We have read with great interest the article by Afonso et al. in the January 2024 issue of Anesthesiology.  Focusing on attending anesthesiologists, the authors found that burnout has become more prevalent in the postpandemic area. As resident physicians, we want to add how this pressing issue substantially affects trainees.

The article cites several studies that demonstrate increased burnout among trainees and younger physicians, explaining that this phenomenon is likely secondary to less-developed “coping mechanisms” and “low levels of personal accomplishments” without acknowledging other well-known causes of trainee burnout. A previous article in Anesthesiology identified even before the pandemic that a lack of institutional and social support, work–life balance, and manageable workload markedly affects resident burnout.  The COVID-19 pandemic and its aftermath only exacerbated the challenges trainees face. Alfonso et al. identified “staffing shortages” and “lack of support at work” as the strongest risk factors for burnout, and trainees are especially implicated in these problems.

The shortage of anesthesiologists and other physicians is anticipated to only increase over time.  Institutions are under more pressure to utilize residents as a major part of their workforce productivity. The inherently conflicting role of residents as students and employees is strained as hospitals become reliant on operating room productivity to meet the hospital’s bottom line. We have seen a corresponding increase in residency programs and positions in order to meet this need.  As a more cost-effective alternative to advanced practice providers, resident physicians often serve as the first-line staff members to fill work hours.  Institutions prioritize their mission to the education and well-being of residents with great consideration of the financial cost.

Although improved over the past few decades, residents have the highest work hours with comparatively lower hourly pay and flexibility. Salaries, benefits, and support for residents have not been commensurate with the demands for efficiency, productivity, and costs of modern life. Unable to leave their work environment conditions, trainees have resorted to change from the bottom up, exemplified in recent unionizing efforts across the country at major academic centers.  Under intense pressure to meet competing demands of their institution and trainees, program leadership are at a great risk of burnout themselves. 

We write this letter not only to shed light on the challenges faced by resident physicians but also to urge the consideration of trainees while thinking about burnout and well-being of attending anesthesiologists. Although not all current attending anesthesiologists work in an academic setting or with residents, all attendings were trainees at some point. Training is a crucial and seminal period of any physician’s journey, and it is imperative that we work toward solving these problems in burnout from the bottom to the top. By doing so, we can improve the culture and fulfillment in medicine of all members of our specialty.

We are writing to express our team’s keen interest and appreciation for the insightful study published in Anesthesiology, “U.S. Attending Anesthesiologist Burnout in the Postpandemic Era” by Afonso et al.  As peers from China, we are particularly intrigued by the parallels and variances we have observed between the findings presented and our analogous research in China. 

The use of the Maslach Burnout Inventory in both American and Chinese surveys reveals a disturbingly high prevalence of burnout among anesthesiologists across the board. Before the pandemic  59.2% of anesthesiologists in the United States experienced burnout, which increased to 67.7% after the pandemic. Our survey in China, which included all anesthesiologists, showed a national cross-sectional survey burnout rate of 69% prepandemic which interestingly decreased to 52.7% postpandemic.  Specifically for Chinese attending anesthesiologists, the burnout rate was 73% prepandemic and 42.6% postpandemic. 

This unexpected trend in China, despite high baseline levels, deserves attention. Risk factors for anesthesiologist burnout in both the United States and China include a perceived lack of support and severe staffing shortages.  In 2018, China had 76,000 anesthesiologists for a population of 1.4 billion, far fewer than the 2.4 anesthesiologists per 10,000 people in the United States and Europe. The United States has also recently faced severe staffing shortages, with 35.1% of attending anesthesiologists reporting shortages in 2020, rising to 78.4% in 2022.  These staffing challenges have likely contributed to high burnout rates in both countries. To address this, China has taken steps to increase its anesthesiologist workforce. In 2018, China’s National Health Commission (Beijing) released Document 21, which aims to increase the number of anesthesiologists to 90,000 by 2020 and 140,000 by 2030. Local governments and hospitals have also been working to increase the number of formally trained anesthesiologists and promote the sustainable development of this workforce. According to the Chinese Society of Anesthesiology, the number of anesthesiologists in China has increased to 105,000 in 2023, an increase of 38% from 2018. Although there is still a significant shortage, this increase may partially explain the decrease in burnout rates. However, we must acknowledge that our research did not follow the same individuals over time, and burnout has complex, multifactorial causes. Therefore, the observed improvements in staffing are likely only one of several contributing elements.

Understanding the complexities of anesthesiologist burnout is essential for developing better interventions and improving their well-being and job satisfaction. Both the U.S. and Chinese studies emphasize that support from leadership at an organizational level is crucial in preventing burnout.  Furthermore, our research in China investigated the psychologic status of anesthesiologists, revealing a positive association between burnout and mental health issues such as depression, anxiety, and posttraumatic stress disorder.  Although the causality between psychologic status and burnout and the impact of COVID-19 on mental health is not entirely clear, prioritizing the psychologic well-being of anesthesiologists is likely beneficial for mitigating burnout. In addition, we believe that pressures related to scientific research and advancement in one’s career might also influence burnout, an aspect that could be explored in future studies. Therefore, it is imperative for our team leaders to pay more attention to improving the work environment and providing additional support to colleagues. Of course, considering the differences in culture and healthcare systems, our interventions need to be adapted accordingly.

It is noticed that our studies have achieved response rates of greater than 70%, possibly due to our WeChat (Tencent, China)–based data collection. Frankly, our methodology took advantage of the use of WeChat, for either social interactions or professional communication to streamline the survey process. Our respondents could conveniently complete the questionnaire on their mobile devices in only a few minutes. Compared to traditional surveys, WeChat has contributed greatly to the response rate of our study.

In conclusion, anesthesiologist burnout is an international problem that requires a global response. Recent studies suggest significant regional variations and potential strategies for improvement. Further research is needed to understand these differences and develop effective interventions. We look forward to further research and dialogue in this area and hope to collaborate with researchers worldwide to improve the working conditions and mental health of anesthesiologists. Addressing burnout is a marathon, not a sprint, and our commitment to this effort is unwavering.

We wish to thank Dr. Cata and Dr. Sessler for their carefully considered review of factors contributing to the failure of promising preclinical study findings to be confirmed in subsequent large clinical trials of the effects of anesthetic technique on cancer surgery outcomes.  Their forensic analysis of the reasons focused on experimental methodology in animal research, and the mechanistic drivers and reductionist approach that characterize preclinical science. Their explanation also included “often unjustified” small sample sizes and “unsophisticated” statistical analysis. (A common example might be failure to correct for multiplicity in experimental comparisons when determining statistical significance, for instance.) They pointed to the “huge effort and the expense” of the clinical trials prompted by this preclinical work, but ultimately with negative findings.

However, the authors did not mention the likely contribution of positive publication bias to this failure in research translation. The damaging effect of publication bias on evidence quality in medicine has been lamented for many years by experts who estimate half of research activity goes unpublished.  In the field of anesthesiology, we and other authors have confirmed this.  We found that, among more than 1,000 abstracts of clinical trials presented at the annual American Society of Anesthesiologists (ASA; Schaumburg, Illinois) meeting from 2001 to 2004, those with positive findings were twice as likely (odds ratio 2.01) to proceed to eventual peer-reviewed journal publication as those with negative findings.  The hallmarks of clinical research that promote publication bias are single center, small trial design, and lack of transparency in prospective hypothesis formation with potential for selective outcome reporting.  These features can all be shared by animal laboratory research, and there is certainly no reason to believe that it is any less prone to publication bias than clinical trials.

With a view to future solutions, we repeated our analysis by using ASA abstracts from 2010 to 2016, following the implementation by the International Committee of Medical Journal Editors (ICMJE) of mandatory prospective clinical trial registration for publication after 2005. We found that the magnitude of imbalance in publication outcome had significantly reduced (odds ratio 1.3), suggesting that this policy successfully limits the influence of publication bias in clinical anesthesiology.  However, mandatory prospective trial registration does not extend to preclinical trials and animal studies, nor to the publication policies of journals in other fields of the biologic sciences. Leaders in preclinical science have recently called for integration of trial registration into the animal ethics review process.  Animal research registries have been established, but with only sporadic use. 

We fear therefore that, in combination with the factors which Dr. Cata and Dr. Sessler have described, the persistence of publication bias offers little prospect that the problem of false promises by preclinical research will be solved any time soon. We can thus expect much wasted cost and effort in subsequent clinical trials to continue into the future.