among US General Surgery Residents. J Am Coll Surg. 2016;223(3):440–51.PubMedPubMedCentralCrossRefGoogle Scholar
  80. 80.
    Dyrbye LN, Eacker A, Durning SJ, et al. The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout. Acad Med. 2015;90(7):961–9.PubMedCrossRefPubMedCentralGoogle Scholar
  81. 81.
    Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302(12):1338–40.PubMedPubMedCentralCrossRefGoogle Scholar
  82. 82.
    Hu Y-Y, Fix ML, Hevelone MD, et al. Physicians’ needs in coping with emotional stressors: the case for peer support. Arch Surg. 2012;147(3):212–7.PubMedCrossRefPubMedCentralGoogle Scholar
  83. 83.
    Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200–4.PubMedCrossRefPubMedCentralGoogle Scholar
  84. 84.
    Hickson GB, Pichert JW, Webb LE, et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82(11):1040–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of SurgerySIU School of MedicineSpringfieldUSA

Personalised recommendations