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Burnout in Canadian Oral and Maxillofacial Surgeons

June 7, 2021
by Tania P. Pynn, BScN, MHS; William J. Montelpare, PhD; Bruce R. Pynn, MSc, DDS, FRCD(C)


INTRODUCTION

Studies on occupational stress in healthcare professionals are not new, however limited information is available on stress impact and ultimately burnout in oral and maxillofacial surgeons and residents.1,2 Occupational stress is the outcome of the clash between job-related factors interacting with personal factors with a resulting change to the individuals’ physical or psychological state.2 No aspect of life is more stressful and has more impact on overall health and well-being than occupational related stress.3,4 Stress can sometimes be a positive motivating factor, however over time when this stress is repetitive, excessive, and leaving little time to decompress, this level of stress can lead to decreased performance, unhealthy behaviors and eventual burnout.1,2,5

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Burnout is considered by the World Health Organization International Classification of Diseases as a worldwide epidemic defined by the direct correlation of work-related high emotional fatigue, excessive depersonalization and a low sense of personal success.1,2,5,6 Emotional fatigue is the feeling of being emotionally exhausted by one’s work. Depersonalization is considered the dehumanized perception of others. Low personal success is the feeling of one’s dissatisfaction with their occupational achievements.7-9

Burnout in the physician population can not only lead to professional and personal dysfunction but can also lead to negative effects on their patient population by impairing the quality of life and quality of the care provided to their patient by increasing the possibility of medical errors.3,9-13 One of the unfortunate ironies of professional burnout is that those most susceptible to burnout appear to be the most dedicated, conscientious, motivated and responsible. It is these types of individuals who are idealistic and have perfectionist qualities that can lead them into diving into their work to the point of having nothing left in reserve to give to their personal life.10

Dentistry has been identified as one of the leading professions that causes high levels of stress and burnout. This stress level has a direct correlation with the relationship between the dentist and their patient, their overall satisfaction with the job, the level of work demand including extended work hours, and exposure to substances that can be toxic.2,9,13,14

Oral and maxillofacial surgery is a specialty that falls under the umbrella of dentistry. Their practices are similar to many other surgical practices by the nature in which they provide and deliver care; that being on-call, performing inpatient and outpatient care, attending to critical traumatic events, and performing major surgical procedures under local and general anesthesia. The Oral and Maxillofacial surgeon (OMFS), after many years of intense training, is then placed into an environment where patients are constantly physically and emotionally stressed, who many times are faced with disfiguring tumors, facial trauma causing deformities, and many times are fearful of dental related procedures, no matter how big or small.4 The OMFS, like many surgeons, have a higher risk of professional burnout due to strong commitment to patients, attention to fine detail, and recognizing the responsibility of engaging their patients’ trust.2,3,14

A finite amount of specific research can be found on the impact that professional stress and burnout has on OMFS across the world and more specifically no information could be found on the Canadian Oral and Maxillofacial surgeons’ population both within the academic and practice setting. For this reason, we conducted a survey among OMFS residents to assess burnout frequency and to assess satisfaction in the workplace, life satisfaction, and general self-efficacy.

MATERIALS AND METHODS
The design of this study was a cross-sectional, observational study with a questionnaire mailed to all oral and maxillofacial surgeons, as well as oral and maxillofacial surgery residents, practicing within Canada. Participants were identified through the Canadian Association of Oral and Maxillofacial Surgeons (CAOMS). The review of 2018 active membership indicated that this cohort represented approximately 237 OMFS professionals and 53 residents.

Many professions have used the Maslach Burnout Inventory Human Services Study (MBI-HSS) survey to quantify the burnout phenomenon and is considered the gold standard tool for measuring burnout.5-7 We also utilized three additional stress assessment tools to gather as much information as we could on our target group. These evaluation tools assessed the following elements: 1) demographic information, 2) workplace stress (8 questions), 3) life satisfaction (25 questions), 4) general self-efficacy (10 questions), and 5) the MBI-HSS (22 questions).

Each surgeon and resident was sent the survey over the internet from the CAOMS secretariat and was asked to complete the surveys using an electronic format to a password-protected server. This was done twice over a two-month interval. In an attempt to improve response rate, this was followed up in six months with a mail out to participants to complete the questionnaire. They were provided with a self-addressed envelope in which to return the completed survey.

Data was first analyzed by deriving summary scores for each of the surveys and then reporting on the descriptive statistics using means and standard deviations to summarize the total survey response scores, and using frequency distributions to compare proportions of respondents to each survey item. Selected two-group comparisons were analyzed using t-tests for unequal variance. For example, the MBI-HSS consisted of 22 questions with a response range of 0 to 6 and the following verbal anchors: ‘0’ => ‘Never’, ‘1’ => ‘A few times a year or less’,’2’ => ‘Once a month or less’, ‘3’ => ‘A few times a month’, ‘4’ => ‘Once a week’, ‘5’ => ‘A few times a week’, ‘6’ => ‘Every day’.

These responses were summed and an average Maslach Burnout score was calculated for each participant. The mean group scores were then computed along with the standard deviations. The group mean score was compared against the independent question which was purported to describe burnout. Similarly, summary scores were created for each of the other surveys – the Workplace Stress Scale, the General Self-Efficacy Scale, and the Life Satisfaction Scale. Each of these survey summary scores was compared in a correlation matrix based on Pearson’s Product Moment Correlation Coefficient to determine relationships between estimates.

Approval to conduct this project was provided by UPEI research ethics board (REB) File # 6007057.

RESULTS
The sample consisted of 206 active member respondents from across Canada, 34 of which were residents/fellows, yielding a response of 72% for members and 64% response rate for resident/fellows. Distribution of the sample by sex showed that there were 186 males (90%) and 20 females (10%) with most respondents in private practice. The age ranged between 28 to 82. The years of practice was split almost evenly, less than 20 years and more than 20 years, 52% and 48% respectively. The following table highlights key results from the four evaluative tools used. (Table 1)

Table 1

 Highlights of evaluation tools. *The members with less than 20 years of practice tended to rate the response significantly higher on average than surgeons that practise more than 20 years.

Highlights of evaluation tools. *The members with less than 20 years of practice tended to rate the response significantly higher on average than surgeons that practise more than 20 years.

DISCUSSION
The results of this study are consistent with previous research within cohorts of health professionals that report prevalence of perceived burnout to range, on average, from 2% to 59%. Moreover, the data in the CAOMS sample indicated an approximate perceived burnout score of 15%, which is similar to the 17% estimated perceived burnout scores for oral and maxillofacial surgeons in the Brazilian study, however the response rate for this study was only 23%.15 This contrasts with the Dutch study that presented a healthy 70% response rate and showed a low burnout risk with a high professional engagement at work.16 The low rate in the Dutch study may be attributed to their work circumstances, which is large group hospital practices that provide a lively supportive work environment and dynamic social interaction.16

While 15% in the CAOMS results may seem somewhat low in relative terms, it gains importance when one considers the actual sample size of the study. This estimate of 15% represents approximately 30 respondents from the total sample. While not separated by age group or sex, the estimated number of respondents indicating a feeling of being burnt out is evidence that more attention to the mental health consequences of work-related stress is required. No doubt as we explore deeper into the roots of such stress, cohort differences will emerge.

As in other studies, it has been documented that across multiple specialties that age and years of practice have lower burnout and psychological distress.1,4,5,16,17 Physicians and surgeons who are older with many years of practice have learned to cope with demands of the profession. In Rose’s article it is also suggested that older surgeons identify that burnout wasn’t a term they heard and adapted to working far more than 40 hours per week to get the work done.5 They have developed mechanisms to protect themselves against burnout such as acquired confidence, maturity, and gaining control over their professional life. These finding are consistent with the results of this study as there were significantly less burnout, work stress and improved coping skills in members with 20 or more years of experience. This result is also in agreement with Brazilian OMFS, which found greater work experience and had less burnout and greater personal accomplishments.15 The Saudi Arabian OMFS study showed that 85% of their surgeons had less than 15 years of work experience which likely correlates to their high burnout and stress.2 The older surgeons in this study tended to take on less interesting cases and decrease their workload, which, in turn, lowered their stress levels.

What we must realize however, that although burnout is important to recognize in our practicing surgeons, the problem in burnout may actually start much earlier, when the surgical resident is still in training.3,5,9 Studies quoted by Moalem noted that the incidence of burnout in residency might also be on the rise noting a study a decade ago had identified a rate of 40% of surgical residents experiencing burnout, with 69% in a more current study experiencing some form of burnout.3 Bittner had stated that, depending on the specialty, burnout in surgical residents can range anywhere from 11.8% (general surgery) to 75% (otolaryngology-head and neck surgery).9 In our study, 36% of residents who responded experienced burnout. The results for the residents were interesting in that comparing the stress scores for those respondents that indicated that they were residents versus those who were currently working in oral surgery as their primary practice, was a significant difference in the average stress score measured with Maslach burnout inventory. The increase in burnout in the resident or younger surgeon may also have a correlation with the added education and training residents now go through to help with awareness of the dangers of fatigue and how to control work hour limitations.5

Workplace stress is defined as the harmful physical and emotional responses that can happen when there is a conflict between job demands on the employee and the amount of control an employee has over meeting these demands. The current survey demonstrates that 14% of the respondents replied that work is negatively affecting their physical and emotional well-being. It also placed too much work on their shoulders with unreasonable deadlines, as well as not having adequate control over their work duties. This third factor was significantly different for those with more than 20 years of experience. This is in steep contrast to the Brazil and Saudi Arabia surveys which found 66% workplace stressors significantly impacted their life.2,15 The high demand, long hours and pace, administration and paperwork provided a difficult and unsatisfactory working environment.

Our results have also identified some significant positive results. We recognize that 85% of respondents within our study felt like they have had a positive influence in their patients’ lives; 80% are excited about learning/developing new skills and talents; and 70% live life with passion and joy. These are encouraging results and correlate with results from other studies noting that those who have been able to find a work life balance without the feeling of guilt of leaving work on time have been able to enjoy both a successful career and positive home life thereby reducing work stress and fatique.1,5,9,16,18

In conclusion, burnout amongst Canadian OMFS is low at approximately 15%, with surgeons having less than 20 years of practical experience exhibiting greater workplace stress and less coping skills. By utilizing the results of this study, we hope to stimulate further collaboration amongst the physicians, surgeons and supportive health professionals who would be in the position to support the mental well-being of the target physician group and their significant others as well as physician groups overall. Promotion of physician health and wellness is an issue of utmost importance for practicing physicians and students heading towards a career in the healthcare industry. Individuals should have access to professional support through their associations and educational institutions, as well mentorship, support and encouragement from colleagues. It also is important to develop hobbies and outside interests to help with general well-being and overall outlook on life. One needs to strive for work life balance!

Oral Health welcomes this original article.

Supported by a grant from the Foundation for Continuing Education and Research, Canadian Association of Oral and Maxillofacial Surgeons.

References

  1. Porto GG, Carneiro SC, Vasconcelos BC, Nascimento MM, Leal JL. Burnout syndrome in oral and maxillofacial surgeons: A critical analysis. Int J Oral Maxillofac Surg. 2014 Mar 12. pii: S0901-5027(14)00062-9. 1016/j.ijom.2013.10.025.
  2. Alkindi M, Alghamdi O, Alnofaie H, AlHammad Z, Badwelan M, Albarakati S. Assessment of occupational stress among oral and maxillofacial surgeons and residents in Saudi Arabia: A cross-sectional study. Adv Med Educ Pract. 2020; 11: 741-753.
  3. Moalem J. Burnout in surgery. In ACS RISE: American College of Surgeons Resources in Surgical Education retrieved April 11, 2021 at https://www.facs.org/education/division-of-education/publications/rise.
  4. LaPorta LD. Occupational stress in oral and maxillofacial surgeons: tendencies, traits, and triggers. Oral and Maxillofacial Surg Clin N Am. 2010; 22: 495-502.
  5. Rose D. Managing burnout: seek outside help and foster a true work-life balance. Bulletin of the American College of Surgeons. 2017 Mar: 26-29.
  6. Contag SP, Golub JS, Teknos TN, Nussenbaum B, Stack BC, Arnold DJ, Johns MM. Professional burnout among microvascular and reconstructive free-flap head and neck surgeons in the United States. Arch Otolaryngol Head and Neck Surg. Oct 2010; 136(10): 950-956.
  7. Maslach C, Leiter MP. Maslach Burnout Inventory Manual, Palo Alto, CA: CPP Inc; 1996.
  8. West CP, Dyrbye LN, Sloan JA, Shanafelt TD. Single item measures of emotional exhaustion and depersonalization are useful for assessing burnout in medical professionals. J Gen Intern Med. 2009; 24(12): 1318-1321.
  9. Bittner JG, Khan Z, Babu M, Hamed O. Stress, burnout, and maladaptive coping: Strategies for surgeon well-being. Bulletin of the American College of Surgeons. 2011 Aug: 17-21.
  10. 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): 371-376.
  11. American Public Health Association. Public health impacts of job stress. Am J Public Health. 201; 91(3): 502-503.
  12. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010; 251(6): 995-1000.
  13. Balch CM, Shanafelt T. Combating stress and burnout in surgical practice: a review. Advances in Surgery. 2010; 44: 29-47.
  14. Gabbard GO. The role of compulsiveness in the normal physician. JAMA. 1985; 254 (20): 2926-2929.
  15. Carneiro SCA, Vasconcelos BC, Nascimento MMM, Leal JLF, Orestes MS, Porto GG. Occupational stress among Brazilian oral-maxillofacial surgeons. Med Oral Patol Oral Cir Bucal. 2009 Dec 1; 14 (12): e646-9.
  16. Gorter RC, Jacobs BLTH, Allard RHB. Low burnout risk and high engagement levels among oral and maxillofacial surgeons. Eur J Oral Sci. 2012; 120: 69-74.
  17. Murtha Y. Perspectives of being spouse, parent, and surgeon. J Orthop Trauma. Oct 2013; 27: S12-S13.
  18. Shanafelt T. A career in surgical oncology: finding meaning, balance, and personal satisfaction. Ann Surg Oncol. 2008; 15(2): 400-406.

About the Authors

Tania Pynn graduated from the University of Toronto with a Bachelor of Science in Nursing and went on to obtain her Masters of Health Studies from Athabasca University. She is the Associate Dean for the School of Health, Negahneewin, and Community Services, Confederation College, in Thunder Bay, Ontario. One of the programs she has direct oversight for is the Oral Health programs.

 

Professor William J. Montelpare, Ph.D., graduated from the University of Toronto with a Ph.D. in Community Health specializing in Biostatistics, Epidemiology and Exercise Science. He began at Brock University, followed by Lakehead University, and then University of Leeds, UK. In July 2012 he returned to Canada to accept the Margaret and Wallace McCain Chair in Human Development and Health at the University of Prince Edward Island.

 

Dr. Bruce R. Pynn is Oral Health’s editorial board member for Oral and Maxillofacial Surgery. He maintains a private practice in Thunder Bay, ON. He is an Assistant Professor, North Ontario School of Medicine, Lakehead University, and Chief of Dentistry, Thunder Bay Regional Health Sciences Centre.


To read more articles from the 2021 Oral Surgery issue, click here!


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