Factors associated with burnout syndrome in surgeons: a systematic review

The prevalence of burnout ranges from 22.2% in one cross multispecialty study,¹⁴ to 85.1% in a study of Chinese adult reconstructive surgeons.¹⁵ The variance is probably explained by the differing definitions of burnout.

Younger surgeons are likely to suffer from higher levels of burnout.^2,11,16–23 The exception is from a study of general surgery residents, which found the opposite using a multivariate logistic regression model (n = 665).⁸

Women are associated with higher risk of burnout.^{8,11,14,16–18,22,24–27} However, three studies found men to have higher levels of burnout, specifically depersonalisation.^4,28,29 A longitudinal study found that there was a greater increase in burnout in men compared with women over one year, although this was based on a small cohort at intern level (n = 21).²⁸

Studies reporting association with training level and experience show mixed outcomes.^{2,4,8,19,23,24,27,30–35} Three studies found that those in their second year of training had significantly higher levels of burnout,^4,23,30 while those in their fifth year of training have been noted to have lower burnout in a multivariate analysis.⁸ One multispecialty study found that those in their third year had higher levels of burnout, but this association was lost when logistic regression was performed.³¹

A longer period of years in practice is associated with higher burnout.^2,23,32 One study of plastic surgeons found that those who had been practising for more than 15 years had lower burnout in a multivariate analysis.¹⁹ Another study reported a difference between number of years in specialty and emotional exhaustion, however it only explained a small proportion of variance (R² = 0.026).³³

Residents tend to have higher burnout than faculty,^23,24,34 but no studies looked at change in burnout in individuals before and after appointment to consultancy. Issues with tenure or promotion are associated with higher levels of emotional exhaustion in orthopaedic surgeons, although it is not clear what these issues are.³⁵

A number of studies have reported an association with family factors.^{2,6,15,19,21,24,34–41} Being single is correlated with burnout,^{15,21,36–39} independently in two orthopaedic studies,^37,39 but not in a study of UK colorectal and vascular surgeons.²¹

Surgeons who had more supportive partners suffered from less burnout.^35,37,40 This was an independent association in obstetricians,³⁷ but was not found to have an independent effect in neurosurgeons.⁴⁰ Having a spouse who is working has been found to independently increase risk of burnout.^2,19,38 More time spent with a spouse has been found to be associated with less burnout.³⁴

Having children is associated with less burnout,^{2,19,24,29,34,38} although in one study this effect was only valid for faculty and not residents.³⁴

Self-reporting more irritable behaviour towards loved ones correlates with higher burnout,⁶ as does those who report more friction with or withdrawal from family in orthopaedic surgeons.⁴¹

Studies generally show that burnout is associated with an increased workload.^{2,6,8,17,19,20,24–27,31,34,35,39,42–52} All studies used self-report measures to identify hours worked. Four studies reported more hours worked being independently associated with burnout.^2,8,19,26 Two studies found correlation in univariate but not multivariate analysis.^39,43 The two longitudinal studies captured that measured burnout before and after a regulated reduction in working hours found reduced burnout with less hours worked.^45,48 Another study of orthopaedic surgeons that looked at two different cohorts before and after working hour directives found increased hours to be associated with higher depersonalisation in residents but lower depersonalisation in faculty.⁵² A study of gynaecologists in Pakistan found that working 50–60 hours was associated with higher burnout than working over 80 hours.³² Eight studies found no correlation.^{6,17,25,27,35,50,51}

Burnout is associated with working nights,^2,15,19,46 work home,^21,47 number of on-calls in plastic surgeons^20,53 and out of hours in orthopaedic surgeons.³⁵

Career satisfaction is consistently associated with less burnout,^{6,17,19,21,22,29,32,38,50,51,54} while those who would choose their specialty or job again,^15,21,40 or who would encourage children to enter their profession, had lower levels of burnout.¹⁷ A desire to leave is associated with higher burnout.^29,38

A number of studies found some association of burnout with colleague factors.^{11,14,18,23,34,35,39,47,54–57} Support from co-workers as measured by the validated Job Content Questionnaire is independently associated with less burnout,¹⁸ but only in univariate analysis in a study of transplant surgeons.⁵⁴ Poor working relationships are associated with more burnout,^34,39,47 as are disputes.³⁵ Support for poor performers and for exams,⁵⁵ as well as access to feedback,¹¹ is associated with less burnout. Frequent shaming and a culture of bravado are associated with more burnout.^56,57 A sense of belonging was associated with less burnout in a multispecialty study.¹⁴

Conflict with patients and higher patient expectations are correlated with burnout.^{18,39,43,54,58} Being accused of malpractice is associated with higher burnout in neurosurgeons (n = 783).⁴⁰

A lack of administrative support and inadequate time for administrative duties has been found to correlate with more burnout,^6,47,54 as has spending more time on non-patient care tasks.²

Autonomy and decisional authority are associated with lower burnout.^11,54 Being challenged at work is associated with lower burnout,^40,59 although the perception of too much responsibility correlates with higher burnout.⁴³ Anxiety over personal competence is associated with higher burnout among residents and faculty.³⁴

Surgeons with access to mentoring have lower levels of burnout.^8,23 A prospective interventional study found lower levels of burnout in otolaryngology residents after mentorship (n = 8),³⁰ but this was not replicated in another randomised controlled trial of obstetric and gynaecological surgeons (n = 27).⁶⁰

Training programme satisfaction has been shown to be associated with less burnout.^21,38 Opportunities for development,¹¹ growth,⁵⁹ personal learning⁶¹ and more practical training⁴³ correlates with less burnout.

Better perceived work–life balance is associated with less burnout,^{6,34,37–41,47,53} as is lower levels of work–life or work–home conflict.^23,26

Errors have been shown to be independently associated with burnout in a large multispecialty study (n = 7905)⁹ and a smaller study of orthopaedic and trauma surgeons.³⁶ Correlation has also been found in plastic surgeons.¹⁹ All three used self-reported errors as a measure rather than documented errors.

A lack of extracurricular activities is associated with higher level of burnout,^3,22,43,50 while those reporting lower quality of life,¹⁸ or physical quality of life^21,23 also have more burnout.

Physical activity and exercise are associated with less burnout,^23,42,53 as is general health.^6,20,38,53 Increased sickness and time off work is associated with more burnout.^16,59

Depression has been found to be independently associated with burnout,^17,36 and has been found to be predictive of burnout using the Profile of Mood States scale.³³ Univariate analysis has also shown depression to be associated with burnout using various validated measures,^4,19,42,51 as has anxiety.⁴ A multispecialty found that post-traumatic stress disorder is associated with higher burnout.⁶²

Suicidal ideation is associated with burnout,^4,5,17,43 as is stress.^4,17,39 Self-reported lack of sleep, sleep deprivation and suffering from sleep disorders are all associated with burnout.^15,23,24,43

Those who drink more or misuse alcohol have higher levels of burnout.^{17,19,21–23,28,34,47} One study looking specifically at sex found this effect only in women (odds ratio of depersonalisation 1.91)²⁸ and another only in faculty.³⁴ Substance abuse is associated with higher burnout (n = 1691),¹⁹ as is smoking cigarettes (n = 29).⁴⁷

Higher levels of emotional intelligence are associated with less burnout as measured by the Trait Emotional Intelligence Questionnaire,^11,63,64 while average resonating level (self-awareness and emotional intelligence) is associated with lower burnout scores in general surgery residents (n = 48).⁶⁵

Personality factors have also been found to be associated with burnout.^11,24 Extraversion, agreeableness, conscientiousness and openness have been linked with lower levels of burnout, while neuroticism is linked with higher burnout in obstetrics and gynaecologists.²⁴ A study of general surgery residents found that agreeableness, emotional stability and conscientiousness correlated with lower burnout.¹¹

General surgery residents with higher dispositional mindfulness and resilience are associated with lower burnout scores (n = 566),⁴ while grit correlates with burnout in a multispecialty study (n = 141).⁶⁶ Increased levels of self-efficacy are related to lower levels of burnout.^31,35

Academic or research work has been found to be protective of burnout.^{4,15,20,22,40,67} One study has found that there was no significant difference between clinical and research status,¹¹ while another found that there was no difference between private and academic paediatric urologists.⁴⁹

Lower income is associated with higher levels of burnout.^19,38,43,47 A study of orthopaedic residents and faculty showed that debt load was associated with higher burnout in faculty members, while financial concerns were also associated with burnout in this group.³⁴ Conversely, two small studies in Fiji and Saudi Arabia found that income did not make a difference to levels of burnout.^44,53