Paper in Focus
Article: How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents?Authors: Verret CI, Nguyen J, Verret C, Albert TJ, Fufa DT Journal: Clinical Orthopaedics and Related Research Year:2021 Volume/Issue: 479(2):251–262 DOI: 10.1097/CORR.0000000000001457 PMCID: PMC7899526 PMID: 32858718
Opening Editorial: Editor’s Perspective
Burnout has become one of the most important conversations in modern medicine, and orthopaedic surgery is no exception. Across surveys and specialties, orthopaedic surgeons have reported some of the highest levels of burnout in the profession. The consequences are significant, including decreased productivity, increased medical errors, and a higher risk of depression and suicidal ideation.
This issue of Conversations in Orthopaedics focuses on how the working environment shapes burnout across the stages of an orthopaedic career. The paper by Verret and colleagues examines burnout not as an individual weakness, but as a mismatch between physicians and their workplace. It studies residents, fellows, and attending surgeons within a single institution and asks how their experiences differ.
For much of its history, burnout research has focused on the individual. Interventions such as mindfulness, resilience training, and coping strategies have been common. These approaches are valuable, but on their own they have not solved the problem. This paper is important because it turns attention toward organizational and structural factors that institutions can actually change.
Burnout should not be viewed only as something a surgeon must overcome personally. It may also be a signal that the work environment itself needs attention. The most meaningful progress will likely come from understanding both the individual and the system in which they work.
Why This Paper Matters
Orthopaedic surgery is a demanding field with heavy clinical volume, long hours, complex procedures, and significant administrative responsibilities. These pressures are experienced differently by residents, fellows, and attending surgeons, yet they often share the same physical work environment.
This paper matters because it moves beyond simply measuring how much burnout exists. It asks which specific areas of work life are most responsible for burnout, and whether those drivers change depending on where a surgeon is in their career.
For students and trainees, the article introduces a practical framework for thinking about burnout as something rooted in workload, control, reward, community, fairness, and values. For practicing surgeons and program leaders, it raises important questions about how institutions might target interventions to the groups who need them most.
As orthopaedics continues to confront physician well-being, understanding the environmental drivers of burnout will be essential for anyone involved in clinical care, education, or leadership.
Study Overview
This is a single-center, cross-sectional, mixed-methods study conducted at the Hospital for Special Surgery. Two hundred orthopaedic surgeons were invited to participate, and 148 responded, for a response rate of 74 percent. The sample included 43 residents, 18 fellows, and 87 attending surgeons.
The authors used two validated instruments. The Maslach Burnout Inventory measured burnout through emotional exhaustion and depersonalization. The Areas of Worklife Survey measured the fit between participants and their work environment across six domains: workload, control, reward, community, fairness, and values.
The study also included a qualitative component. Participants were invited to share their experiences in open comments and to suggest improvements. These responses were analyzed and coded into themes, allowing the authors to understand not only which areas of work life were problematic, but how and why.
Key Concepts From the Article
Burnout as a Mismatch Between Person and Workplace
The article is built on the idea that burnout arises from chronic mismatches between people and their work environment. Rather than framing burnout as a personal failing, this model looks at six domains of work life and asks how well each one fits the individual.
This perspective is important because it shifts the focus from fixing the surgeon to improving the environment. It also allows institutions to identify specific, modifiable problems rather than relying only on general wellness efforts.
Burnout Differs by Career Stage
One of the central findings is that burnout is not experienced equally across career stages. Residents reported the highest levels of depersonalization, the dimension of burnout associated with cynicism and detachment. Thirty-four percent of residents scored in the high range for depersonalization, compared with 9 percent of attending surgeons and 6 percent of fellows.
Emotional exhaustion was common across all groups, though the differences between them did not reach statistical significance. The clearest signal in the data is that residents, who are earliest in their training, carry the greatest burden of depersonalization.
Workload Is the Most Problematic Domain
Across every group, workload was the most problematic area of work life. Both the survey scores and the open comments pointed to workload as the central concern.
Importantly, the workload described in the comments was not only about hours in the operating room. It included administrative tasks, documentation, meetings, the electronic medical record, and hospital-wide email. It also included conflicts between clinical, academic, and personal roles that pull surgeons in competing directions.
Workload and Control Are Closely Linked
Although workload and control are treated as separate domains in the survey, the qualitative analysis showed that they are deeply connected in practice. Participants described frustration not only with the amount of work, but with having little say in how that work was structured.
A heavy workload that a surgeon can influence is difficult but manageable. A heavy workload imposed without input can feel far more damaging. Many participants specifically described being excluded from decision-making processes.
The Drivers of Burnout Are Different for Fellows
Perhaps the most striking finding is that fellows did not follow the same pattern as residents and attendings. For residents and attending surgeons, burnout correlated most strongly with workload and job control. For fellows, workload was not the primary driver at all.
Instead, burnout in fellows correlated most strongly with a declining sense of fairness and a weaker sense of community. The correlations were notably strong, suggesting that for this group, feeling included, respected, and treated fairly mattered more than the volume of work. This finding indicates that interventions effective for residents and attendings may not address the needs of fellows.
Clinical Relevance
The clinical relevance of this article is significant because burnout directly affects patient care, physician well-being, and the sustainability of the orthopaedic workforce.
The study suggests that institutions can take a more precise approach to burnout. Rather than applying a single, uniform solution, leadership can identify which areas of work life are most problematic and tailor interventions to each group. Residents and attending surgeons may benefit most from efforts to reduce workload and improve job control. Fellows may benefit most from efforts to strengthen fairness and community.
For clinicians, the central message is that burnout is not only an individual responsibility. It is also a reflection of the work environment, and that environment can be measured, understood, and improved.
Strengths of the Article
One strength of this article is its mixed-methods design. By combining validated quantitative surveys with qualitative open comments, the authors capture both the scope of the problem and the human experience behind it.
Another strength is the comparison of residents, fellows, and attending surgeons within the same institution. This allows the study to isolate how career stage shapes the experience of burnout, a comparison that is rarely made in the literature.
The article also focuses on modifiable, structural factors. By identifying specific drivers of burnout, it offers institutions a realistic starting point for targeted interventions rather than broad and unfocused wellness initiatives.
Limitations and Considerations
Although the study offers valuable insight, several limitations should be considered.
First, it is a single-center, cross-sectional study. It captures a moment in time and cannot establish causation. A correlation between heavy workload and burnout does not prove that workload alone causes it.
Second, the study population was predominantly male and predominantly white, reflecting the demographics of orthopaedic surgery. This limited the ability to draw meaningful conclusions about the relationship between burnout, gender, and race.
Third, burnout and mental health remain stigmatized within surgical training and practice. This may have influenced how honestly some participants responded, particularly given concerns about professional and licensure repercussions.
Finally, the number of fellows in the study was small. While the findings for this group are striking, they should be interpreted with appropriate caution and confirmed in larger studies.
Discussion
This study encourages a shift in how the orthopaedic community thinks about burnout. For decades, the emphasis has been on individual resilience and coping. While these skills remain valuable, they do not address the structural conditions that contribute to burnout in the first place.
By identifying workload and job control as the strongest drivers for residents and attending surgeons, the article points toward concrete institutional actions. These include reducing administrative burden, improving workflow, streamlining communication and email, reconsidering the volume of mandatory meetings, and adding human support such as physician assistants, medical assistants, research assistants, and scribes.
The finding that fellows respond to different drivers is especially important. It suggests that a single institutional solution will not serve everyone equally. Fairness and community must be considered alongside workload and control.
Perhaps the most actionable insight is the recommendation to include surgeons in institutional decision-making. Restoring a sense of control may be one of the most direct ways to reduce burnout, and it begins with giving physicians a genuine voice in the decisions that shape their work.
Interview Feature
A Conversation with Dr. John Kelly
To explore these themes further, I spoke with Dr. John Kelly, Director of Shoulder Sports Medicine and the Penn Throwing Clinic, Professor of Clinical Orthopaedic Surgery at the Perelman School of Medicine at the University of Pennsylvania, and the 44th President of the Arthroscopy Association of North America (AANA).
Now in his 36th year of practice, Dr. Kelly writes the “Your Best Life” column in Clinical Orthopaedics and Related Research and has long championed a holistic view of orthopaedic surgery. Our conversation ranged widely, touching on his path into shoulder and sports medicine, the throwing shoulder, joint preservation, international outreach, artificial intelligence, and the questions of well-being and meaning that sit at the heart of this issue.
You’ve built a distinguished career as Director of Shoulder Sports Medicine at Penn and a leader in arthroscopic shoulder surgery. What first drew you to the shoulder and to sports medicine specifically?
Dr. Kelly I love sports. I played a lot of them, in both high school and college, and I was drawn to athletes because I had many injuries myself. Probably one of the reasons I chose orthopaedics was that I hurt my knee in college and had a really good doctor. I said to myself one day, “I’m going to be that guy.”
Then I realized that, growing up, I had an identical twin brother who was right-handed, while I’m kind of ambidextrous. I write with both hands, though I throw right. That lends itself very well to shoulder surgery, where you really have to use both hands, particularly for rotator cuff or instability work. So it was a natural evolution. Maybe because of that ambidexterity, and because I tend to be a big-picture person, I was attracted to the idea of shoulder preservation and all the good things we can do with the arthroscope. I’ve had a wonderful career, and I’d like to think I’ve helped a lot of people.
As Director of the Penn Throwing Clinic, you care for some of the most demanding athletes in sports. What makes the throwing shoulder so uniquely challenging, and what advances most excite you in caring for these athletes?
Dr. Kelly I’m a product of my mentors, and I’d like to give credit to three people — Tylee, Steve Thomas, and Ben Kibler — who really taught me the ins and outs of the throwing shoulder. Most throwers don’t need surgery, and most throwing injuries can be prevented. I also think our treatment paradigms for fixing labral tears have been flawed; that’s part of why the results often aren’t good. I don’t believe we’ve been fixing them the right way.
Working with those three researchers, we’ve done meaningful research on which labral tears actually need to be fixed and, more importantly, how to fix them. I have a much clearer understanding now of who needs an operation. I’m averse to the biceps-cutting we see in young people; I don’t think it’s a good idea, and we have data suggesting it isn’t good in the long term. We recently published a paper showing that superior anchors can adversely affect mechanics in the follow-through phase of throwing, and now we’re asking the same question in late cocking. Hopefully, that will help us devise the proper method of fixation — where to place anchors, how many are needed, and who really needs an operation at all.
You’re known for a strong commitment to joint preservation. How do you decide when to preserve versus reconstruct, and how has that philosophy evolved over your career?
Dr. Kelly It’s all about being honest with yourself. You look at your results and ask what works and what doesn’t, and you have to stay on top of the literature — I’m a voracious reader. Mentors like Dr. Stephen Burkhart and Dr. Mihata showed me that not everyone needs a reverse shoulder replacement for an irreparable cuff. I’ve been doing superior capsular reconstructions for over 15 years, and I wouldn’t still be doing them if they weren’t working.
That’s not to say no one needs a reverse — it’s a wonderful operation — but in my opinion, it’s overused. I’d much rather exhaust the minimally invasive options before going to the heavy hitters. The challenge is that these operations are hard, so you have a choice: send the patient to someone who does a lot of them, or be a thick-headed Irishman like me and just learn it. Practice, practice, practice, and continually refine the technique so you can do it well and help people.
You served as the 44th President of the Arthroscopy Association of North America. What were your priorities for AANA, and where do you see the greatest opportunities to advance arthroscopic and sports medicine surgery?
Dr. Kelly My term just expired in May, and it’s now Kevin Bonner, our 45th president, a wonderful man. During my presidential year, my biggest passion was international outreach. We are so blessed in America — most of us have two air-conditioned operating rooms, all the products we could want, and enormous access to technology and knowledge. So one thing I really tried to do was disseminate that knowledge through electronic media to less privileged countries, simply to share the pearls.
We have foundation courses in the journal, and the editor has been very generous in sharing them. We also have ambassadors in different countries who serve as liaisons and tell us what they need. We can send the journal electronically, share webinars and arthroscopy pearls, and invite people into chat rooms. My dad told me, “To whom much is given, much is expected.” We are overflowing with abundance in America, and we have an obligation to share it. And when I’ve traveled to underprivileged countries, I’ve actually learned a great deal — those surgeons make excellent use of what they have and are remarkably innovative. Medicine is a vocation, not just a profession, and your job is to help as many people as you can.
You’re well known for championing holistic orthopaedics and write the “Your Best Life” column in CORR on topics like resilience, detachment from negativity, and caring for the brain. Why do you believe well-being and mindset are so essential for both patients and surgeons?
Dr. Kelly The literature speaks for itself — somewhere between 40 and 50 percent of orthopaedic surgeons are considered burned out. And you can’t give what you don’t have. It’s like the oxygen mask on an airplane: you have to secure your own before you can help the person next to you.
I’ve been blessed. This is my 36th year in practice, and I’m still going strong, because I have a wonderful marriage, a wonderful family, and a faith that has never abandoned me. I’ve learned the principles of self-care, and I prioritize sleep and exercise. I learned the hard way that you cannot give what you don’t have. You have to tend to your own house first. When you do, you can be more present to your patients and endure the 30-plus-year marathon most of us sign up for.
Surgeon burnout and well-being have become urgent issues in medicine. As someone who speaks and writes on this often, what would you say to trainees and colleagues struggling to find balance and meaning in a demanding field?
Dr. Kelly Number one, get help. When my brother died, I saw a therapist. There is nothing wrong with seeing a therapist to get your priorities in order. Focus on relationships. Read about wellness — my colleague Jack Flynn wrote a wonderful book, Peak Performance for Physicians, that I’d consider required reading for any doctor, and my daughter Naomi wrote a book on the resilient physician that I’d also recommend.
But the most important thing is to prioritize. Do whatever it takes to keep the relationships in your life in order, because if you don’t have those right, you’ll burn out. I prioritize my marriage, my relationship with my two daughters, and my faith; those are my inner compass. When I say no to something, it’s usually a yes to something bigger, and that something is usually my family.
You also have to accept that you can’t have it all. I had to make sacrifices. I took trauma call for 21 years and didn’t make every dance recital or every play. But my wife, a nurse, would tell our daughters, “Daddy’s helping somebody right now.” You can reframe it that way for your children. I have two well-adjusted daughters, thank God. The good news is that you can have a vocation in orthopaedics and still have a family life, but you have to say no, make decisions, and put first things first. Everything else flows from that.
Your research has explored less-discussed factors in shoulder outcomes, from metabolic syndrome to cannabis use and orthobiologics. What underappreciated areas do you think deserve far more attention in sports medicine?
Dr. Kelly For the shoulder, I’d say we need to treat it as an organ. Why does a cuff tear? Look at the metabolic picture — diabetes, vascular issues, lipids. There’s interesting work on the relationship between high lipids and rotator cuff disease, and even on whether statins may aid healing. If someone has a stiff shoulder, there is almost always an underlying inflammatory condition, often unrecognized diabetes or glucose intolerance. We published work showing that metabolic syndrome correlates with stiffness.
If the shoulder isn’t respected as an organ, it will fail. There’s a large body of literature on anti-inflammatories, matrix metalloproteinase inhibitors, and cuff healing. An inflammatory condition in the shoulder is really a sign of organ failure, and it can serve as a useful proxy — I’ve diagnosed diabetes, thyroid disease, and other conditions in patients who simply came in with a stiff shoulder. So I look at the shoulder biologically, not just mechanically. When I repair a cuff, I prioritize minimizing tension over putting in the most anchors or building the strongest construct. I’m always looking for a softer, kinder, gentler way to fix the cuff that encourages the biology of healing.
Speaking broadly, where do you see technology and AI offering the greatest promise in sports medicine and arthroscopy, and where do you remain cautious?
Dr. Kelly You have to trust your database and your vehicle. I think it’s an evolutionary tool. I know there are things like hallucinations, but there are platforms — OrthoEvidence is one I use a lot — where I’ll ask what the literature says about a given question. The key principle, though, is that we have to be the master of AI; AI can’t be the master of us.
I’ll go to my grave believing that no AI will ever overcome truly good judgment. I take a spiritual view of this. I have intuition, an inner wisdom I tap into, and I pray when I make a decision — no AI will ever surpass that. So use it as a tool, but don’t become so lazy that it does everything for you. When I give a talk, I’ll consult AI, but I compose the talk myself. If I have a research question, I’ll look at what AI and the literature say and weigh it. You have to master it; it can’t master you.
You often speak about spirituality, intuition, and meaning in medicine. How do those shape the way you practice and the way you think about burnout?
Dr. Kelly I believe you have to have a principal center. One line I love is that you can’t serve two masters — you either do what’s right, or you do what’s best for your OR schedule or your pocketbook. We’re all imperfect, and we all give in to temptation, but I keep my eye on the prize: did I do right today? Did I honor my commitment to do what is right and just in this patient’s eyes, rather than serving the schedule or my bank account? When patients realize you’re in their corner, you’ll never have a bad day in clinic.
The real antidote to burnout is meaning. You can find meaning in everything you do, and that’s where spirituality comes in. I ask myself, “Who is God sending me today? Who can I help?” When you believe that everything that happens to you — even the complications — is ordained and carries a lesson or a gift, then you see life differently. There’s always a lesson, always a gift. You never really have a bad day.
As a leader of the Sports Medicine Fellowship, you’ve mentored many surgeons. What qualities do you try to instill in the fellows and residents you train?
Dr. Kelly Jim Carey is the director, and I’m the co-director, but what I try to give them is confidence. Ninety percent of education is encouragement, and I’d say 95 percent of surgery is confidence. So I try to instill competence and the belief that they can do this. Give them feedback, not harsh critiques. If you can help them walk into the OR feeling capable, you’ve done your job — but you also have to teach them the steps, and never castigate them so that they feel worthless.
I also share the values I’ve learned over a long career. I’ll ask them: Did you call your wife today? Did you get home in time yesterday? Did you spend time with your kids? Did you work out this week? I don’t want them up all night reviewing a paper to the point of overkill; I want them prepared, rested, and ready to work. The demon of perfectionism runs rampant in medicine, and I learned the hard way that you can’t be perfect. Strive for excellence, do an excellent job, but understand that you’ll never be perfect. The sooner you learn that, the more peaceful you’ll be, and the more you’ll have to give your patients. Beyond confidence and technical skill, the biggest thing you learn in fellowship is judgment — knowing who needs an operation.
Finally, what advice would you offer medical students and trainees who hope to build a meaningful and fulfilling career in orthopaedic sports medicine?
Dr. Kelly Focus on the vocation. Remember whether this is a calling, because if it is, you honor it and you look for meaning. Ask yourself, “Who is God sending me today?” Do research to advance the field, not just for your own name in lights. The more you center yourself on a higher purpose — helping patients, advancing knowledge, mentoring, speaking to teach rather than to be seen — the more fulfilled you’ll be. Prioritize relationships, and you’ll figure it out.
If you show competency, people will ask you to lead; you don’t have to lobby for it. I let it be known that I wanted to lead AANA because I had a passion for international outreach and knew it wouldn’t happen otherwise, so it’s fine to say you’re interested. But chasing name, power, and prestige will never fulfill you. I’ve been blessed to surround myself with people more talented than I am, and because of that, our international outreach has never been stronger, and we’ve helped a great many people this past year.
Dr. Kelly closed with a blessing from his Lebanese grandmother, who would call him her sweet one: “Allah will open the world to your face.” If you live your life the right way, he said, and put your faith and family first, the world will open to you.
Key Takeaways
Burnout in orthopaedic surgery is common and is experienced differently across career stages, with residents reporting the highest levels of depersonalization.
Workload is the most problematic area of work life across all groups, including administrative burden, documentation, technology, and role conflicts, not simply operative volume.
For residents and attending surgeons, burnout is most strongly associated with heavy workload and limited job control.
For fellows, burnout is most strongly associated with a reduced sense of fairness and community, indicating that interventions must be tailored to the group.
Institutions should view burnout as a modifiable, environmental problem and consider targeted strategies rather than a single, uniform solution.
Future Directions
Future research should extend this work beyond a single institution to determine how well these findings generalize across different practice settings and regions. Longitudinal studies would help clarify how work-life factors and burnout change over time and whether specific interventions produce lasting improvement.
Additional qualitative research, including interviews and focus groups, could deepen our understanding of the lived experience of burnout, particularly for underrepresented groups within orthopaedics. Larger samples of fellows would also help confirm the distinct drivers identified in this study.
As institutions begin to act on this information, it will be important to measure whether targeted interventions actually reduce burnout and improve both physician well-being and patient care.
Closing Perspective
Burnout remains one of the most pressing challenges in orthopaedic surgery. For years, the response has centered on strengthening the individual. This study reminds us that the environment surrounding the surgeon is just as important, and often more modifiable.
The article by Verret and colleagues offers a practical framework for understanding where burnout comes from and how it differs across a career. It demonstrates that residents, fellows, and attending surgeons can share the same institution while experiencing very different pressures.
The path forward should keep the physician at the center. The goal is not simply to ask surgeons to endure more, but to build environments where they can practice sustainably, with a reasonable workload, a genuine sense of control, and a culture of fairness and community. As Dr. Kelly reminds us, meaning and relationships are powerful protectors against burnout, but they are strongest when the institutions we work within support them rather than stand in their way.
As the field continues to address this issue, the most important conversations will be not only about how individuals can cope with burnout, but about how institutions can prevent it.
Reference
Verret CI, Nguyen J, Verret C, Albert TJ, Fufa DT. How Do Areas of Work Life Drive Burnout in Orthopaedic Attending Surgeons, Fellows, and Residents? Clin Orthop Relat Res. 2021;479(2):251–262. doi:10.1097/CORR.0000000000001457.
Educational commentary on published literature — not medical advice. Reading this issue does not create a physician–patient relationship. Guest statements are the personal views of the speaker. Full terms & disclaimers.