Valuing Balance: When Combatting Burnout, Surgeons Must Consider What Really Matters

The transition to value-based care has been evolving for decades. By now, the value equation (value = quality/cost) is likely more familiar to you than Wolff’s Law. We strive to consider value in terms of the care offered at the patient level. Ideally, “quality” reflects the definition for the individual patient; however, at the system level, it often seems to be driven by benchmarks from payers. Similarly, when viewed through the reimbursement lens, the concept of increasing value may feel focused on minimizing the denominator of costs to the system.

Consider your personal ‘value equation’
Despite the focus on value in medicine, how often do surgeons consider what a value equation might look like for their personal and professional lives? That would likely be a complex equation, but still with quality and cost components. We need factors reflecting quality of personal life (lifestyle, possessions, free or family time) and professional life (maintenance of skills, service of patients, research, leadership roles). In the denominator, increments and decrements to income may be the easiest to calculate, but impacts to physical and mental health are other costs to consider.

Orthopaedic surgery training rewards hard work and overachievement. Not surprisingly, we remain a competitive bunch, and this mentality can include competing for more prestigious positions, more published articles and research, a larger home, or another car. There will always be something more. But achieving (and even maintaining) more and more comes at a cost. In recent years, more attention has been paid to physician well-being. Diminished quality of life and burnout have plagued our profession. Attention to work-life balance emerged as one way to combat these pitfalls. Realistically, we do not get to have it all, so consider reframing the value equation question: What does it cost to achieve a quality balance in your life?

RVU payment versus value
Perhaps the most quantifiable component in a theoretical personal value equation would be compensation. Historically, physicians in academic or employed positions were salaried. Even in independent practice, a salary may be paid as part of the overall compensation. In that model, many surgeons retained autonomy to develop a practice style that suited their patients, the organization, and themselves. Increasingly, salaried positions have been replaced by relative value unit (RVU) productivity-based reimbursement, stymieing both physician wellness and value-based care.

A recent study among hematologists found that RVU-based compensation was associated with high burnout rates for both academic and community physicians, supporting other studies that found that the quantity-over-quality approach contributed to burnout. An article published in JAMA Health Forum noted how such a compensation model creates pressure to maximize revenue. Specific to driving down value in orthopaedic surgery, Dartmouth investigators found that the transition from a salary to an RVU-based compensation model may encourage higher rates of elective arthroplasty procedures.

Two articles in this issue of AAOS Now address facets of achieving (or failing to achieve) balance between our professional and personal lives. In his article “Is Work–Life Balance a False Hope?” Gregory A. Brown, MD, PhD, FAAOS, FAOA, describes achieving balance by transitioning from covering multiple hospitals to providing care in a single, underserved area as a 0.5 full-time equivalent. As described in “Orthopaedic Hospitalist Roles Offer ‘An Unusual Kind of Balance,’” in the face of burnout, Kurt Ehlert, MD, also found a lifestyle that gave professional and personal satisfaction—but noted he sacrificed some financial compensation compared with a private practice model.

Orthopaedic surgeons are high wage earners. The Medscape 2023 annual physician compensation review reported an average salary of $573,000 for orthopaedic surgeons, second only to plastic surgeons. Furthermore, the average bonus was the highest among all physicians, at $134,000. Certainly, variability is great, influenced by geography, subspecialty, payer mix, and practice setting. Most situations have an obligation for baseline productivity. But for a surgeon facing burnout, the cost of capturing balance may be forgoing the next RVU or even the entire productivity bonus.

Focus on valuable work hours
Decreasing hours worked across the board could be the simplest way to support a healthier work-life balance. But for most physicians, an hour of direct patient care creates a different impact on well-being than an hour of clerical work. Flow in the OR during an efficient surgery or gratitude from a patient for whom you have restored function reinforces a sense of personal accomplishment and wards off emotions contributing to burnout. Contrast that with the frustration of filling all the required components to close a chart on the electronic health record or making a third call for prior authorization.

Many physicians experiencing burnout cite the non–clinical care aspects of the profession, most notably increasing clerical duties including the omnipresent burden of the electronic health record. The Association of American Medical Colleges projects significant shortfalls in the physician workforce in the next decade. This dilemma stems from not only an aging physician population but also younger doctors increasingly seeking an alternative to patient care prematurely. Frustration with charting and other clerical work has been cited as a contributor to early retirement. Discussions to increase support staff for clerical duties could be a starting point to restore balance. Recognizing the need to protect their physician assets, more large healthcare organizations have been proactive with reducing non–patient care burdens.

The value of personal health
Beyond compensation gained or lost, a value equation should assess the less tangible costs of physical and mental health. Some surgeons waltz through their 70s spending 12-hour days in the OR; some octogenarians continue treating patients.

Others find we are orthopaedic or cardiac patients sooner than expected. At some age, personal values and physical health may dictate whether we dedicate the remains of our shoulders or lumbar spines to the profession or save a few miles to carry grandchildren or climb another mountain.

Most sensitive of all, a mental health crisis can change everything. Personal experience with the devastation of suicide prompted me to include the article “Losing Balance: How to Address High Rates of Suicide among Orthopaedic Surgeons” on this difficult topic as part of our work-life balance theme.

I believe in the promise of value-based care for our healthcare system and continue to have guarded optimism as we struggle toward better care delivery. Even more strongly, I encourage surgeons to consider their personal and professional values. Sacrifices at the margin of compensation may deliver critical work-life balance.

Physicians and healthcare organizations should work locally and nationally for a system which balances patient treatment with a sustainable physician life, focusing surgeon hours on the care only we are trained to provide. AAOS advocacy work to reduce administrative burdens includes changing prior authorization burdens via the Seniors Timely Access to Care Act and the GOLD Card Act as well as the Centers for Medicare & Medicaid Services’ proposed rule on interoperability and prior authorization. This approach can keep more physicians in the workplace longer, adding value for everyone.

Alexandra E. Page, MD, FAAOS, is a foot and ankle specialist in private practice in San Diego and the deputy editor of AAOS Now.

References

1. Ames SE, Cowan JB, Kenter K, et al: Burnout in orthopaedic surgeons: a challenge for leaders, learners, and colleagues: AOA critical issues. J Bone Joint Surg Am 2017;99(14):e78.
2. Dillon EC, Tai-Seale M, Meehan A, et al: Frontline perspectives on physician burnout and strategies to improve well-being: interviews with physicians and health system leaders. J Gen Intern Med 2020;35(1):261-7.
3. Grossman K, Parise C, Khan E: Productivity of part-time versus full-time primary care physicians. J Med Pract Manage. 2018;33(6):383-8.
4. Hochwald L: Physicians may retire en masse soon. Available at: https://www.medscape.com/viewarticle/990903. Accessed Dec. 28, 2023.
5. Khullar D: Burnout, professionalism, and the quality of US health care. JAMA Health Forum 2023;4(3):e230024.
6. Kane L: Medscape Physician Compensation Report 2023. Available at: https://www.medscape.com/slideshow/2023-compensation-overview-6016341. Accessed Dec. 24, 2023.
7. Lee AI, Masselink LE, De Castro LM, et al: Burnout in US hematologists and oncologists: impact of compensation models and advanced practice provider support. Blood Adv 2023;7(13):3058-68.
8. Molloy IB, Yong TM, Keswani AH, et al: Does productivity-based physician compensation affect surgical rates for elective arthroplasty surgery? J Arthroplasty 2020;35(12):3445-51.e1.