A recent JBJS report by Stein et al. calls attention to the important topic of physician mental health. In particular, the authors sought to determine factors associated with depression and suicidal ideation (SI) in orthopaedics. This survey-based study found that these issues are not uncommon among orthopaedic surgeons. And the authors conclude, “The normalization of discussions of emotional well-being, depression, and SI is imperative.”
Gender-Based Differences
Stein et al. found that gender is a factor significantly associated with depression and/or SI. Among the survey respondents, 32.8% of women compared with 21.3% of men reported active SI in their lifetime.
This warrants further discussion. If we in orthopaedics are to support the well-being of our community, we must also acknowledge and address gender-based differences that contribute to burnout and related issues with attrition and mental health.
“The issues that lead to burnout for physicians are systemic,” says Kim Templeton, MD, speaking to OrthoBuzz. Dr. Templeton is a Professor of Orthopaedic Surgery and the Residency Program Director at the University of Kansas Medical Center-Kansas City.
“While women and men physicians face many similar challenges, there are other issues that are more specific to women. These include a lack of accommodation for women’s gendered roles outside of the workplace, biases and harassment, and lack of support. All of these can contribute to making women feel as though they don’t belong in medicine or in their workplace. This can be a significant contributor to burnout.”
Dr. Templeton was the lead author on a 2019 discussion paper published in the National Academy of Medicine’s NAM Perspectives1 that reviewed the prevalence, causes, and consequences of physician burnout. “Gender-Based Differences in Burnout: Issues Faced by Women Physicians” discusses contributing factors for burnout that have a greater or different impact on women than men.
The paper notes that burnout, depression, and SI are separate but related entities. “It is critically important to distinguish between these conditions, because their remedies are different.” Burnout can contribute to the development of depression. The authors point out that mitigation of burnout requires culture and system change, while depression requires individual medical and/or psychologic treatment.
Contributing Factors
The discussion paper points to both external and individual factors behind burnout. External factors include conflict in work-life integration.
“Women typically perform most of the work within the home, and women employed full time spend 8.5 additional hours per week, compared to men, on childcare and other domestic activities, including care for elderly parents,” notes Dr. Templeton. “Women are also more likely than men to have partners or significant others who are employed full time. Due to societal gendered expectations, a woman who works full time is more likely than a man in a similar situation to be responsible for work at home, especially when typical supports fall through, such as school or child or elder care. We need to follow the impact of the pandemic in this area.”
All of this leads to women attempting to balance responsibilities at work and at home, leaving little time for self-care.
Other external factors include gender bias and discrimination. These can be compounded for women who belong to racial or ethnic minority groups. The biases, often unconscious, can lead not only to disparities in pay but also disparities in mentorship and sponsorship in women’s careers. This includes promotion, participation in speaking engagements, and leadership opportunities.
Templeton et al. also note that gender-related bias appears to especially impact physicians who are mothers. Discrimination related to pregnancy, maternity leave, and breastfeeding are among issues reported by physician mothers. Say the authors, “exposure to maternal discrimination was associated with increased incidence of self-reported burnout.”
In addition, women physicians are more likely to experience workplace harassment. And the authors note that women who belong to a sexual minority group are at risk of also experiencing harassment on the basis of their sexual orientation.
Strategies to Promote Well-Being
Strong and proactive leadership is needed to promote physician well-being. Leaders, women and men, can help shape a culture change that eliminates or reduces not only the bias in the workplace but can develop balance through intentional programs such as gender-specific mentorship and sponsorship programs or policies to improve work-life integration. Given the issues that women face in rising to leadership positions, especially in orthopaedic surgery, this type of change cannot wait until there are more women in the C-suite, as women will never reach a critical mass in this area without culture change.
To mitigate gender-based differences of burnout in physicians, Templeton et al. offer the following recommendations:1
- A consensus definition of burnout is needed. The research community should also promote the use of standardized measures. Assessments of physician wellness should consistently include physician demographics.
- Organizations should develop interventions targeted at personal and institutional factors, with an emphasis on the institutional factors to drive change.
- The culture of medicine must change to eliminate bias (both conscious and unconscious), gender discrimination, and sexual harassment.
- Health-care institutions should prioritize the physical and mental health of all physicians, with specific tactics employed for women physicians (e.g., normalizing self-care; making resources available when women are available, given their other responsibilities).
If we are to continue to promote diversity in orthopaedic surgery, we need to understand the issues that people from non-majority backgrounds face in the workplace. Diversifying the pipeline of orthopaedic surgery requires more than just changing the demographics of residents and early career surgeons but also means intentional efforts to support all orthopaedic surgeons throughout their careers. Part of this requires that as a physician community we recognize gender-based differences and work to change our culture.
Real-World Impact
As a husband in a dual-physician family, I see the risk factors for burnout on a daily basis. I recognize that extra responsibilities inevitably fall on my physician wife, currently the President of the American College of Emergency Physicians (ACEP). Despite leading an organization of 40,000 ER physicians, she is the default person that gets text messages about play dates and school functions, and the first to be called when someone is sick, even when I try to proactively request that information run through me during the busiest times of her presidency. Sweeping change requires movement on an institutional level, but incremental change can start at home.
Read the NAM Perspectives article by Templeton et al.
Access the JBJS study by Stein et al. Two related commentaries, by Julia M. Kim, PhD and Mark Alan Fontana, PhD, provide additional insights.
For readers in need of help, please contact Physician Support Line for urgent confidential help; for longer term help, please contact mental health resources available within your institution. Additional support can be found at the National Suicide Prevention Lifeline (800-273-8255).
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
References
- Templeton, K., C. Bernstein, J. Sukhera, L. M. Nora, C. Newman, H. Burstin, C. Guille, L. Lynn, M. L. Schwarze, S. Sen, and N. Busis. 2019. Gender-based differences in burnout: Issues faced by women physicians. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201905a
