Okay, so it really ties in well. Our last session here on management and prevention of physician burnout. I've asked Casey Hombred to moderate this session, not because she's the only expert on burnout, but because she does a lot of research and thinking into ethics. She was at Sinai Medical School, Hopkins Residency, Mercy Fellowship, now Associate Professor at Hopkins, and she is a faculty member actually at the Institute of Bioethics at Johns Hopkins, and like I said, has a proven track record in the topic. Currently, she's a member at large on the AOFA's board. So Casey, thank you so much and to the group for being here, and I'll turn it over to you. I am so honored to get to moderate our session on burnout, and our presenters tonight include Dr. Catherine Sage, Dr. Sandra Klein, Dr. Michael Arenow, Dr. Bruce Cowan, and Dr. Nugent. We'll begin with Dr. Sage. Hello, let me get my screen shared here. All right, so thank you everybody for having me, and thanks especially to Casey. I really appreciate being part of this. So I'm here to start to talk about work-life balance, and I was really conscious of making sure that this didn't turn into a burnout talk. So it really is about work-life balance and what that means as opposed to burnout. So my disclosures aren't really relevant to anything here. And so what is work-life balance? I'll just jump right in. There's not an agreed definition. It's different among cultures, but one thing that I kept seeing is this quote that it's the amount of time with your job versus doing something that you enjoy, which made me smile because it sort of inherently implies that we don't enjoy our job. So fortunately, that is not necessarily true for us orthopedic surgeons. Medscape job satisfaction survey from last year showed that 92% of us are satisfied or very satisfied with our jobs, and the other 80%, I don't know what they're doing. So real studies on work-life balance began in the 1980s, and so the first generation kind of said that non-work demands can adversely affect work, which looking back now is flawed in so many ways. By the mid-80s, they realized that this is home to work and work to home, and that it's not necessarily an adverse influence. It can be positive and negative, and it flows both directions. Second-level studies show that both work and personal lives are affected by how satisfied we are with both our work and personal lives. So another study that came out in the mid-80s, it really brought it home to time balance, involvement balance, and satisfaction balance. So that tends to be what most of the studies are on now. So jumping ahead from the 80s, because that was a while ago, is it relevant now? And the answer is yes. So again, these medscape studies where they poll people and try and find out what's important, there was one about women in medicine in 2020, and 64% of the respondents said that balance was her top concern in a job, and compare that with only 43%. And this is true not just for women, because there was a lifestyle report on balance and burnout, also from medscape in 2020, where it was more men, 62%, and 38% women. So 3% of the respondents were orthopedics, and you can kind of see the age breakdown there in terms of, these are their words, boomers, millennials, and the generics. So this is what they found. Would you take a salary reduction to get better work-life balance? And 50%, you know, about 50% of all respondents said yes. So I think that really points towards how important this is, if half of us are willing to take a salary reduction. And then they asked the follow-up question of how much of a salary reduction would you take? And it's 20% fewer hours, it's not 20 hours, and they didn't specify how many hours people are working. So you can, you know, guess somebody working 40 hours a week may have a different response than somebody who's working 80 hours a week. But many respondents were willing to take between a $10,000 and a $50,000 pay cut to work 20% fewer hours, which is, again, really impressive about sort of where our mindset as a group of physicians is that, you know, we really care about our work-life balance and to some extent are willing to take a pay change for that. But even with people who are interested in taking a pay cut or having a different work-life balance, still the majority says that they are happy with their work life. So it's not that people are necessarily unhappy right now, it's just that people realize that it could be better, was sort of what I took out of these slides from this Medscape survey. So there's a lot published on what happens when you don't have a good work-life balance. There was a Lancet meta review from 2015 that showed that people who worked more than 55 hours a week had a higher risk of a heart attack and a higher risk of a stroke compared with those who worked fewer hours. And so these were not physicians. When I was doing the background research for this, there actually are a lot of published studies from across the industry. So some of this data was pulled from different industries, but again, it's meta analysis. And then the second bullet point, another study of many people showed that longer working hours is related to poor mental health, anxiety, depression. And just to editorialize here, I couldn't put all the studies in. I mean, if you search PubMed, there are many, many studies that really kind of focus on this mental health side of work-life balance and focus around sleep and anxiety and depression. So there's a plethora of information on that. And again, it's across industries, it's not just for physicians, but it's certainly there for physicians. And then on the other side of the coin, a good work-life balance, there is at least one study that I found that showed that flexible work hours improved staff members' sleep quality, energy levels, and self-reported health, and reduced their emotional exhaustion, psychological distress, and work-family conflict. So both sides of the coin are true. If you have a good work-life balance, then you may overall be healthier, according to some of the literature. And if you have a bad work-life balance, you're very likely to at least suffer some anxiety and depression, things like that. Burnout, I didn't go much into this again, because it is a different topic, but 5,000 physician study from American Medical Association and other places showed that 43.9% of physicians had at least one symptom of burnout. And I didn't put all the symptoms in here, but we know what they are, right? Exhaustion, depression, fatigue, emotional mobility. So this is true, 2019 British Medical Association found the majority of doctors were at a risk of burnout. And then the same 2020 Medscape study that I quoted earlier showed that orthopedics had a 34% risk of burnout when they broke it down by specialty. So then how do you achieve a work-life balance? That's why I'm here. I'll give you the answer right now. No, obviously I can't do that. But there are a lot of studies on this. And again, they are across industries. So it's not specific to physicians, but a lot of different places are studying this. And there's studies out there from McKinsey and different consulting firms that are looking at this for big companies. So a lot of the studies tend to focus on things like flexible hours, telecommuting, working from home, shutting down devices. So we can't really do that in medicine. I mean, I would love to turn off my pager and just say I'm working on my work-life balance, but it's not something that we can really do in this life. There was one study that I found or a strategy that is geared specifically toward physicians. And it's not so much of a balance versus a counterbalance. So the theory is that there are 168 hours in the week, which can be altered. So if you have your normal week and you have your certain number of hours that are spent on work versus your life versus others, then that can shift based on what you're doing. So if you're on vacation, the goal is really to spend more time with yourself and your family. If you are on call or on a hospital service or a grant deadline, then you're going to spend more time at work. So it's not so much that every day has to be balanced. Like I spent enough time at work, I spent enough personal time taking care of myself, and I spent enough time with my family or doing my hobbies. It's more of an overall arching theme, whether that is week to week for you or month to month or year to year. And I will say right now that I didn't see any follow-up studies about if anyone's tried to implement this and how it worked out, but it's a strategy that's out there and it's specifically for physicians. So like I said, there's many studies out there. Some of the strategies can be implemented towards our lifestyle. So the first thing that came up again and again is setting goals. So if you're thinking about what your goals are for work and what your goals are for your personal life and what your goals are for your family or your hobbies, then figure them out. Write them down. Have a plan of what goals you want to achieve and stick to it or reevaluate it every so often. And so then you can move on to your bullet point number two, which is set boundaries. So if you're asked to do something or be part of a committee or even in your personal life, if you have to plan a birthday party or something, like if that doesn't fit into your goals and it's going to stress your work-life balance and help lead you towards burnout, then that's when you can say no or yes. And the other side of it, if you have a goal and you realize that you have an extra couple hours in your week and you want to do something to achieve that goal, like join a committee or plan a birthday party, then you move towards those goals. So at least if you are doing the extra work at work or at home or wherever you are, then you're moving towards things that are important to you and towards your goals. So this last one I really spent some time on because I always take my vacations and I feel a lot of guilt because I think I'm the only one that does. So again, the Medscape survey that showed half of physicians take less than two weeks a year, there's lots of studies. Again, I quoted a couple of them here that taking more paid vacation days, which I know paid, but was positively associated with both overall health and life satisfaction. And then there was actually a study that looked at middle aged men and if they took vacations or not and correlated it to their risk of coronary heart disease. And so if you take a vacation, you'll be healthier if you're a middle aged man, according to the study, at least. So my takeaways are take a vacation, figure out your goals, set your boundaries, and I don't know, try not to get depressed and feel empowered after watching that last lecture from Dr. Weibel. All right. And next I think up is Dr. Klein. So I'm excited to introduce her and I don't know if Casey has anything else to add here. Thank you so much for that wonderful talk, Dr. Sage. We're all excited now to hear from Dr. Klein. Thank you very much, I'm glad to be here. Thank you to Casey and Scott Ellis for including me, and I'm going to talk a little bit about pressure to publish and how that relates to the topic of burnout. Nothing really to disclose, maybe just that I'm not necessarily an expert on this, but I do have an interest and like to think a lot about this topic. So just to take a step back to think a little bit about what defines burnout, it was actually defined back in the 1970s, but I think we talk about it probably more these days than I've ever heard before. And the modern definition of burnout is defined by the Maslach scale, which defines emotional exhaustion, depersonalization, and then sort of a lack of a sense of personal accomplishment as the three components. And there have been quite a few studies that really zero in on the emotional exhaustion and the depersonalization as the key factors that define your burnout. And when we think of things that lead to burnout, the most common are job demands and workload, insufficient resources, a lack of control, and a lot of times poor leadership, and then when our professional and our personal values are not aligned. And if you look at all of these things and if you read about burnout, what we've learned over time is that it's not about the individual, it's about the work environment. So this isn't a lack of resilience or grit on the part of physicians, this isn't because of some personal flaw that we have that we may feel burned out, it's about the system around us, and to some degree our lack of control over that symptom system. And if you look at the Medscape data where they look at causes of burnout, the top cause is just too many things to do, whether it's just dictation or paperwork or phone calls. We get overwhelmed with all of these extra tasks and we're spending a lot of time doing things that may not feel like they fulfill us or may not feel like they're allowing us to function at the level of our education or at the top of our licenses, they say. So how does this relate to publications? Well, there is potential gain for many of us related to publication numbers. And I want to emphasize publication numbers because that's really where I think we can get into the trap of burnout. So we feel this pressure to publish no matter what, and that may lead to a feeling of burnout. Why do we feel this pressure? Well, in academics, you do want to demonstrate your talent and knowledge to peers. They might be seeking some national attention. It's great to present at meetings like this and to show people what we know. It can be used as a measure of performance in our job. Our leadership might look at publications and that might, our career advancement might depend on that. And we all want to have a competitive CV. And all of these things just add pressure to publish, but not necessarily inspiration to do great research. When we look at what the literature says, there's actually not a lot out there, but this was one study among Dutch professors, so not necessarily all, you know, surgeons or even physicians, there's professors at medical institutions. And 54% did feel that the pressure to publish was excessive, and 39% felt that their ability to publish or not would affect their credibility, and 24% had signs of burnout. So it wasn't a direct relationship between pressure to publish and burnout, but they just wanted to highlight that it maybe goes hand in hand. There is this publication pressure questionnaire that I found, and there's one study out there that says that this stress subscale on the publication pressure questionnaire, where it talks about experiencing stress over publications and feeling forced to spend extra time and I can't find time to work on publications, this study basically showed that this stress domain correlated directly with the Maslach inventory for burnout, especially in the exhaustion category. So this pressure to publish has been, you know, very loosely linked to burnout, but I think it's real, even though there may not be a lot of studies to support that. And there's no break from this pressure. This was a study that actually looked to see if people were submitting publications on the weekend and over breaks and on, you know, after hours, and it was variable by country, but in the U.S. there was a high level of holiday submissions and common in the evenings, actually, I didn't put that on here, not as common on the weekends as some other countries. So I think it's interesting to look at that, as we all know in academics, a lot of this publication work or research that we do happens outside of our normal nine to five or six to seven sort of hours. And so what's the impact on research? And this is, you know, critical to look at, too, because this has an impact on us as people, but also has an impact on the research that we do. It tends to lend itself to trivial research with rapid results, sometimes can lead to duplicate publications and worst case scenario, plagiarism or fraud. But even this, what they call salami slicing, where you're breaking research into small parts to create three or four publications out of one research project. And all of these things have an impact on our trusted journals, they have an impact on our ability to move the field of foot and ankle surgery forward in terms of the quality research that we do. And realistically, this was a good article about burnout and what some of the critical factors were. It just said that people who spent less time on the things they really love to do felt more burnt out, which makes sense if you think about it. So what do we do to manage this? Well, I think, you know, the important thing that I got out of all the reading I did about this is that the publication of quality research does help all of us. But there probably do need to be structural changes to the academic environment, which we may or may not have complete control over. But a trend towards prioritizing quality over quantity, valuing academic contributions beyond the number of publications or even just grant funding, and always remembering that meaningful work reduces burnout. So there may be some people among us where research is your passion, and that's where you want to spend most of your time. There may be other people where it's not, if we can balance that in the academic environment so everybody is spending more time on the components of academic medicine or medicine in general that they enjoy the most, we may find that we're all more productive. So changes are important. So, you know, for the leaders of departments out there, these institutional barriers to helping us get good quality research done are important, because the more barriers there are, the higher the level of burnout. And so thank you very much. And I'm going to turn it over to the next speaker. Thank you so much, Dr. Klein. We're now all excited to hear from Dr. Aronow, who's going to speak to us about government regulation and burnout. Thanks, Casey. Thanks, Scott. My topic's a broad one, but first with disclosures, I belong to multiple medical organizations that are involved in government regulation, are assessing it, but do not receive any salary from any of them. And talk about the effects of government regulation on physician burnout, both positive and negative, and how to try to prevent and manage the results of burnout regulations, both by adapting to regulation and attempting to influence it. And I'm going to focus on the Center for Medicare and Medicaid Services, or CMS, for most of this talk. CMS provides an organizational framework where covered patients receive health care and payment for services are provided. The goal is to improve care and control costs. The problem is that regulation isn't always successful. The policy may be flawed, it may be poorly implemented, and there may be unintended and intended side effects. How does government regulation affect physician burnout? Well, compliance with regulation requires both time and money. That means there's less physician time for patients, family, exercise, sleep, hobbies. Also can lead to decreased income, there's less patients per session, less reimbursement per patient, increased staff costs, and the cost of EMR software, consultants, and other vendors required for compliance can cause frustration. The regulations may seem unreasonable, inefficient, and of questionable patient benefit. There's fear of being accused of fraud, resulting in fines, imprisonment, restrictions on your practice. And there's uncertainty, regulations are often extensive and complex, and surgeons like to be knowledgeable, confident, in control in the operating room, it can be very unsettling. All these things can lead to stress, dissatisfaction, and burnout. One example is the proposed Medicare fee schedule for 2021 just came out. Released online August 3rd, it's 1,353 pages, and it affects your practice beyond payment. There's a comment period that ends October 5th, and then the final version is released in around November. But you need to know both, you need to know the proposed version to comment on it, and you need to know the final version to rely on it. That's a lot of work. There's a quality payment program called QPP, which is a result of the HITECH Act of 2009, which promoted the meaningful use of interoperable electronic health records in the U.S., and then the 2015 MACRA Act, which streamlined, in theory, these quality payment programs, and also repealed the SUR formula, which was a good thing. There's now two types of options for the QPP. There's the Advanced Alternative Payment Models, APMs, in which the provider assumes payment risk, and this mainly affects our joint colleagues who are either mandated to be in CDR or choose to be in the BPCI. Then there's the Merit-Based Incentive Payment System, or MIPS. That's fee-for-service, and there's four components. There's quality, clinical improvement activities, and promoting interoperability, which is the EHR part. Those are all purported by the physician. Then there's cost, which is calculated by CMS. The goal of the program is to increase payments to high-value, high-quality Medicare providers and reduce payments if the providers do not meet performance standards. There's a maximum reward and penalty for 2020. It's 7%. For 2020, it's proposed to be 9%, and there's a two-year inflammation delay. Your 2018 reward or penalty will be applied this year. There are exceptions to the program. These physicians don't have any penalty or rewards. If you want to see if you are exempted, you can look it up on this website here. How does QPP affect physician burnout? Well, it requires EMRs with the associated benefits and drawbacks. This is a burnout talk, so we're going to concentrate on the drawbacks. There's a high dissatisfaction rate with medical records. There's decreased patient interaction time if you're spending your patient visit in front of a computer. There's increased time to complete the medical records. It's often several hours of pajama time at night, and you could be doing things with your family. There's often too much information in the medical records, and it's difficult to find the key information. Information gets cloned or copied, which can lead to perpetuation and misinformation. There may be a lack of interoperability between different hospital systems and practices and hospitals. It's expensive, which may decrease your net income, and the systems may become outdated. Compliance with MIPS also has an effect on positions. There's a lot of time spent and stress sustained for trying to understand, meeting, and reporting the very complex requirements. There's a fear of financial penalties. And then there's a loss of income from the associated expense of complying consultants, staff, or vendors to collect and report the compliance data. And then the cost of buying the electronic records and software and updating them. So what are some of the strategies you can use to deal with regulation-induced burnout? Well, one option is just to ignore it and accept the consequences. There's certain times where the financial costs of compliance may exceed the penalty you get by not complying. And then for a lot of people, the emotional death might be worth the financial penalty. You can adapt and comply with regulations, learn to manage them, or you can try to modify them. Either change the onerous ones, advocating for legislative regulatory change, or contact CMS who's actually just trying to do that with initiative for patient-centered paperwork. And you can also lobby for beneficial regulations. Regulations that limit insurance company policies such as prior authorization and their networks can actually make your life better and decrease burnout. Knowledge is helpful. If you understand the basic rules or regulations, you can better adapt and modify. It also can increase your anxiety and improve your confidence. The summary documents available, webinars and support provided by CMS, medical organizations, and private businesses. For example, the post-2021 fee scholar talked about, 1,250 pages is daunting, but you can read the 16-page AMA summary, which is less so, or you can just get the key issues from talking to people in AALS or AOFAS, and that's much more manageable. Also, it's your attitude. You know, the glass can be half full or it can be half empty. EMRs have a lot of disadvantages, but they also have benefits over paper records, including access and legibility, and you can just appreciate them. Just remember, you know, most of us have a well-paid, often fun job helping people. The right people in this world do not. And there's a lot of people who are trying to be where you are, who just can't get there because of the competitiveness. Coping mechanisms include stress reduction techniques, work-life balance, which has already been actually discussed, including exercise, sleep, eating healthy, social interactions, hobbies, helps you do all this stuff better, and there are online resources available. And actually, the AMA has a very good module on how to manage burnout. You can also offload some of the requirements. You can have data entry required for an appliance entered by staff and patients. Those can be generated by scribes, physician assistants, CPRNs, residents, and fellows. You can have staff assist with descriptions, paperwork, communications, and you can also have institutions and staff help with documentation and reporting of MIPS values. There may be associated costs of that, but it may be covered by your hospital or university if you're employed by one of them. It may pay for itself if you're in private practice, either by increased physician efficiency or your emotional well-being, allowing you to have a longer, more productive career. If not, individual and family happiness is priceless. You can be politically active. You can contact and support your state and federal legislators. You can contact regulatory agencies. You can support national, local, and state organizations that advocate on your behalf. Organized medicine will analyze and summarize current and proposed laws and regulations for you. You don't have to read the whole thing. It can identify potential adverse effects on you and your patients and suggest modifications and additions that are beneficial to both you and your patients. They send letters to legislators and regulatory agencies, and AOFS typically signs on to some of these letters. And for the non-501c3 organizations, they can lobby and they can also support sympathetic candidates for their election committees. They help counter the groups working against physician interests, the trial lawyers, and the providers seeking inappropriate increased scope of practice. But the more effective at working on your behalf, they have more financial resources. They represent large percentages of the potential position members. It's very difficult to go to legislatures and say I only represent 20% of orthopedic surgeons and have them take you seriously. And also the individual physicians and patients can also directly contact legislators and regulatory agencies and amplify the message. A lot of organizations will help you do that. So you can just send a letter to your congressman or your senator with just a couple of clicks of a mouse on their website. You don't need to agree with 100% of the organization's policies to join and support. They're working on your behalf. You don't agree with your spouse, parents, and kids 100% of the time, and your perceptions of why the organizations may not be in your best interest may be informed, accurate, and oftentimes people misinterpret the partial wins as a bad outcome. And the alternative is much more onerous. The dues you pay these organizations and the PAC-MUNCH abuses are a high yield investment in my opinion. They prevent a much larger income loss, they facilitate ancillary income, and they decrease the extent of causes of physician burnout by advocating on your behalf. So in summary, government regulation can cause or limit physician burnout. Educate yourself on the rules and regulations. You should recognize and act on symptoms of burnout for yourself and physicians, and be involved politically in joining support medical organizations working on behalf of you and your patients. You're not alone, and you're much more effective with the help of others who share your goals. Thank you very much. Thank you so much, Dr. Arenow. So from one AOFAS board member to another, we now have Dr. Cohen speaking with us, talking about independent practice and burnout. Thanks, Casey. Slideshow, there we go. Thanks a lot. I have no disclosures related to this presentation. I'm gonna talk a little bit about the stressors of being a business owner. Independent practice, the components of it, entrepreneurship, optimization, pressures, and crisis management. And unfortunately, I may not have the answers on how to prevent this, because I may be my own worst enemy. Independent practice, you know, it's a better name than private practice. I really hate that name. But you're an independent business owner. Currently 50% of your orthopedists, the others are hospital-based or university-based, but 50% are business owners. This requires practice governance, business input, business decisions, and competitive efforts. You're always looking over your shoulder. Well, what's the other group doing? What's the hospital doing? What's the insurance company doing? The key components of an independent practice, it's physician-led and physician-owned. You have a strong, or you should have a strong physician governance. The compensation is variable. It's production-based in some way, shape, or form. Overhead is typically divided into two categories. One, which is a shared overhead, and the other is a variable or a production-based overhead. Academic involvement is usually in addition to your normal duties, nights, weekends, and holidays. But you're a small business owner. You have to think about HR, business services, compliance, and all those things. There's not, in most practices, someone doing that for you without supervision. Entrepreneurship is very important. It is an important principle of a thriving, successful, and independent practice. There's various forms of this. Real estate, ambulatory surgery center ventures, ancillary services such as imaging, PT, DME, and others, joint ventures with hospitals, value-based care, and contracting. And this consumes a lot of energy, a lot of strategic planning, and a lot of stress. Entrepreneurship is a double-edged sword. It's truly not for all of us. Some of my partners just want to be a doctor, and they say, just don't tell me about that stuff, just do it. Some see themselves as very astute business person, and they may not have that skillset. This often causes conflict. We don't typically have training in this. I run a very large orthopedic group, and I have no business training whatsoever. Please don't tell my partners who are listening. I call it dumb doctor deals. The whole goal in orthopedic practice or independent practice is to avoid the dumb doctor deals. Surgeons have a different mentality than bankers and business people. We demand immediate results. We're very concrete thinkers, and we're used to being in charge. Oftentimes in a joint venture or a business relationship or a real estate relationship, you aren't in charge. People struggle with that. How do you optimize that? It requires a strong strategic and business plan. It requires engagement and acceptance of the physician owners. A strong culture is absolutely critical. The key thing here is change is inevitable, and it's required, but how do you facilitate change, and how do you embrace it? Sometimes change is forced on you, and I'm gonna give an example of that that we've all lived through recently, but how do you embrace it? How do you embrace the change and not have it be done upon you? You must have a strategic direction and a plan. So what are the pressures? Pressures are financial. The owners bear the financial responsibility of the business. You can't borrow money to pay yourself. So if your revenue's down, your compensation's down. Very little is guaranteed. Strategic, is this the right direction or the right decision? Is adding this doctor, this partner at the right time? How about opening this new office? How about aligning with this facility? Oftentimes it leads to the debate of action versus inaction. Some groups are paralyzed to make a decision. They're fearful. The business owner pressures continue every day. You're responsible for your staff, compliance, legal issues, marketing, and a bunch of other things. Here's a great crisis example that we just lived through. So when COVID hit, it was a significant business interruption. Everyone saw a significant revenue decline. We had concerns about safety issues for the providers and the staff. We were constantly changing the requirements and the concerns. There were critical decisions that had to be made by the physicians who own the business about furloughs or possible furloughs of employees and reductions of compensation for themselves, but also for the staff. It has significant effect on compensation. There's no backstop for a physician owner compensation. You can't borrow money to pay yourself. There were concerns about liquidity of the practice, but also personal liquidity. Unfortunately, it exposed inadequate financial planning and reserves for many of the physicians in independent practice. There was uncertainty. Many of the employed physicians that they were friendly with or colleagues from around the country had salary guarantees, but there's no guarantee in independent practice when the revenue stops or is down. There were concerns about practice viability. I had one of the docs ask me, can I collect unemployment? I'm like, well, I got bad news for you. First of all, it's not gonna support the lifestyle that you live in. The other is you're the business owner and you cannot. Recent study showed that 50% of independent practices and all specialties will seek financial relief either from hospitals or private equity in the next one to two years. What happens to your practice volume post-crisis? 11 million unemployed, safety issues, exposures, concerns about elective volume. Other contributing factors were the social isolation that we all felt. And we continue to feel as I said, my office in an empty building right now. Health concerns, childcare issues, when schools came back or didn't come back and the whole issue of schools. So in conclusion, the independent practice participants are business owners. You have obligations and responsibilities associated with this. Strong leadership is absolutely critical, but physician engagement is the key. You need to cultivate the business acumen. If it's not in you, it needs to be in some of your partners. Strong culture is the key and crisis management is critical. Thank you. Thank you so much, Dr. Cohen. Our final speaker is Dr. Nugent. And this is an exciting talk because it's actually original research that we're gonna get to see. So Dr. Nugent, please take it away. Good evening, everyone. The title of my study is Burnout Rates Amongst General Orthopedic Surgeons and Subspecialists, a Pilot Study. We have no relevant conflicts of interest or disclosures. So as we discussed, burnout is a syndrome of emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment that occurs in individuals who work in human services. Burnout tends to be most common amongst physicians as a consequence of long working hours, limited resources, lack of physician autonomy, insufficient support from coworkers, stresses associated with the responsibilities of patient care, as well as emotional contact with patients. Unfortunately, the rates of burnout amongst physicians has been increasing from about 46% in 2012 to as high as 54.4% in 2014. And while burnout rates amongst orthopedic surgeons have been reported up to 50% to 60% versus 30% to 40% in general surgeons, no studies have evaluated burnout rates amongst orthopedic generalists and subspecialists. Thus, the primary goal of this study was to examine the prevalence of burnout amongst orthopedic disciplines. So this was a multi-center cross-sectional study conducted from March 2019 to December 2019, attending general orthopedic surgeons and all orthopedic subspecialists, including adult recon, foot and ankle, hand, oncology, pediatric, shoulder, elbow, spine, sports medicine, and trauma were included in the study. For our survey, we utilized an abbreviated 12-item version of the normally 22-item Maslock Burnout Inventory Human Services Survey, which is considered the gold standard tool for measuring burnout and assesses emotional exhaustion, depersonalization, and personal accomplishment. In addition to this abbreviated Maslock Burnout Inventory, we added 27 questions to assess physician demographics, personal and professional characteristics, family, life and spousal support, stress management, feelings of depression, as well as suicidal ideation. So the final survey consisted of 39 questions, and these surveys were distributed amongst 343 orthopedic surgeons in New Jersey, New York, Delaware, Pennsylvania, and North Carolina utilizing RedCap, which is a HIPAA-compliant and secure web-based platform for building and managing online surveys and databases. So of the 343 orthopedic surgeons that were sent the survey, 149 responded for a response rate of 43.4%. The median age of respondents lay within the 40 to 49 age cohort. There were 100 females and 49 males, as well as 10 generalists and 139 subspecialists. Subspecialty participation included 31 sports medicine surgeons, 31 pediatric surgeons, 21 hand, 14 adult recon, 13 foot and ankle, 12 spine, 8 trauma, 5 oncology, and 4 shoulder elbow. Mean burnout amongst all orthopedic surgeons was 62.29%. Subspecialties with the highest rates of burnout were oncology at 100%, sports medicine at 67.7%, and trauma at 62.5%. Contrarily, shoulder elbow at 50%, pediatrics at 51.6%, and foot and ankle at 53.8% had the lowest rates of burnout. Similarly, trauma at 50%, oncology at 40%, and general at 20% had the highest positive depression screening rates, while shoulder elbow at 0%, spine at 0%, and sports medicine at only 6.5% had the lowest rate of positive depression screening. Overall, 16.8% of participants screened positive for depression. In addition, the average rate of suicidal ideation within the past 12 months was 12.1%. So we found that the following are independent factors associated with higher risk of burnout, including older age, higher debt load, and oncology subspecialty. Furthermore, the following are independent factors associated with a lower risk of burnout, and these include being satisfied with work environment, being satisfied with family and home life, as well as working more hours. So in conclusion, this study sought to determine the rate of burnout within each orthopedic discipline, with a secondary aim of disclosing contributing factors. Trauma and oncology were found to have the highest rates of burnout and positive depression screening. In addition, this is the first study focusing on burnout across orthopedic subspecialties, and will hopefully shed some light on an oppressing issue facing the orthopedic community, as well as the medical community at large. However, larger studies are needed so that burnout can be more appropriately managed within the field of orthopedic surgery in the future. These are my references. Thank you very much. Thank you so much, Dr. Nugent. We can tell that you are still in training, as you did not try and go over your time, which is the true sign of an attending surgeon. Thank you so much, everybody. We're all online now. We'll have 15 minutes for discussion to close out the first day of AOFAS meeting at home. So no softballs. We only have 15 minutes. So I'd like to start with Dr. Klein and Dr. Aronow. Dr. Klein, Dr. Aronow, you both spoke about how systems can create distress that lead to burnout, and how when we feel constrained in our care and our actions, that is a driver for burnout. To me, as someone who likes to try and rethink systems, my solution is fix the system. But that isn't realistic, especially when we're talking about a federal government, particularly as dysfunctional as it is these days. So we'll start with Dr. Klein. And I want to really understand what strategies do you use personally, or what strategies would you recommend to try and help us work within systems when we are trapped within a publish or perish system? And we know we can't change it. Is it just trying to increase our resilience, which is a word I'd love to retire? Is it that I just have to do more mindfulness on my Apple Watch? Is it just digging deep? I loved your statement about doing what you love preventing burnout. That's an awesome concept, doing more of what we love. What are some functional strategies, and then even some aspirational strategies? And then Dr. Aronow, you have a minute to prepare. Well, thanks for that question. I think that if you really read a lot of what's recently been looked at in terms of burnout, it really does have to do with symptoms. Then if you turn around and look at how we treat burnout, the treatment is always focused on the individual position. And again, there's plenty of evidence that suggests that we as physicians, especially as orthopedic surgeons, are very resilient. We have a lot of grit. And trying to increase those characteristics in ourselves probably isn't a reasonable proposition. So when I think about reasonable treatments for burnout, I do think it goes back to carving out your own work to include the things that you love and try to focus on your strengths. And it goes back to something that Catherine talked about too, in terms of setting limits. In terms of what you think is feasible for you to accomplish and what isn't. And I think when we're early in our career, that's really hard to do. I think it's really easy to be overcome with the pressure of publication and achieving and getting a national reputation. And so to some degree, I continue to aspire to be always at peace with what I'm doing and how much I've done and all of my accomplishments. I don't know that I've achieved that yet, but I do think the farther along you get in your career, the potentially easier it is. So I think you just have to keep things in perspective. The serenity prayer has a lot of relevance here. You got to know what you can change and what you can't change. And try to change what you can and accept what you can't. I think there's a lot of things that if you look at them, they're not quite as bad as you think they are. And there's a lot of things that you can change, but it may take time. And you need to work together with other people and other physicians. But you just have to have patience and realize that you can get closer to where you want to get to. You make the efforts. Thank you so much. I always do think of Dr. Aronow with the serenity prayer, because that's what he mentions every time that we're trying to move legislation through the American Medical Association or state legislatures. My other recent favorite quote was, if you think that everybody hates you, you need to sleep. If you hate everybody, you need to eat. And that's fairly true for me in my life. Dr. Sage, you talked to us about balance. One of my mentor's great quotes is, balance is a verb. And I think that's helped me. And your diagram that you had of where you're allocating effort definitely fits with that, that it's not a state of being. It's an action. It's not a noun. It's not something we're going to achieve balance. And then from there on out, life is easy. One thing that I think a lot of particularly young physicians face is the second shift for both men and women, physicians with children at home, where you do your work at home. And I'm sorry, you do your work and then you come home and you have a second job. Are you able to speak at all about how this contributes to burnout? And then any strategies that you perhaps personally have employed or strategies that you would recommend? Yeah, I mean, I think it absolutely contributes to burnout. I don't have any hard numbers on that. But you're absolutely right. You work all day and then you go home. And if you're a person that's trying to take care of a family and takes that role on at least 50% or maybe more, then it is like a second job. In terms of balance, I will say that since COVID and since my kids have sort of gone back to school and they're in this hybrid model, one thing I've done is moved my morning office hours to start at nine. And it's not going to be that way forever. And my kids' school won't be that way forever. But it's something that we have to do to create balance right now, just living in a dual working household with both parents. And the other thing that I've personally done for a period of time, I'm working four days a week. And it's working really well for me with young children. It's like my time to get things done that I think otherwise I'd be pulling my hair out. So, you know, not all these strategies are right for everybody. And I was lucky to find a group that was willing to work with me on that. And again, it's not something I'll do forever. You know, three days a week someday. No, I'm just kidding. Eventually, I'll go more full time again. But I think it's just different for every person. And again, you have to look at your goals and figure out where you want to be at whatever moment in time and then reassess them when you need to. Thank you so much. So I did prep Dr. Nugent that I had a question for him based on his research. So I was fascinated by a lot of components of it. But 67% of your respondents were women, which to me is the only time I've ever seen that in orthopedic study. Can you speak to that at all? Yeah, so we surveyed a women in orthopedics group out of New York and we had a great response rate. So that's really why we had a disproportionate percentage of females. So obviously, because of that, it's difficult to say that our results are generalizable, you know, of the orthopedic community at large. But we do hope to perform a larger study with a more even distribution of males to females that would represent the orthopedic surgery field. Great, thank you. Of course. Dr. Cohen, I wanted you to tell us, how would you work in an independent practice to try and create a culture? You spoke about culture. How would you try and create a culture to prevent burnout? And perhaps even more fun, the converse of that, if you wanted to create a structure for burnout, how would you design that? Because I certainly sometimes feel like I am functioning within systems that have been specifically designed to create burnout. Yeah, it's really hard. And we put a lot of effort into it and we're still not completely there. I think the thing that we don't do well in medicine is mentorship. We do it well in residency. We do it in fellowship. You know, in my practice, we do it for the first two years and then you're on your own. And that's when most people fail is not in the first two years, it's after that from a burnout standpoint. Because, you know, early on, they have energy, enthusiasm, maybe they're starting to build a family. But when the stresses come on, it's typically that combination of life stressors, financial stressors, practice stressors, and it's later in practice. So you have to create an environment where people can have mentorship, they can have collegiality. They're not on an island. I think isolation, as we've seen recently, because we don't have a lot of personal contact, really is stressful. And so, you know, I think if I was to create the optimum practice to create burnout, it would be on a completely production-based financial model with individual practices with a maximum of one or two docs. And they have no contact, they have no feedback on their cases, they have no outlet for the stress of difficult cases and bouncing things off each other. And, you know, and obviously, you know, increased financial strains, decreased liquidity. It's a recipe for disaster, and we lived through it in March. You know, and it really exposed the fact that we don't save well, we don't financial plan, the life stressors hit really, really hard. I was very worried about a lot of our folks and communication is the key. People need to know, very similar to the talk we just heard, just a simple email, a simple text, a simple phone call, or just, hey, do you need some help? I think makes a big difference. So I think everybody rowing in the same direction, you can still have competition, but people have to communicate. You have to build that culture that, you know, and some people aren't gonna fit in when you start to build a culture, and maybe this group is not the place for you. And so, you know, people move from job to job. It doesn't mean you failed. It just means maybe the fit wasn't right. Thank you so much. It may be my final question. I wanted to ask Dr. Klein, because something I've seen speaking to trainees about the publication pressures is that this isn't something that's isolated to our young faculty members and people early career. There's interesting research on how many more publications medical students have going into residency, and then residents have going into fellowship. It seems a publish or perish is kind of becoming universal. And I certainly have concerns that this may be impacting the burnout cycle earlier and earlier. I was wondering if you could speak to whether or not you saw any research on this or your insights as a clinician educator about the impact on our trainees and what we should be doing, especially when we're trying to recruit all these amazing residents to come join us in foot and ankle. And as a brief plug, please join us for that on Saturday, every faculty member that is able to. So would you be able to answer that or speak to that a bit, please? You know, that's a great question. And I can't really say that I've seen extensive research about it. But what I have seen as a program director and as somebody who mentors a lot of medical students and sees a lot of applications for residency is that more and more medical students sort of have this belief that the number of publications matters to get into orthopedics. They have to do a year of research and they have to extend their training in medical school just to make it into an orthopedic residency. And I don't know that that's a burden that we put on them. I don't think so. I think it's somewhat of a burden they put on themselves, but it's just the nature of how competitive this specialty is. Students are so fearful that they're not gonna match. They want a formula. And the formula they've worked out for themselves is that they have to have a certain number of publications in order to be able to match into orthopedics. And I think it is in our best interest as a specialty to maybe encourage that they find things to do that they love, whether it's volunteering, whether it's some sort of business-related endeavor in anything that they're passionate about. Maybe some of the things that Mike does in terms of government involvement and advocacy. We want a diverse group of people going into orthopedics. And if everybody's trying to follow the formula in terms of maximum number of publications at a certain board score, that doesn't really help us. Thank you so much. So no expertise, but an opinion. Thank you so much. What a wonderful session. And I'm so glad that this will be available in the future because I'm definitely gonna ask all of my residents to watch it and my colleagues to watch it. I so appreciate everyone's time, especially on a Thursday evening. Not that there's anything to watch on TV anymore, but I do hear that the NFL is trying to return. So I'm sure some folks in Kansas City are hopping on that. I now hand off, I think, to Dr. Ellis to close out our first day of programming. Thank you, Casey. Great job.

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