We read with interest “U.S. Attending Anesthesiologist Burnout in the Postpandemic Era” by Afonso et al. This work advances our understanding of anesthesiologists’ wellness, support, and retention. Its key findings indicate that compared to prepandemic data, anesthesiologists are experiencing worsening burnout, which in turn predicted increased intent to leave their institutions. In multivariate analysis, by far the strongest predictor of burnout was lack of workplace support, a finding that we believe connects burnout, retention, and workplace support to a potential driver for all of those realities: belonging.

Belonging has been described as a fundamental human need by American psychologist Abraham Maslow and is defined as “the experience of personal involvement in a system where an individual feels valued, needed, and in alignment with the values or goals of a larger social group.”  Feeling supported is critical to belonging, and belonging has been strongly linked to decreased burnout and turnover. Schaechter et al. have identified a number of workplace belonging factors including feeling valued, having input regarding decisions, and feeling supported in professional advancement.  Belonging has been shown to be protective against burnout in residents and in women physicians, increasing numbers of belonging factors are associated with decreasing intent to leave.  We suggest, therefore, that belonging is a key missing factor in the model linking burnout to turnover, and may even break the link between burnout and intent to leave that was found in this study.

Structurally, our role as anesthesiologists can be isolating, presenting unique challenges to intradisciplinary connectedness. Limited common space and limited contact with anesthesiology colleagues decrease connectedness. Our workplace communities are multidisciplinary and change daily, with most of our time spent with nonanesthesiologists. Surgical and nursing colleagues are often our closest workplace relationships, and the high turnover of our teammates from these and other disciplines puts strain on our connectedness, belonging, and well-being. Conversely, those close relationships with operating room colleagues are sometime fraught with conflict, and occasional depersonalization decreases feelings of value. For example, knowing colleagues’ names seems a baseline factor for workplace support and belonging. Birnbach et al. found that although 98% of operating room staff correctly named the surgery attending, only 62% could similarly name the anesthesiology attending.  Stressful workplace conditions contribute not only to burnout and mental distress but also to decreased physical health.  Social isolation conveys a host of physical ailments as measured by elevated markers of chronic inflammation. Taken together, structural and cultural elements unique to anesthesiology leave practitioners vulnerable to stress, isolation, and mental and physical health concerns, making engendering belonging both difficult and urgently important.

Anesthesiologists, already at high risk for burnout and turnover prepandemic, have reached a critical state in the postpandemic world. Given the risk to mental and physical health, and the correlation between burnout and intent-to-leave, the factor of belonging should be a key target in reduction of burnout and turnover. Afonso et al. suggest that organizations “[build] an inclusive community that allows for constructive associations between peers and leaders within the organization.” We wholeheartedly agree. Given the enormous healthcare cost associated with physician turnover, these factors should be a priority target in asset allocation and employee retention. We believe that belonging is critical to inclusive communities, physician well-being, and lowered attrition, and suggest that it be both included in further iterations of this important survey work and prioritized by departments, leaders, and their institutions.