Anesthesiology is a high-stress field that subjects anesthesiologists to life-and-death decisions, production pressure, environmental risks, and interpersonal challenges. Unfortunately, these conditions can result in health care professional burnout. Given that a strong safety culture is crucial for patient safety, it is imperative to find a way to cultivate a culture centered on safety despite the current threats of increasing burnout and anesthesiologist attrition.

Burnout syndrome, consisting of emotional exhaustion, depersonalization, and diminished professional accomplishment, is rapidly increasing in anesthesiology.1 Even before COVID-19, up to 41% of anesthesiologists in the United States were at high risk for burnout, and up to 59% reported a moderate risk of burnout.2 Burnout in anesthesiology is a global issue, with reported rates of up to 66%, 61.5%, and 26%-59% in Italy, France, and Asia, respectively.3-5 Anesthesiology trainees and early graduates may be at an even higher risk for burnout, as one study showed pre-pandemic rates of burnout of 51% in anesthesiology residents and first-year graduates.6 

While burnout was already prevalent in anesthesia, the stresses of COVID-19 have exacerbated symptoms of burnout and burnout syndrome in anesthesiologists. In a November 2022 survey of 2,698 ASA members, burnout syndrome increased from 13.8% to 18.9% since 2020, and those at “high risk for burnout” increased from 59.2% to 67.7%.7 

Burnout can lead to underperformance and contribute to physician attrition.8 The ongoing U.S. health care workforce shortage presents one of the greatest threats to the health care industry, and anesthesiology is no exception. Recent staffing shortages have been reported by 78.4% of anesthesiologists.7 Thirty-six percent of anesthesiologists intend to leave their jobs within the next two years,7 and one study demonstrated that anesthesiologists have the highest intention to leave out of all specialties (46.8% vs. mean 32.6%).9 Therefore, it is critical to recruit and retain anesthesiologists, especially given the financial implications; it costs an organization $500,000 to $1,000,000 to replace one physician, and the lost revenue associated with replacing a procedurally based subspecialty physician is likely to be substantially higher.10 Moreover, the OR generates approximately 40% of hospital revenue, with an estimated 60% of hospitalized patients needing surgery during their admission.11 Thus, the loss of an anesthesiologist can have significant financial impact.

The safety culture of an organization is defined as “the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization's commitment to quality and patient safety.”12 Organizations with strong safety cultures are characterized by a shared belief among all members that safety is an organizational priority (Figure). Such organizations exhibit open, effective communication and teamwork.13 Leaders of organizations with strong safety cultures demonstrate a commitment to safety by consistently prioritizing safety over competing demands and providing adequate training and resources for safety work.14 A strong safety culture is also characterized by a commitment to learning from prior errors and finding ways to improve the system to prevent future errors.15 These organizations address adverse events with a transparent, nonpunitive, and just culture approach, where individuals are held accountable for their actions but not blamed or punished for errors due to flawed systems. Staff are encouraged to speak up whenever there is a safety issue without fear of retaliation or blame.

Figure: Characteristics of a weak and optimal safety culture.

Figure: Characteristics of a weak and optimal safety culture.

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Having a strong safety culture is associated with significant positive patient outcomes. Organizations with strong safety cultures have lower rates of surgical site infections,16,17 hospital readmissions, adverse events, and preventable harm.18 Hospitals with strong safety culture scores were also associated with lower rates of morbidity,17 and in some cases, even mortality.18,19 In addition, health care institutions with strong safety cultures were found to have improved efficiency and costs,19,20 higher patient satisfaction scores,21 high staff satisfaction,22 and lower rates of staff turnover.23 Therefore, a strong safety culture has significant benefits for patients and staff and must be cultivated by all health care institutions.

Anesthesiologist burnout is intertwined with the challenges of fostering a culture of safety. Burnout in anesthesiology largely stems from factors such as excessive workload, insufficient autonomy, and inadequate support structures.8 These factors not only result in burnout, but they also contribute to poor safety culture. Given the importance of cultivating a strong safety culture, it's crucial to explore the areas of intersection between safety culture and burnout to identify what can help move organizational toward safety and away from the quicksand of burnout.

Safety is strongly dependent on effective communication. Emotional exhaustion in anesthesiologists with burnout syndrome may lead to problems with communication, collaboration, and the ability to learn from errors.7 Effective and collaborative team relationships between anesthesiologists and other perioperative staff contribute positively to safety culture by promoting effective communication; for example, more frequent collaboration between the same team of surgeons and anesthesiologists is associated with better patient outcomes.24 Unfortunately, emotional exhaustion, depersonalization, and eventual staff attrition all detract from this rapport and hinder safety culture.

Anesthesiologist staffing can impact both safety culture and burnout. Insufficient staffing is a vicious cycle that negatively affects workload and anesthesia staff support, driving physicians out of practice, in part, due to increased burnout. Those understaffed groups then become more understaffed, driving more physician dissatisfaction and attrition. This is detrimental to patient care and contributes to moral injury, which describes “the challenge of simultaneously knowing what care patients need, but being unable to provide it due to constraints that are beyond our control”.25 A national shortage of anesthesiologists was predicted before COVID-19,26 and there has since been a subsequent loss of anesthesiologists, with the potential for further attrition.7 Definitive Healthcare, which tracks health data and analytics, cites the loss of 2,826 anesthesiologists in 202127 and 7,459 in 2022.28 Clearly, innovative strategies that match workload with staffing are necessary to break this vicious cycle.

“Having a strong safety culture is associated with significant positive patient outcomes. Organizations with strong safety cultures have lower rates of surgical site infections,16,17 hospital readmissions, adverse events, and preventable harm.18 Hospitals with strong safety culture scores were also associated with lower rates of morbidity,17 and in some cases, even mortality.”

An organization's focus on individual performance metrics contributes to anesthesiologist burnout by undermining the collaborative and transparent nature required for a robust safety culture. Reducing physician anesthesiologists from individuals to staffing numbers, cases performed, or other performance metrics directly depersonalizes caregivers who must carry the burden of that work. Organizational efforts should focus on supporting and valuing anesthesiologists, who should be involved in the process of determining the meaningful metrics that improve clinical practice.

Fear of speaking up, chronic staffing shortages, and burnout all contribute to distrust of the system, which is the antithesis of psychological safety. When staff have psychological safety, they feel comfortable voicing concerns and speaking up. In health care, psychological safety is associated with improved patient safety outcomes, increased clinician engagement, and greater creativity.29 Distrust and disengagement imperil a just, strong safety culture. When staff know that errors and near-misses will not be held against them, but instead will be used for system improvement, error reporting improves.30,31 Fostering psychological safety and trust enables anesthesia staff to feel engaged and supported.

Health care organizations can no longer afford to ignore well-being as a key element of their organizational strategies. Well-being efforts should be reframed as efforts to recruit and retain professionals by increasing engagement and decreasing burnout. An organizational strategy to promote well-being requires setting measurable goals and defining what actions the organization will take, and even more importantly, what actions it will not take. An organizational well-being strategy must include systems-level and individual-level approaches. Resilience training alone is not the answer; physicians are already generally resilient, and even the most resilient physicians report substantial rates of burnout.32 Along with an organizational strategy, tactics are required to advance specific components of the strategic plan.33 Tactics are distinct from strategy. For example, one strategy to promote a culture of wellness is to enhance teamwork, which can be achieved through tactics such as 1) designing team-based care models that allow their members to provide the care most appropriate to their training and licensure, 2) fostering team psychological safety, and 3) maintaining adequate staffing to manage the workload, absences, and turnover.34 

Anesthesiologists have long been leaders in patient safety. Although anesthesiologists have made anesthesia care safer than ever, increasing burnout threatens to slow these gains and possibly erode the progress made in creating strong safety cultures. Any progress that can be made to reduce anesthesiologist attrition through coordinated well-being efforts will have a profound and lasting effect on both patient safety and clinician well-being. It is time for all organizations to tackle the drivers of burnout head-on before the situation worsens.

Stephen Rivoli, DO, MPH, MA, CPHQ, CPPS, ASA Committee on Patient Safety and Education, ASA Committee on Performance and Outcomes Measurement, ASA Committee on Quality Management and Departmental Administration, and Anesthesiologist, Mount Sinai West, New York, New York.

Stephen Rivoli, DO, MPH, MA, CPHQ, CPPS, ASA Committee on Patient Safety and Education, ASA Committee on Performance and Outcomes Measurement, ASA Committee on Quality Management and Departmental Administration, and Anesthesiologist, Mount Sinai West, New York, New York.

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Monica W. Harbell, MD, FASA, Chair, ASA Committee on Patient Safety and Education, Member, ASA Committee on Practice Parameters, and Associate Professor, Mayo Clinic, Phoenix, Arizona.

Monica W. Harbell, MD, FASA, Chair, ASA Committee on Patient Safety and Education, Member, ASA Committee on Practice Parameters, and Associate Professor, Mayo Clinic, Phoenix, Arizona.

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Jennifer A. Feldman-Brillembourg, MD, ASA Committee on Patient Safety and Education, Vice President, District of Columbia Society of Anesthesiologists, and Anesthesiologist, Department of Anesthesiology, Sibley Memorial Hospital and Howard University Hospital, Washington, D.C.

Jennifer A. Feldman-Brillembourg, MD, ASA Committee on Patient Safety and Education, Vice President, District of Columbia Society of Anesthesiologists, and Anesthesiologist, Department of Anesthesiology, Sibley Memorial Hospital and Howard University Hospital, Washington, D.C.

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Jina Sinskey, MD, FASA, Vice Chair, ASA Committee on Physician Well-Being; Member, ASA Committee on Specialty Societies; Member, ASA Ad Hoc Committee on Harassment, Incivility and Disrespect; Member, Anesthesia Patient Safety Foundation Advisory Group on Clinician Safety; Member, Society for Pediatric Anesthesia Board of Directors, and Associate Professor and Vice Chair of Well-Being, University of California, San Francisco, San Francisco, California.

Jina Sinskey, MD, FASA, Vice Chair, ASA Committee on Physician Well-Being; Member, ASA Committee on Specialty Societies; Member, ASA Ad Hoc Committee on Harassment, Incivility and Disrespect; Member, Anesthesia Patient Safety Foundation Advisory Group on Clinician Safety; Member, Society for Pediatric Anesthesia Board of Directors, and Associate Professor and Vice Chair of Well-Being, University of California, San Francisco, San Francisco, California.

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