Burnout in the senior medical workforce five years on

HEALTH DIALOGUEISSUE 17 | APRIL 2021

“My employer is exhausting”Burnout in the senior medical workforce five years on

Dr Charlotte Chambers, ASMS Director of Policy and Research

Queries about this research can be sent to [email protected]

WWW.ASMS.ORG.NZ HEALTH DIALOGUE i

ContentsForeword ii

Introduction 1

Definitions 2

Whyburnoutstillmatters 2

Methodology 4

Qualitativedataanalysis 5

Results 6

Demographicinformation 6

Burnout results 8

Burnoutanddemographicvariables 10

Genderandburnout2020 11

Dependants 13

Hoursofworkandburnout 15

Hoursofworkanddependants 17

Burnoutandplaceofwork 17

Specialtyandburnout 20

Qualitativedataanalysis 21

Qualitativeanalysisoftrends 24

Discussion 26

Timingofsurvey 26

Responderbias 26

Factorsassociatedwithburnout 27

Genderandburnout 27

Ageandburnout 28

Impactofdependants 28

Burnoutandmedicalspecialty 29

Conclusions 30

Whatneedstochange 31

Whatwearecallingfor 31

Appendix 1 32

References 32

ii HEALTH DIALOGUE APRIL2021

Foreword

Inourlatestsurvey,nearly50%ofrespondentsreportburnout.Thismeansinfiveyears,therehasbeennosubstantiveimprovementsinceourlastburnoutsurvey.

Thedoctorsanddentistswhosharedtheirexperiencesinthisresearchconveyedtheirpassionanddetermination,butalsospokeofthechallengingcircumstancesoftheirwork.

“The work is wonderful. I love caring for the patients but it is relentless and impossible to actually achieve within the current staffing climate.” – Radiation Oncologist

Thefactthatoneintwodoctorscontinuetosufferfromburnoutrepresentsaseriousfailurebythesystemtoaddresstherootcauseoftheproblem.Ourseniordoctorsanddentistscontinuetoshouldertheloadinourchronicallyunderstaffedandincreasinglybusyhospitals.Weknowtherearespecialiststaffingshortages(estimatedbyASMStobe24%),andwealsoknowthisrateofburnoutisunsustainable.Itseffectsarestartingtosnowballasacutedemandcontinuestooutstripworkforceresourceandsupply.

Burnoutisnotanindividualproblem;itisasystemfailure.Accordingly,wearecallingforformal

recognitionofemployers’responsibilitiestoprovidephysicallyandpsychologicallysafeworkplaces.Adequateresourcing,includingincreasedadministrativeandITsupport,mustalsoplayapart.

Wealsoneedacultureshiftinhospitalsandotherpublichealthcareemployers.Thenormalisationofexcessivelylongworkinghoursmuststop.

AstheGovernmentlaunchesitsresponsetotheHealthandDisabilitySystemReviewthereisnobettertimetotackletheburnoutproblem.

AsHealthMinisterAndrewLittleacknowledgedinhis24Marchspeechtosectorrepresentativesabouttheloomingchanges,thehealthworkforceisincreasinglystressed.

Ourmemberscanonlyworkwithgovernmenttoenactthesechangesiftheyhavethetime,space,andsupporttodoso.Thismeansinvestinginourpeoplefirst.

Wepresentthisburnoutstudywithspecificrecommendationsastowhatneedstochange.Wewelcomeconversationsabouthowthesechangescanbeimplemented.Ourhealthsystemandthoseworkingwithinitcannotwaitanylonger.Thetimeforactionisnow.

Sarah Dalton Executive Director Association of Salaried Medical Specialists

Burnout is now an entrenched feature of our specialist medical and dental workforce.

WWW.ASMS.ORG.NZ HEALTH DIALOGUE 1

IntroductionIn 2015 ASMS conducted the first nationwide survey of a senior medical workforce using the Copenhagen Burnout Inventory (CBI). The results were stark; one in two New Zealand medical and dental specialists were found to be suffering from high levels of fatigue and exhaustion. Many ascribed their symptoms to the conditions and experiences of their work. In August 2020, we repeated this study to see what, if anything, had changed in the intervening years. The 2020 survey findings are the focus of this report. This research extended observations made in the previous study regarding potential contributing factors to burnout, as well as improving aspects of the original methodology. This report focuses on differences in scores between the two surveys, and provides an updated commentary on the significance of burnout for the medical workforce. It concludes by presenting recommendations for change.

2 HEALTH DIALOGUE APRIL2021

DefinitionsPersonal burnout The degree of physical and psychological fatigue and

exhaustion experienced by the person overall, including work-related, patient-related burnout and non-work-related factors.

Work-related burnout The degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work.

Patient-related burnout The degree of physical and psychological fatigue and exhaustion that is perceived by the person as related to his/her work with patients.

Why burnout still mattersThe2015reportintoburnoutprovidedacriticallensontheconsequencesofamedicalworkforceenduringlong-termstaffingshortages,growingpatientdemandandclinicalcreep.Atthetime,itwasthefirstnationwidestudyofburnoutinthecountry’spublichealthworkforceofseniordoctorsanddentistsusingtheCBI.Burnoutisnow established as a key indicator of the health andwellbeingoftheseniormedicalanddentalworkforceinNewZealandandemployershaveadutyofcareinthisregard.

In2019thedefinitionofburnoutwaschangedbytheWorldHealthOrganisation(WHO)torecogniseburnoutasanoccupationalsyndrome.TheInternationalClassificationofDiseasesdiagnosticmanualnowdefinesburnoutas“resultingfromchronicworkplacestressthathasnotbeensuccessfullymanaged”(WHO2019).Thischangeindefinitionsignalsanimportantshiftinunderstandingburnoutasbeingaconsequenceofwork.Burnoutisnotasignofanindividualweaknessorfailuretocope.Thissyndromeiscausedbystressorsintheworkplace.Thischangeinemphasisrequiresthedeploymentofnewstrategiestoaddressburnout.Whilemindfulnesstechniques,stressmanagement,andpersonal

resiliencehavetheirplace,fixingburnoutwillentailaddressingtheconditionsofworkwhichcreatestressandconsideringhowthesecanbemodified(MaslachandLeiter2017).

Burnout is not a sign of an individual weakness or failure to cope. This syndrome is caused by stressors in the workplace. This change in emphasis requires the deployment of new strategies to address burnout.

WhilescreeningtoolssuchastheCBIandtheMaslachburnoutinventory(MBI)arenotclinicaldiagnostictools(Bianchi,Boffyetal.2013,Lall,Gaetaetal.2019),surveysthatsignalahighprevalenceofburnoutinapopulationwarrantseriousconsiderationandattention.Asmyriadstudieshavedemonstrated,therearecloseassociationsbetweenburnoutandintentionstoleavework(Ran,Chenetal.2020),workingthroughillness(Pei,Linetal.2020),suicidalideation(Kane2019,Menon,Shanafeltetal.2020),andqualityofpatientcare(Hewitt,Ellisetal.2020).Burnouthassignificantassociationswithsleepdeprivationandisinturnrelatedtothelikelihoodofmakingclinicallysignificantmedicalerrors(Trockel,Menonetal.2020).Definedasacomplexanddynamic


phenomenon,ratherthanafixedendpoint(Danhauer,Filesetal.2020),burnoutstudiessuchastheseundertakenbytheASMSprovideimportantinsightsintothehealthandwellbeingofcriticalworkforces.Thesestudiesarekeymarkerpoints,providingvaluableinformationanddataregardingburnout,hoursofwork,gender,andageaswellasperceptionsofkeystressorsthatindividualsviewaskeycontributingfactors.

Burnout is now established as a key indicator of the health and wellbeing of the senior medical and dental workforce in New Zealand and employers have a duty of care in this regard.

Oneofthekeyfindingsfromthe2015researchwasthehighlevelofburnoutexperiencedbydoctorsintheir30s,particularlywomen.Thesubsequentqualitativestudyintothelivedexperiencesofwomenworkinginmedicine(ASMS2019a)exploredwhetherburnoutcanresultfromchallengeswithwork-lifeintegration(Johnson,Irishetal.2020).Astheresearchdemonstrated,concernsforwork-lifeintegrationreflectedgenderschemaswhichframeresponsibilityfordomesticaffairsasthedutyofwomen(ChadwickandBaruah2020).Akeycontributionofthisstudy,moreover,wasthedemonstrationofthepervasivenature

ofgenderedassumptionsconcerningappropriatebehaviour,comportment,andindicatorsofsuccessanddedicationastheypertaintomedicine.Someoftheseindicatorssuchaslongworkinghours,negativeviewsconcerningpart-timework,andtheexpectationtoalwaysprioritiseworkwereshowntoresultinsignificantstressandillustratedconcerningaspectsofcurrentworkingpractices(ParedesandCochran2020).Theyalsoillustratedhowgender-baseddiscriminationcanaddsignificantpressuretothealreadydemandingnatureofmedicalwork(Wang,Taniousetal.2020).The2020studysoughttofurtherexplorethesetrendsbyincludingquestionspertainingtothenumberofdependantsaswellashoursofwork.

Atpresent,ASMSestimatesNewZealandhasanSMOstaffingshortageofapproximately24%basedontheviewsofclinicaldirectorsworkingaroundthecountry(ASMS2019b).Attendingtoconditionsofworkwhichmayimprovework-lifeintegration,andinturn,reduceburnoutpropensity,islikelytopaydividendsintheretentionofthishighlyqualifiedworkforce(Nuss,Tessieretal.2020).Aswithprevioussurveys,thisresearchsoughttoanalysequalitativecommentsleftbyresponderstohighlightissuesthatindividualsfeltweremostpressingintermsoftheirrespectivework-lifebalanceandsatisfactionatwork.


MethodologyAtotalof4653membersoftheASMSwereaskedbyemailtotakepartinananonymousonlinesurveyinAugust2020.HostedbySurveyMonkey,itwasopenforonemonthandfourremindersweresenttoencouragesurveycompletion.Participationwasvoluntaryandnoincentivesforparticipationwereprovided.

Aswiththeoriginal2015burnoutsurvey,theresearchusedtheCBItoassessthedegreeofburnoutintheASMSmembership.TheCBIattemptstosimplifyandrefinetheconceptofburnouttoastateofemotionalandphysicalexhaustion.Inthisexaminationofburnout,personalburnoutisassessedonthedegreetowhichrespondentsfeeltired,wornout,orphysicallyandemotionallyexhausted,regardlessofperceivedcause.Itisconceptualizedasthedegreeofoverallburnoutexperiencedbyanindividual.Work-relatedburnoutisameasureofthe“degreeofphysicalandpsychologicalfatigueandexhaustionthatisperceivedbythepersonasrelatedtotheirwork”(Kristensen,Hannerzetal.2005p197).Clientorpatient-relatedburnoutis“thedegreeofphysicalandpsychologicalfatigueandexhaustionthatisperceivedbythepersonasrelatedtotheirworkwithclients”(Ibid).This‘client’or‘patient’relatedaspectisdeemedtobeasecondtierofwork-relatedissues,butonewhichhasafocusontheimpactof‘peoplework’.Onlythosewhoworkface-to-facewithclients,orinthemedicalcontext,patients,wererequiredtoanswerthissectionoftheinventory.

Degreeofburnoutwasmeasuredaccordingtoafive-itemLikertscaleusingresponsecategories‘Always’,‘Often’,‘Sometimes’,‘Seldom’,‘Never/almostnever’,and‘Toaveryhighdegree’,Toahighdegree’,‘Somewhat’,‘Toalowdegree’,and‘Toaverylowdegree’.Burnoutwasdefinedaccordingtoinstructionsintheinventorywherethosewhoscoreequaltoorabove50onaverageineachofthethreescalesareclassedasexperiencingahighlevelofburnout.Prevalencescoreswerecalculated

byassessingthepercentageofindividualswhoscoreas‘burnt-out’(i.e.withscores≥50)asapercentageoftheoverallrespondents.Meanburnoutscoreswerethencalculatedbyaveragingthescoresforeachlineofquestioningandtakinganoverallaverageofthescore(seeinstructionsontheCBIinKristensen,Hannerzetal.2005).

AdditionalquestionswerebasedontheAustralianMedicalAssociation’s(AMA)RiskAssessmentchecklistintohoursofwork,includingwhetherparticipantshadworkedmorethan24consecutivehours,andwhethertheyhaveaperiodofrestoflessthan10hours(AMA2005).Respondentswerealsoaskedtoestimatetotalhoursofworkfortheweekpriortocompletingthesurvey.Hoursofworkweredefinedasincludingstandardhoursworked,privatework,hourson-call(includingtimeon-callbutnotcalledin),andanytimespentdoingadministrativetasksathome,includingemail.Hoursofworkwerereportedintenhourincrements.

IndependantvariablesweretakenfromresponsestotheWorldHealthOrganisation’s(WHO)self-healthassessmenttool(asingleitemmeasureofhealth)anddemographicdataincludinggender,age(accordingtofivecategories),lengthoftimeworkedinNewZealand(accordingtofivecategories),primaryDHBandspecialty.Specialtiesweresummarisedaccordingtonumberofrespondentsandallspecialtieswithn>/=20wereincluded in the analysis. Others were included accordingtobroaderspecialtygroupings.Foralistofspecialties<20andtheirgroupingseeAppendix1.Additionaldemographicdatawassoughtonnumberofdependants.Dependantsweredefinedaschildrenforwhomanindividualwasparentorguardian,livinginthesamehousehold.Ethnicity data was not collected in this study. This isalimitationandfutureworkwillincludethisdemographicvariable.

TheCBIwassituatedalongsideabroadersuiteofquestionsexaminingindicatorsofworking


conditions,staffingissuesandmembershipprioritiesfortheyearahead.Whererelevant,thesequestionswereusedincorrelationanalysis,butthisreportmainlyfocussesonthefindingsoftheburnoutquestionnaire.Associationsbetweenthemeanandprevalencescoresonthethreeburnoutscales,hoursofwork,responsestotheriskassessmentchecklistquestions,andtheindependantdemographicvariablesspecifiedaboveweretestedusingSpearman’srho,Chi-squareandone-wayANOVAasappropriateonSPSS(version23.0).Theseresultsaresummarisedusing95%confidenceintervals.

Qualitative data analysisDataanalysisofthecommentsleftineachsectionoftheburnoutsurveywasundertakenseparatelybyimportingthemintoNVivopro(version11),readingthemindetailandcodingthemesastheyemerged.Thosefromthe‘generalcomments’

sectionattheendofthesurveywerealsoexaminedbutthequalitativedataanalysiswasrestrictedinthisinstancetothecommentsleftintheburnoutsectionofthesurvey.

Patternsandtrendsemergingfromthequantitativedataanalysiswereexploredbycross-cuttingcommentsbygender,selectedspecialtieswithhighburnoutscoresandselectedDHBswithhighburnoutscores.Thiscross-cutqualitativematerialwasconsideredfurtherandwhererelevantcomparativeanalysiswasperformedbetweencategoriesofcommentstoexamineanydifferencesinhowthemeswereexpressedorthefrequencyofthematicexpression.

Commentsselectedforinclusioninthefinalreportwerethosethatbestexpressedthethemes.Theseweretranscribedverbatimandanyomittedwordsaresignalledbyellipses.Anywordsreplacedoralteredtopreserveanonymityorcorrectfortenseorsenseareplacedinsquarebrackets.


Results

Demographic informationThedemographicpatternofrespondentsisbroadlyconsistentwithprevioussurveys.2020wasthefirsttimegender-diversewasincludedasanoption.Thelownumberofgender-diverserespondentsmeanttheiranswerswereexcludedfromthemainstatisticalanalysis.FulldemographiccharacteristicsofrespondentsaresummarizedinTable1.Mostrespondentsweremale(54%),agedbetween40-49(35%),andhadworkedinNewZealandforbetween15-30years(45%).48%hadtwoormoredependants.

HOW MANY YEARS HAVE YOU WORKED IN THE NEW ZEALAND PUBLIC HEALTH CARE SYSTEM? Lessthan5years 194 10%5-14years 644 33%15-30years 877 45%Morethan30years 225 12%IN GENERAL HOW WOULD YOU RATE YOUR HEALTH?Excellent 452 23%Verygood 855 44%Good 474 24%Fair 146 8%Poor 13 1%WHAT IS YOUR AGE GROUP?20-29 6 0.3%30-39 285 15%40-49 670 35%50-59 619 32%60orover 355 18%WHAT DO YOU PRIMARILY IDENTIFY AS? Male 1037 54%Female 837 43%Genderdiverse 5 0.3%Prefer not to answer 53 3%HOW MANY CHILDREN ARE YOU PARENT OR GUARDIAN FOR AND LIVE IN YOUR HOUSEHOLD?None 672 35%1 317 17%2 606 32%3 259 14%4 47 2%Morethan4 17 1%

TABLE 1: DEMOGRAPHIC INFORMATION OF RESPONDENTS

A total of 2102 of the 4653 potential respondents responded to the survey (45% response rate). Analysis was undertaken using the best available data. Where applicable, n values are specified for each question. Only 1.2% of the survey applied to non-DHB members. For ease of comparability, analysis of the burnout data is restricted to DHB members as this was the focus of the 2015 survey.


WHAT IS YOUR PRIMARY SPECIALTY? Anaesthesia 289 16%Psychiatry 211 12%EmergencyMedicine 164 9%Medicine 146 8%Paediatrics 136 8%Diagnostic&InterventionalRadiology

94 5%

Obstetrics/Gynaecology 77 4%Geriatric Medicine 60 3%GeneralSurgery 55 3%IntensiveCareMedicine 51 3%Pathology 52 3%OrthopaedicSurgery 47 3%Dentistry 37 2%GeneralPractice 32 2%MedicalOncology 28 2%Otolaryngology 27 2%Public Health Medicine 26 2%RuralHospitalMedicine 22 1%Gastroenterology 21 1%Ophthalmology 21 1%RadiationOncology 20 1%RespiratoryMedicine 20 1%Internal Medicine 76 4%Surgery 58 3%WHICH DHB IS YOUR PRIMARY PLACE OF WORK? (% = PROPORTION OF POTENTIAL DHB RESPONDENTS)Auckland 302 37%Bay of Plenty 106 52%Canterbury 227 43%Capital&Coast 137 39%CountiesManukau 194 43%Hawke's Bay 59 44%HuttValley 59 47%Lakes 47 51%MidCentral 67 48%NelsonMarlborough 72 56%Northland 64 40%SouthCanterbury 20 48%Southern 101 63%Tairawhiti 17 40%Taranaki 38 37%Waikato 145 39%Wairarapa 9 47%Waitemata 178 39%WestCoast 12 46%Whanganui 15 35%


Burnout resultsTheCBIwasusedtoascertaintheproportionofindividualASMSmemberswhowerescoredaslikelyburnt-out(i.e.hadscores≥50)aswellascalculatingthemeanburnoutscoresforthesurveypopulationtosummarisetheoveralllevelofburnoutwithintheASMSsample.Proportionately,nearly50%oftherespondentsidentifiedashavinghighpersonalburnoutwhileonly16.7%attributedtheirburnouttointeractionswithpatients.TheseproportionateburnoutscoresaredetailedinTable2.Analysisfound13%oftheASMSsurveyrespondentswerelikelytobeexperiencingburnoutinallthreedimensionswithover25%ofthoserespondingtothesurveyexperiencingburnoutintwooutofthethreedimensions.808(43.5%)individualsdidnotscoreassufferingfromburnoutinanyofthethreedimensions.

TABLE 2: PROPORTION OF ASMS RESPONDENTS WITH BURNOUT BY SCALE

% OF ASMS PARTICIPANTS WITH

BURNOUT 2020 n=2005 (2015 scores)

% OF FEMALE ASMS PARTICIPANTS WITH


% OF MALE ASMS PARTICIPANTS WITH


Personal Burnout 49.3%(49.9%) 57.1%(59.4%) 42.2%(43.9%)

Work-related Burnout

43.5%(42.1%) 50.4%(46.9%) 36.4%(39.0%)

Patient-related Burnout

16.7%(15.7%) 15.7%(17.0%) 17.7%(14.7%)

ThemeanASMSburnoutscoresaredetailedinTable3withcomparativemeanburnoutscoresfromotherstudiesusingtheCBI.Notethatlownumbersofparticipantsintheotherstudiesmakemeaningfulcomparisonsdifficult.Themeanscoresfoundinthecurrentstudyareslightlyhigher,althoughnotsignificantlydifferentfromthemeanscoresinthe2015research.


TABLE 3: MEAN AND STANDARD DEVIATION SCORES FOR RECENT STUDIES EXAMINING RATES OF BURNOUT IN MEDICAL PROFESSIONALS USING THE COPENHAGEN BURNOUT INVENTORY

2020 ASMS SURVEY

(n=2005)

2015 ASMS STUDY (n=1487)

(Chambers, Frampton et al.

2016)

UK TERTIARY TRAUMA

CENTRE STUDY ED DOCTORS

(n=51) (Caesar, Barakat et al. 2020)

HONG KONG DOCTORS

(n=496) (Ng, Chin et al. 2020)

GERMAN UNIVERSITY

HOSPITALS (n=995) (Messias,

Gathright et al. 2019)

NZ ED STAFF (DRS SCORES

DETAILED) (n=40) (Kumar, Pio

et al. 2019)

Personal Burnout

47.5(18.3) 47.4(17.5) 50(14.4) 57.4(21.4) not used 41.8(16.7)

Work-related Burnout

45.8(17.3) 44.0(19.0) 53.5(13.1) 48.9(7.4) not used 37.4(16.3)

Patient-related Burnout

31.1(16.5) 29.5(17.9) 32.65(13.9) 41.5(21.8) 28.0(16.5) 31.0(18.1)

AsindicatedinFigure1therewerenosignificantdifferencesindegreeofburnoutacrossanyofthetypesofburnoutoverthefiveyearperiodsincethelastsurveywasundertaken.Aswith2015,thedegreeofoverall‘personal’burnoutwassignificantlyhigherthaneitherthedegreeofburnoutattributedtoworkorinteractionswithpatients.

FIGURE 1: OVERALL INDICATORS OF BURNOUT 2015-2020

60%

50%

0%

10%

20%

30%

40%

Patient-related burnout (p=0.41) Work-related burnout (p=0.41) Personal burnout (p=0.70)

20202015

49.9%

42.1%

15.7%

49.3%43.5%

16.7%


Burnout and demographic variables Aswiththe2015surveyallformsofburnoutweresignificantlyassociatedwithworseninghealthstatus(Figure2).

Whenbrokendownbygender,maleandfemalerespondentshadaslightdecreaseinoverallburnoutbutthiswasnotsignificant(Figure3).Femalerespondentshadaslightincreaseintheproportionwithwork-relatedburnoutbutthiswasalsonotsignificant(Figure4).Nosignificantdifferenceswererecordedinthedegreeofburnoutrelatedtopatientinteractions(Figure5).

FIGURE 2: RELATIONSHIP BETWEEN BURNOUT AND SELF-RATED HEALTH STATUS (p=0.000)

% with personal burnout% with work-related burnout

90%

80%

70%

60%

50%

0%

10%

20%

30%

40%

Excellent Very good FairGood Poor

89

98108

250288

343392

113 128

FIGURE 3: PERSONAL BURNOUT BY GENDER 2015-2020

20202015

70%

60%

50%

0%

10%

20%

30%

40%

Female (p=0.38) Male (p=0.46)

59.4%

43.9%

57.1%

42.2%


Gender and burnout 2020Figure6andFigure7displaytheproportionofrespondentsbyagegroupandgenderscoringaslikelytobeexperiencingpersonalandwork-relatedburnout.Therewasastatisticallysignificantdifferenceintheproportionofrespondentsexperiencingburnoutbygenderinallagegroupswithahigherproportionofwomenlikelytobeexperiencingburnoutthantheirmalecounterpartsoverall.Respondentsinyoungeragecohortsaremorelikelytoexperienceburnoutthanthoseintheolderagecohorts.Bothmenandwomenaremostlikelytoexperiencepersonalandwork-relatedburnoutintheir40s.Ofnotewasthedecreaseintheproportionofwomenintheir30slikelytobesufferingfromburnoutwhencomparedtothe2015data

FIGURE 4: WORK-RELATED BURNOUT BY GENDER 2015-2020

20202015

50.4%

60%

50%

0%

10%

20%

30%

40%


46.9%

39.0%36.4%

FIGURE 5: PATIENT-RELATED BURNOUT BY GENDER 2015-2020

20202015

17.0%15.7%

17.7%

25%

20%

0%

5%

10%

15%


14.7%


(56.5%cf70.5%,p=0.033).Forallotherfemaleagegroupstherewasnegligibledifferencewiththe2015data.Therewasaslightdecreaseintheproportionofmalerespondentsintheir30sexperiencingburnout(51.4%cf43.6%)butthiswasnotstatisticallysignificantduetothelowernumbersinthe2015survey(p=0.295).Therewasastatisticallysignificantincreaseintheproportionofmenintheir50sexperiencingpatient-relatedburnout(22.7%cf14.7%,p=0.010).

FIGURE 6: DEGREE OF PERSONAL BURNOUT BY GENDER AND AGE 2020

MaleFemale

30-39 (p<0.001)

43.6%

56.5%

47.1%

62.1%

46.4%

54.9%

28.4%

46.7%

40-49 (p<0.001) 50-59 (p<0.001) 60 or over (p<0.001)

80%

70%

60%

50%

0%

10%

20%

30%

40%

FIGURE 7: DEGREE OF WORK-RELATED BURNOUT BY GENDER AND AGE GROUP 2020

MaleFemale

30-39 (p<0.001) 40-49 (p<0.001) 50-59 (p<0.001) 60 or over (p<0.001)

80%

70%

60%

50%

0%

10%

20%

30%

40%

35.0%

46.9%

40.8%

55.6%

40.9%

49.6%

23.8%

41.9%


DependantsInthe2020surveywesoughttodeterminewhetherhavingdependants,specificallychildrenstilllivinginthehome,wasassociatedwithahigherdegreeofburnoutexperienced.Overall,wefoundthatthemeanscoreforpersonalburnoutincreasedslightlywithnumberofdependants(p=0.015).

Therewasnostatisticalrelationshipbetweenexperiencingeitherwork-relatedorpatient-relatedburnoutandwhetherrespondentshaddependants.

Whenthedatawassplitaccordingtogender,furtherpatternsemerged.Therewasnegligibledifferenceintheproportionoffemalerespondentsexperiencingeitherwork-relatedburnoutorpersonalburnoutandwhetherornottheyhaddependants.Formen,however,havingoneormorechildrenresultedinhigherratesofpersonalandwork-relatedburnout,aswellasaslightincreaseintheproportionexperiencingpatient-relatedburnout(Figure8,Figure9,Figure10).Thep-valuessignalthesignificantdifferenceindegreeofburnoutbygender.

FIGURE 8: PROPORTION OF RESPONDENTS EXPERIENCING PERSONAL BURNOUT BY DEPENDANT STATUS AND GENDER

MaleFemale

No children (p<0.001) One or more children (p<0.001)

70%

60%

50%

0%

10%

20%

30%

40%

54.9%

33.4%

58.3%

46.9%


There was no statistical relationship between experiencing either work-related or patient-related burnout and whether respondents had dependants.

Furtheranalysiswasundertakentoexploretherelationshipbetweenage,dependants,andburnout.Thehighestproportionofwomenexperiencingpersonalburnoutwereintheir30sand40swithoutchildren(65.3%and64.4%respectively).Justover50%ofmenexperiencingpersonalburnoutwereintheir50swithchildren(50.4%).Similartrendsexistedforwork-relatedburnoutwiththehighestproportionexperiencingwork-relatedburnoutbeingwomenintheir30sand40swithoutchildren(57%and63%respectively).Furtheranalysisofthesetrendswasundertakenbyexaminingthenumberofhoursworkedbyage,gender,andnumberofdependants.

MaleFemale

FIGURE 9: PROPORTION OF RESPONDENTS EXPERIENCING WORK-RELATED BURNOUT BY DEPENDANT STATUS AND GENDER

No children (p<0.001) One or more (p<0.001)

70%

60%

50%

0%

10%

20%

30%

40%

51.4% 50.0%

40.1%

29.4%

FIGURE 10: PROPORTION OF RESPONDENTS EXPERIENCING PATIENT-RELATED BURNOUT BY DEPENDANT STATUS AND GENDER

MaleFemale

No children (p<0.001) One or more (p<0.001)

25%

20%

15%

0%

5%

10%

16.5%14.8%

18.5%16.6%


Hours of work and burnout Consistentwithtrendsfromthe2015survey,work-relatedandpersonalburnoutwaspositivelycorrelatedwithincreasingnumbersofhoursworked.Therewasnorelationshipbetweenhoursofworkandthemeanscoreofpatient-relatedburnout(Figure13)Therewasaslightnegativecorrelationbetweenincreasingnumbersofprivatehoursworkedperweekandthelikelihoodofexperiencingpersonalburnout(correlationcoefficient=-0.046,p=0.042).

FIGURE 11: PROPORTION OF RESPONDENTS WITH WORK-RELATED BURNOUT BY AGE, GENDER AND DEPENDANTS

MaleFemale

30-39 no kids (p=0.134)

30-39 kids (p=0.114)

40-49 no kids (p<0.001)

40-49 kids (p<0.001)

50-59 no kids (p<0.001)

50-59 kids (p=0.229)

60 or over no kids (p<0.001)

60 or over kids (p=0.003)

80%

70%

60%

50%

0%

10%

20%

30%

40%

57.1

%

42.3

%

41.8

%

33.0

% 41.5

%

63.0

%

41.0

%53.2

%

33.3

%

48.2

%

44.5

%

50.4

%

21.8

%

40.3

%

29.2

%

48.1

%

MaleFemale

FIGURE 12: PROPORTION OF RESPONDENTS WITH PERSONAL BURNOUT BY AGE, GENDER AND DEPENDANTS

30-39 no kids (p=0.134)

30-39 kids (p=0.114)

40-49 no kids (p<0.001)

40-49 kids (p<0.001)

50-59 no kids (p<0.001)

50-59 kids (p=0.229)

60 or over no kids (p<0.001)

60 or over kids (p=0.003)

90%

80%

70%

60%

50%

0%

10%

20%

30%

40%

42.3

%

44.0

%

39.0

% 48.7

%

37.1

% 50.4

%

28.3

%

29.2

%

65.3

%

52.0

% 64.4

%

61.2

%

50.6

%

57.4

%

42.9

% 59.3

%


CorrelationsbetweentheburnoutscoresandAMAsafeworkguidelinessuggestasignificantassociationbetweenrespondentsreportingworkingmorethan14consecutivehoursaswellasfailingtohavea24hourbreakfreeofanyscheduledworkandtheproportionscoringasburntoutforwork-relatedandpersonalburnout(Table4).

TABLE 4: BURNOUT AND RESPONSES TO THE AMA SAFE WORK GUIDELINES

PERSONAL BURNOUT WORK-RELATED BURNOUT PATIENT-RELATED BURNOUT

NOT BURNT-

OUT

BURNT-OUT

p VALUE NOT BURNT-

OUT

BURNT-OUT

p VALUE NOT BURNT-

OUT

BURNT-OUT

p VALUE

Have you worked more than 14 consecutive hours in any one period?

No 54.7% 45.3% 61.1% 38.9% 84.7% 15.3%

Yes 43.0% 57.0% <0.001 46.9% 53.1% <0.001 80.4% 19.6% 0.020

Did you have a period of rest between scheduled work

No 51.5% 48.5% 58.3% 41.7% 83.3% 16.7%

Yes 49.8% 50.2% 0.467 54.3% 45.7% 0.075 84.1% 15.9% 0.672

Did you have a 24-hour break free of any scheduled work

No 41.5% 58.5% 49.1% 50.9% 80.6% 19.4%

Yes 53.9% 46.1% <0.001 59.1% 40.9% <0.001 84.4% 15.6% 0.060

FIGURE 13: MEAN BURNOUT SCORE AND WEEKLY HOURS OF WORK

Work PersonalPatient

None <10 hours 10-20 hours

20-30 hours

30-40 hours

70-80 hours

40-50 hours

80-90 hours

50-60 hours

90-100 hours

60-70 hours

>100 hours

70

60

50

0

10

20

30

40


Hours of work and dependants Thedatashowsthat40%ofwomenwithoneormorechildrenworkfewerthan40hoursperweek.Justoverhalfofmenwithoneormorechildrenworkinexcessof50hoursperweek(Figure14).Thedatasuggestsfemaleswithoutchildrenworkmorehoursthanthosewithchildren.

Burnout and place of workBurnoutscoresandplaceofworkanalysisofthedatasuggeststhatdegreeofwork-relatedandpersonalburnoutdifferedsignificantlybymainplaceofwork.Elevenofthe20DHBshadoverhalfoftheirrespondentsscoringaslikelytobesufferingfrompersonalburnout.Eightofthe20DHBshadoverhalfoftheirrespondentslikelytobesufferingfromwork-relatedburnout.AsdisplayedinFigure15,justover60%ofrespondentsatSouthernDHBwereexperiencingwork-relatedburnoutand62%wereexperiencingpersonalburnout.SouthernDHBhadahighresponseratewith63%ofthepossible161respondentscompletingthesurvey.Over75%ofWairarapaDHBrespondentswerelikelytobeexperiencingpersonalburnoutbuttheDHBresponseratewaslowerat47%.

FIGURE 14: GROUPED WEEKLY HOURS OF WORK PER WEEK BY GENDER AND DEPENDANTS STATUS

Female one or more children Male no children Male one or more childrenFemale no children

<40 40-50 >50

Grouped hours of work per week

Prop

ortio

n of

resp

onde

nts

60%

50%

0%

10%

20%

30%

40%

28.4%35.1% 36.5%

39.5%

29.8%31.7%

24.4%

35.5%40.1%

16.2%

31.6%

52.2%


FIGURE 15: WORK-RELATED AND PERSONAL BURNOUT BY DHB 2020

10% 20% 30% 40% 50% 60% 70% 80%

80%

70%

60%

50%

0%

10%

20%

30%

40%

Personal burnout

Wor

k-re

late

d bu

rnou

t

Wairarapa DHBTaranaki DHB

Nelson Marlborough DHBHawke’s Bay DHB

Canterbury DHB

Waikato DHB

Lakes DHB

Northland DHB

Whanganui DHB

Southern DHBMidCentral DHB

Bay of Plenty DHBWest Coast DHB

Tairawhiti DHB

Hutt Valley DHBWaitemata DHB

Counties Manukau DHBSouth Canterbury DHB

Capital & Coast DHB

Auckland DHB

Whencomparedwiththe2015data,12DHBshadincreasedtheirrateofpersonalandwork-relatedburnoutandsevenhaddecreased(Table5&Table6).OnlySouthernDHB’sincreasedburnoutscorewasstatisticallysignificantwhencomparedtothe2015survey(p=0.013).TheimprovementinpersonalburnoutforHuttValleyDHBwasalsostatisticallysignificant(p=0.033).SouthernDHBwasalsoastatisticallysignificantincreasedscoreforwork-relatedburnout(p=0.002).


Greentextindicatesimprovementandredtextindicatesanincreaseintherateofburnout.Blueindicatesnochange. **indicatesstatisticalsignificance.

TABLE 5: PERSONAL BURNOUT AND DHB BY YEAR OF SURVEY

TABLE 6: WORK-RELATED BURNOUT AND DHB BY YEAR OF SURVEY

PERSONAL BURNOUT 2020 2015Auckland 48.7% 54.8%Bay of Plenty 50.0% 44.9%Canterbury 50.2% 46.8%CapitalandCoast 42.3% 46.5%CountiesManukau 36.6% 47.3%Hawke's Bay 50.8% 51.1%HuttValley 42.4% 63.6%Lakes 48.9% 44.8%MidCentral 56.7% 55.6%NelsonMarlborough 52.8% 59.6%Northland 48.4% 53.1%SouthCanterbury 35.0% 17.6%Southern 62.4% 44.6%Tairawhiti 47.1% 52.2%Taranaki 60.5% 58.3%Waikato 55.2% 48.7%Wairarapa 77.8% 42.9%Waitemata 50.0% 50.0%WestCoast 41.7% 40.0%Whanganui 53.3% 0.0%

WORK-RELATED BURNOUT 2020 2015Auckland 41.5% 48.3%Bay of Plenty 50.9% 38.8%Canterbury 44.1% 38.3%CapitalandCoast 34.3% 32.5%CountiesManukau 33.0% 32.8%Hawke's Bay 50.8% 40.4%HuttValley 42.4% 45.5%Lakes 40.4% 41.4%MidCentral 53.7% 57.8%NelsonMarlborough 51.4% 61.5%Northland 39.1% 48.4%SouthCanterbury 30.0% 29.4%Southern 60.4% 38.5%Tairawhiti 47.1% 47.8%Taranaki 52.6% 50.0%Waikato 39.3% 37.0%Wairarapa 55.6% 50.0%Waitemata 43.3% 39.4%WestCoast 50.0% 50.0%Whanganui 26.7% 0.0%

Greentextindicatesimprovementandredtextindicatesanincreaseintherateofburnout.Blueindicatesnochange. **indicatesstatisticalsignificance.

**

**

**


Specialty and burnoutThelargernumberofrespondentsinthe2020surveymeantthatburnoutscorescouldbepresentedinamorefinelydelineatedmanner.AsdisplayedinFigure16,therewasagoodspreadofburnoutscoreswithRadiationOncologyandRespiratoryMedicinetoppingprevalenceforbothpersonalandwork-relatedburnout(totaln=20forboth).RespondentsinRuralHospitalMedicinehadthesecondhighestscoreforoverallpersonalburnout(totaln=21,64%personalburnout)andthoseinEmergencyMedicine(totaln=164)hadveryhighscoresforbothpersonalandwork-relatedburnout.

FIGURE 16: WORK-RELATED AND PERSONAL BURNOUT BY SPECIALTY 2020

30% 35% 40% 45% 50% 55% 60% 65% 70%

70%

65%

60%

55%

30%

35%

40%

45%

50%

Personal burnout

Wor

k-re

late

d bu

rnou

t

Radiation Oncology

Respiratory Medicine

Rural Hospital MedicineEmergency Medicine

Obstetrics/Gynaecology

PsychiatryDiagnostic & Interventional Radiology

Medical Oncology

Internal Medicine

Opthamology

Pathology

General Practice

Geriatric Medicine

General SurgeryPaediatrics

Surgery

Orthopaedic SurgeryPublic Health Medicine

Dentistry

Anaesthesia

Intensive Care MedicineOtolaryngology

Gastroenterology

General Medicine

Forpatient-relatedburnout,thoseworkinginGeneralPractice(n=39)hadthehighestprevalencescorefollowedbythoseinRuralHospitalMedicine(n=25).Specialtiesshadedingreyhadhigherthantheoverallpatient-relatedburnoutscore(16.7%).Comparisonswiththe2015groupeddatafoundthatonlyPsychiatryhadastatisticallysignificantchangeintheirpatient-relatedburnoutscores;30.1%in2015scoredwithpatient-relatedburnoutcomparedwith21%in2020(p=0.032).


SPECIALITY n≥20 % PATIENT-RELATED BURNOUT TOTAL nGeneralPractice 35.9% 39

RuralHospitalMedicine 32.0% 25

MedicalOncology 28.6% 28

EmergencyMedicine 25.0% 160

RespiratoryMedicine 25.0% 20

Ophthalmology 23.8% 21

OrthopaedicSurgery 21.3% 47

Psychiatry 21.0% 210

Medicine 19.2% 146

Otolaryngology 17.9% 28

Other 17.1% 70

GeneralSurgery 16.4% 55

Obstetrics/Gynaecology 14.3% 77

Gastroenterology 13.6% 22

Geriatric Medicine 13.3% 60

Paediatrics 11.7% 137

Diagnostic&InterventionalRadiology 11.4% 79

Dentistry 10.8% 37

Anaesthesia 9.2% 292

IntensiveCareMedicine 8.0% 50

PalliativeMedicine 6.9% 29

Personal burnout n=202

Work-relatedburnout n=187

Patient-relatedburnout n=192

Overallcomments n=426

Qualitative data analysisInthisiterationoftheburnoutsurvey,therewerefewerqualitativecommentsleftbyrespondents.Analysiswasundertakenoncommentsbysectionoftheburnoutsurveyasfollows:


Aswiththe2015survey,commentsreferencearangeofissuesincludingtheemotionallydrainingnatureofwork,theimpactofextradutiessuchasbeingaheadofdepartment,issuesoutsideofworksuchashavingyoungchildren,andthevariousstrategiesindividualshadimplementedtoavoidburnoutsuchasreducinghoursofwork.Consistentwiththe2015survey,themainthemesexpressedwereworkloadpressures,lackofstaffincludinglackofadministrativesupport,poorrelationshipswithmanagementandfrustrationswithresourcing,growingpatientload,lackofcontrolandautonomy.Consistentwithprevioustrends,mostrespondentsnotedthepleasuresassociatedwithpatientcontactandsignalledhowenergisingthiscomponentoftheirworkcouldbe.Notableinthisyear’ssurveywerecommentsexpressingtheimpactofCOVID-19withmanyreflectingonthesignificanttollCOVID-19hadtakenontheirworkandtheirpersonalstressandexhaustionlevels.

Onerespondentsummedupthecorethemesasfollowing:

“Lack of resources. Inefficiencies. Focus on targets rather on service provision. Low morale due to cultural factors. Lack of administrative support.”

Anothersummarisedtheirfeelingsas:

“I love my work, I love dealing with the patients, I wish I had more time to do my job properly. But I and my colleagues are frustrated by the unrealistic expectations of the management teams of our capability within the constraints of time and budgets.”

Aswithprevioussurveys,thecommentsprovidedimportantcontextualdetailtothestatisticaltrends,aswellasreflectinghowburnoutwasconceptualisedbytheparticipants,andwhatwassubjectivelyperceivedtobethemaincontributingfactors.ThemainthemesaregroupedintoTable7andsummarisedwithillustrativequotes.


TABLE 7: MAIN THEMES FROM QUALITATIVE ANALYSIS

THEME ILLUSTRATIVE QUOTEWorkloadpressures Oftenfeelveryrushedandpressuredfortime,andfrequentlyinterrupted.I

usuallyneedtoworkduringmyhalfdayoff(likefillinginthissurvey)andworklateonenightperweek.Worryaboutclinicalsituationsornextday’sworkout-sideofwork.Thinkabouthowtofitmoreworkintheday....Verypoorsupportfor one role I do.

Personalstrategiestoavoidburnout

I’mverycarefulnowtosetasidedayswhereIdon’tlookatanythingtodowithwork,thisisduetopreviousburnout.Ihaveenergytospendonactivitieswhichregenerateme,butseldomcanmustertheenergytodedicatetothosethingsthatarenotwork,butthatIshoulddobutwhichdrainme.I’veusedallmyenergyforthatatwork.

Impactofpersonalsituation,family,health

Ihaveayoungchildathome.Shiftworkontopofthiscanmeanseveraldaysofverylittlesleep.Daysoffaredevotedtochildcareandnotthatrestorative.

Lackofrecognition/supportfrommanagement/frustrationswithmanagement

Inthelast2yearsorsotherehasbeenadramaticincreaseinworkload.Thishasnotbeenopenlyrecognizedbymanagementinanywayatall.Onthewholemanagementdeniesthatthereisaproblem.

Thelast3yearshavebeenparticularlybadwithincreasedin-patientworkload,alongwithconsistentveryhighout-patientworkload.Norecognitionofthisinanymeaningfulwaybythemanagerialgroup.Thelatterdonotengageastheyknowtheycannotsolvetheproblemsonexistingbudget.

Outofhourswork,callwork

Thisisduetoworkinglongconsecutivehoursontheweekendsandworkingwithinadequatesleeponweekendsandafterovernightoncall.

IfacemostdayswithananxiousfeelingbeforeI’veevenleftthedoor,andworseifIamoncall.TheburdenofcontinuitynowliesfirmlywiththeSMOanddemands/expectationsareincreasingyearbyyear,withmoretasks(includingclericalduties)fallingontoSMOs.

ImpactofCOVID DuringtheCOVID-19lockdownIworkedeverydayfor6weeks.Theongoingworkload(Iworkinpublichealth)isnotsustainable.

Stressful nature of work Workinginaverystressfulcombinationsofjobs,withverypoor/nopoorresourcinginatleastoneareaIworkin.Complexdynamicsinteamarestressful.Verylimitedadministrativesupport.Istillenjoyjobbutbattlingtogetadequatecareforpatientsandmakeafailingsystemworkisverytiring.

Thelonghoursofworkareacontributingfactorbutthemainexhaustingcomponentoftheworkisthedemands(unmetpatientneed)andstress(tryingtoaccommodatethisunmetneed)thatcomesfromthedemandsandunrealisticexpectationsfrommanagementthatthepressureofthisunmetneedwillbeaccommodatedbytheendprovider“thedoctors”.

Ifindpatienttimeusuallyquitesatisfyingbutendlesspaperworkisirritatingandcomplaintsinvolvehugestress,endlessunpaidhoursandmakemewishIwasn’tdoingmedicineinawayIneverfeltbefore.

Poorresourcing Itisexhaustingbecauseofchronicunder-resourcingandworkinginsubstandardconditions(physicalenvironmentandcrappyITsystemswhichcreateunnecessaryextrastress)-withnoendinsightorhopeofitimprovingbeforeIretire.

Thestraincomesfromalackofresources.Aconstantpressureregardingrequestsforradiologyandthelongwaitsassociatedisabigone-thefearofonceagainbeingpushedback.Difficultyingettingtheappropriatespecialistservicetoseethepatientinatimelywayisalsofrustrating.WhenIseewhatisavailableinprivate,it’sverydemoralisingforthoseofuscommittedtopublicpracticeandmeetingtheneedsofallofourpatientsnotjustthosewithmeans.


THEME ILLUSTRATIVE QUOTEImpactofextraduties Mostofthefeelingofburnoutissecondarytohavingaclinicalworkloadontop

ofmanagerialwork(clinicaldirectorwork).Itisthemanagerial/DHBsideoftheworkthatisthemostfrustrating.

Lack of control Thereareveryspecificstressorswithworkwhichliearoundlackofcontroloverclinicsize,operatinglistsandtheconflictingpressuresofpatientcare,teachingjuniorsandmeetingDHBcompliancethresholds.IfIhadcontroloverthismystresscouldbemanagedbutIamforcedtohaveclinicsthataretoobigandpatientloadsthatprovidecompetingdemands.

Qualitative analysis of trendsFurtheranalysiswasundertakentoseeifthecommentscouldassistwithunderstandingsomeofthequantitativetrendswithburnout.Forexample,thequalitativedatawascutbyspecialtyandDHBtoseeiftherewereanyapparenttrends,especiallyforwork-relatedburnout.Thefollowingprovidesquotestakenfromrespondentsinthespecialtieswiththehighestcombinedwork-relatedandpersonalburnoutscores(seeFigure16)aswellasSouthernDHBwhichhadthehighestwork-relatedandpersonalburnoutscoresfortheplacesofworkanalysis.


SPECIALTY QUALITATIVE COMMENTSRadiationOncologists

IncreasedfrustrationcausedbygapbetweencareIwouldliketoprovidetopatientsandthecareIamabletoprovideduetodepartmentalandDHBresourceconstraints.Insufficienttimetospendwithindividualpatients/whanauduetolackofFTEandhavingtoseetoomanypatientsperSMO.Newideaswhichcouldbehelpfularenotdevelopedbecauseofpossiblefundingramifications.

Weareunderstaffed.Thisdoesnotmeanpeopledonotgetleave,butitdoesplaceaburdenonthoseremaining.Iamsicktoday-insteadoftakingthedayoff,Iwillbeworkingthismorning,doingemailsattendingaclinicalmeetingviazoom,andmyclinicwillbeconvertedtophone.ProbablyasIhavehadleaveoverthelastwhileandupcoming,Ifeelless able to be sick.

MymainworkrelatedstressisthatIamtheoreticallyparttimeandworkmuchmorethanthehoursIampaidtowork.

Theworkiswonderful-Ilovecaringforthepatientsbutitisrelentlessandimpossibletoactuallyachievewithinthecurrentstaffingclimate,sowearealwaysgivingbeyondourselvestotryandmeettargetsetc.

EmergencyMedicine specialists

Admintimeneverends.Constantlybeingaskedtorespondtoemailsisabigpartoffatigue.

Workpressurehasincreased.Covid-19hashadaninsidiouseffectofgenerallyincreasingmanyworkplacestressors.Accessblockhasbecomeextremelydifficulttomanageinthefaceofpoorphysicalresourceandinadequatesystemwideplanning.

Southern Frustrationiswithmanagement.Growingdividebetweenmanagementandthoseatthecoal face.

Frustrationsareoftenaboutthesystem,e.g.operatinglistsinsufficientfortheservice,managersconstantlywantingtochangeprocessesthatareworking,inadequatephysicalspacetoworkin,lackofgoodequipment.ExpectationthatwewilldoextraworktocatchuponCOVID-19delayswithoutaclearideaofwhenwewillhaveachievedthetarget.Offeringoutsiderslocumratesbutnotwantingtobegeneroustocurrentstaffdoingextra.

MycolleaguesandIoftenworkwelloverthepaidnumberofhourstogetthejobdoneforourpatients.

TABLE 8: QUALITATIVE COMMENTS BY SPECIALTY AND DHB


DiscussionThefindingsfromthisresearchprovideanupdatednationwideperspectiveonthedegreeofburnoutexperiencedbyseniordoctorsanddentistsworkingintheNewZealandhealthsystem.TheresearchsuggeststhatburnoutcontinuestobewidespreadamongsttheseniormedicalanddentalworkforceinNewZealandwithlittlechangeinthefiveyearssincethefirststudy.Thehighscoresforwork-relatedburnoutsuggestthattheimpactofwork,andparticularlythestressandexhaustionassociatedwithwork,continuetobeadrivingfactorforburnoutinthisprofessionalgroup.Therelativelylowincidenceofpatient-relatedburnoutsuggeststhatforthemajoritytheirfeelingsofexhaustionarenotdrivenbytheirinteractionswithpatients.Onthecontrarymanyreferencedtheircontactwithpatientsasbeingasourceofpleasureandfulfilment.

TheCBIcontinuestobeausefultoolforunderstandingwhichfactorsindividualsmostclearlyassociateasdrivingtheirfatigueandexhaustion.Inthisregard,thethemesnotedinthequalitativecommentsareparticularlyillustrativeforprovidingdetailastowhatindividualsperceiveasstressfulelementsoftheirlivesatthetimeofthesurvey.NotableinthesurveythisyearwerereferencestotheimpactofCOVID-19aswellasfindingsregardingtheimpactofdependantsanddegreeofburnout.Theseissuesarediscussedingreaterdetailbelow.

Thecorrelationanalyseswereconsistentwiththefindingsinthe2015survey;burnoutcontinuestobestronglyassociatedwithworseningself-ratedhealthstatus,youngerageandbeingfemale.Duetothecross-sectionalnatureofthesurvey,however,directionalcausalitycannotbeinferred.

Inthefollowingsections,matterswiththetimingandresponseratestothesurveyarediscussedasarepointspertainingtothe2015researchandcorefindingsregardinggender,age,anddependants.

The high scores for work-related burnout suggest that the impact of work, and particularly the stress and exhaustion associated with work, continue to be a driving factor for burnout in this professional group.

Timing of surveyThesurveywasdistributedintheAugustof2020,threemonthsafterthenationwidelockdownendedandNewZealandmovedtoAlertLevel2.Thetimingofthesurveywasdeliberateasitwasdecidednottodistributethesurveytoosoonafterthelockdownperiodended.Formanyspecialistslockdown had been an intensely stressful and uncertainperiod.Somequalitativecomments,however,referencedthattheirexperiencesofCOVID-19lockdownhadresultedinincreasedworkloadpressures,particularlyforthosewithworkthatwascancelledordelayedduringthatperiod.Forexample,onerespondentnoted:“It’sabitofatoughtimetoanswerthesequestions,theoverhangofCOVIDworkhastakenitstoll.IthinkI’mstillrecoveringfromthat!”.Anothernoted:“ThecurrentCOVID-19responsehasaccentuatedalotoftheissuesthathavebeenidentifiedinthissurvey”.ItispossibletheimpactofCOVID-19exacerbatedtheproblemofburnout.Again,itisnotpossibletointerrogatethisfullyduetothenatureofthesurveydesign.

Responder biasTheresponserateofthesurveywasreasonablegiventhemodeofdelivery(electronicdistribution)andwasconsistentwiththeresponseratesinprevioussurveysoftheASMSmembership.Therepresentativenessofthesurveyrespondentsisamootpoint.ResearchpublishedbySimonetti,Clintonetal.(2020)suggestthatdespitemanyburnoutsurveysofmedicalprofessionals


experiencinglowresponserates,non-responderbiasmayslightlyfavourthoseexperiencingburnout.Intheirresearch,burnoutprevalencewasfoundtobe3-4%higherafteradjustingfornon-response(p3).Giventhathighworkloadsandlackoftimearekeycontributingfactorsforburnout,itispossiblethatnon-responderbiasmayresultinanunderestimationoftrueburnoutprevalence.Forexample,commentsonearlypresentationsofthesefindingsnotedthelowestimateofburnoutprevalenceforspecialistsworkinginpublichealthmedicine,particularlygiventheimpactofCOVID-19onthesemedicalspecialists.Itispossiblethatnon-responderbiasmayaffectthosewhowereexhaustedoroverworkedintheimmediateaftermathoftheCOVID-19outbreakwhomightnothavehadthecapacitytoanswerthesurveyrequest.Giventhecross-sectionalnatureofthedata,however,itisnotpossibletointerrogatethisfurther.Nevertheless,theclosecongruencebetweenthe2015and2020resultssuggeststhe50%burnoutprevalenceisareasonablyreliableestimate.

Factors associated with burnoutBurnoutscoresincreasedconcurrentlywithmorehoursworkedeachweek,atrendconsistentwiththe2015findings,aswellasotherrecentstudies(Ng,Chinetal.2020).Thequalitativecommentsfurthersuggestedthatissuessuchaslonghoursofwork,shiftworkandlackofrecoverytimeareperceivedassignificantfactorsforindividualrespondent’slevelsoffatigueandexhaustion.RecentresearchbyTrockel,Menonetal.(2020),foundacloseassociationbetweenburnoutandsleepdeprivation.Theirstudyfoundsleepdeprivationreducedcognitiveperformanceaswellasnegativelyaffectingmoodleadingtoagreaterpropensityforemotionalexhaustion.They.recommendcloserattentiontotheimpactofsleepdeprivationanditsrelationshiptoburnoutandsuggesttighterregulationonhoursofworkasasignificantfactorinreducingburnoutprevalence.Thecorrelationbetweenscoringasburnt-outandfailingtohavea24-hourbreakfreeofscheduledworkandworkingmorethan14consecutivehourssuggeststhatprotectingrestandrecovery

timeislikelytohaveasignificantpositiveeffectonburnoutpropensityintheNewZealandseniormedicalworkforce.

Totalhoursofprivateworkwerelowinthisstudy;overhalfofallrespondents(54%)hadworkednoprivatehours.Theslightnegativecorrelationbetweenhoursofprivateworkandburnoutwasconsistentwiththe2015studyandappearstosuggestworkinginprivatemaybeprotectiveagainstburnout.ThisfindingwasconsistentwithotherresearchincludingastudyintoNewZealandradiationoncologistsin2015(Leung,Riosecoetal.2015)andmorerecentresearchbyLiuandCheng(2018).

The qualitative comments further suggested that issues such as long hours of work, shift work and lack of recovery time are perceived as significant factors for individual respondent’s levels of fatigue and exhaustion.

Gender and burnoutVeryfewsurveyrespondentsidentifiedasgender-diverse(n=4);asaconsequenceoflownumberstheir burnout scores were not included in the analysis.Abriefassessmentfoundtheirscoreswereveryclosetotheoverallscoresforwomensurveyed.Ofnoteweretheproportionatelyhigherburnoutscoresexperiencedby52individualswhowishednottodisclosetheirgenderidentity.Thismaybeduetofearofidentification.Theburnoutscoresforthisgroupwereapproximately65%forwork-relatedburnoutand64%forpersonalburnout. These scores are of concern.

Consistentwiththe2015studyandotherresearch,thissurveyfoundwomencontinuetohavesignificantlyhigherburnoutscoresthantheirmalecounterparts(Obregon,Luoetal.2020).Gyorffy,Dweiketal.(2016),forexample,foundfemaledoctorshadsignificantlyworseindicatorsofmentalhealththanotherprofessionalwomen.Theirresearchalsofoundcorrelationsbetween


workloadandfrequencyofwork-relatedstressfulsituationswithmanyexperiencingsleepdisordersandadecreasedsenseofpersonalaccomplishment(akeydimensionofburnout).Otherresearchfocusesonthewiderimpactofgender-baseddiscriminationonwomeninmedicineandsuggestsassociationswithburnout(Chesak,Cutshalletal.2020).ThesignificanceofgenderedexpectationsasanadditionalburdencarriedbywomeninmedicineisalsoemphasisedinresearchbyLinzerandHarwood(2018).Otherrecentresearchfoundexperienceofgender-baseddiscriminationtobeakeypredictorofwomenexperiencingburnout(Wang,Taniousetal.2020).Despitegrowingacknowledgementoftheexistenceandsignificanceofgenderdiscrimination,thepersistenceofhighburnoutscoresforwomeninthisstudysuggestfurtherattentionisrequired.Furtherdiscussionregardingtheinterfacebetweengender,dependantsandburnoutisbelow.

Age and burnoutIncontrasttothepriorresearchwhereburnoutscoresofrespondentspeakedintheir30s,thehighestprevalenceofburnoutinthiscurrentstudywasforbothmenandwomenintheir40s.Whileinitiallyitwasthoughtperhapstherewasacohorteffect(burnt-outrespondentsaging),therewasnegligibledifferenceinburnoutscoresforbothmaleandfemalerespondentsintheir40swhencomparingthe2015and2020studies.

Thischangeinburnoutscorebyagecohortisnotablebutgiventhelimitationsofthestudydesign,itisnotpossibletointerrogatefurther.Alongitudinalstudyexaminingthechangesinworkexperiencesandlevelsofburnoutofaconsistentcohortwouldbeausefulcontributiontothisresearchspace.Longitudinalresearchwouldhavetheadditionalbenefitofassessingtheimpactofsolutionsimplementedtoaddressburnout,aswellasenablingresearchtounderstandmorefullyhowexperiencesofburnoutchangeovertimeandwithwhatconsequences(West,Dyrbyeetal.2018).Thesignificantdecreaseofburnoutforwomenrespondentsintheir30sisalsoanotableand

pleasingimprovement;again,itisnotpossibletounderstandthefactorsthatmayhavecontributedtothisdecreaseinburnout,butitisapositivechange.

The significant decrease of burnout for women respondents in their 30s is also a notable and pleasing improvement; again, it is not possible to understand the factors that may have contributed to this decrease in burnout, but it is a positive change.

Impact of dependants Thissurveyimprovedupontheoriginal2015methodologybyexamininghowburnoutrelatedtonumbersofdependants.Forwomen,theirratesofburnoutwerearoundthesameirrespectiveofwhethertheyhaddependants.Formalerespondents,however,therewasasignificantassociationbetweenhavingdependantsandexperiencinghigherratesofburnout.Thistrendisnotconsistentwithotherstudies.ForexampledatapublishedbyElmore,Jeffeetal.(2016)suggestthatmenwhoareeitherpartneredorhavechildrenwillexperiencelowerratesofemotionalexhaustion(akeyfacetofburnoutaspertheMBI)thantheirfemalecounterpartsinthesamesituation.

Analysisofthequalitativedataforthoserespondentswithdependantsfoundanumberofcommentsleftbymalerespondentsnotingthattheirexhaustionwasaconsequenceofhavingsmallchildren.Forexample,“muchoftheexhaustionisduetohavingyourchildren”;“myanswersareaffectedbyhavingayoungfamily”;“Notsurethisiswork-related–Ihaveatoddlertoo”.Thiswasanunexpectedfindingintheresearchandmaysuggestthatmen’sexperiencesofwork-lifeconflictareasignificantcontributortotheirfeelingsofexhaustion.

Otherresearchpostulateswork-lifeconflictasbeingakeysourceofstressandexhaustionforwomeninmedicine,oftenbutnotalwaysduetothepressuresandexpectationsassociatedwithhavingchildren.Thenegligibledifferencesin


burnoutratesforwomenwithdependantsversusthosewithoutinthisstudysuggeststhatfactorsotherthandependantsmaybecontributingtotheirlevelsofburnout(McMurray,Linzeretal.2000).AsexploredinASMS’HealthDialogue,‘Makingupforbeingfemale’(ASMS2019a)theconsistentlyhigherratesofburnoutexperiencedbywomenmayreflecttheimpactofgenderedbehaviouralexpectationsandthestressorsassociatedwithbeingawomaninmedicineratherthanwork-lifeconflictperse.

Burnout and medical specialtyThepatternofcertainmedicalspecialtieshavingconsistentlyhigherratesofburnoutisworryingandcauseforconcern.ThespikeinburnoutratesforthoserespondentsworkinginRadiationOncologyandRespiratoryMedicineisconcerning;duetothelowernumbersofrespondentsinthe2015surveyitisnotpossibletocheckwhetherthechangeisstatisticallysignificant.Itishoweverofconcern.TheconsistentlyhighratesofburnoutfordoctorsworkinginEmergencyMedicinesuggestslittlehasimprovedforthiscohortofdoctors.Thehighequalscoresforwork-relatedandpersonalburnoutfordoctorsinthesethreespecialtiessuggestthatworkingconditionsarethemainfactorstowhichrespondentsattributetheirfeelingsofexhaustionandfatigue.ThescoresforEmergencyMedicinespecialistsinthisstudyarehigherthanthosefoundinthestudybyKumar,Pioetal.(2019)whichfoundpersonalburnoutratesof42%(cf56%)andwork-relatedburnoutratesof37%(cf56%)fordoctorsworkinginasingleemergencydepartment(n=40cfn=167).

Knownfactorsthatleadtoburnoutincludelonghoursofwork,fatigue,andlackofcontrol.Thecommentsleftbydoctorsinemergencymedicinesettingsemphasisethewearingeffectsofpoorresourcing,growingadministrativeloadsandincreasingpatientnumbersandacuity.RecentUSresearchbyHarry,Sinskyetal.(2021)founddoctorsworkinginEmergencyMedicinehadthehighestscoresforphysiciantaskloads(ameasureofcognitivetaskloading)ofthedoctorssurveyed;theyfurtherfoundacloserelationship

betweenthedegreeofphysiciantaskloadandburnout.Theirresearchconcludesthatreducingthecognitivetaskloadingofdoctorsislikelytopaydividendsinreducingthepropensityfordoctorstoexperienceburnout,aswellasimprovingtheabilityofdoctorstoperformtheirjobwell.OtherstudiessummarizedbyZhang,Muetal.(2020)foundthatEmergencyMedicinedoctorswerelikelytobemoresusceptibletoburnoutlikelyduetotheparticularlystressfulnatureofEmergencyMedicine. These consistent trends for burnout inEmergencyMedicinespecialistshighlighttheimmediateneedtoattendtotheworkingconditionsofthisparticulargroupoftheASMSmembership.

The consistently high rates of burnout for doctors working in Emergency Medicine suggests little has improved for this cohort of doctors.


Whiledoctorsaremorelikelytosufferfromburnoutthanotherprofessionalgroups(Shanafelt,Gorringeetal.2015),sufferingfromburnouthascriticalconsequencesandshouldnotbetakenasaninevitableconsequenceofchoosingtoworkinthemedicalprofession.Burnouthassignificantnegativeconsequencesforindividualdoctorsexperiencingthesyndrome(Menon,Shanafeltetal.2020),theircolleagues(Shanafelt,Makowskietal.2020),andthequalityofcaretheirpatientsreceive(Chung,Dillonetal.2020).Asnumerousstudiescontinuetosubstantiate,havingahighproportionofdoctorssufferingfromburnouthassignificantnegativeconsequencesforthequality,sustainability,andlongevityofamedicalworkforce(Willard-Grace,Knoxetal.2019,NiconchukandHyman2020).

ThefindingsfromthisresearchsuggestthatlittlehaschangedintermsoftheratesofburnoutexperiencedbyseniordoctorsanddentistsworkingintheNewZealandpublichealthsystem.ThenegligiblechangeinallthreespheresoftheCBIsuggestthatburnoutcontinuestobeasignificantandpressingproblem.

Consistentwiththechangeindefinitionofburnoutfromindividualisedfailingtoanoccupationalsyndrome,solutionsmustreflectthissignificantshiftinfocus.Fixingburnoutshouldnotbeseenastheresponsibilityofindividualsalone.Theproblemandfindingsolutionstomitigateburnoutinmedicineisasharedresponsibilitybetweenemployersandleadersaswellasindividualswhomaybeatrisk.Furthermore,failuretoenactorganisationallevelsolutionscanhavenegativeconsequences;researchhasfoundthatemphasisingindividualresponsibilityforburnoutcanunintentionallyincreasefeelingsofstresswhichcanleadtohigherratesofburnout(Eden,Jabbarpouretal.2020).

Thefindingsfromthisresearchcontinuetoemphasiseburnoutasarisingfromlongworkinghours,failuretohaveadequaterestbreaks,

medicalspecialtieswithgrowingpatientdemandandperpetualstaffingshortfalls.Thesethemesareechoedinthequalitativecommentswithclearemphasisonthesignificanceofhighworkloads,lackofadministrativesupport,lackofcontroland/orautonomyinworkplaces,poorworkplacecultureandissueswithleadershipormanagerialism(West,Dyrbyeetal.2018).

AssummarisedbyWest,Dyrbyeetal.(2018),ensuringfairlydistributedworkloads,roles,andhourscanassistwithmitigatingtheriskofburnoutascanincreasingnumbersofadministrativestafftorelievetheburdenplacedondoctors.Activelyrespectinghomeresponsibilitieswhenworkandmeetingsarescheduledcanpaydividendsinreducingwork-lifeconflictissues.Otherorganisationallevelstrategieslikelytohaveapositiveimpactonreducingratesofburnoutincludejobsizingallexpectedtaskstoexpectedhoursofwork(i.e.removingtheneedtotakeworkhome),supportingflexibleworkingschedulesincludingnormalisingpart-timeworkinmedicine,ensuringactiveengagementofdoctorsinallmanagerialdecision-makingprocessesthatimpactworkexpectationsandstructure,andhavingshareddecision-making(seep522forafulllist).

ASMSisoftheviewthatburnoutstrategiesneedtobebasedonformalrecognitionthatitistheemployer’sresponsibilitytoprovideaworkplacethatisbothphysicallyandpsychologicallysafe(Kendrick,Kendricketal.2020).Further,thosetaskedwithensuringthewellbeingandsustainabilityoftheseniormedicalanddentalworkforcemustlookatstrategiesandapproachestopreventburnoutbeforeitresultsinseriousconsequences,includingpotentialstaffattrition,doctorsuicide,patientcomplaints,andmedicalerror.Researchevidencesuggeststhatimplementingchangestoworkingpatternstoenableadequatesleep,restandrecoverytimewouldbeasensibleplacetostart(Ng,Chinetal.2020).Assummarisedinarecent

Conclusions


Lancetarticle(Marchalik2019)thewellbeingofmedicalanddentalworkforcesmustbeseenasanorganisationalprioritywhere“likeoperatingbudgetsandexpansionplans,itmustbecomeastandingagendaitemattheleadershiptable”(p869).ParticularlyinlightoftherecentCOVID-19pandemic,thestressorsandpressuresthatmedicalprofessionalscontinuetofaceemphasisethepressingneedtoputwellbeingfirmlyontheagenda(RimmerandChatfield2020).

ASMS is of the view that burnout strategies need to be based on formal recognition that it is the employer’s responsibility to provide a workplace that is both physically and psychologically safe.

What needs to change: • Normalisationoflongworkinghoursthat

extendbeyondcontractedjob-sizing.

• Outdatedandinefficienttechnology,includingITsystemsandcumbersomeadministrativeprotocols.

• Lackofadministrativesupportandtheexpectationthatadminwillbecompletedoutsideofworkinghours.

• Poorconnectionsbetweenmanagementandclinicians,particularlyintermsofwork-placecultureandlackofunderstandingfrommanagementoftheday-to-dayrealitiesofthecoalface.

• Insufficientresourcestoenableclinicianstodothe work.

What we are calling for: • Formalrecognitionthatitistheemployer’s

responsibilitytoprovideaworkplacethatisbothphysicallyandpsychologicallysafe.

• Formalisedregularassessmentofburnoutratesusingconsistentandvalidatedtools.Inaddition,othermentalwellbeingsurveysshouldbeundertakenregularlyandreportedinanon-punitivemanner.

• Adequateresourcingofdepartmentsintermsofstaff,technology,andprovisionofappropriatelevelsofadministrativesupport.ThisshouldincludeworkwithunionsandCollegestoagreesafestaffinglevelsforeachserviceandrecognisingthatthesewillvarydependingonhospitalsize,location,andotherstaffing(Residentdoctors,allied,andnursing).

• Staffinglevelsandworkinghoursdatashouldbecollectedandreviewedtoestablishandmaintainsafesustainableworkforallclinicians.Thisdatashouldbepubliclyavailable.

• Regularstaff-focussedservicereviewsto accurately assess social factors and psychologicalstressorsaswellasphysicalworkplacefactorswhichpresentspecificstressfactorsfordoctorsandtheirteams.Placinganemphasisonthecreationofcongenialworkplacesandcivilbehaviourtominimisestaffexperiencesofstressatwork.

• Formalisedstrategiestopromoteprofessionalwellbeingincludingtheprovisionofconfidentialeasilyaccessibleprofessionalsupervisionandcounselling.Establishmentandnormalisationofano-blamecultureforreportingandhoursof(over)workandaspeakingoutcultureonmattersofstaffandpatientsafety,asperexistingMECAclauses.

• Ashiftinfocusawayfromfinancialprioritiestopeopleandattachingadollarvaluetowellbeing(decreaseinpresenteeism,decreaseinturnoverrates,bettermedicaloutcomes,bettercollegialityindepartmentsetc).

• AddingindicatorsofstaffwellbeingasstandingitemsinhospitalauditsandreportingtoBoardsandhavingMOHtargetsforDHBsonthesestaffwellbeingmeasures.

• NormalisingthepracticeofDHBleaders(Boardandexecutivestaff)speakingupaboutresourceconstraints,limitstocare,waitinglists.Thiswouldbedifferentfromthecurrentcultureofmakingdoandpretendingthereisenoughhealthresourceifwealljust“worksmarter”,whichisdamagingtostaffandcommunities.


Appendix 1SPECIALTY GROUPINGPlastic&reconstructivesurgery Surgery

Urology Surgery

Paediatricsurgery Surgery

Neurosurgery Surgery

Vascularsurgery Surgery

Cardiothoracicsurgery Surgery

Oral&MaxillofacialSurgery Surgery

Haematology Internal Medicine

PalliativeMedicine Internal Medicine

InfectiousDiseasesMedicine Internal Medicine

Dermatology Internal Medicine

RehabilitationMedicine Internal Medicine

Sexual Health Medicine Internal Medicine

ClinicalGenetics Internal Medicine

Pain Medicine Internal Medicine

OccupationalMedicine Internal Medicine

Musculoskeletal Medicine Internal Medicine

FamilyPlanning&ReproductiveHealth GeneralPractice

Accident&MedicalPractice EmergencyMedicine

MedicalAdministration Miscellaneous

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