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National Ophthalmologist Wellness Survey (NOWS) 2019

      Recognizing the importance of physician health and wellness, and its impact on patient care and productivity, in 2017 the Canadian Medical Association (CMA) launched the online National Physician Health Survey (NPHS)

      Canadian Medical Association. CMA National Physician Health Survey: A National Snapshot, October 2018. https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf [accessed 20 January 2020].

      to obtain data on the health and wellness of Canadian doctors. Although ophthalmologists who were members of the CMA were invited to participate, there was no specific category dedicated to ophthalmology. Instead, it was placed under the umbrella of surgical specialties. Due to unique differences in ophthalmology from other surgical specialties (including the fact that a significant number of ophthalmologists do not have a surgical practice),
      • Micieli JA
      • Buys YM
      Proportion of medical-only versus surgical ophthalmology practices: associations and trends.
      the authors believed that there is a need to obtain Canadian data specific to ophthalmology.
      Our objective was threefold: (i) obtain data regarding the health and wellness of Canadian ophthalmologists, (ii) compare our results with those of the CMA 2017 NPHS,

      Canadian Medical Association. CMA National Physician Health Survey: A National Snapshot, October 2018. https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf [accessed 20 January 2020].

      and (iii) identify, if possible, high-risk groups for ill-health within ophthalmology.
      Obtained with permission of the CMA, slight modifications were made to the NPHS to improve its suitability for ophthalmology. The survey included 79 questions, including demographics and mental health and activity/ lifestyle questions according to validated scales (see Appendix B of the CMA report).

      Canadian Medical Association. CMA National Physician Health Survey: A National Snapshot, October 2018. https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf [accessed 20 January 2020].

      Ethics approval was obtained from the University of Manitoba Research Ethics Board. Eligible participants included members of the Canadian Ophthalmological Society (COS). Links to the National Ophthalmologist Wellness Survey (NOWS) were emailed in French and English versions to all 1130 COS members using the secure online platform SurveyGizmo, with a reminder after 2 weeks. The survey was closed after 4 weeks.
      Results from the figure on page 10 of the CMA report

      Canadian Medical Association. CMA National Physician Health Survey: A National Snapshot, October 2018. https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf [accessed 20 January 2020].

      were extracted to permit qualitative comparison between the health and wellness of the CMA respondents and ophthalmologists. In general, conventional descriptive statistics (counts and percentages) are presented. Where relevant, χ
      • Micieli JA
      • Buys YM
      Proportion of medical-only versus surgical ophthalmology practices: associations and trends.
      tests were used to compare the distribution of categorical variables between groups of respondents to the NOWS, with p values less than 0.05 considered to be significant. Values of p between 0.01 and 0.05 were considered marginally significant. Analyses were performed in the R statistical computing language (version 3.6.1) and using the tidyverse package (version 1.3.0).
      The response rate for the survey was 22.7% (257 respondents from 1130 individuals invited to participate).
      Overall, 60.5% of ophthalmologists are flourishing, and 38.9% are moderately mentally healthy, with only 0.6% languishing; 90.6% are resilient though 42.5% are burnt out; 24.3% screen positively for depression; 17.4% have had suicidal ideation (SI) during their lifetime and 6.9% in the past 12 months.
      These findings appear overall qualitatively similar to the NPHS, though there may be slightly higher ratio of burnout to depression for NOWS respondents (Fig. 1).
      Fig 1
      Fig. 1Comparison of NPHS and NOWS responses. The number of respondents to the NPHS and NOWS, respectively, was as follows: overall mental health, n = 2693 and 162; resilience, n = 2693 and 149; burnout, n = 2744 and 174; depression, n = 2740 and 189; suicidal ideation (lifetime), n = 2735 and 190; suicidal ideation (recent), n = 2735 and 188.
      Though the numbers were small (n = 19), residents reported higher rates of burnout (p = 0.021), and SI lifetime (p = 0.004) and within the past year (p = 0.004; Fig. 2).
      Fig 2
      Fig. 2Comparison of responses to the NOWS between residents (n = 19) and current physicians (n = 201). Retired physicians were excluded.
      Among current physicians, surgeons in our survey appear significantly more depressed than nonsurgeons (30.7% scored positively for depression versus 8.3% in nonsurgical respondents, p = 0.002).
      Although there were no significant differences in overall mental health between male and female current physicians (p = 1.00), males showed higher resilience than females (p = 0.038) and lower burnout (p = 0.035); see Figure 3. The distribution of hours worked did not differ significantly between females and males (not shown; p = 0.186).
      Fig 3
      Fig. 3Comparison of NOWS responses by sex among current physicians. Overall sample sizes: female, n = 67; male, n = 134.
      In terms of regional differences, Quebec ophthalmologists were less likely to have high resilience (i.e., 72% vs 95–100% with high resilience in all other regions).
      The numbers of subspecialists in each category were too small to determine any real significant differences.
      Of the physicians responding to our survey, 78% reported having a primary care physician and 73% had at least some awareness of physician help programs (PHPs).
      Overall our survey results shared many similarities to the NPHS, which suggests that many of the issues ophthalmologists face are not unique to our specialty, but similar across the profession. Likely many of the strategies created to improve physician health can be aimed at the profession at large, rather than specialty specific.
      Although the majority of ophthalmologists are flourishing with high resilience, rates of burnout (42.53%), depression (24.3%), and recent SI (6.9 %) are still too high.
      With the general population having an estimated rate of burnout of 10% to 15%,
      • Dean E
      Burnout and surgeons.
      it is concerning to see a rate of 42.5%, particularly in view of the known consequences of burnout and its impact on the quality of patient care and productivity.
      • Panagioti M
      • Geraghty K
      • Johnson J
      • Zhou A
      • Panagopoulou E
      • Chew-Graham C
      • Peters D
      • Hodkinson A
      • Riley R
      • Esmail A
      Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction: A Systematic Review and Meta-analysis.
      ,
      • Han S
      • Shanafelt TD
      • Sinsky CA
      • Awad KM
      • Dyrbye LN
      • Fiscus LC
      • Trockel M
      • Goh J
      Estimating the Attributable Cost of Physician Burnout in the United States.
      Although the medical profession is not alone in having a high incidence of burnout, the inherent responsibilities of a physician and the potential for serious consequences, such as from medical errors, make addressing burnout in physicians very important. Burnout is defined by the International Classification of Diseases (ICD-11; www.who.int) as an occupationally induced syndrome, characterized by emotional exhaustion, depersonalization, or negativism toward one’s job and reduced professional efficacy. Many respondents’ comments expressed frustration with the system, that is, “lack of resources,” equipment deficiencies, inadequate access to operating room time, long waiting lists for surgery, frequent staff turnover, conflict between the government’s fiscally driven goals and the physician’s goal of providing high-quality care, and manpower shortages. Physicians and relevant stakeholders are encouraged to refer to the CMA Policy on Physician Health (www.cma.ca) for recommendations at both the individual and system levels.
      There was a significant difference between depression in surgeons and those in nonsurgical disciplines of ophthalmology (i.e., 30.7% vs 8.3% in nonsurgical ophthalmologists). This is particularly worrisome because surgeons are often under-represented accessing PHPs for mental health concerns.
      • Gerada C
      Clinical depression: surgeons and mental illness.
      In our survey, the most common reasons for not accessing a PHP were lack of knowledge about PHPs, feeling ashamed to seek help, and belief that the situation was not severe enough to warrant a PHP consultation. Increasing awareness of the programs, reducing the stigma attached to seeking help, and improving the awareness of primary care physicians that surgeons are a higher risk group who may not be open about their mental health challenges are important steps to consider.
      Recent SI in residents was more than 10 times higher than physicians in practice. Over half of the residents were burned out and depressed. Comments in the survey by residents included excessive workload, long hours, and lack of collegiality. Even though the resident respondent rate was low (n = 19), this still raises serious concerns and warrants further attention.
      Resilience was significantly lower among Quebec ophthalmologists. Resilience, a personality attribute that promotes the ability to adapt or “bounce back” after adversity, is felt to help protect against burnout and help manage stress. A study in 2008 by Viviers et al
      • Viviers S
      • Lachance L
      • Maranda MF
      • Ménard C
      Burnout, psychological distress, and overwork: the case of Quebec’s opthalmologists.
      reported concerning levels of “burnout and psychological distress in Quebec ophthalmologists” and attributed this to “work overload and systemic organizational deficiencies.” The regional difference found in our survey suggests that the mental health of Quebec ophthalmologists continues to be of concern.
      In our survey, females were noted to have marginally significant lower resilience.
      Women in our survey reported at least the same number of working hours as their male counterparts, which is consistent with findings in a previous Canadian study.
      • McAlister C
      • Jin YP
      • Braga-Mele R
      • DesMarchais BG
      • Buys YM
      Comparison of lifestyle and practice patterns between male and female Canadian opthalmologists.
      Previous studies have also found that women were more likely to have a spouse working full time, and were more likely to be the primary caregiver.
      • McAlister C
      • Jin YP
      • Braga-Mele R
      • DesMarchais BG
      • Buys YM
      Comparison of lifestyle and practice patterns between male and female Canadian opthalmologists.
      ,
      • Dyrbye LN
      • Shanafelt TD
      • Balch CM
      • Satele D
      • Sloan J
      • Freischlag J
      Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex.
      One possible reason for lower resilience in women may be greater work–home conflict. Dyrbye et al. have suggested that strategies to reduce conflict and still meet both home and work responsibilities could be particularly beneficial for female surgeons.
      • Dyrbye LN
      • Shanafelt TD
      • Balch CM
      • Satele D
      • Sloan J
      • Freischlag J
      Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex.
      Female ophthalmologists may also benefit in this regard.
      The voluntary nature of the survey and its presentation as a wellness survey may have introduced bias in those who chose to respond. The survey was self-reported with many questions retrospective in nature, which could affect accuracy, and was open for only 1 month. Keeping the survey open for longer may have captured more respondents. Although the percentage of respondents was reasonable for this type of medical survey,
      • Dean E
      Burnout and surgeons.
      it still represents only a small portion of COS membership and may not be a true reflection of the profession.
      Overall, our study suggests that ophthalmologists in Canada are flourishing, with high levels of reported resilience. We are in a privileged position to help people, and make a marked difference in their lives for the better, but with this privilege come responsibility, system-related stress, demands on our time, and repeated exposure to human suffering, making it easy to make our own health a lower priority. The CMA has recommended that physician health and wellness “be assessed at regular intervals to identify relevant changes, grow our understanding, and help inform and refine actions in promoting a healthy, vibrant, and engaged profession.”
      • Dean E
      Burnout and surgeons.
      Our study has shown that burnout and depression remain significant issues within the medical profession, and that ophthalmology is not spared. Within ophthalmology, our survey suggested that surgeons, females, and residents are at higher risk for ill-health. Furthermore, regional differences may exist, particularly in Quebec. This survey may help identify priorities and enhance initiatives to promote physician wellness for ophthalmologists and other physicians.

      Footnotes and Disclosure

      Publication of this supplement was supported through the Affinity Agreement between MD Financial Management, the Canadian Medical Association, and Scotiabank.
      The authors have no proprietary or commercial interest in any materials discussed in this article.
      Acknowledgements: We acknowledge the help of Justin Dyck and Robert Balshaw of the Data Science Platform and Patricia Roche with Knowledge Translation at the George & Fay Yee Centre for Healthcare Innovation at the University of Manitoba for consulting services.

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