Burnout in Australasian Younger Fellows. Running head A survey of burnout in RACS younger fellows. Authors Dr Sarah Benson, BSSc (Psych), BA (Hons), Assoc MAPS

General Manager - Specialty Support & Relationships General Surgeons Australia Melbourne, Australia

Dr Tarik Sammour, MBChB

Research Fellow Dept of Surgery, South Auckland Clinical School, University of Auckland Auckland, NZ

Dr Susan J Neuhaus, PhD, FRACS

Clinical Associate Professor, University of Adelaide Surgeon, Breast, Endocrine and Surgical Oncology Unit, Royal Adelaide Hospital Adelaide, South Australia

Dr Bruce Findlay BA, BSc(Hons), MSc, PhD

Senior Lecturer Dept of Life and Social Sciences, Swinburne University of Technology Melbourne, Australia

Assoc Prof Andrew G Hill, MD, FRACS

Assoc Professor of Surgery Dept of Surgery, South Auckland Clinical School, University of Auckland Auckland, NZ

Corresponding Author Dr Tarik Sammour Research Fellow, South Auckland Clinical School, University of Auckland Middlemore Hospital Private Bag 93311 Auckland, NZ Tel no. +6421317417 Fax no. +6496264558 Email: tsammour@middlemore.co.nz Sources of funding Tarik Sammour (the corresponding author) is supported by the Foundation for Surgery Research Scholarship 2008, administered through the Royal Australasian College of Surgeons. Conflict of interest There is no conflict of interest pertaining to this publication from the point of view of the authors, or the institution. Previous communication This document was reviewed and has received publication approval by the RACS Professional Development Council. Word and table count 1,940 words, 5 tables, 3 figures

Burnout in Australasian Younger Fellows.

Benson S, Sammour T, Neuhaus SJ, Findlay B, Hill AG

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 (RACS), and its relationship to demographic variables.

Methods

In March 2008, a survey was sent via email to 1,287 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

hours 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.

Keywords Burnout, Fatigue, Fellow, Surgeon

Burnout in Australasian Younger Fellows.

Benson S, Sammour T, Neuhaus SJ, Findlay B, Hill AG

Background

Burnout is defined as the prolonged physical, emotional, and psychological exhaustion

characteristic of individuals working in human service occupations.1, 2 The practice of modern

medicine involves a complex array of challenges with excessive workloads, administrative

stressors, and the emotional pressure of patient demands. As a result, the rate of burnout in

clinicians is high.3-5 Only a limited number of studies have examined burnout in surgeons,

despite surgery as a profession being particularly vulnerable to the phenomenon.6-12

Burnout has the potential to impact negatively on the surgical workforce.13-17 The individual

and social consequences of burnout include extreme fatigue, insomnia, drug and alcohol

abuse, depression, relationship breakdown, anxiety and suicide.18-20 Surgeons reporting

higher levels of burnout are more likely to consider early retirement or retraining.8, 11, 12, 21 It is

also possible that a surgeon suffering from burnout may be more prone to making errors in

the work-place.

Studies examining burnout in surgeons have found an inverse relationship between age and

burnout, with younger, less experienced surgeons reporting higher levels of burnout.11, 21, 22

The purpose of this study is to estimate the prevalence of burnout among Younger Fellows of

the Royal Australasian College of Surgeons (RACS), and examine the relationship between

burnout and several demographic variables within this group.

Methods

Survey

A survey was designed including pertinent demographic questions such as age, gender,

marital status, number of children, surgical specialty, hospital size, work division, number of

hours worked per week, and region of practice (see appendix 1). The survey also

incorporated the Copenhagen Burnout Inventory (CBI),23 and a modified version of the

Marlowe-Crowne Social Desirability Scale – Form C (MC-C).24

The CBI is a 19 item self reported measure of burnout. It is comprised of three subscales that

together provide a comprehensive description of burnout according to its perceived source.

Burnout reported by participants can either be general (Personal Burnout), specific to their

work (Work Burnout), and/or specific to their work with patients (Patient Burnout). Each

subscale is scored as a continuous variable ranging from 1-100. High levels of burnout are

defined as 50 points or more on any subscale.

The MC-C is a 13 item measure that is used to assess whether a social desirability bias is

present in responses, and by doing so offsets any potential transparency in the self-reporting

of burnout.

Distribution

In March 2008, the survey was emailed to 1,287 surgeons practicing within 10 years of

receiving Fellowship of the Royal Australasian College of Surgeons (classified as Younger

Fellows). The survey was provided as an Adobe Acrobat form (Adobe Systems Incorporated,

San Jose, California) that could be completed electronically and returned via email. Hard

copies were physically mailed to Younger Fellows with incorrect or missing email contact

details. Reminder emails were sent to all participants in April and May 2008. All

questionnaire responses were anonymous and confidential, and no individually recognisable

data were disclosed. Participation was voluntary, and participants were free to withdraw

consent or discontinue participation at any time. Ethical approval was granted by the Royal

Australasian College of Surgeons research ethics panel.

Statistical analysis

Analyses were performed using SPSS (Statistical Package for the Social Sciences version

13.0 for Windows, Lead Technologies Inc, United States). Reliability coefficients of the

measures used were determined, and data were screened for outliers, normality, linearity,

and homoscedasticity. Pearson correlation coefficients were calculated to explore

relationships between burnout, age, and gender, and to determine whether there was social

desirability bias in the responses. MANOVA and univariate tests (with Bonferroni adjustment)

were used to determine differences in burnout between different subgroups. A series of

independent t-tests were also conducted to compare burnout levels with norms for a

population of Australian general surgeons and surgical trainees determined by a previous

study conducted by two of the current authors (SB, BF).22 P-values < 0.05 were considered

statistically significant.

Results

Participants

The sample comprised 278 participants - an overall response rate of 21.6%. After the data

were screened, one participant was excluded as an extreme outlier for age. Of the remaining

277 respondents, 52 were female and 225 were male, ranging in age from 32 to 59 years

(mean = 39.2, SD = 4.6). Ninety-four percent of all participants were married or in a

permanent relationship, and 80% of participants had one or more dependents.

Thirty-seven percent of participants practiced in General Surgery, 24% in Orthopaedic

Surgery, 10% in Otolaryngology Head and Neck Surgery, 8% in Neurosurgery, 7% in

Urology, 5% in Plastic Surgery, 4% in Vascular Surgery, 3% in Cardiothoracic Surgery, and

2% in Paediatric Surgery.

Eighty-four percent of participants were from Australia, 14% were from New Zealand, and the

remaining 2% were practicing overseas. Twenty-six percent of participants worked in full-

time public practice, with 9% working in full-time private practice. Thirty percent of

participants worked more than 60 hours per week on average, and 12% had taken less than

two weeks leave in the previous 12 months.

Based on CBI definitions, the percentage of participants reporting high levels of burnout were

26.7% for personal burnout, 20.2% for work burnout, and 6.1% for patient burnout.

Scale reliability and inter-relationships

The scales used in this study achieved reliability coefficients between 0.64 and 0.83

indicating adequate internal consistency. Although some variables were moderately skewed,

this did not violate the assumptions of the statistical analyses used in the study.25 The

means, standard deviations (SD), theoretical ranges, and Cronbach alpha coefficients for the

CBI and MC-C are presented in table 1.

Moderate to strong correlations were detected between all three burnout subscales (table 2).

There was also a significant inverse relationship between these subscales and social

desirability. This means that actual burnout levels may be even greater than reported.

Age

Older surgeons in the Younger Fellows’ population had a slight tendency to report higher

levels of burnout than younger surgeons, but no statistically significant correlation was

identified. (Pearson coefficients 0.09, 0.07 and 0.11 for personal, work, and patient burnout

respectively).

Gender

There was a significant correlation between gender and both personal burnout (0.23,

p<0.001) and work burnout (0.17, p<0.01). MANOVA analysis also revealed a significant

difference in overall burnout levels between male and female Fellows (p<0.001). Univariate

tests isolated this further, showing that females exhibited higher levels of personal burnout

(p<0.001) and work burnout (p<0.025), with no significant gender differences in patient

burnout (table 3).

Country of Practice

Younger Fellows from New Zealand reported slightly higher general, work-related and

patient-related burnout levels than Younger Fellows from Australia or overseas, but these

differences were not statistically significant (p>0.05).

Surgical Specialty

Younger Fellows practicing in Cardiothoracic Surgery reported the highest levels of both

personal and work-related burnout, while Younger Fellows practicing in Plastic Surgery

reported highest levels of patient-related burnout (Figures 1 - 3). These differences were not

statistically significant.

Hospital Size

There was an overall statistical significance when hospital size (as defined by the number of

beds) was included in a MANOVA analysis (p<0.01). Univariate testing was consistent with

this for patient burnout only (p<0.05). Post-hoc analysis confirmed that Younger Fellows

working in hospitals with less than 50 beds reported significantly higher patient-related

burnout levels than those working in hospitals with 50 or more beds (mean patient burnout

37.0 and 22.1 respectively, p 0.004).

Work Division and Hours

Younger Fellows with equal work division between public and private practice reported

higher personal and work-related burnout than those with work concentrated in one sector

(posthoc univariate analysis, p<0.05).

Younger Fellows who worked more than 60 hours per week reported significantly higher

personal burnout than those who worked less than this, (table 4; posthoc univariate analysis,

p<0.05).

Comparison with Surgeons and Trainees

Burnout levels were compared with those of Australian General Surgeons and Trainees

using data from a study conducted by two of the current authors (SB, BF).22 As seen in table

5, patient burnout was significantly lower (p<0.01) in Younger Fellows than in Australian

General Surgeons, and all three subscale levels were significantly lower than in Trainees

(p<0.001).

Discussion

Previous studies have demonstrated that medical professionals, including surgeons, are

particularly vulnerable to the experience of burnout.3-5 In the current study, almost 27% of

Younger Fellows reported high levels of personal burnout. A similar survey-based study

(using a different burnout measure) conducted on 582 American Surgeons in 2001 reported

a burnout rate of 32%. 21 A highly significant inverse relationship between age and burnout

was demonstrated, indicating that burnout was more common among young surgeons. This

is consistent with the findings of a more recent study in Surgical Oncologists in the United

States, 11 a smaller study of German Urologists,7 and the GSA study mentioned above. 24

Interestingly, in our study, the percentage of respondents with high levels of patient-related

burnout (6.1%) was lower than that of Australian General Surgeons (16.4%), 22 We also

found that older surgeons in the Younger Fellows’ population had a tendency to report higher

levels of burnout than younger surgeons (not significant). Both these findings appear to be

inconsistent with the previously reported relationship between age and burnout. It must be

noted, however, that the significant inverse relationships found between the burnout

subscales and social desirability suggests that burnout may be under-reported in our sample.

Furthermore, given that Younger Fellows are classified as surgeons practicing within 10

years of receiving Fellowship of RACS (rather than by age per se), it may be that the older

surgeons in this group were characterised by factors not captured within the current study,

for example international medical graduates, or doctors who may have had a delayed career

in surgery.

Females had a tendency to report higher levels of general and work-related burnout than

males. This has previously been reported by Kuerer et al in the study American Surgical

Oncologists.11 In that study, 36.8% of women, compared to 26.1% of men were burnt out (p

0.029). The reason for the gender discrepancy is unclear, but may be due to additional social

or work-related stressors experienced by this gender group.

Another potential risk factor identified in our survey is work in smaller hospitals, with higher

patient burnout reported by Fellows from hospitals with less than 50 beds. These hospitals

tend to be remote, with limited sub-specialty and collegial support, and one can speculate

that this could lead increased stress. Younger Fellows with an even work division between

public and private practice had higher burnout levels than those engaged in full-time private

or full-time public practice. This is implies that concentration of work load in one sector

reduces stress, perhaps be due to a more constant practicing environment, or simply to

geographical practicality. These relationships between surgeon burnout and work setting

have not been previously reported in international studies.

This study has several limitations. The first is the low response rate of 21.6% which may not

be representative of the entire group of Younger Fellows. This is a lower response rate than

in similar surveys conducted in US surgical institutions.21 Second is the apparent under-

reporting of burnout as indicated by the inverse relationship between the social desirability

and burnout measures. Finally, the impact of individual personality traits, and cultural factors

(particularly pertaining to Fellows that belong to minority groups or international medical

graduates), were not assessed.

Conclusion

There is a significant incidence of burnout amongst RACS Younger Fellows. While this is

lower than that previously reported for Australian General Surgeons and Trainees, there are

particular cohorts within the Younger Fellow population that are at high risk of burnout. These

are female surgeons, surgeons that work in smaller hospitals, those that work more than 60

hours per week, and those with practice division between the private and public sectors.

Further enquiry into potentially remediable causes for the increased burnout in these groups

is indicated.

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Tables Table 1: Means, standard deviations, and alpha reliabilities for the CBI and MC-C scales. CBI: Copenhagen Burnout Inventory, MCC: Marlowe-Crowne Social Desirability Scale – Form C, SD: standard deviation, n: number of participants.

Measure Subscale Mean SD Alpha

CBI

Personal Burnout 39.5 15.3 0.83

Work Burnout 35.5 15.3 0.82

Patient Burnout 22.2 15.7 0.83

MC-C Social Desirability 50.4 5.6 0.64

Table 2: Pearson correlations between sub-scales. * p < 0.001 (two tailed)

1. 2. 3. 4.

1. Personal Burnout - 0.82* 0.57* - 0.25*

2. Work Burnout - 0.68* - 0.33*

3. Patient Burnout - - 0.31*

4. Social Desirability -

Table 3: Levels of burnout by gender. CBI: Copenhagen Burnout Inventory, SD: standard deviation, n: number of participants.

CBI Subscale Gender Mean SD n

Personal Burnout Male 37.8 14.5 225

Female 46.8 16.5 52

Work Burnout Male 34.3 14.7 225

Female 40.9 16.9 52

Patient Burnout Male 22.5 15.8 225

Female 20.7 15.5 52

Table 4: Levels of burnout by work division and hours worked. CBI: Copenhagen Burnout Inventory, SD: standard deviation, n: number of participants.

CBI Subscale Work Division Mean SD n

Hours per week Mean SD n

Personal Burnout

> half public 38.4 14.1 127 0 – 39 36.6 15.4 33

public = private 43.7 16.5 60 40 – 59 38.1 15.3 161

> half private 37.8 15.6 85 > 60 42.9 14.7 82

Work Burnout

> half public 34.9 14.5 127 0 – 39 34.0 14.5 33

public = private 40.4 16.3 60 40 – 59 34.3 14.5 161

> half private 33.1 15.2 85 > 60 38.6 16.9 82

Patient Burnout

> half public 21.1 13.5 127 0 – 39 23.1 15.1 33

public = private 23.1 16.6 60 40 – 59 21.7 15.2 161

> half private 23.3 18.0 85

> 60 22.7 17.3 82

Table 5: Comparison of burnout levels between Younger Fellows, and Australian General Surgeons and trainees (GSA study 2007). In any row means with identical superscripts are significantly different at p < 0.05. CBI: Copenhagen Burnout Inventory, GSA: General Surgeons Australia, SD: standard deviation, %: percentage with high burnout, n: number of participants.

Current study

(n = 277) GSA study - Surgeons

(n = 73) GSA study - Trainees

(n = 53)

CBI Subscale Mean SD % Mean SD % Mean SD %

Personal Burnout 39.5 a 15.3 26.7 43.1 18.8 34.2 53.5 a 14.2 66.0

Work Burnout 35.5 b 15.3 20.2 37.4 19.3 32.9 45.1 b 15.6 49.1

Patient Burnout 22.2 c d 15.7 6.1 30.5d 20.3 16.4 33.4c 18.2 20.8

Figures legends Figure 1: Personal burnout levels by surgical specialty. Vertical lines indicate 95% confidence intervals. CBI: Copenhagen Burnout Inventory, ENT: Otolaryngology, Head and Neck Surgery.

Figure 2: Work burnout levels by surgical specialty. Vertical lines indicate 95% confidence intervals. CBI: Copenhagen Burnout Inventory, ENT: Otolaryngology, Head and Neck Surgery. Figure 3: Patient burnout levels by surgical specialty. Vertical lines indicate 95% confidence intervals. CBI: Copenhagen Burnout Inventory, ENT: Otolaryngology, Head and Neck Surgery.