Bibliografie Vrouwelijke arts en burn-out Periode 2000 – 2012 (18 april)* Inleiding In deze bibliografie is de centrale vraag: komt burn-out vaker voor bij vrouwelijke of mannelijke artsen? Er werden zoekacties uitgevoerd in PubMed, Embase, PsycINFO, maar ook in de eigen databank VALUE. Als tijdsperiode werd gekozen: 2000 – 18 april 2012. Taal: Engels, Duits, Frans en Nederlands. Doelgroep: artsen (geen studenten en/of aios). De response rate moest minstens 40% bedragen, hoewel hier in vijf gevallen van werd afgeweken. In die gevallen stonden er in de abstract en het artikel redelijk veel man/vrouw verschillen. De zoekacties leverden 535, veelal irrelevante treffers op. Een eerste selectieronde leverde aanvankelijk 64 goedgekeurde referenties op, maar er vielen in een tweede selectieronde 34 referenties af (3 vanwege de taal, 14 vanwege te lage response, te beperkte doelgroep of onjuiste doelgroep (aios), 10 omdat er geen man/vrouw verschillen zijn gevonden zowel in abstract als artikel, of onjuiste publicatievorm (geen artikel), en 7 artikelen konden niet opgevraagd worden via een Nederlandse bibliotheek). Tijdens een laatste zoekactie in PubMed werden nog 4 extra referenties gevonden. Uiteindelijk leverde dit 34 relevante referenties op.
Wat is burn-out? Burn-out bestaat uit drie, min of meer samenhangende verschijnselen: emotionele uitputting (een gevoel van extreme vermoeidheid), depersonalisatie (vervreemding ten opzichte van anderen: een negatieve, cynische, afstandelijke en kille houding hebben tegenover collega’s en werk), en verminderde persoonlijke bekwaamheid (het gevoel dat men minder goed presteert dan in het verleden het geval was, ook wel verminderd werkgerelateerd zelfvertrouwen).
Vragenlijsten Maslach Burn-out Inventory (MBI) De MBI bestaat uit 22 items die drie scores opleveren: emotionele uitputting (9 items), depersonalisatie (5 items) en persoonlijke bekwaamheid (8 items). De MBI is in de volgende artikelen gebruikt: Adam (2008); Carr (2003); Chiron (2010); Dumesnil (2009); Dyrbye (2011); Goehring (2005), Grassi (2000); Houkes (2008 en 2011), Keeton (2007), Kushnir (2004), Leiter (2009); Orton (2012); Ozyurt (2006), Putnik (2011); Roth (2011); Shanafelt (2009); Soler (2008); Toyry (2004); en Twellaar (2008). Copenhagen Burn-out Inventory (CBI) De CBI bestaat uit 19 items en drie subschalen. Deelnemers kunnen burn-out rapporteren als algemeen (Persoonlijke Burn-out), specifiek tot hun werk (Werk Burn-out) en/of specifiek in relatie tot hun werkzaamheden met patiënten (Patiënten Burn-out). De CBI is in de volgende artikelen gebruikt: Benson (2009); Doppia (2011); Estryn-Behar (2011a en 2011b); Fuss (2008); Heinke (2011) en Klein (2010). Oldenburg Burn-out Inventory (OLBI) De OLBI bestaat uit 16 items die twee dimensies van burn-out meet: uitputting en depersonalisatie / cynisme. *
Aanwezig in VALUE Databank. Bibliografie afgerond op 29 augustus 2012
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De OLBI is in de volgende artikelen gebruikt: Innstrand (2011) en Langballe (2011). In de volgende artikelen zijn andere vragenlijsten gebruikt: Kinzl (2007): Stress Overcoming Questionnaire; McMurray (2000): eigen vragenlijst; Mechaber (2008): PWS en MEMO; Rabatin (2010): MEMO; en Voltmer (2011): AVEM. In onderstaande artikelen zijn meerdere vragenlijsten gebruikt: Benson (2009); Chiron (2010); Dyrbye (2011); Grassi (2000); Klein (2010); Kushnir (2004), Leiter (2009); Mechaber (2008); Ozyurt (2006), Putnik (2011); Roth (2011) en Soler (2008).
Prevalentie A. Percentages en meer algemeen Groot onderzoek onder 7858 Amerikaanse chirurgen wees uit dat meer vrouwen dan mannen een burn-out (43,3% vs 39,0%) en hoge niveaus van emotionele uitputting (35,9% vs 31%) hadden. Maar ze hadden gelijke gemiddelde scores voor depersonalisatie en persoonlijke bekwaamheid als de mannen (Dyrbye, 2011). Duits onderzoek onder 1311 chirurgen toont aan dat bijna de helft van hen blootgesteld wordt aan burn-out, met een hogere prevalentie bij de vrouwen (Klein, 2010). Uit Frans onderzoek onder 1924 artsen blijkt dat vrouwelijke artsen meer last hebben van burn-out dan de mannelijke artsen, zowel onder de representatieve sample (overige artsen) als de spoedeisende hulp artsen (49,1% vrouwelijke artsen vs 37,5% mannelijke artsen binnen de representatieve groep en 65,5% vrouwelijke artsen vs 43,2% mannelijke spoedeisende hulp artsen) (Estryn-Behar, 2011a). Duits onderzoek toont aan dat vrouwelijke ziekenhuisartsen een groter risico lopen op burn-out dan mannelijke artsen (45,4% vs 40,8%) (Heinke, 2011). Meer vrouwelijke dan mannelijke Amerikaanse ziekenhuisartsen hebben last van burn-out (43% vs. 31%) (Shanafelt, 2009). Amerikaanse vrouwelijke huisartsen melden twee keer zovaak burn-out als mannelijke artsen (36% vs. 19%) (Rabatin, 2010). Zwitsers onderzoek onder 1784 eerstelijnsartsen toont aan dat gematigde burn-out meer voorkomt bij mannelijke dan bij vrouwelijke artsen (33,9% vs. 19,2%). Een hoge mate van burn-out komt ook meer voor bij de mannelijke dan de vrouwelijke eerstelijnsartsen (4,1% vs. 0,7%). Deze studie wijkt hiermee af van andere studies (Goehring, 2005). Significant meer vrouwelijke pediatrisch oncologen (47% vs. 32%) dan hun mannelijke collega’s hadden last van burn-out (Roth, 2011). Uit een grote studie onder 3196 anesthesisten en andere specialisten in Franse ziekenhuizen blijkt dat in de beide groepen de vrouwelijke artsen de meeste last hebben van burn-out, maar vrouwelijke anesthesisten hebben minder last van burn-out dan de vrouwen in de vergelijkingsgroep (Doppia, 2011).
B. Diverse groepen 19,4% van de Nederlandse huisartsen (20,7% van de mannen en 17,6% van de vrouwen) had last van burn-out. Dit percentage is ongeveer twee keer hoger dan de prevalentie van burn-out in de algemene Nederlandse bevolking en de subgroep van hoger opgeleiden (HBO en universitair). Huisartsen leiden meer aan emotionele uitputting en depersonalisatie dan de gewone bevolking. Er is dus geen significant genderverschil bij de huisartsen. Er waren geen verschillen tussen de beide geslachten voor wat betreft emotionele uitputting en persoonlijke bekwaamheid, maar depersonalisatie was significant hoger bij de mannelijke huisartsen (Twellaar, 2008). Noors onderzoek onder 4965 personen uit diverse beroepsgroepen (advocaten, artsen, verpleegkundigen, leraren, predikanten, buschauffeurs, en personen werkzaam in de reclame en informatietechnologie) toont aan dat vrouwen over het algemeen vaker uitputting rapporteren, maar niet vaker depersonalisatie dan mannen. De meeste uitputting werd gemeld door leraren, personen werkzaam in de reclame, buschauffeurs, artsen en predikanten, zowel bij mannen als vrouwen. Terwijl de vrouwelijke predikanten en zij die in de reclame werkten vaker depersonalisatie meldden dan hun 2
mannelijke collega’s, rapporteerden de vrouwelijke artsen, leraressen en verpleegkundigen minder depersonalisatie in vergelijking tot hun mannelijke beroepsgenoten (Innstrand, 2011). Duits onderzoek onder 632 ondernemers, 5196 leraren en 549 artsen. Er werden 4 patronen gebruikt: gezond (patroon G), niet ambitieus (patroon S), te hoge inspanning (risicopatroon A) en burn-out (risicopatroon B). Vrouwelijke artsen lieten zowel lagere scores zien voor professionele ambitie en een offensieve copingstijl met betrekking tot problemen, als hogere scores voor een neiging tot berusting. Mannelijke artsen waren minder tevreden met hun leven en meldden minder sociale ondersteuning. Bij de ondernemers was er geen verschil tussen mannen en vrouwen binnen de verdeling van de patronen. Bij de leraren en de artsen was het verschil significant. Vrouwelijke leraren lieten een kleiner aandeel in het gezonde patroon G zien en een hoger aandeel in het burn-out gerelateerde risicopatroon B in vergelijking tot de mannelijke leraren. Bij vrouwelijke artsen werd het tegenovergestelde waargenomen (Voltmer, 2011).
C. Overige artikelen bij prevalentie Emotionele uitputting, depersonalisatie en verminderde persoonlijke bekwaamheid Volgens de meeste studies komt emotionele uitputting meer voor bij vrouwelijke dan bij mannelijke artsen. Een Hongaarse studie bevestigt dit (Adam, 2008). Een Franse studie toonde een genderverschil aan in de preventie van burn-out bij Franse anesthesisten, en meer specifiek een hoog niveau van emotionele uitputting onder vrouwelijke artsen in vergelijking tot mannelijke artsen (Chiron, 2010). In een studie onder 212 Nederlandse huisartsen stelde men vast dat burn-out bij vrouwen getriggerd wordt door emotionele uitputting (Houkes, 2011). Volgens de meeste studies komt depersonalisatie meer voor bij mannelijke dan vrouwelijke artsen. Vooral studies onder huisartsen tonen dat aan, zoals een internationaal onderzoek in 12 Europese landen onder 1393 huisartsen (Soler, 2008), een Nederlands onderzoek onder 212 huisartsen dat vaststelde dat het proces van burn-out bij mannelijke huisartsen getriggerd wordt door depersonalisatie (Houkes, 2011). Ook Frans, Engels en Italiaans onderzoek bevestigen dit (Dumesnil, 2009), (Orton, 2012) en (Grassi, 2000). Daarnaast toonde Israëlisch onderzoek aan dat burn-out, met name depersonalisatie, meer voorkwam bij de mannelijke dan de vrouwelijke kinderartsen. Bij de huisartsen was dit omgekeerd: hier kwam burn-out meer voor bij de vrouwelijke dan de mannelijke huisartsen. Burn-out nam mogelijk toe bij de eerstelijns artsen als gevolg van een toegenomen werkdruk en rollenconflicten door de invoering van een nieuwe gezondheidswet en een patiëntenwet (Kushnir, 2004). De score voor depersonalisatie was bij de mannelijke artsen significant hoger dan voor de vrouwelijke artsen, bleek uit onderzoek onder 598 Turkse artsen (Ozyurt, 2006). Een internationale studie onder 1393 huisartsen en een Italiaanse studie onder ziekenhuisartsen geven aan dat verminderde persoonlijke bekwaamheid meer voorkomt bij mannelijke dan vrouwelijke artsen. (Soler, 2008) en (Grassi, 2000) Een Servische studie wijkt af van de overige artikelen voor wat betreft depersonalisatie en een verminderde persoonlijke bekwaamheid. Een onderzoek, onder 373 Servische eerstelijnsartsen, toont aan dat meer vrouwen dan mannen weinig controle over hun werk en een hoge depersonalisatie ervaren. In tegenstelling tot andere studies ervaren in deze sample significant meer vrouwen dan mannen hoge niveaus van depersonalisatie: 14,4% van de vrouwen vs. 5,2% van de mannen. Meer vrouwen dan mannen ervaren een verminderde persoonlijke bekwaamheid: 10% vs. 4% (Putnik, 2011). Persoonlijke, werkgerelateerde en patiëntgerelateerde burn-out Uit een Australische studie onder 278 jonge chirurgen blijkt dat vrouwelijke artsen hogere niveaus van persoonlijke burn-out en werkgerelateerde burn-out vertonen, maar geen significant verschil in patiëntgerelateerde burn-out. Zij lopen een bijzonder hoog risico op burn-out (Benson, 2009). Ook een Duitse studie onder ziekenhuisartsen toonde aan dat vrouwelijke artsen hoger scoorden op de persoonlijke burn-out schaal dan de mannelijke artsen (Fuss, 2008). 3
Risico’s Balans werk-privé Vrouwelijke artsen zijn gevoeliger voor de balans tussen werk en privé. Zij melden vaker werk-privé conflicten dan mannelijke artsen. Werk-privé conflicten vormen dan ook het grootste risico voor vrouwelijke artsen op een burn-out. Dat blijkt uit een Hongaarse studie (Adam, 2008). Een grote Franse studie onder 3196 anesthesisten en andere specialisten in Franse ziekenhuizen toonde dit ook aan (Doppia, 2011); evenals een andere Franse studie onder spoedeisende hulp artsen en andere specialisten (Estryn-Behar 2011a en 2011b). Ook een groot Amerikaans onderzoek onder 7858 chirurgen bevestigt dit (Dyrbye, 2011). Nederlands onderzoek onder huisartsen (Houkes, 2008) en onderzoek onder Noorse artsen onderschrijven dit (Langballe, 2011). Overigens, uit een Duits onderzoek onder 296 ziekenhuisartsen bleek geen genderverschil voor wat betreft werk-privé conflicten. Wellicht had dat te maken met de kleine sample (Fuss, 2008). Onderzoek onder 3313 Finse artsen stelt dat het waarschijnlijker is dat vrouwelijke artsen, met of zonder kinderen, vaker ernstige of matige uitputting ervaren dan mannelijke artsen, maar ze ervaren minder vaak cynisme als component van de burn-out dan mannelijke artsen (Toyry, 2004). Controle over de werkplek en het aantal werkuren Minder controle over de werkplek of invloed op het aantal werkuren vormt de tweede risicofactor voor vrouwelijke artsen. Uit Amerikaans onderzoek bleek dat vrouwelijke artsen 1,6 keer meer kans hadden om een burn-out te krijgen dan mannelijke artsen, waarbij de kans op burn-out bij de vrouwen met 12% tot 15% toenam voor elke extra 5 uur die ze boven de 40-urige werkweek werkten (McMurray, 2000). Oostenrijks onderzoek gaf ook aan dat minder controle over het werk, minder invloed op de taken en het werkrooster en minder mogelijkheden om te communiceren met anderen op het werk bronnen van stress waren (Kinzl, 2007). In een onderzoek onder 935 Amerikaanse artsen (internisten, chirurgen, kinderartsen, gynaecologen en huisartsen) rapporteerden de vrouwelijke artsen dat ze tevredener waren over hun carrière, wekelijks minder uren werkten en wekelijks minder bereikbaarheidsdiensten draaiden dan hun mannelijke collega’s. Deze verschillen kunnen het kleine verschil verklaren tussen mannelijke en vrouwelijke artsen met betrekking tot de balans tussen werk en privé en burn-out. De grootste voorspeller voor de balans tussen werk en privé en burn-out is enige controle te hebben over het dienstrooster en het aantal werkuren (Keeton, 2007). Uit een ander Amerikaans onderzoek bleek dat carrièreconflicten meer voorkomen bij vrouwelijke dan bij mannelijke chirurgen (52,6% vs 41,2%). Een carrièreconflict werd opgelost ten gunste van de chirurg: bij de vrouwen was dat in 59,0% van de gevallen zo, bij de mannen in 87,3% van de gevallen (Dyrbye, 2011). Uit Frans onderzoek bleek dat de genderverschillen die zij vonden bij de anesthesisten ook aanwezig waren in Hongarije, de VS en het Verenigd Koninkrijk, maar niet in Duitsland en Nederland. De auteurs leggen een verband met de mogelijkheid om parttime te werken in Duitsland en Nederland. Het gebrek aan mogelijkheden om parttime te werken en het hoge aantal werkuren kunnen hebben bijgedragen aan de hoge niveaus van emotionele burn-out onder vrouwelijke Franse anesthesisten (Chiron, 2010). Vrouwelijke artsen hebben verder last van een matige kwaliteit van het teamwerk en een hoge werkdruk bleek uit Frans onderzoek onder anesthesisten (Doppia, 2011). Een ongunstige verhouding tussen inspanning-beloning en minder gunstige arbeidsomstandigheden (met name teamwerk) waren ongunstiger voor vrouwelijke dan mannelijke artsen (Estryn-Behar, 2011b). Daarnaast vormt een conflict tussen persoonlijke waarden en die van het gezondheidszorgsysteem ook een risicofactor voor vrouwelijke artsen. Dit blijkt uit Canadees onderzoek (Leiter, 2009). Wat de mannelijk artsen betreft wordt een burn-out goed voorspeld door gedoe op het werk en gebrek aan controle over het nemen van medische beslissingen, maar niet door extra werkuren (McMurray, 2000). Naast de werkdruk en de werk-privé conflicten die ook groot blijven, voegen zich nog de impact van gespannen interpersoonlijke relaties, het belagen van hun positie en de ontevredenheid over hun salaris (Doppia, 2011). Een lage kwaliteit van teamwerk is de hoogste risicofactor op burn4
out voor mannelijke spoedeisende hulp artsen (Estryn-Behar, 2011a). Onderzoek onder Noorse artsen toonde aan dat bij mannelijke artsen het effect van werkbelasting op uitputting bijzonder hoog is (Langballe, 2011). Burn-out wordt significant geassocieerd met de waargenomen kwaliteit van zorg bij mannelijke chirurgen, maar niet bij hun vrouwelijke collega’s. Dat komt misschien, omdat burn-out hier nauwer gelinkt is aan werkgerelateerde factoren. Dit blijkt uit Duits onderzoek onder 1311 chirurgen (Klein, 2010).
Coping Vermijding als copingstrategie lijkt alleen bij mannelijke huisartsen positief gerelateerd te zijn met emotionele uitputting, terwijl bij de vrouwelijke huisartsen een actieve copingstrategie de ontwikkeling van emotionele uitputting voorkomt. Dit blijkt uit onderzoek onder 261 Nederlandse huisartsen. Voor vrouwen is vermijding waarschijnlijk niet effectief, omdat ze niet kunnen stoppen met piekeren en uiteindelijk dan toch depersonaliseren (Houkes, 2008). Uit Servisch onderzoek blijkt dat er hoge niveaus van depersonalisatie voorkomen bij eerstelijns artsen. Een mogelijke verklaring hiervoor is dat mannen meer vermijdingsgedrag vertonen, wat hen kan beschermen tegen overdreven betrokkenheid bij patiënten. Deze copingstijl van mannen kan een buffer zijn tegen depersonalisatie. De communicatiestijl van vrouwen wordt meer gekarakteriseerd door een grotere betrokkenheid bij de cliënten. Dit kan op een bepaald punt te inspannend zijn en tot depersonalisatie leiden (Putnik, 2011). Bij stress hanteren vrouwelijke anesthesisten positieve coping strategieën zoals het “zoeken naar zelfbevestiging” en “controle van de situatie”. Mannelijke anesthesisten gaven er de voorkeur aan te vertrouwen op hun beroepsmatige vaardigheden, terwijl vrouwelijke anesthesisten de nadruk legden op intelligentie en lichamelijke conditie (Kinzl, 2007).
Aanbevelingen Wanneer vrouwelijke artsen het gewenste aantal uren (fulltime of parttime) kunnen werken, dan is dat de belangrijkste factor om minder vaak een burn-out te hebben, blijkt uit twee Amerikaanse studies (Carr, 2003) en (Mechaber, 2008). Strategieën om werk-privé conflicten te verminderen of die uitwegen bieden om conflicten op te lossen op een wijze die zowel tegemoetkomen aan professionele als huiselijke verantwoordelijkheden kunnen burn-out bij chirurgen verminderen en de tevredenheid over de carrière doen toenemen. Dit soort strategieën kunnen vooral gunstig zijn voor vrouwelijke chirurgen, aangezien zij vaker in aanraking komen met werk-privé conflicten. Dit adviseert een andere Amerikaanse studie onder chirurgen (Dyrbye, 2011). Voor mannelijke huisartsen is sociale ondersteuning van collega’s belangrijk om depersonalisatie en verminderde persoonlijke bekwaamheid te voorkomen, aldus een Nederlandse studie (Houkes, 2008). Een groep anesthesisten gaf in volgorde van belangrijkheid aan op welke manieren stress op het werk gereduceerd kon worden. Dat kan door meer vrije tijd (58,4%), meer personeel (42,7%), meer flexibele werkuren (41,6%), meer betrokkenheid bij de planning van het werk (41,6%) en meer autonomie (27%) (Kinzl, 2007). Er moet beter gekeken worden naar de positie van vrouwelijke artsen op de werkplek, omdat meer vrouwen dan mannen weinig controle en een hoge depersonalisatie op het werk voelen. Misschien hebben vrouwelijke eerstelijnsartsen meer empowerment, vertrouwen en positieve feedback nodig (Putnik, 2011).
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Referenties 1. Adam, S., Z. Gyorffy, and E. Susanszky, "Physician burnout in Hungary: a potential role for work-family conflict," Journal of Health Psychology 13 (7): 847-856 (2008). Abstract: In a study among Hungarian physicians (N = 420), we tested the hypothesis that compared to men female physicians experience higher work-family conflict (WFC) and consequent burnout. As predicted, female physicians scored significantly higher on the emotional exhaustion subscale of the Maslach Burnout Inventory and significantly more female physicians experienced high levels of emotional exhaustion compared to male physicians. WFC emerged as a significant predictor of burnout (emotional exhaustion and depersonalization). These findings suggest a potential path from WFC to burnout in a scarcely researched population of physicians in a unique cultural setting and provide further data for cross-cultural burnout research.
2. Benson, S. et al., "Burnout in Australasian Younger Fellows," ANZ.Journal of Surgery 79 (9): 590-597 (2009). Abstract: BACKGROUND: Burnout is the state of prolonged physical, emotional and psychological exhaustion characteristic of individuals working in human service occupations. This study examines the prevalence of burnout among Younger Fellows of the Royal Australasian College of Surgeons and its relationship to demographic variables. METHODS: In March 2008, a survey was sent via email to 1287 Younger Fellows. This included demographic questions, a measure of burnout (Copenhagen Burnout Inventory), and an estimate of social desirability (Marlowe-Crowne Social Desirability Scale - Form C). RESULTS: Females exhibited higher levels of personal burnout (P < 0.001) and work-related burnout (P < 0.025), but no significant difference in patient-related burnout. Younger Fellows in hospitals with less than 50 beds reported significantly higher patient-related burnout levels (mean burnout 37.0 versus 22.1 in the rest, P = 0.004). An equal work division between public and private practice resulted in higher work-related burnout than concentration of work in one sector (P < 0.05). Younger Fellows working more than 60 hours per week reported significantly higher personal burnout than those who worked less than this (P < 0.05). There was no significant correlation between age, country of practice, surgical specialty and any of the burnout subscales. CONCLUSION: Female surgeons, surgeons that work in smaller hospitals, those that work more than 60 h per week, and those with practice division between the private and public sectors, are at a particularly high risk of burnout. Further enquiry into potentially remediable causes for the increased burnout in these groups is indicated.
3. Carr, P. L., K. C. Gareis, and R. C. Barnett, "Characteristics and outcomes for women physicians who work reduced hours," Journal of Women’s Health (Larchmt.) 12 (4): 399-405 (2003). Abstract: OBJECTIVES: To understand the characteristics of women physicians who work reduced hours in dual-earner couples and how such work schedules affect the quality of the marital role, parental role, and job role, as well as indicators of psychological distress, burnout, career satisfaction, and life satisfaction. METHODS: Survey of a random sample of female physicians between 25 and 50 years of age, working within 25 miles of Boston, whose names were obtained from the Registry of Board Certification in Medicine in Massachusetts. Interviewers conducted a 60-minute face-to-face close-ended interview after a 20-minute mailed questionnaire had been completed. RESULTS: Fifty-one full-time physicians and 47 reduced6
hours physicians completed the study, for a completion rate of 49.5%. There was no difference in age, number of years as a physician, mean household income, number of children, or presence of an infant in the home between reduced-hours and full-time physicians. Reducedhours physicians, however, were more likely to be in a generalist specialty (40% vs. 12%, p = 0.001) and to spend a greater portion of their time in patient care (64.5% vs. 50.1%, p = 0.003) and less time in research (4.9% vs. 18.0%, p = 0.002) than full-time physicians. In addition, there was no difference between the two groups in the perception of work interfering with family life (1.8 vs. 1.7, p = 0.17; scale 1-7 with 7 high) or family life interfering with work (1.4 vs. 1.5, p = 0.62). Physicians who worked their preferred number of hours (25% of full-time and 57% of reduced-hours physicians), regardless of full-time (self-reported hours 35-90 hours per week) or reduced-hours (20-60 hours per week) status, reported better job role quality (r = 0.35, p = 0.001), schedule fit (r = 0.41, p < or = 0.001), lower burnout (r = -0.22, p = 0.03), better marital role quality (r = 0.28, p = 0.006), and higher life satisfaction (r = 0.29, p = 0.005). CONCLUSIONS: Women physicians who work their preferred number of hours achieve the best balance of work and family outcomes.
4. Chiron, B. et al., "Job satisfaction, life satisfaction and burnout in French anaesthetists," Journal of Health Psychology 15 (6): 948-958 (2010). Abstract: The present study aimed to examine the prevalence of burnout, levels of life satisfaction and job satisfaction in anaesthetists in France. A cross-sectional study was conducted among 193 anaesthetists from eight French public hospitals. The results indicated low levels of emotional exhaustion and depersonalization scores, but high levels of reduced accomplishment. The results also revealed differences between subgroups: physician anaesthetists reported higher levels of depersonalization and reduced accomplishment than nurse anaesthetists, female and junior anaesthetists reported higher levels of emotional exhaustion and job dissatisfaction than male and senior anaesthetists. The results and the implications to reduce burnout symptoms in anesthesia teams are discussed.
5. Doppia, M. A. et al., "[Burnout in French doctors: A comparative study among anaesthesiologists and other specialists in French hospitals (SESMAT study).]," Annales Francaises d Anesthesie et de Reanimation 30 (11): 782-794 (2011). Abstract: OBJECTIVE: Burnout is one of the main chronic health problems with negative consequences on health care givers but also on quality of care. The main goal of Physician Health Survey was to study the frequency of burnout among salaried physicians and pharmacists and to compare anesthesiologists and intensivists (AI) with other practitioners (OP). The secondary end points were to analyze risk factors of burnout in each group. MATERIAL AND METHODS: An anonymous, self-administered questionnaire was diffused via a specific website. Burnout was measured using the Copenhagen Burnout Inventory (CBI). Several different factors were examined: work/family conflict, salary satisfaction, quality of teamwork, interpersonal relationships, workplace influence, workload and perceived health. The role of each factor was calculated by multivariate logistic regression and comparisons were made between AI and OP. RESULTS: Among the 3196 responses, CBI revealed an elevated score of burnout in 38.4% in AI and in 42.4% in OP. In each group, a great gap was displayed between the CBI results and the self-assessment of burnout (15%). Among AI, risk factors of burnout were high quantitative demand (ORadj=3.40; CI(95) 1,34-8,63), Work/family conflict (ORadj=; 3.12 CI(95) 1.60-6.08), low quality of teamwork (ORadj=1.99; CI(95)1.14-3.47) and tense Relation within team (ORadj=1.92; CI(95) 1.25-2.95). All these factors are observed also among OP. Female gender, young age and dissatisfaction with pay have significant influence but different in the two groups. Claims of recurrent harassment by superiors is a risk factor for 7
burnout only for the AP (adj.OR=1.83; CI(95) 1.04-3.22). DISCUSSION: Burnout affected near one about two salaried physicians and pharmacists in France. AI were not more concerned by burnout than OP but all of whom have difficulty identifying their own levels of psychological stress and burnout. Decreasing the level of different risk factors i.e. by improving the quality of teamwork should lead to reduce burnout frequency.
6. Dusmesnil, H. et al., "[Professional burn-out of general practitioners in urban areas: prevalence and determinants]," Sante Publique 21 (4): 355-364 (2009). Abstract: A telephone survey was carried out in 2007 to evaluate prevalence of burnout in private GPs in South-eastern France and its determinants. Doctors were selected at random, and this list was stratified according to gender, age and size of the place of practice. Burnout was evaluated with the French validated version of the Maslach Burnout Inventory. 511 GPs participated (96,4%). The prevalence of the complete burnout syndrome was 1% (CI 95% [0,32,3]). Dealing with long working hours on a weekly basis and high-levels of mental strain, managing palliative care, unrealistic patients' expectations, work-home conflicts, having one's abilities questioned by patients, confronting judicial situations and legal cases or living with a partner, were all associated with one or several dimensions of burnout syndrome.
7. Dyrbye, L. N. et al., "Relationship between work-home conflicts and burnout among American surgeons: a comparison by sex," Archives of Surgery 146 (2): 211-217 (2011). Abstract: OBJECTIVES: To evaluate differences in burnout and career satisfaction between men and women surgeons and to determine the relationships among personal factors, professional characteristics, and work-home conflicts. DESIGN: Cross-sectional study, with data gathered through a survey. SETTING: The United States. PARTICIPANTS: Members of the American College of Surgeons. MAIN OUTCOME MEASURES: Burnout and career satisfaction. RESULTS: Of approximately 24,922 surgeons sampled, 1043 women and 6815 men returned surveys (31.5% response rate). Women surgeons were younger, less likely to be married, less likely to be divorced, and less likely to have children (all P < .001). No differences between women and men in hours worked or number of nights on call per week were observed. Women surgeons were more likely to believe that child-rearing had slowed their career advancement (57.3% vs 20.2%; P < .001), to have experienced a conflict with their spouse's/partner's career (52.6% vs 41.2%; P < .001), and to have experienced a work-home conflict in the past 3 weeks (62.2% vs 48.5%; P < .001). More women than men surgeons had burnout (43.3% vs 39.0%; P = .01) and depressive symptoms (33.0% vs 29.5%; P = .02). Factors independently associated with burnout on multivariate analysis were generally similar for men and women and included recent experience of a work-home conflict, resolving the most recent work-home conflict in favor of work, and hours worked per week. CONCLUSIONS: Work-home conflicts appear to be a major contributor to surgeon burnout and are more common among women surgeons. Although the factors contributing to burnout were remarkably similar among women and men surgeons, the women were more likely to experience work-home conflicts than were their male colleagues.
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8. Estryn-Behar, M. et al., "Emergency physicians accumulate more stress factors than other physicians-results from the French SESMAT study," Emergency Medicine Journal 28 (5): 397410 (2011a). Abstract: Introduction France is facing a shortage of available physicians due to a greying population and the lack of a proportional increase in the formation of doctors. Emergency physicians are the medical system's first line of defence. Methods The authors prepared a comprehensive questionnaire using established scales measuring various aspects of working conditions, satisfaction and health of salaried physicians and pharmacists. It was made available online, and the two major associations of emergency physicians promoted its use. 3196 physicians filled out the questionnaire. Among them were 538 emergency physicians. To avoid bias, 1924 physicians were randomly selected from the total database to match the demographic characteristics of France's physician population: 42.5% women, 57.5% men, 8.2% <35 years old, 33.8% 35-44 years old, 34.5% 45-54 years old and 23.6% >/=55 years old. The distribution of physicians in the 23 administrative regions and by speciality was also precisely taken into account. This representative sample was used to compare subgroups of physicians by speciality. Results The outcomes indicate that the intent to leave the profession (ITL) was quite prevalent across French physicians and even more so among emergency physicians (17.4% and 21.4% respectively), and burnout was highly prevalent (42.4% and 51.5%, respectively). Among the representative sample and among emergency physicians, work-family conflict (OR=4.47 and OR=6.14, respectively) and quality of teamwork (OR=2.21 and OR=5.44, respectively) were associated with burnout in a multivariate analysis, and these risk factors were more prevalent among emergency physicians than other types. A serious lack of quality of teamwork appears to be associated with a higher risk of ITL (OR=3.92 among the physicians in the representative sample and OR=4.35 among emergency physicians), and burnout doubled the risk of ITL in multivariate analysis. Conclusions In order to prevent the premature departure of French doctors, it is important to improve work-family balance, working processes through collaboration, multidisciplinary teamwork and to develop team training approaches and ward design to facilitate teamwork.
9. Estryn-Behar, M. et al., "Work week duration, work-family balance and difficulties encountered by female and male physicians: Results from the French SESMAT study," Work 40 (0): 83-100 (2011b). Abstract: Objective: France encounters difficulties attracting physicians to work in hospitals. Organisation at work and at home may be at the heart of the problem for female as well as for male physicians. Participants: A comprehensive questionnaire was filled out online by a representative sample of 1924 French hospital physicians. Methods: We conducted gender bivariate and multivariate analysis of the risk factors for burnout and intent to leave the profession(ITL). Results: ITL was declared by 17.4% of physicians. According to 41.3% of female physicians (FP), their profession was an obstacle to having children (versus 19.3% for male physicians (MP)). Major factors linked with burnout were Effort/Reward imbalance (FP adjOR=5.09, MP adjOR=5.93), Work-family conflicts (FP adjOR=2.97, MP adjOR=3.04), and Low quality of teamwork (FP adjOR=1.82, MP adjOR=2.68). Major factors linked with ITL were Low quality of teamwork (FP adjOR=4.49, MP adjOR=3.03), Patient-related burnout (FP adjOR=2.10, MP adjOR=2.35) and General burnout (FP adjOR=1.85, MP adjOR=1.45). Conclusions: Excessive job demands are linked with burnout and with work-family conflicts, conducting to difficulties in organising one's life in order to have and raise children. Potential solutions include facilitating teamwork in order to reduce departure, which increase workload on those who stay increasing their work family conflict.
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10. Fuss, I. et al., "Working conditions and Work-Family Conflict in German hospital physicians: psychosocial and organisational predictors and consequences," BMC Public Health 8 (2008). Abstract: Background: Germany currently experiences a situation of major physician attrition. The incompatibility between work and family has been discussed as one of the major reasons for the increasing departure of German physicians for non-clinical occupations or abroad. This study investigates predictors for one particular direction of Work-Family Conflict - namely work interfering with family conflict (WIF) - which are located within the psychosocial work environment or work organisation of hospital physicians. Furthermore, effects of WIF on the individual physicians' physical and mental health were examined. Analyses were performed with an emphasis on gender differences. Comparisons with the general German population were made. Methods: Data were collected by questionnaires as part of a study on Psychosocial work hazards and strains of German hospital physicians during April - July 2005. Two hundred and ninety-six hospital physicians ( response rate 38.9%) participated in the survey. The Copenhagen Psychosocial Questionnaire (COPSOQ), work interfering with family conflict scale ( WIF), and hospital-specific single items on work organisation were used to assess WIF, its predictors, and consequences. Results: German hospital physicians reported elevated levels of WIF ( mean = 74) compared to the general German population ( mean = 45, p < .01). No significant gender difference was found. Predictors for the WIF were lower age, high quantitative demands at work, elevated number of days at work despite own illness, and consequences of short-notice changes in the duty roster. Good sense of community at work was a protective factor. Compared to the general German population, we observed a significant higher level of quantitative work demands among hospital physicians ( mean = 73 vs. mean = 57, p < .01). High values of WIF were significantly correlated to higher rates of personal burnout, behavioural and cognitive stress symptoms, and the intention to leave the job. In contrast, low levels of WIF predicted higher job satisfaction, better self-judged general health status, better work ability, and higher satisfaction with life in general. Compared to the German general population, physicians showed significantly higher levels of individual stress and quality of life as well as lower levels for well-being. This has to be judged as an alerting finding regarding the state of physicians' health. Conclusion: In our study, work interfering with family conflict (WIF) as part of Work-Family Conflict (WFC) was highly prevalent among German hospital physicians. Factors of work organisation as well as factors of interpersonal relations at work were identified as significant predictors for WIF. Some of these predictors are accessible to alteration by improving work organisation in hospitals.
11. Goehring, C. et al., "Psychosocial and professional characteristics of burnout in Swiss primary care practitioners: a cross-sectional survey," Swiss.Medical Weekly 135 (7-8): 101-108 (2005). Abstract: OBJECTIVE: To measure the prevalence of burnout and explore its professional and psychosocial predictors among Swiss primary care practitioners. METHODS: A cross-sectional postal survey was conducted to measure burnout, work-related stressors, professional and psychosocial characteristics among a representative sample of primary care practitioners. Answers to the Maslach burnout inventory were used to categorize respondents into moderate and high degree of burnout. RESULTS: 1784 physicians responded to the survey (65% response rate) and 1755 questionnaires could be analysed. 19% of respondents had a high score for emotional exhaustion, 22% had a high score for depersonalisation/cynicism and 16% had a low score for professional accomplishment; 32% had a high score on either the emotional exhaustion or the depersonalisation/cynicism scale (moderate degree of burnout) and 4% had scores in the range of burnout in all three scales (high degree of burnout). Predictors of moderate burnout were male sex, age 45-55 years and excessive perceived stress due to global workload, health-insurance-related work, difficulties to balance professional and private life, changes in the health care system and medical care uncertainty. A high degree of burnout was associated with male sex, practicing in a rural area, and excessive perceived stress due to global 10
workload, patient's expectations, difficulties to balance professional and private life, economic constraints in relation to the practice, medical care uncertainty and difficult relations with nonmedical staff at the practice. CONCLUSION: About one third of Swiss primary care practitioners presented a moderate or a high degree of burnout, which was mainly associated with extrinsic work-related stressors. Medical doctors and politicians in charge of redesigning the health care system should address this phenomenon to maintain an efficient Swiss primary care physician workforce in the future.
12. Grassi, L. and K. Magnani, "Psychiatric morbidity and burnout in the medical profession: An Italian study of general practitioners and hospital physicians," Psychotherapy and Psychosomatics 69 (6): 329-334 (2000). Abstract: Background: Burnout and psychological stress symptoms represent a major problem among health care professionals. The aim of this study was to investigate the prevalence of and the relationship between psychiatric morbidity and burnout among a convenience sample of Italian primary care physicians (GPs) and hospital physicians (HPs). Method: The sample consisted of 328 physicians (182 GPs and 146 HPs) who completed the 12-item version of the General Health Questionnaire and the Maslach Burnout Inventory (MBI). Results: The global prevalence of psychiatric morbidity was 22.3% (20.3% among GPs and 24.6% among HPs). Symptoms of emotional exhaustion were reported by 27.5% of the participants (GPs: 32.4%; HPs: 21.2%), depersonalization by 25.6% (GPs: 27.4%; HPs: 22.6%) and low personal accomplishment by 12.8% (GPs: 13.1%; HPs: 12.3%). No significant difference was found between the two groups, except higher levels of emotional exhaustion among GPs. Female GPs reported lower scores on MBI depersonalization and female HPs lower scores MBI personal accoplishment than male GPs and HPs, respectively. Conclusions: The study underscores the significant problem of stress among physicians and indicates the need for supporting health professionals in order to improve their psychological well-being and, possibly, the quality of their relationship with the patients.
13. Heinke, W. et al., "[Burnout in anesthesiology and intensive care : Is there a problem in Germany?]," Anaesthesist 60 (12): 1109-1118 (2011). Abstract: BACKGROUND: With the demands faced by anesthetists and intensive care physicians apparently increasing continuously in Germany, the increased risk of burnout in comparison with the general working population is discussed. This debate has previously been merely speculative because of the lack of studies comparing the burn-out risk of the German working population with anesthetists. Accordingly it was not certain whether anesthetists really are at greater risk of developing burnout as has often been suggested. Moreover, age, gender, function, workplace environment, e.g. working at a hospital compared to a general practitioner (GP) surgery, may influence the risk of burnout. Therefore, this study examined whether the risk for anesthetists in Germany suffering from burnout really is greater than in other occupations. In addition, factors influencing the burnout risks of anesthetists were analyzed. METHOD: A total of 3,541 questionnaires completed by German aaesthetists for a study on work satisfaction by the CBI (Copenhagen Burnout Inventory, part of the Copenhagen Psychosocial Questionnaire, COPSOQ) were analyzed. Apart from calculating the number of participants with a high risk of developing burnout syndrome, the data were used to calculate a generalized burnout score for all participants. The score was compared with data from both a random sample representing a wide variety of occupations from among the general population in Germany (n = 4,709) and a random sample of German hospital doctors (n = 616). In addition, subgroups were formed by gender, function (senior consultant, senior physician, specialist, junior doctor) and type and place of work (university hospital, public hospital, private clinic, GP 11
surgery, freelance work) and the proportion of each group with a high risk of burnout syndrome was calculated. In addition, general burnout scores were compared statistically for differences among the various groups. RESULTS: The proportion of study participants with a high risk of burnout was 40.1%. Differences were found to exist between genders (male 37.2% versus female 46%), qualifications (senior consultant 28.9%, senior physician 38%, specialist 41.5%, junior doctor 46.7%) and working in a hospital (41.3%) compared to a GP surgery (33.2%). The random sample of hospital doctors (n = 616) showed a burnout score of 49 +/- 19 (mean +/standard deviation), compared to 44 +/- 19 for a random sample of the German population (n = 4,709) and 42 +/- 19 for anesthetists (p < 0.01). Of the subgroups formed, the highest score (49.1 +/- 19) was recorded for female junior doctors working in anesthesia. The type of hospital did not influence the burnout score (university hospital 43.8 +/- 19.8 versus public hospital 42.9 +/- 19.1 versus private hospital 42.4 +/- 18.7, p > 0.05). Working in a hospital was found to result in higher burnout scores than in a GP surgery or freelance work (43 +/- 19.2 versus 38.1 +/- 20.5; t(3531) = 5.0, p < 0.001) CONCLUSIONS: Despite 40.1% of anesthetists being at high risk of burnout, generally speaking the risk of burnout among anesthetists was not higher than in other occupational groups in Germany. However, burnout risks for specific groups, such as female junior doctors in anesthesia, were higher and the possibility of providing social support in the workplace should be considered.
14. Houkes, I. et al., "Development of burnout over time and the causal order of the three dimensions of burnout among male and female GPs. A three-wave panel study," BMC.Public Health 11: 240 (2011). Abstract: BACKGROUND: A good understanding of the aetiology and development of burnout facilitates its early recognition, prevention and treatment. Since the prevalence and onset of this health problem is thought to differ between men and women, sex must be taken into account. This study aims to assess the prevalence and development of burnout among General Practitioners (GPs). In this population the prevalence of burnout is high. METHODS: We performed a three-wave longitudinal study (2002, 2004, 2006) in a random sample of Dutch GPs. Data were collected by means of self-report questionnaires including the Maslach Burnout Inventory. Our final sample consisted of 212 GPs of which 128 were male. Data were analyzed by means of SPSS and LISREL. RESULTS: Results indicate that about 20% of the GPs is clinically burned out (but still working). For both sexes, burnout decreased after the first wave, but increased again after the second wave. The prevalence of depersonalization is higher among men. With regard to the process of burnout we found that for men burnout is triggered by depersonalization and by emotional exhaustion for women. CONCLUSIONS: As regards the developmental process of burnout, we found evidence for the fact that the aetiological process of burnout, that is the causal order of the three burnout dimensions, differs between men and women. These sex differences should be taken into account in vocational training and policy development, especially since general practice is feminizing rapidly.
15. Houkes, I., Y. H. W. M. Winants, and M. Twellaar, "Specific determinants of burnout among male and female general practitioners: A cross-lagged panel analysis," Journal of Occupational and Organizational Psychology 81: 249-276 (2008). Abstract: This study aimed to develop and test a specific pattern of relationships between job demands, job resources and person-related factors on the one hand, and the three burnout dimensions on the other, among Dutch General Practitioners. In addition, we aimed to test whether gender differences exist in this regard. Based on several theoretical models such as the job Demand-Control model and the job Demands-Resources model of burnout as well as a review of burnout studies among physicians, we formulated a research model of burnout. The 12
research questions were answered by means of self-report questionnaires using a full panel design with two waves. Cross-lagged panel analyses indicated that the causal direction of the relationships between demands, resources and person-related factors on the one hand, and burnout on the other is reciprocal. In addition, multi-sample analyses revealed that the pattern of relationships between job demands, job resources, person-related factors and burnout is different for men and women, although results are less clear at the second measurement point. Among other things, we recommend anticipating in a gender sensitive way on risk factors for burnout and motivation loss for young professionals by coaching and empowerment in vocational training.
16. Innstrand, S. T. et al., "Exploring within- and between-gender differences in burnout: 8 different occupational groups," International Archives of Occupational and Environmental Health 84 (7): 813-824 (2011). Abstract: OBJECTIVES: The aim of this study was to examine gender differences in burnout within and between occupations using latent mean analysis. METHODS: Burnout was measured using the Oldenburg Burnout Inventory (OLBI), designed to assess the two sub-dimension exhaustion and disengagement. Men and women from eight different occupational groups in Norway were investigated: lawyers, physicians, nurses, teachers, church ministers, bus drivers and people working in advertising and information technology (n = 4,965). The average age was 42 years (SD 10.8), and 50.5% of the respondents were female. Within- and between-gender differences were examined by multi-group latent mean analysis by means of LISREL. RESULTS: Significant latent mean differences in the two dimensions of burnout between men and women were demonstrated. In general, the analyses indicate that overall, women report more exhaustion, but not more disengagement, than men. However, separate analyses indicate that the gender differences vary across occupational groups, especially for the disengagement dimension. Within-gender analyses suggest an approximately similar burnout profile across occupational groups for men and women. CONCLUSIONS: Despite gender equality in society in general, and inconclusive findings in previous studies on gender differences in burnout, women in this study seem to experience slightly higher burnout levels than men. Occupational differences found in the burnout profiles indicate that some professions may be more prone to burnout than others. For the occupational groups most at risk, more research is needed to disclose potential organizational factors that may make these workers more prone to burnout than others.
17. Keeton, K. et al., "Predictors of physician career satisfaction, work-life balance, and burnout," Obstetrics and Gynecology 109 (4): 949-955 (2007). Abstract: OBJECTIVE: To explore factors associated with physician career satisfaction, worklife balance, and burnout focusing on differences across age, gender, and specialty. METHODS: A cross-sectional, mailed, self-administered survey was sent to a national sample of 2,000 randomly-selected physicians, stratified by specialty, age, and gender (response rate 48%). Main outcome measures included career satisfaction, burnout, and work-life balance. Scales ranged from 1 to 100. RESULTS: Both women and men report being highly satisfied with their careers (79% compared with 76%, P<.01), having moderate levels of satisfaction with work-life balance (48% compared with 49%, P=.24), and having moderate levels of emotional resilience (51% compared with 53%, P=.09). Measures of burnout strongly predicted career satisfaction (standardized beta 0.36-0.60, P<.001). The strongest predictor of work-life balance and burnout was having some control over schedule and hours worked (standardized beta 0.28, P<.001, and 0.20-0.32, P<.001, respectively). Physician gender, age, and specialty were not strong independent predictors of career satisfaction, work-life balance, or burnout. CONCLUSION: 13
This national physician survey suggests that physicians can struggle with work-life balance yet remain highly satisfied with their career. Burnout is an important predictor of career satisfaction, and control over schedule and work hours are the most important predictors of work-life balance and burnout. LEVEL OF EVIDENCE: II.
18. Kinzl, J. F. et al., "Work stress and gender-dependent coping strategies in anesthesiologists at a university hospital," Journal of Clinical Anesthesia 19 (5): 334-338 (2007). Abstract: STUDY OBJECTIVE: To evaluate stressors and coping strategies for stress in a sample of anesthesiologists working at a university hospital. DESIGN: Cross-sectional study via survey instrument. SETTING: University department of anesthesiology and critical care at a 1305-bed hospital. PARTICIPANTS: 135 anesthesia specialists and specialist trainees of anesthesia. MEASUREMENTS AND MAIN RESULTS: A total of 135 self-reporting questionnaires used to assess sociodemographic data, workload, task demands, stress-coping strategies, physical health, emotional well-being, and working conditions, were distributed. Of these, 89 questionnaires were completed and returned, for a response rate of 65.9%: 33 (37.1%) female anesthesiologists and 56 (62.9%) male anesthesiologists. The burden of task-related stressors and of communication possibilities was assessed differently by male and female anesthesiologists. Female anesthesiologists more frequently reported higher concentration demands (P = 0.013) and limited possibilities to control work (P = 0.009) than did their male colleagues. Work at intensive care units (P = 0.001) was particularly demanding and burdensome for female anesthesiologists. Combined evaluation of various stress-coping strategies did not show significant differences between the genders. Generally, anesthesiologists had more confidence in their own personal capabilities and resources and in their socialparticularly family-support outside the workplace, than in their social support from colleagues and superiors. CONCLUSIONS: Task-related stressors and communication possibilities differed between male and female anesthesiologists in our institution. Female anesthesiologists felt that they had less control over their work.
19. Klein, Jens et al., "Burnout and perceived quality of care among German clinicians in surgery. [References]," International Journal for Quality in Health Care 22 (6): 525-530 (2010). Abstract: Objective: Burnout is highly prevalent among clinicians but there is not much known about the association between burnout and quality of care. In this paper, burnout, perceived quality of care and medical errors among German clinicians in surgery are explored. Design: Data were collected during 2008 by a cross-sectional, standardized mail survey. Participants and Setting: A total of 1311 clinicians in surgery in 489 German hospitals. Measure(s): Burnout was measured by using the Copenhagen Burnout Inventory (CBI). The measurement of self-rated patient care was based on a 13 item instrument (Chirurgisches Qualitatssiegel) and two questions assessing the frequency of medical errors. Results: About 48.7% of the clinicians meet the criteria for burnout according to the CBI. Moreover, in multivariate logistic regression analyses, burnout is significantly associated with perceived quality of care among male (odds ratios vary from 1.5 to 2.6) but not among female surgeons (odds ratios vary from 1.3 to 1.5). Conclusions: The high prevalence of burnout in our study corresponds with former studies of burnout among physicians. Furthermore, the results of the study suggest a relationship between burnout and perceived quality of care among men. Thus, reducing burnout among surgeons could not only improve their health and well-being but also the quality of care.
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20. Kushnir, T., C. Levhar, and A. H. Cohen, "Are burnout levels increasing? The experience of Israeli primary care physicians," Israel Medical Association Journal 6 (8): 451-455 (2004). Abstract: BACKGROUND: Burnout is a professional occupational disease that puts both physicians and patients at risk. Triggered by the increase in burnout levels among physicians, the European Forum of Medical Associations and the World Health Organization issued a statement in February 2003 expressing serious concerns about the situation, urging all national medical associations to increase awareness of the problem, monitor it and study its causes in order to develop preventive strategies. OBJECTIVES: To compare burnout levels in two separate samples of primary care physicians measured in the mid-1990s, with burnout levels in a similar but small and independent sample, assessed in 2001; and to outline the theoretical bases of burnout. METHODS: Altogether, 508 primary care physicians employed by Clalit Health Services responded anonymously to a self-report questionnaire. The samples were not representative and included family physicians, pediatricians and clinic directors. RESULTS: Burnout levels were significantly higher in the 2001 sample than in the mid-1990s samples, especially among clinic directors. CONCLUSIONS: Despite methodologic limitations of the study, the findings suggest that burnout levels may be increasing among primary care physicians in Israel. This may be due to substantial increases in workload and role conflicts following implementation of the Health Insurance Law and Patients' Rights Act. Because these findings are consistent with the trend in Europe, this situation cannot be ignored and systematic studies of burnout among all medical specialties should be carried out to uncover current sources of the syndrome and to devise measures of prevention and treatment.
21. Langballe, E. M. et al., "The predictive value of individual factors, work-related factors, and work-home interaction on burnout in female and male physicians: A longitudinal study," Stress and Health 27 (1): 73-87 (2011). Abstract: The purpose of this study was to examine physician burnout in association with individual factors, work characteristics and work-home interaction (job performance-based selfesteem, goal orientation, value congruency, workload, autonomy, work-home conflict and work-home facilitation). This two-wave panel study includes a sample of Norwegian physicians collected in 2003 (N = 683) and 2005 (N = 523). Hierarchical multiple regression analysis was used to test the assumed effects in male and female physicians separately. The results imply that many of the assumed predictors play significant parts in physician burnout. A noticeable finding was that the pattern and strength of significant effects differed within the separate analyses of men and women. Work-home conflict was a particularly strong burnout predictor in female physicians whereas workload was the strongest burnout predictor in male physicians. The findings may have implications when planning future interventions.
22. Leiter, M. P., E. Frank, and T. J. Matheson, "Demands, values, and burnout: relevance for physicians," Canadian Family Physician 55 (12): 1224-1225, 1225 (2009). Abstract: OBJECTIVE: T o explore the interaction between workload and values congruence (personal values with health care system values) in the context of burnout and physician engagement and to explore the relative importance of these factors by sex, given the distinct work patterns of male and female physicians. DESIGN: National mailed survey. SETTING: Canada. PARTICIPANTS: A random sample of 8100 Canadian physicians (response rate 40%, N = 3213); 2536 responses (from physicians working more than 35 hours per week) were analyzed. MAIN OUTCOME MEASURES: Levels of burnout, values congruence, and workload, by sex, measured by the Maslach Burnout Inventory-General Scale and the Areas of Worklife Scale. RESULTS: Results showed a moderate level of burnout among Canadian 15
physicians, with relatively positive scores on exhaustion, average scores on cynicism, and mildly negative scores on professional efficacy. A series of multiple regression analyses confirmed parallel main effect contributions from manageable workload and values congruence. Both workload and values congruence predicted exhaustion and cynicism for men and women (P = .001). Only values congruence provided a significant prediction of professional efficacy for both men and women (P = .001) These predictors interacted for women on all 3 aspects of burnout (exhaustion, cynicism, and diminished efficacy). Howevever, overall levels of the burnout indicators departed only modestly from normative levels. CONCLUSION: W orkload and values congruence make distinct contributions to physician burnout. Work overload contributes to predicting exhaustion and cynicism; professional values crises contribute to predicting exhaustion, cynicism, and low professional efficacy. The interaction of values and workload for women in particular has implications for the distinct work-life patterns of male and female physicians. Specifically, the congruence of individual values with values inherent in the health care system appeared to be of greater consequence for women than for men.
23. McMurray, J. E. et al., "The work lives of women physicians: Results from the physician work life study," Journal of General Internal Medicine 15 (6): 372-380 (2000). Abstract: OBJECTIVE: To describe gender differences in job satisfaction, work life issues, and burnout of U.S. physicians. DESIGN/PARTICIPANTS: The Physician Work life Study, a nationally representative random stratified sample of 5,704 physicians in primary and specialty nonsurgical care (N = 2,326 respondents; 32% female, adjusted response rate = 52%). Survey contained 150 items assessing career satisfaction and multiple aspects of work life. MEASUREMENTS AND MAIN RESULTS: Odds of being satisfied with facets of work life and odds of reporting burnout were modeled with survey-weighted logistic regression controlling for demographic variables and practice characteristics. Multiple linear regression was performed to model dependent variables of global, career, and specialty satisfaction with independent variables of income, time pressure, and items measuring control over medical and workplace issues. Compared with male physicians, female physicians were more likely to report satisfaction with their specialty and with patient and colleague relationships (P < .05), but less likely to be satisfied with autonomy, relationships with community, pay, and resources (P < .05). Female physicians reported more female patients and more patients with complex psychosocial problems, but the same numbers of complex medical patients, compared with their male colleagues. Time pressure in ambulatory settings was greater for women, who on average reported needing 36% more time than allotted to provide quality care for new patients or consultations, compared with 21% more time needed by men (P < .01). Female physicians reported significantly less work control than male physicians regarding day-to-day aspects of practice including volume of patient load, selecting physicians for referrals, and details of office scheduling (P < .01). When controlling for multiple factors, mean income for women was approximately $22,000 less than that of men. Women had 1.6 times the odds of reporting burnout compared with men (P < .05), with the odds of burnout by women increasing by 12% to 15% for each additional 5 hours worked per week over 40 hours (P < .05). Lack of workplace control predicted burnout in women but not in men. For those women with young children, odds of burnout were 40% less when support of colleagues, spouse, or significant other for balancing work and home issues was present. CONCLUSIONS: Gender differences exist in both the experience of and satisfaction with medical practice. Addressing these gender differences will optimize the participation of female physicians within the medical workforce.
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24. Mechaber, H. F. et al., "Part-time physicians...prevalent, connected, and satisfied," Journal of General Internal Medicine 23 (3): 300-303 (2008). Abstract: OBJECTIVE: The health care workforce is evolving and part-time practice is increasing. The objective of this work is to determine the relationship between part-time status, workplace conditions, and physician outcomes. DESIGN: Minimizing error, maximizing outcome (MEMO) study surveyed generalist physicians and their patients in the upper Midwest and New York City. MEASUREMENTS AND MAIN RESULTS: Physician survey of stress, burnout, job satisfaction, work control, intent to leave, and organizational climate. Patient survey of satisfaction and trust. Responses compared by part-time and full-time physician status; 2-part regression analyses assessed outcomes associated with part-time status. Of 751 physicians contacted, 422 (56%) participated. Eighteen percent reported part-time status (n = 77, 31% of women, 8% of men, p < .001). Part-time physicians reported less burnout (p < .01), higher satisfaction (p < .001), and greater work control (p < .001) than full-time physicians. Intent to leave and assessments of organizational climate were similar between physician groups. A survey of 1,795 patients revealed no significant differences in satisfaction and trust between part-time and full-time physicians. CONCLUSIONS: Part-time is a successful practice style for physicians and their patients. If favorable outcomes influence career choice, an increased demand for part-time practice is likely to occur.
25. Orton, P., C. Orton, and Gray D. Pereira, "Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice," BMJ Open 2: e000274 (2012). Abstract: OBJECTIVES: The objectives of this study were to assess burnout in a sample of general practitioners (GPs), to determine factors associated with depersonalisation and to investigate its impact on doctors' consultations with patients. DESIGN: Cross-sectional, postal survey of GPs using the Maslach Burnout Inventory (MBI). Patient survey and tape-recording of consultations for a subsample of respondents stratified by their MBI scores, gender and duration of General Medical Council registration. SETTING: UK general practice. PARTICIPANTS: GPs within NHS Essex. PRIMARY AND SECONDARY OUTCOME MEASURES: Scores on MBI subscales (depersonalisation, emotional exhaustion, personal accomplishment); scores on Doctors' Interpersonal Skills Questionnaire and patient-centredness scores attributed to tape-recorded consultations by independent observers. RESULTS: In the postal survey, 564/789 (71%) GPs completed the MBI. High levels of emotional exhaustion (261/564 doctors, 46%) and depersonalisation (237 doctors, 42%) and low levels of personal accomplishment (190 doctors, 34%) were reported. Depersonalisation scores were related to characteristics of the doctor and the practice. Male doctors reported significantly higher (p<0.001) depersonalisation than female doctors. Doctors registered with the General Medical Council under 20 years had significantly higher (p=0.005) depersonalisation scores than those registered for longer. Doctors in group practices had significantly higher (p=0.001) depersonalisation scores than single-handed practitioners. Thirty-eight doctors agreed to complete the patient survey (n=1876 patients) and audio-record consultations (n=760 consultations). Depersonalised doctors were significantly more likely (p=0.03) to consult with patients who reported seeing their 'usual doctor'. There were no significant associations between doctors' depersonalisation and their patient-rated interpersonal skills or observed patientcentredness. CONCLUSIONS: This is the largest number of doctors completing the MBI with the highest levels of depersonalisation reported. Despite experiencing substantial depersonalisation, doctors' feelings of burnout were not detected by patients or independent observers. Such levels of burnout are, however, worrying and imply a need for action by doctors themselves, their medical colleagues, professional bodies, healthcare organisations and the Department of Health.
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26. Ozyurt, A., O. Hayran, and H. Sur, "Predictors of burnout and job satisfaction among Turkish physicians," QJM 99 (3): 161-169 (2006). Abstract: BACKGROUND: Burnout is associated with decreased job performance and low career satisfaction. It has a special significance in health care, where staff experience both psychological-emotional and physical stress. AIM: To investigate levels of job satisfaction and burnout among Istanbul physicians, and the relationships between demographic characteristics, job characteristics, job satisfaction and burnout. DESIGN: Questionnaire-based survey. METHODS: We collected data from a randomly selected sample group of 598 physicians from different health-care institutions in Istanbul. A questionnaire regarding sociodemographic characteristics of the physicians, the Maslach Burnout Inventory (MBI) and the Minnesota Job Satisfaction Questionnaire (MSQ) were all administered during face-to-face interviews. RESULTS: Job satisfaction was inversely correlated with emotional exhaustion and depersonalization, and positively correlated with personal accomplishment. Under multilevel regression, the most significant and common predictors of all burnout dimensions and job satisfaction were the number of vacations at individual level, and public ownership of healthcare facilities at group level. Number of shifts per month was also a significant predictor of all burnout dimensions. DISCUSSION: Organizational efforts aimed at increasing the level of job satisfaction among physicians could help to prevent burnout.
27. Putnik, K. and I. Houkes, "Work related characteristics, work-home and home-work interference and burnout among primary healthcare physicians: a gender perspective in a Serbian context," BMC.Public Health 11: 716 (2011). Abstract: BACKGROUND: Little information exists on work and stress related health of medical doctors in non-EU countries. Filling this knowledge gap is needed to uncover the needs of this target population and to provide information on comparability of health related phenomena such as burnout across countries. This study examined work related characteristics, work-home and home-work interference and burnout among Serbian primary healthcare physicians (PHPs) and compared burnout levels with other medical doctors in EU countries. METHODS: Data were collected via surveys which contained Maslach Burnout Inventory and other validated instruments measuring work and home related characteristics. The sample consisted of 373 PHPs working in 12 primary healthcare centres. Data were analysed using ttests and Chi square tests. RESULTS: No gender differences were detected on mean scores of variables among Serbian physicians, who experience high levels of personal accomplishment, workload, job control and social support, medium to high levels of emotional exhaustion, medium levels of depersonalisation and work-home interference, and low levels of home-work interference. There were more women than men who experienced low job control and high depersonalisation. Serbian physicians experienced significantly higher emotional exhaustion and lower depersonalisation than physicians in some other European countries. CONCLUSIONS: To diminish excessive workload, the number of physicians working in primary healthcare centres in Serbia should be increased. Considering that differences between countries were detected on all burnout subcomponents, work-related interventions for employees should be country specific. The role of gender needs to be closely examined in future studies as well.
28. Rabatin, J. Williams, "The effect of burnout on patient outcomes: Results from the MEMO study," Journal of General Internal Medicine Conference (var.pagings): June (2010). Abstract: BACKGROUND: Rates of physician burnout are high, with up to 60% of primary care physicians reporting symptoms. The predictors of burnout are well known, as are effects on 18
providers. The impact on patient care, however, is less clear. Burned out physicians perceive providing suboptimal care, but is poorer care actually delivered? Using data from the MEMO (Minimizing Error, Maximizing Outcome) Study, we investigated if burned out physicians provide poorer care compared to colleagues who reported they were not burned out. METHODS: Generalist physicians from New York City and the Midwest completed two surveys, 12 months apart, assessing job satisfaction, job stress, organizational culture, and selfreported assessment of medical errors. Burnout was measured with a single question with five responses ranging from "no symptoms" to "completely burned out, wonder if I can go on." Up to six patients per physician with hypertension or diabetes completed a survey on care satisfaction, physician trust, and quality of life. Chart review determined quality of care for diabetes (A1C), hypertension (blood pressure measurement) and preventive health care. Examples of errors include missed treatment opportunities, inattention to behavioral factors, lack of tobacco use documentation and missed cervical cancer screening. RESULTS: A total of 449 physicians from 119 practices (60% of those approached) consented to participate, and 422 (94%) completed the baseline survey for a participation rate of 56%. Sixty-one percent of respondents reported job stress, 27% reported burnout, and 30% predicted leaving their practice within two years. Women physicians were nearly twice as likely as men to report burnout (36% vs. 19% p=.0001). Physicians under the age of 50 were significantly more likely than older physicians to experience burnout (p=.0001). Compared with non-burned out physicians, burned out physicians felt significantly less control of their work environment (p=.0001) and reported a greater proportion of difficult patient encounters (p=.0001). Prediction of errors did not differ between burned out and non burned out doctors The patient outcome measures for quality of care among 36 domains of quality of care for diabetes, hypertension and preventive care were not significantly different between burned out and non-burned out physicians. Patient report of trust and satisfaction were equivalent between burned out and non-burned out doctors. CONCLUSIONS: Contrary to our hypothesis, burned out physicians provided equivalent care when measured by patient outcome variables. Although our study validates prior research on the high prevalence and predictors of burnout, we found that patient care is essentially preserved. Our study supports the theoretical model of conservation of resources which suggests that a person under great stress will still focus on their most important duties. We recommend further confirmation of this theory.
29. Roth, M. et al., "Career burnout among pediatric oncologists," Pediatric Blood & Cancer 57 (7): 1168-1173 (2011). Abstract: BACKGROUND: Burnout is a work-related syndrome consisting of emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment. Physicians who care for patients with life-threatening illnesses are at high risk for developing burnout. This survey evaluates the prevalence of burnout among pediatric oncologists, and assesses risk factors associated with the development of burnout. PROCEDURE: A questionnaire was sent via email to 1,047 practicing pediatric oncologists. The survey included the 22 question Maslach Burnout Inventory (MBI), as well as questions regarding work-related and lifestylerelated factors associated with developing burnout. RESULTS: Four hundred ten pediatric oncologists (40%) responded to the survey. Thirty-eight percent of pediatric oncologists had high levels of burnout on the MBI, while 72% had at least moderate levels of burnout. Women (47% vs. 32%, P < 0.004) and physicians practicing for <10 years (50% vs. 33%, P < 0.004) had significantly higher rates of burnout. Physicians who reported satisfaction with their lives outside of work were less likely to have burnout (odds ratio 0.238, 0.143-0.396, P < 0.001). The availability of a forum for debriefing, and services for physicians affected by burnout were both associated with lower rates of burnout (24% vs. 46%, P < 0.001 and 23% vs. 46%, P < 0.001). Thirty-six percent of respondents reported their institution has a forum for debriefing and 40% of respondents reported their institution has services available for physicians experiencing symptoms of burnout. CONCLUSIONS: Approximately three quarters of pediatric oncologists 19
experience burnout. Further research is needed on the effectiveness of interventions aimed at preventing and treating work-related burnout.
30. Shanafelt, T. D. et al., "Career fit and burnout among academic faculty," Archives of Internal Medicine 169 (10): 990-995 (2009). Abstract: BACKGROUND: Extensive literature documents personal distress among physicians and a decrease in their satisfaction with the practice of medicine over recent years. We hypothesized that physicians who spent more of their time in the aspect of work that they found most meaningful would have a lower risk of burnout. METHODS: Faculty physicians in the Department of Internal Medicine at a large academic medical center were surveyed in the fall of 2007. The survey evaluated demographic variables, work characteristics, and career satisfaction. Burnout was measured using the Maslach Burnout Inventory. Additional questions evaluated which professional activity (eg, research, education, patient care, or administration) was most personally meaningful and the percentage of effort that was devoted to each activity. RESULTS: Of 556 physicians sampled, 465 (84%) returned surveys. A majority (68%) reported that patient care was the aspect of work that they found most meaningful, with smaller percentages reporting research (19%), education (9%), or administration (3%) as being most meaningful. Overall, 34% of faculty members met the criteria for burnout. The amount of time spent working on the most meaningful activity was strongly related to the risk of burnout. Those spending less than 20% of their time (approximately 1 d/wk) on the activity that is most meaningful to them had higher rates of burnout (53.8% vs 29.9%; P<.001). Time spent on the most meaningful activity was the largest predictor of burnout on multivariate analysis (odds ratio, 2.75; P = .001). CONCLUSIONS: The extent to which faculty physicians are able to focus on the aspect of work that is most meaningful to them has a strong inverse relationship to their risk of burnout. Efforts to optimize career fit may promote physician satisfaction and help to reduce attrition among academic faculty physicians.
31. Soler, J. K. et al., "Burnout in European family doctors: the EGPRN study," Family Practice 25 (4): 245-265 (2008). Abstract: INTRODUCTION: The aim of this study was to determine the prevalence of burnout, and of associated factors, amongst family doctors (FDs) in European countries. Methodology. A cross-sectional survey of FDs was conducted using a custom-designed and validated questionnaire which incorporated the Maslach Burnout Inventory Human Services Survey (MBI-HSS) as well as questions about demographic factors, working experience, health, lifestyle and job satisfaction. MBI-HSS scores were analysed in the three dimensions of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). RESULTS: Almost 3500 questionnaires were distributed in 12 European countries, and 1393 were returned to give a response rate of 41%. In terms of burnout, 43% of respondents scored high for EE burnout, 35% for DP and 32% for PA, with 12% scoring high burnout in all three dimensions. Just over one-third of doctors did not score high for burnout in any dimension. High burnout was found to be strongly associated with several of the variables under study, especially those relative to respondents' country of residence and European region, job satisfaction, intention to change job, sick leave utilization, the (ab)use of alcohol, tobacco and psychotropic medication, younger age and male sex. CONCLUSIONS: Burnout seems to be a common problem in FDs across Europe and is associated with personal and workload indicators, and especially job satisfaction, intention to change job and the (ab)use of alcohol, tobacco and medication. The study questionnaire appears to be a valid tool to measure burnout in FDs. Recommendations for employment conditions of FDs and future research are made, and suggestions for improving the instrument are listed. 20
32. Toyry S.Kalimo, "Children and work-related stress among physicians," Stress and Health 20 (4): 213-221 (2004). Abstract: The aim of this study was to analyse the influence of gender and children on physicians' stress and burnout and to obtain information on the compromises physicians make between family and work. The study was based on a nationwide survey of 3313 Finnish physicians. The results showed that work was the commonest reason for stress for both male and female physicians. If physicians had children, combining work and family was the commonest reason for stress among the women, but work still remained the commonest reason for stress among the men. The female physicians had made compromises between family and work more often than the male physicians (limited the number of children, delayed having children, given up postgraduate or continuing medical education, worked part-time because of family, and given up a job because of a spouse's need to move). The female physicians - with or without children - were more likely than the male physicians to experience severe or moderate exhaustion and less likely than the male physicians to experience cynicism as components of burnout. Among both genders of physicians, having children was associated with less cynicism and reduced personal accomplishment, but the children did not affect exhaustion. In conclusion, having children is associated with a lower level of some burnout symptoms. Additional studies are needed to explain the health effects of work-family balance for physicians.
33. Twellaar, M. Winants, "How healthy are Dutch general practitioners? Self-reported (mental) health among Dutch general practitioners," European Journal of General Practice 14 (1): 4-9 (2008). Abstract: Objective: To investigate the level of burnout and health status of male and female Dutch general practitioners (GPs), and to compare this with former samples of GPs and with the Dutch general population. Methods: A postal survey of 350 male and 350 female practising GPs in the Netherlands. Results: Although levels of emotional exhaustion of Dutch GPs were lower than those of national samples of GPs in the 1990s, the prevalence of burnout was still almost twice that of the general population. In contradiction with this, GPs reported better general health and fewer diseases than their fellow countrymen. Another remarkable finding was that female GPs were as healthy as their male colleagues, while in the general population, males report better health than females. Conclusion: The positive self-reported health status of general practitioners might reflect the high standards of the medical profession, which make physicians reluctant to show their own vulnerability. This might result in fewer, but more serious cases of (mental) illness among GPs as compared to the general population.
34. Voltmer, E. et al., "Work-related behavior and experience patterns of entrepreneurs compared to teachers and physicians," International Archives of Occupational and Environmental Health 84 (5): 479-490 (2011). Abstract: PURPOSE: This study examined the status of health-related behavior and experience patterns of entrepreneurs in comparison with teachers and physicians to identify specific health risks and resources. METHODS: Entrepreneurs (n = 632), teachers (n = 5,196), and physicians (n = 549) were surveyed in a cross-sectional design. The questionnaire Work-related Behavior and Experience Patterns (AVEM) was used for all professions and, in addition, two scales (health prevention and self-confidence) from the Checklist for Entrepreneurs in the sample of entrepreneurs. RESULTS: The largest proportion of the entrepreneurs (45%) presented with a healthy pattern (compared with 18.4% teachers and 18.3% physicians). Thirty-eight percent of entrepreneurs showed a risk pattern of overexertion and stress, followed by teachers (28.9%) and physicians (20.6%). Unambitious or burnout patterns were seen in only 9.3/8.2% of 21
entrepreneurs, respectively, and 25.3/27.3% of teachers, and 39.6/21.5% of physicians. While the distribution of patterns in teachers and physicians differed significantly between genders, a gender difference was not found among entrepreneurs. Entrepreneurs with the risk pattern of overexertion scored significantly (P < 0.01) lower in self-confidence and health care than those with the healthy pattern. CONCLUSIONS: The development of a successful enterprise depends, in part, on the health of the entrepreneur. The large proportion of entrepreneurs with the healthy pattern irrespective of gender may support the notion that self-selection effects of healthy individuals in this special career might be important. At the same time, a large proportion was at risk for overexertion and might benefit from measures to cope with professional demands and stress and promote a healthy behavior pattern.
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