Burnout Levels Among Portuguese Family Doctors: a Nationwide Survey.

March 02, 2022 Post a Comment

Research

Prevalence of exhaustion amid GPs: a systematic review and meta-analysis

British Journal of General Do 21 February 2022; BJGP.2021.0441. DOI: https://doi.org/10.3399/BJGP.2021.0441

Abstract

Groundwork Burnout is a work-related syndrome documented to have negative consequences for GPs and their patients.

Aim To review the existing literature apropos studies published up to December 2020 on the prevalence of burnout among GPs in full general do, and to make up one's mind GP burnout estimates worldwide.

Design and setting Systematic literature search and meta-analysis.

Method Searches of CINAHL Plus, Embase, MEDLINE, PsycINFO, and Scopus were conducted to place published peer-reviewed quantitative empirical studies in English up to December 2020 that take used the Maslach Burnout Inventory — Human being Services Survey to establish the prevalence of burnout in practising GPs (that is, excluding GPs in training). A random-effects model was employed.

Results Wide-ranging prevalence estimates (6% to 33%) across different dimensions of burnout were reported for 22 177 GPs across 29 countries were reported for 60 studies included in this review. Mean burnout estimates were: 16.43 for emotional exhaustion; 6.74 for depersonalisation; and 29.28 for personal accomplishment. Subgroup and meta-analyses documented that country-specific factors may be important determinants of the variation in GP burnout estimates. Moderate overall burnout cut-offs were found to exist determinants of the variation in moderate overall burnout estimates.

Conclusion Moderate to high GP burnout exists worldwide. Nonetheless, substantial variations in how burnout is characterised and operationalised has resulted in considerable heterogeneity in GP burnout prevalence estimates. This highlights the challenge of developing a uniform arroyo, and the importance of considering GPs' piece of work context to amend characterise burnout.

exhaustion, professional
family medicine
family physicians
family unit exercise
general practice
general practitioners

INTRODUCTION

GP burnout (including physicians and other medical specialties) is a recognised healthcare problem that has become widespread over time and for which the adverse furnishings on clinicians¹ ^– ¹³ and patientsⁱⁱ ^, ¹⁴ accept been documented. Given these deleterious furnishings, estimating the prevalence of GPs' burnout is important. Burnout is generally referred to every bit an inability to cope with chronic psychological stress at piece of work because of insufficient resources to cope with job demands.^fifteen ^, ^xvi Researchers accept denoted that burnout captures three dimensions/subscales: emotional exhaustion, cynicism/depersonalisation, and personal accomplishment.¹⁷ ^– ^nineteen

This characterisation of burnout is also used in health care, as is aptly captured in the World Wellness Organization's 11th revision of the International Classification of Diseases (https://icd.who.int). GP tasks are related to treating illness in the context of the patient's life, belief systems, and customs (thus it is person focused rather than disease focused),²⁰ ^, ²¹ and working with other healthcare professionals to coordinate care and make efficient apply of health resources.²² ^, ²³ Although surveys on doctor burnout in the United states of america conducted by other researchers take reported that physician specialties that often deal with patients and their families, such equally GPs, experienced considerably higher burnout rates than other specialties, it is unclear how prevalent GP exhaustion is.¹² ^, ²⁴

This systematic review aimed to comport a synthesis of the evidence on the prevalence of GP burnout documented in the literature. In doing so it aimed to deliver a baseline moving-picture show of burnout in the GP context to establish the burden GP burnout imposes on the healthcare system. This, in turn, may do good policymakers, healthcare institutions, clinicians, researchers, and the public to develop interventions to address the syndrome. This is especially important in the post-COVID-19 environment, which has witnessed considerably greater burden placed on GPs via more frequent patient visits and other requirements.

GP exhaustion is widely recognised equally a problem in health care. However, to the authors' noesis, no study has been conducted on the global burden of this status. The systematic review and meta-analysis conducted show that moderate to high levels of burnout exist worldwide. Even so, a claiming to policymakers is the broad variation in burnout estimates across studies and countries documented in this review. The findings from this review highlight that the context within which GPs work should be considered in better understanding GP exhaustion.

METHOD

Data sources and searches

The search strategy for this systematic review was conducted using a combination of keywords and subject headings to include ii concepts: 'general practise or GP' and 'burnout'. Primary care physicians typically include GPs every bit well every bit other physicians such as paediatricians, emergency physicians, and internal medicine specialists. Nonetheless, this study focuses specifically on physicians who typically undertake generalist patient intendance such as GPs, and excludes the other subspecialties of primary intendance.

Merely studies that reported prevalence estimates on GP exhaustion in general practise using the Maslach Burnout Inventory — Human Services Survey (MBI-HSS) were included in this review. Although dissimilar burnout scales have been used in prior enquiry, the MBI-HSS was used in this review to allow comparisons in burnout prevalence estimates across studies. Moreover, the MBI-HSS is the most widely used exhaustion instrument in the literature that measures burnout by capturing the different dimensions of exhaustion that take been identified in the literature, namely, emotional exhaustion, depersonalisation, and personal accomplishment.

The following databases were searched for potentially relevant articles, followed by screening the reference lists of identified articles: CINAHL Plus, Embase, MEDLINE, PsycINFO, and Scopus. The study eligibility criteria and option are outlined in Supplementary Appendix S1. Details pertaining to the search terms, inclusion and exclusion criteria, and search strategy used for each database are also outlined in Supplementary Appendix S1. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Data extraction

The post-obit data were extracted from each article using a standardised course by i of the reviewers (the first author): geographic location; survey period; sample size with response charge per unit; average age of participants (GPs); number and proportion of male participants; average number of years the participants take worked in general do; do size; number of hours worked per week; version of MBI-HSS instrument used to measure exhaustion; cut-off criteria to denote subcomponents of burnout (emotional burnout, depersonalisation, and personal achievement) and overall burnout (divers using the criteria used in the study); and mean and proportion estimates of subcomponents of exhaustion and overall exhaustion for all the GPs and for male person versus female GPs.

Take a chance of bias and quality assessment

The risk of bias of the included studies was assessed by one reviewer (the first author) using the Joanna Briggs Found (JBI) Disquisitional Appraisement Checklist for Studies Reporting Prevalence Data, which scored studies based on ix items that assessed quality. This checklist is described in Supplementary Appendix S2. Full details of the scoring method used and the quality appraisal results for the studies included in this review are provided in Supplementary Appendices S2–S4.

Pooled analysis

A meta-assay of high-quality studies, defined using a threshold of seven out of nine items (77.8%) that satisfied the respective quality criteria pertaining to the JBI checklist, was conducted. Stata statistical software (version 16.0) was used to obtain pooled burnout estimates. The meta-analysis commands used are summarised in Supplementary Appendix S5. Pooled mean estimates of the exhaustion subscales were computed using the metan command for means and standard error, with the standard errors having been calculated in advance using the standard deviations. Prevalence estimates (rates) were computed from these numbers using the metaprop command, reflecting the pooled proportion of GPs who were reported to have experienced burnout. Accounting for potential heterogeneity across studies, a random-effects model was employed to estimate variances of the raw proportions or means.

RESULTS

Study characteristics

The PRISMA flow diagram detailing the selection process for the 60 articles included in the systematic review²⁵ ^– ⁸⁴ is given in Figure 1. Thirty-i of the 60 (51.7%) identified studies met the threshold of 'high quality'.³¹ ^, ³³ ^, ³⁵ ^, ³⁸ ^– ^xl ^, ⁴² ^, ⁴³ ^, ⁴⁵ ^, ⁴⁷ ^– ⁴⁹ ^, ⁵¹ ^– ⁵⁶ ^, ⁵⁸ ^– ⁶³ ^, ⁶⁵ ^, ⁷⁰ ^, ⁷² ^– ⁷⁵ ^, ⁸³ Of these studies, 74.two% (n = 23/31) reported the number of GPs that had high or moderate burnout along ≥1 of the burnout subcomponents (emotional exhaustion, depersonalisation, and personal accomplishment) and overall burnout; 58.i% (n = eighteen/31) reported mean and standard divergence estimates for ≥1 of the burnout subcomponents (data not shown).

Figure 1.

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Figure i.

PRISMA flow diagram on identification and selection of articles. ^a n-values are greater than 31 because studies can report burnout as both a dichotomous and continuous variable. MBI = Maslach Burnout Inventory — Human Services Survey.

Supplementary Appendix S6 provides a description of selected demographic data extracted from the 60 included studies in this review; burnout cut-offs, mean, and proportion estimates are provided in Supplementary Appendices S7 and S8. Estimates are provided separately for male and female person GPs if they are reported in the respective study.

Report fourth dimension periods ranged from 1987 to 2020, comprising data from 22 177 GPs beyond 29 countries spanning five continents. The bulk of these studies (70.0%, n = 42/60) were conducted in Europe, xviii.iii% (n = 11/sixty) were conducted in Asia, with the remaining studies conducted in the following three continents: Africa 1.7% (n = 1/threescore), North America 3.3% (n = 2/threescore), and Oceania half-dozen.seven% (n = four/60). Where a study was conducted over dissimilar time periods, information for the earliest menstruation were extracted (Supplementary Appendix S6). Virtually of the studies (70.0%, due north = 42/lx) used the 22-detail version of the MBI-HSS (Supplementary Appendix S6).

The studies predominantly used the following standard cut-offs¹⁹ to denote high exhaustion for the three burnout subscales: emotional exhaustion ≥27 (38.3%, n = 23/lx), depersonalisation ≥10 (30.0%, n = 18/60), and personal achievement ≤33 (28.iii%, n = 17/60) (Supplementary Appendix S7). Every bit for high overall burnout, the studies (28.3%, north = 17/60) generally used the following criteria: high emotional exhaustion and depersonalisation, and depression personal achievement.

The reported findings collectively bear witness that in that location is wide variation in the demographic information, besides as burnout cut-offs and estimates, extracted from the studies included in the review. Selected demographic characteristics reported in the 31 high-quality studies are provided in Supplementary Appendix S9. The heterogeneity in demographic and burnout data observed for the sixty included studies remained for the college-quality 31 studies included in the meta-analysis. Still, the ranges of the burnout estimates reported in these studies are considerably narrower than those reported for all sixty studies.

Pooled results

Effigy ii reports the pooled random-effect hateful estimates using continuous data based on the scores obtained for the divergence burnout subscales: 16.43 (95% confidence interval [CI] = 13.57 to 19.29; I ² = 100.0%; P≤0.001) for emotional exhaustion; 6.74 (95% CI = v.29 to 8.18; I ² = 99.8%; P≤0.001) for depersonalisation; and 29.28 (95% CI = 23.61 to 34.96; I ^two = 100.0%; P≤0.001) for personal achievement.

Figure 2.

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Figure 2.

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Figure two.

Meta-analysis of GP burnout using continuous data: a) emotional burnout; b) depersonalisation; and c) personal accomplishment. Weights are from random-furnishings analysis. ^a

^a Additionally, while the 31 studies comprised the total gear up of studies on which the meta-assay was conducted across all dimensions of burnout, some types of estimates were not reported in some studies. Some studies reported only proportions and/or percentages whereas others reported but mean estimates, and withal others reported both proportions and mean estimates. The total number of studies is 31, which would be reflected past all the studies captured in Figure ii and also Supplementary Appendix S11. ES = mean score.

These estimates denote moderate levels of burnout for emotional burnout and depersonalisation, and a loftier level of burnout for personal accomplishment, based on standard exhaustion cut-offs for these subscales, indicating significant levels of burnout amidst GPs. As axiomatic in the high I ² (>99%), there is considerable heterogeneity across studies. Supplementary Appendix S10 shows that the hateful burnout estimates for the different burnout subscales varied depending on the country's geographical region (P-value for heterogeneity ≤0.001). Meta regressions results showed that the continent in which studies were conducted had no effect on variation in mean burnout estimates across studies. In that location were bereft observations within subgroups to carry meta regressions for state. Overall, in that location was no evidence that the geographical region influenced variation in mean burnout estimates across studies.

Studies reported the following pooled prevalence estimates for GPs that exceeded the threshold for loftier or moderate exhaustion (Supplementary Appendix S11): high emotional exhaustion 32% (95% CI = 26 to 39; I ⁱⁱ = 97.95%; P≤0.001); high depersonalisation 31% (95% CI = nineteen to 43; I ^two = 99.49%; P≤0.001); low personal accomplishment 27% (95% CI = 22 to 32; I ² = 96.86%; P≤0.001); high overall burnout 6% (95% CI = 4 to 9; I ^two = 95.42%; P≤0.001); moderate emotional exhaustion 28% (95% CI = 22 to 35; I ² = 95.79%; P≤0.001); moderate depersonalisation 23% (95% CI = 15 to 31; I ² = 97.55%; P≤0.001); moderate personal achievement 33% (95% CI = 22 to 44; I ⁱⁱ = 98.51%; P≤0.001); and moderate overall burnout 32% (95% CI = xix to 44; I ² = 99.xl%; P≤0.001).

As evident in the high I ² (>95%), there is considerable heterogeneity across studies. The results (in Supplementary Appendix S10) of subgroup analyses conducted with at to the lowest degree 10 studies to investigate this heterogeneity show that the prevalence of burnout dimensions varied depending on the country's geographical region and cut-off for moderate overall exhaustion (P-value for heterogeneity ≤0.001). Although some covariates were dropped because of collinearity, meta regressions conducted using the metareg command showed that the continent in which the studies were conducted was mostly not an of import determinant of high or moderate exhaustion (P>0.20); all the same, loftier depersonalisation was significantly lower in Europe (regression coefficient −0.565; 95% CI = −0.768 to −0.362; P≤0.001) and North America (regression coefficient −0.354; 95% CI = −0.646 to −0.063; P≤0.001) compared with Asia, and moderate overall exhaustion was significantly lower in Europe (regression coefficient −0.424; 95% CI = −0.803 to −0.046; P = 0.03) compared with Asia.

Taken together, the findings signal that, although the continent in which the studies were conducted is not a robust determinant of GP burnout across studies, there is some evidence that GP burnout is lower in Europe and higher in Asia.

The subgroup assay by country revealed that the land the study was conducted in did non influence high emotional exhaustion; high depersonalisation was significantly higher in People's republic of china (regression coefficient 0.543; 95% CI = 0.386 to 0.700; P≤0.001) than in the other countries included in the meta regression; depression personal accomplishment was significantly higher in People's republic of china (regression coefficient 0.213; 95% CI = 0.088 to 0.339; P = 0.01), Denmark (regression coefficient 0.220; 95% CI = 0.117 to 0.324; P≤0.001), and England (regression coefficient 0.211; 95% CI = 0.080 to 0.341; P = 0.01) than in other countries. Overall, there is some prove that GPs from People's republic of china experienced higher depersonalisation than GPs from other countries (Supplementary Appendix S10).

In add-on, overall, in that location was loftier residue heterogeneity for high burnout (≥95% for continent and ≥seventy% for country) and moderate burnout (≥84% for continent) There was no remainder heterogeneity (0.00%) and high explained between-report variance for the cut-off for moderate overall burnout (adapted R ² 99.93%), indicating that this cut-off may exist an important determinant of heterogeneity in moderate overall burnout estimates beyond studies. The findings also reveal that less restrictive exhaustion criteria used in the studies are associated with higher GP burnout prevalence. For case, the more restrictive criteria for moderate overall burnout used in the studies of high emotional exhaustion and/or loftier depersonalisation take a smaller regression coefficient of 0.170 compared with the less restrictive criteria of high emotional exhaustion and/or high depersonalisation and/or low personal accomplishment, which has a regression coefficient of 0.355 (Supplementary Appendix S10).

Tests of publication bias via funnel plots⁸⁵ and Egger tests⁸⁶ were conducted and results provided in Supplementary Appendix S12. The results provide no evidence of publication bias using the dichotomous data. Visual inspection of the funnel plots showed no disproportion in all distributions for exhaustion studies. Furthermore, the Egger tests did non show significant results and thus suggested no prove of publication bias among the studies on burnout proportions. However, Egger tests on studies using the continuous data showed some show of possible small-written report effects, with significant results (P≤0.001) for mean emotional exhaustion, mean depersonalisation, and mean personal accomplishment.

Equally another sensitivity test, the meta-assay was conducted including studies of lower quality (rated ≤6 on the JBI) that were more susceptible to risk of bias. The results (Supplementary Appendix S13) showed that the exhaustion estimates were similar and even so displayed significant heterogeneity for all studies (including those of lower quality) as for merely higher-quality studies.

DISCUSSION

Summary

The 60 studies included in this systematic review reported a wide range of demographic characteristics, burnout cut-offs, and prevalence estimates. Some studies characterised burnout as uni- or bi-dimensional, although the vast majority of studies characterised burnout as multidimensional. Other studies contribute to the ambivalence with how burnout is characterised by partitioning exhaustion into high, moderate, and low dimensions, or using dissimilar labels (for example, 'severe', 'high', 'extreme', 'full', or 'complete' were used to denote high exhaustion). These variations beyond studies were observed despite narrowly focusing on only one burnout instrument, the MBI-HSS, and ane specialty, full general practice.

In the nowadays written report there appears to be some evidence that the state the study was conducted in may influence this heterogeneity. It is conceivable that different national cultural factors (for example, general practice being perceived every bit a calling versus a turn a profit-making enterprise) may influence how workload is perceived and thus burnout experienced past GPs. Furthermore, the different features of the primary intendance organization across countries may influence the GP's work environment, which in turn may influence the likelihood of burnout. This review has provided evidence that the cut-offs used to denote burnout play an of import function in influencing GP burnout estimates across studies. The more restrictive the burnout criteria used, the lower the burnout estimate reported across studies.

Strengths and limitations

This report is, to the authors' knowledge, the first to undertake a systematic review and meta-analysis of studies on the prevalence of GP burnout worldwide. Another force of this study is that information technology attempted to deport a rigorous test of the burden of GP burnout worldwide based on a clearly defined concept of burnout using the MBI-HSS, and focusing only on general practice.

This study, however, has several limitations. First, the studies included in this review were not conducted concurrently. Hence, the findings may exist subject to different interpretations across different fourth dimension periods. Second, the different demographics, at the GP and other levels, beyond the studies may have influenced how exhaustion is perceived, and may in turn influence the generalisability of the findings.

Third, although every endeavor was made to select studies that were similar in their methodological arroyo for the quantitative assay, several differences in the written report design remained and reduced comparability beyond the studies.

Fourth, given this review'south focus on studies using the MBI-HSS, the insights derived in this review should be interpreted with caution, peculiarly given the criticism some researchers take directed toward the MBI-HSS instrument and who accept used other instruments such every bit the Oldenburg Burnout Inventory and the Copenhagen Burnout Inventory. Related to this, the MBI-HSS is subject to criticism of bias generated by self-ratings by responders on the questionnaire used in the assessed studies. To focus narrowly on burnout, studies on constructs related to burnout, such as psychological or occupational stress, were not included in the review. To the extent that these studies also capture GP experiences like to burnout, this review could be criticised as ignoring a vast literature that may be relevant. In a like vein, what constitutes burnout has been debated in the literature, and the literature that conflates burnout and low was excluded. It is believable that there is an important overlap between GP mental health, psychological distress, and exhaustion. More than importantly, burnout may exist more a manifestation of the GP's underlying mental condition than solely as a effect of the workplace context. Hence, the generalisability of this review's findings beyond studies using merely the MBI-HSS could be chosen into question. Related to this, this literature may also include articles on exhaustion using the MBI-HSS that may not accept been identified in the search strategy used in this systematic review. The MBI-HSS, used in this review, was designed to capture burnout associated with interpersonal relations. However, GP burnout also arises every bit a result of factors external to man relations such as workload and electronic documentation. Thus, the MBI-HSS may not fully capture GP burnout.

Fifth, studies conducted in a language other than English language were not included, which may limit this review's generalisability to other studies not conducted in English.

Finally, this review but considered peer-reviewed publications and did non consider published data from non-peer-reviewed outlets, which also may have introduced another type of selection or publication bias.

Comparison with existing literature

The wide ranges in burnout estimates reported in this review are consistent with those reported in two recent systematic reviews on the prevalence of doctor burnout beyond a range of specialties.⁸⁷ ^, ⁸⁸ The evidence provided in these studies and the present study may reflect the heterogeneity across studies in the criteria used to define and measure burnout, and thus highlight the importance of uniformity in how exhaustion is measured and defined across studies.

Implications for inquiry and practice

This study has shown that the approaches used in prior studies to characterise and operationalise GP exhaustion are inconclusive, with the reported wide-ranging prevalence estimates possibly influenced by a range of factors, such as using different measurement scales, differing cut-off points to define burnout, differing approaches to how burnout is characterised, and different cultural attributes across countries. An implication of this finding for inquiry, practice, and policy pertaining to addressing GP burnout is that assessing and addressing the syndrome should exist undertaken by considering the context GPs work in.

The work surround is challenging for the GP, as the GP's decisions and deportment are influenced by those of the patients and other agents that operate inside the primary intendance system who may have different expectations and demands.²² ^, ⁸⁹ These differences in values and priorities betwixt the GP and other individuals in the primary care system tin can result in hard interactions betwixt the GP and these individuals. Additional research on the reasons for loftier/moderate burnout was beyond the telescopic of this study, but could be related to differences in priorities betwixt the private GP and the practice the GP is employed at. For example, the accent on efficiency could be perceived by GPs as being at the expense of patient welfare, leading to a potential mismatch in values between the practice and the GP. This could interact with the piece of work-related burden imposed on the GP, perhaps exacerbating the level of exhaustion.

Recent studies have shown that the COVID-19 pandemic has also played an important role in influencing physician exhaustion. For example, one study showed that infection or decease from COVID-xix among colleagues or relatives showed meaning association with college emotional exhaustion and lower personal accomplishment.^xc Two other studies reported that GPs described feeling more than stressed during the pandemic than they had been previously because of the college workload (for example, as a result of new responsibilities such every bit additional safety protocols, learning new technology, and daily emails for prescriptions).⁹¹ ^, ⁹² The boggling impact of the COVID-19 emergency on GPs, as frontline medical providers, was in part produced past the uncertainty of the procedures and treatments required and the immediate saturation of hospitals for critical case management. GPs had to respond direct to a large number of requests without articulate prevention or screening instruments. At the time of writing, GPs were the foundation of COVID-19 vaccination programmes in several countries and remain heavily involved in administering vaccines, with some fifty-fifty involved in COVID-19 diagnoses, thus increasing their workload fifty-fifty further. Differences beyond countries in the severity of the illness also as the resources available and methods used to curb and care for it (including inefficiencies associated with supplying vaccines to GPs), and operating under unlike master care systems, are likely to exacerbate the bear on of COVID-19 on GP burnout beyond countries. Probing GP burnout in more than detail within the GP's workplace environs is left for time to come research.

Notes

Funding

This study received no funding.

Upstanding approval

Not applicable.

Data

The dataset is available upon request.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors take declared no competing interests.

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Received July 17, 2021.
Revision requested October 13, 2021.
Accustomed Dec nine, 2021.

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