key: cord-0695979-w0i3yp8d
authors: Lorello, G. R.; Gautam, M.; Barned, C.; Peer, M.
title: Impact of the intersection of anaesthesia and gender on burnout and mental health, illustrated by the COVID‐19 pandemic
date: 2021-03-07
journal: Anaesthesia
DOI: 10.1111/anae.15360
sha: 5aba2df6c9825c1caeeede4da0ecd011e4682064
doc_id: 695979
cord_uid: w0i3yp8d

Physician burnout and poor mental health are prevalent and often stigmatised. Anaesthetists may be at particular risk and this is further increased for women anaesthetists due to biases and inequities within the specialty. However, gender‐related risk factors for and experiences of burnout and poor mental health remain under‐researched and under‐reported. This negatively impacts individual practitioners, the anaesthesia workforce and patients and carries significant financial implications. We discuss the impact of anaesthesia and gender on burnout and mental health using the COVID‐19 pandemic as an example illustrating how women and men differentially experience stressors and burnout. COVID‐19 has further accentuated the gendered effects of burnout and poor mental health on anaesthetists and brought further urgency to the need to address these issues. While both personal and organisational factors contribute to burnout and poor mental health, organisational changes that recognise and acknowledge inequities are pivotal to bolster physician mental health.

Physician burnout and poor mental health are prevalent [1] [2] [3] [4] , with specific aspects of the role of the anaesthetist placing individuals at particular risk [5] . While data on gender are conflicting [4, 6] , there are particular gendered risk factors contributing to burnout and poor mental health [7] . Although these are under-researched and under-reported, they likely interact with additional risk factors associated with being a woman anaesthetist [8, 9] . The COVID-19 pandemic has amplified inequities, to the detriment of women, such as disproportionate job and wage losses and disproportionate care-giving responsibilities [10] . To date, little attention has been illustrating an extreme version of these effects. This paper not only highlights issues that need to be considered by our colleagues, leaders and policy creators to assist in providing support to one another now, but also in the aftermath of the pandemic and in the longer term to protect the mental health of our healthcare workers.

We take the opportunity to discuss sex and gender as constructs. Although sex and gender remain active topics of discussion with differing opinions and theories, sex can be defined as biological differences between male and female (e.g. chromosomal complement, hormonal differences); sexrelated terminology consists of male and female. Gender is a social construct that is rooted in history, politics, and culture;

gender-related terminology consists of man and woman.

Gender binaries are typically discussed (i.e. man and woman [1, 4] . Notably, however, burnout rates in physicians remain higher than in other professions even after adjusting for other factors such as work hours [4] . Burnout in physicians is associated with negative consequences for physicians, patients and the healthcare system overall.

Physician burnout is linked with: poorer mental and physical health in physicians; problems in personal life; decreased job satisfaction; increased medical errors and patient safety risks; worse quality of patient care; and lower patient satisfaction [1, 4, 15] . Burnout is also associated with:

reduced work hours and number of patients seen;

increased sick leave; intent to leave medicine or change jobs; and early retirement [1, 16] . These have significant financial implications on healthcare systems, for example, they have been estimated to cost over $213 million in Canada alone (£123 million; €137 million) [16] .

Rates of burnout symptoms differ across medical specialties with up to three-fold increased odds in acute care physicians such as emergency medicine, general internal medicine and neurology [4] . However, data are conflicting on whether burnout rates in anaesthetists follow this pattern [5] . Anaesthetists' peri-operative work requires constant vigilance, relative isolation and remaining well- illustrate that fatigue is a highly pervasive and problematic issue among anaesthetists and anaesthetic trainees with significant negative impacts on physical health, well-being and personal relationships [18, 19] . Preliminary evidence suggests that fatigue-reducing strategies such as a reduced on-call model may improve anaesthetic trainee well-being and reduce the risk of burnout [20] . As anaesthetists, we must refute the notion that fatigue is an acceptable sacrifice.

It is imperative that anaesthetists continue to advance a culture that ensures education about fatigue, reasonable workloads, regular rest breaks and rest facilities are de facto provided and accessible.

Much has been written on the relationship between gender and physician burnout. Although gender is associated with burnout in some studies [6] , others suggest that after controlling for age and other variables, gender may not be a consistent risk factor [4] . The conflicting findings in burnout prevalence according to sex likely arise from substantial between-study differences in burnout assessment tools, as well as study populations [2, 5] . Moreover, these distract from the more useful question of whether the experiences of and contributors to burnout differ by physician gender. For example, a UK study of anaesthetists reported elevated work-related fatigue in women respondents across all age categories [18] . There are well-known sex-and genderrelated differences in stress responses [21, 22] and vulnerability to stress-related mental health disorders [23] [24] [25] as well as differences in symptomatic expression of the same mental health problem [15, 26] . Similar findings are reported in the burnout literature with some studies reporting that women's experiences of burnout are linked with emotional exhaustion, whereas men's experiences are linked with depersonalisation [27, 28] . In some cases, higher rates of burnout in anaesthetists who are men appear to result from significantly higher levels of depersonalisation [29, 30] . Of additional interest, one study of Norwegian physicians found not only higher exhaustion levels in women and higher disengagement levels among men, but also gender differences in predictors of burnout with workhome conflicts predominating in women and workload the strongest predictor in men [7] .

Gender bias and gender-related inequities are significant stressors, to which medicine, and anaesthesia in particular, is not immune. Women physicians report inequities in opportunity, recognition and credibility [8] that may impact their work, working relationships and mental health. There are fewer women in leadership positions within anaesthesia compared with men [31, 32] , resulting in less gender-concordant allyship opportunities and genderconcordant mentorship, which has been identified as particularly important for anaesthesia trainees [33] . It is unclear whether the gender gap in leadership arises from differences in a desire to pursue a leadership career [9, 34] or from the numerous systemic barriers that prevent women from attaining leadership roles, as women anaesthetists report a greater frequency of barriers to career promotion than their counterparts who are men [34, 35] . There are also substantial gender inequities in professional and academic opportunities in anaesthesia. Reports reveal that women receive fewer grants, awards and are under-represented as speakers at conferences [36] ; they are also assigned lower academic rank and pay [37, 38] .

Furthermore, gender discrimination is experienced significantly more frequently by women anaesthetists compared with men during training [39, 40] and throughout their careers, with one survey revealing that women anaesthetists report experiencing the highest rate of maternal discrimination in the workplace of all medical specialties [41] . In addition to this, large-scale studies report very high levels of gender-based mistreatment in anaesthesia. Particularly alarming is the finding from an international survey of over 11,000 anaesthetists from 148 countries, which showed that women anaesthetists are 10 times more likely to report being mistreated in the workplace compared with men [9] . Likewise, a study of over 27,000 medical students in the USA found women students were significantly more likely to report mistreatment compared with men students, with over 40% of women students reporting at least one episode of mistreatment [40] . These inequities undoubtedly contribute to feelings of frustration and mistrust of colleagues and leadership among women anaesthetists [39] . These various forms of bias, mistreatment and discrimination may significantly impact patient safety and, for trainees, their performance evaluations. In a randomised experiment, anaesthesia trainees who were exposed to incivility in a simulated operating room crisis, involving a rude environment, showed worse technical and non-technical performance in areas including vigilance, diagnosis, communication and patient management [42] .

It is crucial at this time to also acknowledge that vigilance in detecting and addressing the mental health needs of anaesthetists and healthcare workers more generally must include attention to disparities experienced across multiple axes and social locations, for example: gender; race; ability; and sexual orientation. Furthermore, research and policies should extend gender binaries (women or men) to be inclusive of anyone who does not identify with the woman-man gender binary or who does not take on 'traditional' social gender roles [43] .

Anaesthetists from around the world report experiencing bias as a result of being foreign-born and/or of the region's non-dominant race, as well as bias related to religion or caste [9] . Recent studies also report significantly elevated among anaesthetists. Previous work shows that the risk of burnout among anaesthetists' increases significantly with longer number of hours worked and increased workload [5] , but this risk decreases with proper supervision and/or job support [5] as well as higher perceived workplace resource availability [49] . infection. At least one study has found women healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 were at increased risk of subsequent COVID-19 diagnosis or symptoms requiring self-isolation or hospitalisation [50] , with speculation that this may be related to gendered designs of personal protective equipment [51] . The COVID-19

pandemic may also bring about anxieties about protecting oneself and one's family. Similarly, anaesthetists' workload is increased due to COVID-19 as hospitals attempt to 'make up for lost time' for elective or non-emergency surgeries that were delayed, potentially increasing the risk for burnout in all anaesthetists [7] .

In drawing attention to the gender inequity among anaesthetists during COVID-19, we must also address the role that structural racism plays in workplace discrimination and access to opportunities, such as promotions and Repeated and prolonged exposure to these stressors contributes to the onset of burnout or similar mental health issues as well as worse physical health and job performance [54] .

Emerging research on the intersections of gender, mental health and COVID-19 suggests that healthcare workers who identify as women are more likely to experience mental health symptoms during the pandemic [4] . In a cross-sectional survey in China of over 1200 healthcare workers in 34 hospitals treating patients exposed to COVID-19, of whom 77% were women and 61% were nurses, women reported more symptoms of depression and anxiety, more distress and more severe insomnia [23] .

Similarly, controlling for confounders, being a woman was associated with severe symptoms of depression, anxiety and distress [23] . There may also be ill effects on healthcare workers' mental health in the longer term, as was observed up to one year following the SARS outbreak [55] , with women at potentially greater risk given the numerous gender differences in the development and maintenance of post-traumatic stress disorder [56] . Indeed, one recent study found that women were more likely to report posttraumatic stress symptoms of re-experiencing negative alterations in cognition and mood and hyper-rousability one month after the COVID-19 outbreak in Wuhan, China [57] .

These findings are further exacerbated when analysed in the context of limited social support or experiences of gender-based violence. Social isolation and loneliness are strongly associated with symptoms of depression and anxiety, whereas strong social networks and social relationships are negatively associated with depression, anxiety and suicide [58] . This appears to hold true during the current pandemic as at least one small cross-sectional study of 180 medical staff treating patients with COVID-19

found social support was negatively associated with anxiety and stress levels and positively associated with self-efficacy and sleep quality [59] . Thus, gender differences in perceived social support, types of social support, social networks and willingness to seek out social support may moderate the relationship between COVID-19-related stress and poor mental health. Globally, approximately 243 million women have experienced physical and/or sexual abuse by an intimate partner or a perpetrator [10] . In Australia, 40% of healthcare workers have had victims of domestic violence request help from them [10] . Violence against women tends to increase during emergencies [10] .

Staying at home during the current pandemic has increased the likelihood of gender-based violence and domestic abuse [45] . The United Nations reported a 'horrifying global surge' [60] 

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The authors would like to thank V. Robinson and R. Brewster at COVID Creatives for producing Fig. 1 . GL would like to