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as physicians, nurses, and social workers. Of all physicians, surgeons may be particularly prone to this syndrome due to the intensity of caring for their often very ill and complex patients, the high level of commitment and responsibilities of a surgical practice, the unpredictable and long hours (median hours worked per week according to a recent survey of US surgeons: 60 h), and the physical demands associated with the profession.23 In the USA, according to several studies, up to 40% of all surgeons are burned out.7, 8, 12-14, 19, 22 Interestingly, a high prevalence of burnout among surgeons has also been reported from other countries. In a survey of the Young Fellows of the Royal Australasian College of Surgeons, 53% of all respondents reported high burnout levels (20% suf- fered work burnout, 27% suffered personal burnout, and 6% suffered patient burnout).15, 16 A similar study among colorec- tal and vascular surgeons from the UK reported high burnout scores for 31% of the respondents.10 Burnout thus does not appear to be associated with a particular culture or type of healthcare system.

Factors independently associated with burnout – in some or all – of the aforementioned studies included age (younger > older), gender (women > men), age of children under 21 years, work–home conflicts, spouse in the health care profession, area of specialization (highest in trauma surgery), hospital size <60 beds, number of nights on call per week, hours worked per week, and compensation based entirely on bill- ing.7, 8, 13, 14, 19, 22, 31 Not surprisingly, burnout was found to strongly correlate with the desire to retire early.22

Prevention of and Recovery from Work–Life Imbalance

As with any medical problem, prevention is by far preferable to treatment. From a practical perspective, preventive and therapeutic measures overlap to a large extent and are often indistinguishable. They will therefore be discussed jointly in this section.

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“Know thyself” should always be the starting point. What is your heart telling you? What are your needs and your fam- ily’s needs? What are your interests? What are your talents? What are your core values? What is your mission? What is your vision?

With regard to any personal or professional action plan, setting priorities and establishing realistic goals is paramount and derives directly from the aforementioned self analysis. The following is intended to help in setting such priorities and goals, but it is ultimately up to each surgeon to ensure that these goals are realistic and appropriately tailored to individual life situations and professional circumstances.

Action Plan for Finding Balance: Personal Level

At a personal level, it is important to take the time to foster and nurture friendships and relationships. They can serve to “reground” and reenergize you, will enrich your nonwork time and add meaning to your life. These relationships also provide a critical support system, especially during challeng- ing phases of your life.

The relationship with the spouse or partner is the one that is most often neglected and taken for granted due to the lim- ited free time in the surgical profession. In a recent study, two-thirds of academic surgeons felt that the demands of work adversely affected their relationships with their spouses.24 The potential beneficial effects of limiting, or even reducing, work hours have been suggested by the results of a study of surgery residents after the introduction of the 80-h workweek. Seventy-one percent of respondents noted that the quality of their relationships improved subsequent to the restriction of work hours.2, 32 For maintaining a healthy rela- tionship, you must have specific “you and me” time with your spouse or partner. It is acceptable to use, at least occasionally, a babysitter or nanny to enjoy truly protected time together (e.g.,“date nights”).When spending time with your spouse or partner, you must be rested and mentally present in order to be able to devote all attention to, and to make the most of,

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your joint time.This will strengthen, reinforce, and invigorate both the emotional and the physical aspects of your relationship.

Fixedfamilytimemustbebuiltintotheschedule.Important family events cannot be missed and must be prioritized. Multitasking (combined pursuit of work and home duties) at home must be – if not eliminated – at least severely restricted. When with the family, you must be 100% present in mind and body and not pursue work-related tasks at the same time (except, for instance, when being on-call from home). If duties at home become too overwhelming, you should strongly consider hiring help with house chores and other routine duties in order to minimize avoidable stress and time not directly devoted to the family. Ideally, pastimes and hob- bies should be chosen that allow for spending time with the family (e.g., hiking, skiing, music, chess playing, coaching child’s sports team). Nonetheless, even chores, errands, and other tasks that cannot be delegated to hired outside helpers can be viewed as opportunities to spend time together with the children. Vacation time should be reserved for true dedi- cated family vacations and not for attending medical meetings.

Imperfection around the house must be accepted, particu- larly at times when family demands are high, such as with younger children.The house does not always have to be spot- less and you should heed the important tenet “Don’t sweat the small stuff.” Overall, it is paramount to be as invested in your spouse or partner and the children as you are invested in yourself and in your career.

The “me” aspect is often excluded from a personal action plan due to lack of time, attention, and priority, yet it is essen- tial for an individual’s well-being, too.Time for self reflection and meditation is an important component of the mainte- nance of an adequate work–life balance. Even with a very busy professional and family life, it is acceptable and neces- sary to have time for hobbies and personal interests, even if these involve only relatively short, but recurrent, time spans (e.g., reading a newspaper, learning a language). Many sports fulfill the needs of both physical and mental rejuvenation.

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It is important to acknowledge that a fulfilled life outside of work enhances the insight into your patients’ problems and helps you to better understand them.33

Personal health must be optimized. This involves mainte- nance of an active exercise schedule, intake of good nutrition, and provision of sufficient sleep. Optimization of personal health should also include seeking adequate preventive medical care and establishing a relationship with a primary care physician. Prompt attention should be sought for any physical or mental health issues. Unfortunately, surgeons (and other physicians) tend to be reluctant to seek psychiat- ric or psychological help when needed.Among surgeons with suicidal ideations, for instance, only 26% had sought profes- sional help over the preceding 12 months, and 60% reported that they were reluctant to seek such help because of the concern that it might adversely affect their license to practice medicine.21

For the achievement and maintenance of an adequate mental balance, time must also be made for the pursuit of specific spiritual, religious, or meditation practices in accor- dance with personal beliefs.

In trying to incorporate and maintain the above recom- mendations into your schedule, it is of utmost importance to acknowledge that their implementation will require active (re)scheduling, active protection of time, and ongoing moni- toring. Otherwise, work-related elements frequently creep back into the daily schedule.

Action Plan for Finding Balance: Professional Level

All actions taken at the personal and family level in order to achieve work–life balance must be mirrored by correspond- ing actions at the professional level.The characterization of a physician from a previous generation as “He was always overworked and proud of it” has become anachronistic and is completely out of place in today’s surgical work environ- ment.34, 35 There is a fine line separating dedication from

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overwork. Again, thorough self analysis at the outset is important to allow you to match your competencies, interests, and available time to the demands of your particular position. You must be ready to adjust your expectations.

When looking at potential surgical positions and practices, you should choose a position, practice, or group that shares your values, respects personal boundaries, and is able to appreciate your talents and contributions. During the inter- view process, these needs must be kept in mind. Are there surgical hospitalists? Who covers call? What are call and work-hour requirements? How flexible is the workplace? Is childcare available at the workplace (as already offered by some institutions)? What is the flexibility regarding potential part-time positions should children be added to the family? What is the maternity and paternity leave policy?

Identifying and focusing on areas at work to which you can contribute most, and from which you can derive the most meaning and gratification (e.g., research vs. clinical care vs. medical education vs. administrative tasks), is an important strategy. Minimizing all nonessential activities is critical. The latter may involve prioritizing your commitments to local, regional, and national committees and organizations. It is dif- ficult, if not impossible, to actively participate in multiple committees and societies at the same time and to significantly contribute to each one. Not infrequently, increasing your focus will require a certain amount of callousness in order to be able to let go of certain tasks and duties. In the current era, it is particularly important to acknowledge that you cannot be a master in all areas. For instance, the “triple threat” status may be de facto unattainable by many of the currently prac- ticing academic surgeons given the expectations, complexity, and rigors of the surgical field. Overall, it is important to remind yourself periodically that at work everybody is replaceable. Nonetheless, cherish and appreciate your position.

Besides focusing and restricting the scope of the work, you may also consider obtaining additional training, undergoing retraining, or changing the work focus to achieve work–life balance. Such measures may help decrease stress if, as a