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Burnout in orthopaedic surgeons: A systematic review
Accepted Manuscript Burnout in orthopaedic surgeons: A systematic review Rex Wan Hin Hui, Ka Chun Leung, Shicong Ge, Amanda Chin Hwang, Gevon Ge Woon Lai, Arnold Nicholas Leung, John Shung Lai Leung PII:
S0976-5662(18)30261-3
DOI:
https://doi.org/10.1016/j.jcot.2019.01.028
Reference:
JCOT 736
To appear in:
Journal of Clinical Orthopaedics and Trauma
Received Date: 8 May 2018 Revised Date:
6 July 2018
Accepted Date: 30 January 2019
Please cite this article as: Hui RWH, Leung KC, Ge S, Hwang AC, Lai GGW, Leung AN, Leung JSL, Burnout in orthopaedic surgeons: A systematic review, Journal of Clinical Orthopaedics and Trauma (2019), doi: https://doi.org/10.1016/j.jcot.2019.01.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE
Title: Burnout in orthopaedic surgeons: a systematic review Running head: Burnout in orthopaedic surgeons
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Category: Review article
Authors: Rex Wan Hin HUI 1*^, Ka Chun LEUNG 1*, Shicong GE 1, Amanda Chin
* = these authors contributed equally to the article
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^ = corresponding author
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HWANG 1, Gevon Ge Woon LAI 1, Arnold Nicholas LEUNG 1, John Shung Lai LEUNG 1
Li Ka Shing Faculty of Medicine, The University of Hong Kong
Corresponding author: Rex Wan Hin HUI
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Correspondence email: [email protected]
Correspondence phone number: (852) 61139278
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Funding: This research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
Declaration of conflicting interests: All authors have nothing to disclose
Acknowledgements: none
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ACCEPTED MANUSCRIPT ABSTRACT Occupational burnout is a syndrome composed of emotional exhaustion, depersonalisation and low sense of personal accomplishment. Burnout has been shown to negatively affect both the personal lives and professional performance of doctors. Orthopaedic surgery is a
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challenging specialty, and while burnout has been studied in orthopaedic surgeons, a
comprehensive review article in this area is lacking. Hence we performed a systematic review
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to summarise the evidence regarding burnout in orthopaedic surgeons.
We conducted a systematic literature review using the terms “orthopaedic surgeons” and
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“burnout” and related terms. Studies were reviewed by two independent reviewers. English articles that were (a) peer-reviewed original research articles; (b) measures burnout directly in study participants; (c) uses validated scales for burnout assessment; and (d) on orthopaedic
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surgeons, were included. Discrepancies between reviewers were resolved by panel discussion.
216 papers were identified and 14 papers were selected for qualitative synthesis. The prevalence of burnout varied considerably between orthopaedic surgeons from different
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centers and of different seniority. There is insufficient evidence to suggest that the burnout rate in orthopaedic surgeons is different from doctors in other specialties. A range of risk
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factors and protective factors associated with burnout were identified. Similar to prior studies in the general medical population, key determinants of burnout included, personal, family, working environment and career factors. One paper identified an association between burnout and irritable behaviour during operation, yet no studies have assessed the effect of burnout on orthopaedic patient outcomes. We did not identify papers on the management of burnout in orthopaedic surgeons.
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ACCEPTED MANUSCRIPT To conclude, the evidence on burnout in orthopaedic surgeons is preliminary and key methodological limitations have been noted in the current studies. Large-scale prospective studies are warranted to better understand the determinants and effects of burnout in orthopaedic surgeons, in order to guide appropriate interventions against this occupational
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mental health hazard.
Keywords
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Orthopaedics, Orthopaedic surgeon, Professional burnout, Psychological stress
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ACCEPTED MANUSCRIPT INTRODUCTION Occupational burnout is a syndrome composing of emotional exhaustion (EE), depersonalisation (DP) and low sense of personal accomplishment (PA), secondary to chronic occupational stress [1]. The Maslach Burnout Inventory (MBI) scale is a scoring system that
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has been validated in multiple physician [2, 3] and non-physician [4] populations, and is
considered as the gold-standard for burnout assessment. The scale consists of 22 seven-point Likert scale questions, which measures EE, DP and PA separately [1]. In clinical practise and
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research studies, clinically significant burnout is defined as the presence of either high level
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EE or high level DP [2, 5].
In recent years, burnout in doctors has been a topic of increasing research interest , and has been widely studied in doctors from various specialties [2, 6, 7]. Professionally, burnout is associated with medical errors [8-10], unprofessional conduct [11], and reduced quality of
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patient care [8]. On a personal scale, burnout is associated with alcohol abuse [12], poorer physical quality of life [12], and reduced career satisfaction [13, 14]. All in all, burnout poses major impact to the medical profession and negatively affects both the personal lives and
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professional performance of doctors.
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Orthopaedic surgery is a challenging specialty, covering broad anatomy, complex pathologies, major trauma cases and a wide range of procedures [15]. Orthopaedic surgeons have a heavy workload and commonly work long hours [16]. The postgraduate orthopaedic training programme is also notoriously difficult [17]. In the modern medical environment, reduced independent surgical practice and exposure has made it increasingly difficult to achieve surgical skills [17], further steepening the learning curve and putting additional pressure on the already high expectation and demands of orthopaedics [18]. Given the
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ACCEPTED MANUSCRIPT challenges in practising orthopaedics, the data on burnout in other medical specialties may not be generalisable to orthopaedic surgeons. While burnout has been studied in orthopaedic surgeons, a comprehensive review article in this area is lacking. Accordingly, we performed a systematic review to summarise and discuss the evidence regarding the prevalence,
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determinants, outcome and management of burnout in orthopaedic surgeons.
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METHODS Literature search
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A systematic literature search was conducted in PubMed to identify relevant articles published through 20 March 2018. The search terms ("Orthopedics"[Mesh] OR "Orthopedic+Surgeons"[Mesh] OR Orthop*[tiab]) AND ("Burnout, Professional"[Mesh] OR
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burnout*[tiab] OR "Stress, Psychological"[Mesh] OR "Mental Fatigue"[Mesh]) was used.
Inclusion/ exclusion criteria
The articles retrieved from PubMed were further screened by two independent reviewers.
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Articles that were (a) peer-reviewed original research articles; (b) measures burnout directly in study participants; (c) uses validated scales for burnout assessment; and (d) on orthopaedic
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surgeons, were included. There was no limit on place and time of publication. Articles without English full texts were excluded. Given the high variability in methodology and quality of studies, no studies were excluded based on methodological factors. The corresponding limitations of the studies were noted and discussed.
Discrepancy resolution For discrepancies between reviewers during study review and data collection, a panel
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ACCEPTED MANUSCRIPT discussion involving all research team members was carried out to achieve consensus.
RESULTS
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We identified 216 papers from the literature search (Figure 1). 200 papers were excluded. Two articles were subsequently excluded in panel discussion, as surgeons were discussed in general without specific analysis of orthopaedic surgeons. 14 remaining articles, which
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reported 12 independent studies, were included in the analysis and discussion.
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Prevalence of burnout
Nine papers reported the prevalence of burnout in orthopaedic surgeons [6, 16, 19-25]. The prevalence of burnout varied considerably between orthopaedic surgeons from different centres and of different seniority. Varying methodologies of the studies were also observed,
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and not all components of burnout were reported in some studies. The reported prevalence of EE and DP ranged from 16.2% to 50.7% and 11.4% to 59.4% respectively. The rates of EE and DP were both lowest in Netherlands [19] and highest in Saudi Arabia [23]. Low PA was
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reported in only 4.0% of US orthopaedic chair professors or chiefs [24], but was up to 43.0% in Australian orthopaedic trainees [20], demonstrating the difference in burnout prevalence
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among orthopaedic surgeons of different seniority. The prevalence of burnout in the studies is illustrated in Table 1.
An overall burnout rate has been reported in some studies. Arora et al. ascertained that 53% of Australian orthopaedic surgeons fulfilled the criteria for burnout [20], while Balch et al. reported a burnout rate of 32.0% in general orthopaedic surgeons and 51.6% in trauma surgeons [6]. Zheng et al. specifically focused on surveying Chinese arthroplasty surgeons,
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ACCEPTED MANUSCRIPT and demonstrated a high burnout rate of 85.1% [25].
Studies have also compared the burnout rates in orthopaedic surgeons with doctors from other specialties. Lesic et al. compared the MBI in 30 Serbian orthopaedic surgeons and 38 general
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practitioners. The orthopaedic group had higher EE (40.0% vs 29.0%), higher DP (34.5% vs 11.1%), and were less likely to have low PA (29.6% vs 48.5%) when compared with general practitioners. The differences were non-significant but this may be attributable to the small
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sample size and low statistical power of the study [22]. Balch et al. assessed the burnout rates of general orthopaedic surgeons, trauma surgeons and surgeons from 12 other surgical
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subspecialties. Overall, trauma surgeons had the highest burnout rates (51.6%), followed by vascular surgeons (44%) and urologists (43%). General orthopaedic surgeons were second last in burnout prevalence (32%), only higher than paediatric surgeons (31%) among the 14
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surgical subspecialties surveyed in the study [6].
Factors associated with burnout
Ten of the included papers reported factors associated with burnout in orthopaedic surgeons
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[16, 21, 24-30]. The factors associated with burnout are illustrated in Table 2.
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Personal factors including being female or being a racial minority were associated with higher rates of EE. Both groups faced the problems of harassment and discrimination, which were significantly associated with burnout [28]. Financial concern was a risk factor for EE, while alcohol and drug abuse was associated with higher DP [29]. Spending more time on hobbies was associated with lower rates of EE [21, 29]. Among orthopaedic department heads, having high self-efficacy was a protective factor against clinically significant burnout [24].
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ACCEPTED MANUSCRIPT Family also played an important role in burnout. Conflict between work and family life [27, 29], lack of support from spouses and poor marital relationship were positively associated with EE [21, 24, 27, 29]. Among orthopaedic surgeons working in a military hospital, having significant others on active military duty was a risk factor for burnout [16]. The small-scale
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pilot study conducted by Sargent et al. found that having a father who is a physician and spending more time with spouses reduced rates of EE respectively, while having a good
relationship with one’s mother reduced the risk of DP. Satisfaction from talking with friends
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and long working hours of spouse were associated with a higher sense of PA [29]. Sargent et al. also reported that being a parent was associated with higher PA in orthopaedic surgeons.
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This was echoed in a 2016 multinational cross-sectional study, where parenthood was an independent protective factor of clinically significant burnout among orthopaedic surgeons [30].
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Working environment was also identified as a significant determinant of burnout. Sleep deprivation had a major effect and was associated with raised EE, raised DP and low PA [21, 25]. Long working hours and number of nights on-call per week were also significant
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predictors of burnout [24-26, 29]. Barrack et al. utilised a prospective study design and assessed the change in burnout rates after standard working hours have been implemented in
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the US. After the initiation of standard working hours, only the orthopaedic residents recorded improved PA scores, while no demonstrable changes to burnout was observed in faculty members [26]. While working hours are associated with burnout rates, orthopaedic surgeons who had research duties on top of their clinical duties were less likely to be burnt out. This may be attributable to higher job satisfaction and sense of accomplishment [25]. Perception of stress in work was associated with EE [29], whereas stress in relationships with colleagues was linked to increased EE and DP [24, 29]. Apart from workload and stress, residents from
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ACCEPTED MANUSCRIPT large residency programmes demonstrated significantly higher rates of EE and DP than residents from smaller residency programmes [21]. Support in workplace was shown as a protective factor for burnout, as perceived support from faculty, satisfaction from talking to colleagues, and frequent contacts with mentors were negatively associated with EE and low
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PA [21, 29]. Quality mentorship is a protective factor against burnout in residents, as those who enjoyed talking with their mentors had lower rates of all EE, DP and low PA. Having a senior resident as a mentor was associated with lower EE, whereas having a faculty member
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as a mentor was linked to higher PA [21].
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The factors associated with burnout may vary in different stages of a surgeon’s career. Compared with faculty members, residents were more prone to all three burnout features of EE, DP and low PA [21, 28]. Early career orthopaedic surgeons were at higher risk of burnout, as the rates of EE and DP peaked at postgraduate year two in residency programs in
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the US, while surgeons with more than 10 years of post-residency experience were less likely to have EE and DP in the same study [21]. While senior staff had lower rates of burnout overall, Sargent et al. reported that senior faculty staff may worry about the competition due
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to the increasing number of orthopaedic surgeons, which was linked to higher EE. No significant association was demonstrated between concerns about competition and burnout in
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junior residents [29].
Anxiety about clinical competence was associated with higher EE, regardless of seniority and experience [29]. A surgeon’s perception of their career choice may be associated with burnout - Simons et al. reported that regret in choosing a medical career was a risk factor for EE and low PA [16], while job satisfaction was an independent negative predictor of overall burnout in Palthe’s study [30]. Factors specifically concerning senior orthopaedic surgeons in
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ACCEPTED MANUSCRIPT administrative positions were studied in a survey of orthopaedic chair professors. Increasing overhead, departmental and hospital budget deficits, tenure and promotion, loss of key faculty, staff dismissal and credentialing were all stressors which were significantly correlated
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with EE [24].
Effects of burnout on clinical practise
One study assessed the effect of burnout on clinical practise [25]. In their study on 202
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Chinese arthroplasty surgeons, Zheng et al. demonstrated that surgeons with higher EE were significantly more likely to lose their temper during operations. DP was not associated with
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incidences of intraoperative irritability [25]. Interestingly, Zheng’s study demonstrated that the seniority of the surgeon was associated with the likelihood that he/she has lost their temper once or more during operations in the past month (24% in residents, 58.9% in attendings, 65.0% in vice-chiefs, and 70.7% in chiefs; p<0.001). In contrast, the surgeons’
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seniority trended towards an inverse relationship with the prevalence of burnout, yet the trend was non-significant. The potential confounding relationships between intraoperative
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irritability, seniority and burnout were not further explored in the study.
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DISCUSSION
To the best of our knowledge, this is the first systematic review on burnout in orthopaedic surgeons. The prevalence of burnout varied in different centres and in staff with different seniority. A landmark study on 7288 US doctors from various specialties demonstrated rates of EE, DP and low PA to be 37.9%, 29.4% and 12.4% respectively [2], which appear comparable with the rates reported in the orthopaedic-specific studies in this paper. Among 6512 surgeons from 14 surgical subspecialties in Balch’s paper, trauma surgeons ranked top
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ACCEPTED MANUSCRIPT in burnout prevalence (51.6%), but general orthopaedic surgeons had the second lowest burnout prevalence of 32% [6]. Lesic’s study compared Serbian orthopaedic surgeons with general practitioners and could not demonstrate any significant differences in burnout rates [22]. In spite of the common notion that orthopaedics is a challenging specialty [15, 16], there
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is insufficient evidence to suggest that burnout rates are higher in orthopaedic surgeons than in other specialties.
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Despite the definition of burnout as an occupational condition [1], our review demonstrated that occupational factors were not the only factors associated with burnout, and personal or
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family factors were also key determinants of burnout in orthopaedic surgeons. Nonetheless, the risk and protective factors identified in this review should be treated with caution, as most of the factors were bivariate associations identified in small-scale cross-sectional surveys. The majority of studies did not perform multivariate analysis [16, 21, 24, 27-29], and it remains
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unclear whether the factors are independent predictors or covariates. It should also be noted that factors such as work-family conflict and anxiety about clinical competence could be effects of burnout. Reverse causality should be considered and it is difficult to determine
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whether such factors are the causes or effects of burnout. The studies also utilised nonvalidated questionnaires for the identification of demographic and family factors associated
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with burnout. The vague and subjective nature of such questions limit the external validity of the results and future studies should aim to utilise validated measures such as the Family Harmony Scale [31], the Connor-Davidson Resilience Scale [32] and the Subjective Happiness Scale [33].
As the literature illustrates that residency programme differences can influence rates of burnout [21, 34], we further analysed the training programmes and career pathways of the six
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ACCEPTED MANUSCRIPT countries with reported burnout rates in orthopaedic surgeons (Table 3). Overall, the general structure of the training programmes and length of training are similar. Of note, China is the only country without a centralised and structured orthopaedic training programme in the six countries [35, 36]. We hypothesize that the variability in training quality and lack of
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qualification recognition in China may increase trainees’ uncertainty, and may be attributable for the high burnout rates (85.1%) in Chinese orthopaedic surgeons [25]. Nonetheless, this would require further validation by studies involving more countries. A key discrepancy
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between the training programmes is the time required for orthopaedic trainees to rotate out to other specialties [35-39]. Yet, no patterns regarding rotation periods and burnout rates have
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been observed. Another interesting point to note is that certification by the American Board of Orthopaedic Surgery is technically voluntary, and surgeons do not have to get board certification after accredited residency. However, 98% of US doctors will complete the two parts of Orthopaedic board certification exams within five years of completing residency,
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hence this arrangement is unlikely to result in burnout rate differences between US and other countries. To further study the impact of residency training on burnout rates, future studies should stratify their cohorts by the orthopaedic surgeons’ seniority and year in training to
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enable comparison.
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Our systematic review identified one paper that showed a significant association between burnout and the likelihood of losing temper during operations, yet no further analysis on the effect of the irritable behaviour was documented [25]. This corresponds to prior studies, which demonstrated irritability as an early sign of burnout among other occupations [1, 27]. While irritable and disruptive behaviour in the operating theatre have been shown to affect patient care [40, 41], the direct effects of burnout on clinical performance in orthopaedic surgeons has not been quantified previously. Burnout has been associated with medical errors
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ACCEPTED MANUSCRIPT in internal medicine residents [9, 10] and general surgeons [42]. However, orthopaedic surgery is distinct from other specialties as it involves major trauma cases, diverse pathologies and complex procedures [15]. The potential negative effect of burnout on the challenging clinical work of orthopaedic surgeons is of particular significance and large scale
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prospective studies are warranted.
Major methodological limitations have been noted in the reviewed studies. The studies were
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from single centres [16, 23, 29], or targeted specific subgroups of surgeons such as trainees [19, 20] or department heads [24]. Hence, the generalisability of the results remains unclear.
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National and multi-centre assessment of the mental health of orthopaedic surgeons is required to provide further insight into the burnout epidemic [43]. With the availability of the MBI scale, mass screening of burnout in orthopaedic surgeons after specialty exams or during annual meetings may provide comprehensive and representative data for reference. A low
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response rate was also noted in the reviewed studies. Most studies had response rates of less than 60% [16, 21, 24, 28, 30], and the response rate was lowest in Zheng’s study at 12.3% [25]. The low response rate could lead to volunteer bias, and measures to enhance
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participation such as cash incentives should be utilised in future studies [44]. None of the reviewed studies addressed whether anonymity was maintained during the data collection
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process. Since the studies were carried out in single centres [16, 22, 26] or in small cohorts of orthopaedic surgeons [19-21, 23, 24, 27-29], non-anonymity of questionnaires could lead to social desirability bias, where the respondents try to present themselves as more socially desirable [45]. This is particularly relevant in the context of sensitive questions in relation to mental health and could lead to underestimation of burnout. Concerted efforts to maintain anonymity or conducting surveys through third parties may reduce the risk of social desirability bias and provide a more accurate depiction of the burnout rate.
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This systematic review did not identify any papers on the management of burnout in orthopaedic surgeons. The evidence on treatment of burnout in doctors is generally scarce. Educational and mindfulness training programmes for doctors have demonstrated positive
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results in pilot studies [46-48], yet the long-term outcome and scalability of such
interventions remain undetermined. An alternative approach for burnout management is to identify the key protective factors and optimise such factors [43]. It is clear that the current
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data in orthopaedic surgeons is limited, and more rigorous research to identify protective factors against burnout is required. While policy changes and workplace interventions such as
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mentorship programmes and standard working hours may have a role in reducing burnout rates, a holistic approach to target the family and personal factors of burnout as well should be adopted [5].
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CONCLUSIONS
The evidence on burnout in orthopaedic surgeons is preliminary, and key methodological limitations have been noted. Large scale prospective studies are warranted to assess the
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determinants and effects of burnout in orthopaedic surgeons, in order to guide interventions
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against this occupational health hazard.
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Reliability and Construct Validation. Soc Indic Res. 1999; 46: 137-155. journal article. DOI:
34.
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10.1023/a:1006824100041.
Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature
35.
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review. J Grad Med Educ. 2009; 1(2): 236-42. Leung KS, Ngai WK, Tian W. Orthopaedic training in China: experiences from the
promotion of orthopaedic specialist training in China. J Bone Joint Surg Br. 2011. 93(9):1165-8. 36.
Ma ZS, Zhang HJ, Lei W, et al. Musculoskeletal training for orthopaedists and
nonorthopaedists in China. Clin Orthop Relat Res. 2008. 466(10): 2360-8. 37.
Poos HP. Trauma surgery training: the Dutch approach. Trauma und Berufskrankheit.
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ACCEPTED MANUSCRIPT 2017. 19(1): 52-54. 38.
Vukasinovic Z, Spasovski D, Zivkovic Z. Musculoskeletal trauma services in Serbia.
Clin Orthop Relat Res. 2008. 466(10): 2337-42. 39.
Al-Ahaideb A, Alrabai HM, Alrehaili O, et al. Evaluation of the orthopedic residency
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training program in Saudi Arabia and comparison with a selected Canadian residency program. Adv Med Educ Pract. 2014. 5: 315-21. 40.
Patel P, Robinson BS, Novicoff WM, et al. The disruptive orthopaedic surgeon:
e1261-1266. 2011/11/04. DOI: 10.2106/jbjs.j.01933.
Cochran A and Elder WB. A model of disruptive surgeon behavior in the
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41.
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implications for patient safety and malpractice liability. J Bone Joint Surg Am. 2011; 93:
perioperative environment. J Am Coll Surg. 2014; 219: 390-398. 2014/07/30. DOI: 10.1016/j.jamcollsurg.2014.05.011. 42.
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among
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American surgeons. Ann Surg. 2010; 251: 995-1000. 2009/11/26. DOI: 10.1097/SLA.0b013e3181bfdab3. 43.
Arora M, Diwan AD and Harris IA. Burnout in orthopaedic surgeons: a review. ANZ J
44.
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Surg. 2013; 83: 512-515. 2013/06/26. DOI: 10.1111/ans.12292. Leung GM, Ho LM, Chan MF, et al. The effects of cash and lottery incentives on
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mailed surveys to physicians: a randomized trial. J Clin Epidemiol. 2002; 55: 801-807. 2002/10/18. 45.
Christensen AI, Ekholm O, Glumer C, et al. Effect of survey mode on response
patterns: comparison of face-to-face and self-administered modes in health surveys. Eur J Public Health. 2014; 24: 327-332. 2013/06/15. DOI: 10.1093/eurpub/ckt067. 46.
Martins AE, Davenport MC, Del Valle MP, et al. Impact of a brief intervention on the
burnout levels of pediatric residents. J Pediatr (Rio J). 2011; 87: 493-498. 2011/12/16. DOI:
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ACCEPTED MANUSCRIPT doi:10.2223/JPED.2127. 47.
Fortney L, Luchterhand C, Zakletskaia L, et al. Abbreviated mindfulness intervention
for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med. 2013; 11: 412-420. 2013/09/11. DOI: 10.1370/afm.1511. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in
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48.
mindful communication with burnout, empathy, and attitudes among primary care physicians.
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JAMA. 2009; 302: 1284-1293. 2009/09/24. DOI: 10.1001/jama.2009.1384.
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Low personal High depersonalization achievement (%) (%) NR NR
Overall burnout rate (%)^
37.0
25.9
37.0
25.0
33.3
33.3
11.4
NR
16.2
45 NR
35 NR
43 NR
45 32
NR 32 28.4 40.0 36
NR 56 24.8 34.5 27
NR 18 10 29.6 4
51.6 56 28.4 40.0 36
50.7
59.4
17.4
59.4
Setting
Cohort
High emotional exhaustion (%)
Zheng et al. 2017 25
China
202 surgeons
NR
27 residents
29.6
11 staff surgeons
33.3
Netherlands
105 trainees
16.2
Australia US
51 trainees 155 general orthopaedic surgeons 345 Trauma surgeons 384 residents 264 faculty members 30 surgeons 110 current chairs or chiefs 69 surgeons
Sargent et al. 2009
US
21
Serbia US
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Lesic et al. 2009 22 Saleh et al. 2007 24
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Sadat-Ali et al. 2005 Eastern province, Saudi 23 Arabia Table 1. Prevalence of burnout among orthopaedic surgeons *NR= not reported
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van Vendeloo et al. 2014 19 Arora et al. 2014 20 Balch et al. 20116
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Simons et al. 2016 16 US Army Medical Centre
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Study
^Burnout rate is defined as the presence of high emotional exhaustion or high depersonalization by the Maslach Burnout Inventory.
85.1
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Family factors
Working environment
Career
Positively associated with burnout
• Female 28 • Racial minorities 28 • Harassment and discrimination 28 • Financial concerns 29 • Alcohol and drug abuse 29
• Work-family conflict 27, 29 • Lack of spousal support/poor marital relationship 24, 27 • Significant others on military service 16
• Sleep deprivation 21 • Working in large residency programmes 21 • Excessive work/long work hours 24, 29 • Nights on-call per week 25 • Perception of stress in work 29 • Stress in workplace relationships 29
• Regret in choosing medicine 16 • Current residents 21 • Anxiety about clinical competence 29 • Worry about competition from other orthopaedic surgeons 29
Negatively associated with burnout
• High self-efficacy 24 • Time for hobbies 21, 29
• Physician father 29 • Good relationship with mother 29 • Satisfaction from talking to friends and family 29 • Spends personal time with spouse 29 • Spouse work long hours 29 • Good marriage quality 21,
• Perceived support from faculty 29 • Satisfaction from talking with colleagues 29 • Frequent contacts with mentor 21 • Standard working hours 26 • Research duties on top of clinical duties 25
• Completed residency for more than 10 years 21 • Job satisfaction 30
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29
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• Parenthood 29, 30
Table 2. Factors associated with burnout
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Personal factors
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China
Netherlands
Saudi Arabia
Serbia
US
6
5
6
5
5
5
2
3
1.5
2
1
1
4
2
4.5
3
4
4
Structured training
Yes
Variable
Yes
Yes
Yes
Yes
Continuous
Yes
Variable
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Minimal duration of training programme (years) Basic surgical
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training/ Rotation to other surgical
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specialties Orthopaedic
assessment
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training
Yes
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Exit examination
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Australia
Table 3. Brief overview of Orthopaedic training pathways
(Board certification is voluntary)
ACCEPTED MANUSCRIPT 216 articles identified through database search
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200 articles were excluded - 25 articles: not in English language - 19 articles: not original research articles - 142 articles not relevant to topic - 12 articles did not assess orthopaedic surgeons - 2 articles did not use validated scales for burnout assessment 16 articles remained, with full text accessed for eligibility
14 articles included in qualitative synthesis
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2 articles were excluded in panel discussion - Articles assessed burnout in surgeons in general, without specific analysis for orthopaedic surgeons
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FIGURE 1. PRISMA flow diagram of studies included into the systematic review
S0976-5662(18)30261-3
DOI:
https://doi.org/10.1016/j.jcot.2019.01.028
Reference:
JCOT 736
To appear in:
Journal of Clinical Orthopaedics and Trauma
Received Date: 8 May 2018 Revised Date:
6 July 2018
Accepted Date: 30 January 2019
Please cite this article as: Hui RWH, Leung KC, Ge S, Hwang AC, Lai GGW, Leung AN, Leung JSL, Burnout in orthopaedic surgeons: A systematic review, Journal of Clinical Orthopaedics and Trauma (2019), doi: https://doi.org/10.1016/j.jcot.2019.01.028. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE
Title: Burnout in orthopaedic surgeons: a systematic review Running head: Burnout in orthopaedic surgeons
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Category: Review article
Authors: Rex Wan Hin HUI 1*^, Ka Chun LEUNG 1*, Shicong GE 1, Amanda Chin
* = these authors contributed equally to the article
1
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^ = corresponding author
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HWANG 1, Gevon Ge Woon LAI 1, Arnold Nicholas LEUNG 1, John Shung Lai LEUNG 1
Li Ka Shing Faculty of Medicine, The University of Hong Kong
Corresponding author: Rex Wan Hin HUI
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Correspondence email: [email protected]
Correspondence phone number: (852) 61139278
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Funding: This research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors.
Declaration of conflicting interests: All authors have nothing to disclose
Acknowledgements: none
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ACCEPTED MANUSCRIPT ABSTRACT Occupational burnout is a syndrome composed of emotional exhaustion, depersonalisation and low sense of personal accomplishment. Burnout has been shown to negatively affect both the personal lives and professional performance of doctors. Orthopaedic surgery is a
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challenging specialty, and while burnout has been studied in orthopaedic surgeons, a
comprehensive review article in this area is lacking. Hence we performed a systematic review
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to summarise the evidence regarding burnout in orthopaedic surgeons.
We conducted a systematic literature review using the terms “orthopaedic surgeons” and
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“burnout” and related terms. Studies were reviewed by two independent reviewers. English articles that were (a) peer-reviewed original research articles; (b) measures burnout directly in study participants; (c) uses validated scales for burnout assessment; and (d) on orthopaedic
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surgeons, were included. Discrepancies between reviewers were resolved by panel discussion.
216 papers were identified and 14 papers were selected for qualitative synthesis. The prevalence of burnout varied considerably between orthopaedic surgeons from different
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centers and of different seniority. There is insufficient evidence to suggest that the burnout rate in orthopaedic surgeons is different from doctors in other specialties. A range of risk
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factors and protective factors associated with burnout were identified. Similar to prior studies in the general medical population, key determinants of burnout included, personal, family, working environment and career factors. One paper identified an association between burnout and irritable behaviour during operation, yet no studies have assessed the effect of burnout on orthopaedic patient outcomes. We did not identify papers on the management of burnout in orthopaedic surgeons.
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ACCEPTED MANUSCRIPT To conclude, the evidence on burnout in orthopaedic surgeons is preliminary and key methodological limitations have been noted in the current studies. Large-scale prospective studies are warranted to better understand the determinants and effects of burnout in orthopaedic surgeons, in order to guide appropriate interventions against this occupational
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mental health hazard.
Keywords
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Orthopaedics, Orthopaedic surgeon, Professional burnout, Psychological stress
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ACCEPTED MANUSCRIPT INTRODUCTION Occupational burnout is a syndrome composing of emotional exhaustion (EE), depersonalisation (DP) and low sense of personal accomplishment (PA), secondary to chronic occupational stress [1]. The Maslach Burnout Inventory (MBI) scale is a scoring system that
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has been validated in multiple physician [2, 3] and non-physician [4] populations, and is
considered as the gold-standard for burnout assessment. The scale consists of 22 seven-point Likert scale questions, which measures EE, DP and PA separately [1]. In clinical practise and
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research studies, clinically significant burnout is defined as the presence of either high level
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EE or high level DP [2, 5].
In recent years, burnout in doctors has been a topic of increasing research interest , and has been widely studied in doctors from various specialties [2, 6, 7]. Professionally, burnout is associated with medical errors [8-10], unprofessional conduct [11], and reduced quality of
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patient care [8]. On a personal scale, burnout is associated with alcohol abuse [12], poorer physical quality of life [12], and reduced career satisfaction [13, 14]. All in all, burnout poses major impact to the medical profession and negatively affects both the personal lives and
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professional performance of doctors.
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Orthopaedic surgery is a challenging specialty, covering broad anatomy, complex pathologies, major trauma cases and a wide range of procedures [15]. Orthopaedic surgeons have a heavy workload and commonly work long hours [16]. The postgraduate orthopaedic training programme is also notoriously difficult [17]. In the modern medical environment, reduced independent surgical practice and exposure has made it increasingly difficult to achieve surgical skills [17], further steepening the learning curve and putting additional pressure on the already high expectation and demands of orthopaedics [18]. Given the
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ACCEPTED MANUSCRIPT challenges in practising orthopaedics, the data on burnout in other medical specialties may not be generalisable to orthopaedic surgeons. While burnout has been studied in orthopaedic surgeons, a comprehensive review article in this area is lacking. Accordingly, we performed a systematic review to summarise and discuss the evidence regarding the prevalence,
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determinants, outcome and management of burnout in orthopaedic surgeons.
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METHODS Literature search
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A systematic literature search was conducted in PubMed to identify relevant articles published through 20 March 2018. The search terms ("Orthopedics"[Mesh] OR "Orthopedic+Surgeons"[Mesh] OR Orthop*[tiab]) AND ("Burnout, Professional"[Mesh] OR
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burnout*[tiab] OR "Stress, Psychological"[Mesh] OR "Mental Fatigue"[Mesh]) was used.
Inclusion/ exclusion criteria
The articles retrieved from PubMed were further screened by two independent reviewers.
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Articles that were (a) peer-reviewed original research articles; (b) measures burnout directly in study participants; (c) uses validated scales for burnout assessment; and (d) on orthopaedic
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surgeons, were included. There was no limit on place and time of publication. Articles without English full texts were excluded. Given the high variability in methodology and quality of studies, no studies were excluded based on methodological factors. The corresponding limitations of the studies were noted and discussed.
Discrepancy resolution For discrepancies between reviewers during study review and data collection, a panel
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ACCEPTED MANUSCRIPT discussion involving all research team members was carried out to achieve consensus.
RESULTS
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We identified 216 papers from the literature search (Figure 1). 200 papers were excluded. Two articles were subsequently excluded in panel discussion, as surgeons were discussed in general without specific analysis of orthopaedic surgeons. 14 remaining articles, which
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reported 12 independent studies, were included in the analysis and discussion.
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Prevalence of burnout
Nine papers reported the prevalence of burnout in orthopaedic surgeons [6, 16, 19-25]. The prevalence of burnout varied considerably between orthopaedic surgeons from different centres and of different seniority. Varying methodologies of the studies were also observed,
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and not all components of burnout were reported in some studies. The reported prevalence of EE and DP ranged from 16.2% to 50.7% and 11.4% to 59.4% respectively. The rates of EE and DP were both lowest in Netherlands [19] and highest in Saudi Arabia [23]. Low PA was
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reported in only 4.0% of US orthopaedic chair professors or chiefs [24], but was up to 43.0% in Australian orthopaedic trainees [20], demonstrating the difference in burnout prevalence
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among orthopaedic surgeons of different seniority. The prevalence of burnout in the studies is illustrated in Table 1.
An overall burnout rate has been reported in some studies. Arora et al. ascertained that 53% of Australian orthopaedic surgeons fulfilled the criteria for burnout [20], while Balch et al. reported a burnout rate of 32.0% in general orthopaedic surgeons and 51.6% in trauma surgeons [6]. Zheng et al. specifically focused on surveying Chinese arthroplasty surgeons,
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ACCEPTED MANUSCRIPT and demonstrated a high burnout rate of 85.1% [25].
Studies have also compared the burnout rates in orthopaedic surgeons with doctors from other specialties. Lesic et al. compared the MBI in 30 Serbian orthopaedic surgeons and 38 general
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practitioners. The orthopaedic group had higher EE (40.0% vs 29.0%), higher DP (34.5% vs 11.1%), and were less likely to have low PA (29.6% vs 48.5%) when compared with general practitioners. The differences were non-significant but this may be attributable to the small
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sample size and low statistical power of the study [22]. Balch et al. assessed the burnout rates of general orthopaedic surgeons, trauma surgeons and surgeons from 12 other surgical
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subspecialties. Overall, trauma surgeons had the highest burnout rates (51.6%), followed by vascular surgeons (44%) and urologists (43%). General orthopaedic surgeons were second last in burnout prevalence (32%), only higher than paediatric surgeons (31%) among the 14
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surgical subspecialties surveyed in the study [6].
Factors associated with burnout
Ten of the included papers reported factors associated with burnout in orthopaedic surgeons
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[16, 21, 24-30]. The factors associated with burnout are illustrated in Table 2.
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Personal factors including being female or being a racial minority were associated with higher rates of EE. Both groups faced the problems of harassment and discrimination, which were significantly associated with burnout [28]. Financial concern was a risk factor for EE, while alcohol and drug abuse was associated with higher DP [29]. Spending more time on hobbies was associated with lower rates of EE [21, 29]. Among orthopaedic department heads, having high self-efficacy was a protective factor against clinically significant burnout [24].
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ACCEPTED MANUSCRIPT Family also played an important role in burnout. Conflict between work and family life [27, 29], lack of support from spouses and poor marital relationship were positively associated with EE [21, 24, 27, 29]. Among orthopaedic surgeons working in a military hospital, having significant others on active military duty was a risk factor for burnout [16]. The small-scale
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pilot study conducted by Sargent et al. found that having a father who is a physician and spending more time with spouses reduced rates of EE respectively, while having a good
relationship with one’s mother reduced the risk of DP. Satisfaction from talking with friends
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and long working hours of spouse were associated with a higher sense of PA [29]. Sargent et al. also reported that being a parent was associated with higher PA in orthopaedic surgeons.
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This was echoed in a 2016 multinational cross-sectional study, where parenthood was an independent protective factor of clinically significant burnout among orthopaedic surgeons [30].
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Working environment was also identified as a significant determinant of burnout. Sleep deprivation had a major effect and was associated with raised EE, raised DP and low PA [21, 25]. Long working hours and number of nights on-call per week were also significant
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predictors of burnout [24-26, 29]. Barrack et al. utilised a prospective study design and assessed the change in burnout rates after standard working hours have been implemented in
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the US. After the initiation of standard working hours, only the orthopaedic residents recorded improved PA scores, while no demonstrable changes to burnout was observed in faculty members [26]. While working hours are associated with burnout rates, orthopaedic surgeons who had research duties on top of their clinical duties were less likely to be burnt out. This may be attributable to higher job satisfaction and sense of accomplishment [25]. Perception of stress in work was associated with EE [29], whereas stress in relationships with colleagues was linked to increased EE and DP [24, 29]. Apart from workload and stress, residents from
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ACCEPTED MANUSCRIPT large residency programmes demonstrated significantly higher rates of EE and DP than residents from smaller residency programmes [21]. Support in workplace was shown as a protective factor for burnout, as perceived support from faculty, satisfaction from talking to colleagues, and frequent contacts with mentors were negatively associated with EE and low
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PA [21, 29]. Quality mentorship is a protective factor against burnout in residents, as those who enjoyed talking with their mentors had lower rates of all EE, DP and low PA. Having a senior resident as a mentor was associated with lower EE, whereas having a faculty member
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as a mentor was linked to higher PA [21].
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The factors associated with burnout may vary in different stages of a surgeon’s career. Compared with faculty members, residents were more prone to all three burnout features of EE, DP and low PA [21, 28]. Early career orthopaedic surgeons were at higher risk of burnout, as the rates of EE and DP peaked at postgraduate year two in residency programs in
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the US, while surgeons with more than 10 years of post-residency experience were less likely to have EE and DP in the same study [21]. While senior staff had lower rates of burnout overall, Sargent et al. reported that senior faculty staff may worry about the competition due
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to the increasing number of orthopaedic surgeons, which was linked to higher EE. No significant association was demonstrated between concerns about competition and burnout in
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junior residents [29].
Anxiety about clinical competence was associated with higher EE, regardless of seniority and experience [29]. A surgeon’s perception of their career choice may be associated with burnout - Simons et al. reported that regret in choosing a medical career was a risk factor for EE and low PA [16], while job satisfaction was an independent negative predictor of overall burnout in Palthe’s study [30]. Factors specifically concerning senior orthopaedic surgeons in
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ACCEPTED MANUSCRIPT administrative positions were studied in a survey of orthopaedic chair professors. Increasing overhead, departmental and hospital budget deficits, tenure and promotion, loss of key faculty, staff dismissal and credentialing were all stressors which were significantly correlated
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with EE [24].
Effects of burnout on clinical practise
One study assessed the effect of burnout on clinical practise [25]. In their study on 202
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Chinese arthroplasty surgeons, Zheng et al. demonstrated that surgeons with higher EE were significantly more likely to lose their temper during operations. DP was not associated with
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incidences of intraoperative irritability [25]. Interestingly, Zheng’s study demonstrated that the seniority of the surgeon was associated with the likelihood that he/she has lost their temper once or more during operations in the past month (24% in residents, 58.9% in attendings, 65.0% in vice-chiefs, and 70.7% in chiefs; p<0.001). In contrast, the surgeons’
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seniority trended towards an inverse relationship with the prevalence of burnout, yet the trend was non-significant. The potential confounding relationships between intraoperative
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irritability, seniority and burnout were not further explored in the study.
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DISCUSSION
To the best of our knowledge, this is the first systematic review on burnout in orthopaedic surgeons. The prevalence of burnout varied in different centres and in staff with different seniority. A landmark study on 7288 US doctors from various specialties demonstrated rates of EE, DP and low PA to be 37.9%, 29.4% and 12.4% respectively [2], which appear comparable with the rates reported in the orthopaedic-specific studies in this paper. Among 6512 surgeons from 14 surgical subspecialties in Balch’s paper, trauma surgeons ranked top
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ACCEPTED MANUSCRIPT in burnout prevalence (51.6%), but general orthopaedic surgeons had the second lowest burnout prevalence of 32% [6]. Lesic’s study compared Serbian orthopaedic surgeons with general practitioners and could not demonstrate any significant differences in burnout rates [22]. In spite of the common notion that orthopaedics is a challenging specialty [15, 16], there
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is insufficient evidence to suggest that burnout rates are higher in orthopaedic surgeons than in other specialties.
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Despite the definition of burnout as an occupational condition [1], our review demonstrated that occupational factors were not the only factors associated with burnout, and personal or
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family factors were also key determinants of burnout in orthopaedic surgeons. Nonetheless, the risk and protective factors identified in this review should be treated with caution, as most of the factors were bivariate associations identified in small-scale cross-sectional surveys. The majority of studies did not perform multivariate analysis [16, 21, 24, 27-29], and it remains
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unclear whether the factors are independent predictors or covariates. It should also be noted that factors such as work-family conflict and anxiety about clinical competence could be effects of burnout. Reverse causality should be considered and it is difficult to determine
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whether such factors are the causes or effects of burnout. The studies also utilised nonvalidated questionnaires for the identification of demographic and family factors associated
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with burnout. The vague and subjective nature of such questions limit the external validity of the results and future studies should aim to utilise validated measures such as the Family Harmony Scale [31], the Connor-Davidson Resilience Scale [32] and the Subjective Happiness Scale [33].
As the literature illustrates that residency programme differences can influence rates of burnout [21, 34], we further analysed the training programmes and career pathways of the six
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ACCEPTED MANUSCRIPT countries with reported burnout rates in orthopaedic surgeons (Table 3). Overall, the general structure of the training programmes and length of training are similar. Of note, China is the only country without a centralised and structured orthopaedic training programme in the six countries [35, 36]. We hypothesize that the variability in training quality and lack of
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qualification recognition in China may increase trainees’ uncertainty, and may be attributable for the high burnout rates (85.1%) in Chinese orthopaedic surgeons [25]. Nonetheless, this would require further validation by studies involving more countries. A key discrepancy
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between the training programmes is the time required for orthopaedic trainees to rotate out to other specialties [35-39]. Yet, no patterns regarding rotation periods and burnout rates have
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been observed. Another interesting point to note is that certification by the American Board of Orthopaedic Surgery is technically voluntary, and surgeons do not have to get board certification after accredited residency. However, 98% of US doctors will complete the two parts of Orthopaedic board certification exams within five years of completing residency,
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hence this arrangement is unlikely to result in burnout rate differences between US and other countries. To further study the impact of residency training on burnout rates, future studies should stratify their cohorts by the orthopaedic surgeons’ seniority and year in training to
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enable comparison.
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Our systematic review identified one paper that showed a significant association between burnout and the likelihood of losing temper during operations, yet no further analysis on the effect of the irritable behaviour was documented [25]. This corresponds to prior studies, which demonstrated irritability as an early sign of burnout among other occupations [1, 27]. While irritable and disruptive behaviour in the operating theatre have been shown to affect patient care [40, 41], the direct effects of burnout on clinical performance in orthopaedic surgeons has not been quantified previously. Burnout has been associated with medical errors
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ACCEPTED MANUSCRIPT in internal medicine residents [9, 10] and general surgeons [42]. However, orthopaedic surgery is distinct from other specialties as it involves major trauma cases, diverse pathologies and complex procedures [15]. The potential negative effect of burnout on the challenging clinical work of orthopaedic surgeons is of particular significance and large scale
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prospective studies are warranted.
Major methodological limitations have been noted in the reviewed studies. The studies were
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from single centres [16, 23, 29], or targeted specific subgroups of surgeons such as trainees [19, 20] or department heads [24]. Hence, the generalisability of the results remains unclear.
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National and multi-centre assessment of the mental health of orthopaedic surgeons is required to provide further insight into the burnout epidemic [43]. With the availability of the MBI scale, mass screening of burnout in orthopaedic surgeons after specialty exams or during annual meetings may provide comprehensive and representative data for reference. A low
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response rate was also noted in the reviewed studies. Most studies had response rates of less than 60% [16, 21, 24, 28, 30], and the response rate was lowest in Zheng’s study at 12.3% [25]. The low response rate could lead to volunteer bias, and measures to enhance
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participation such as cash incentives should be utilised in future studies [44]. None of the reviewed studies addressed whether anonymity was maintained during the data collection
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process. Since the studies were carried out in single centres [16, 22, 26] or in small cohorts of orthopaedic surgeons [19-21, 23, 24, 27-29], non-anonymity of questionnaires could lead to social desirability bias, where the respondents try to present themselves as more socially desirable [45]. This is particularly relevant in the context of sensitive questions in relation to mental health and could lead to underestimation of burnout. Concerted efforts to maintain anonymity or conducting surveys through third parties may reduce the risk of social desirability bias and provide a more accurate depiction of the burnout rate.
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This systematic review did not identify any papers on the management of burnout in orthopaedic surgeons. The evidence on treatment of burnout in doctors is generally scarce. Educational and mindfulness training programmes for doctors have demonstrated positive
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results in pilot studies [46-48], yet the long-term outcome and scalability of such
interventions remain undetermined. An alternative approach for burnout management is to identify the key protective factors and optimise such factors [43]. It is clear that the current
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data in orthopaedic surgeons is limited, and more rigorous research to identify protective factors against burnout is required. While policy changes and workplace interventions such as
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mentorship programmes and standard working hours may have a role in reducing burnout rates, a holistic approach to target the family and personal factors of burnout as well should be adopted [5].
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CONCLUSIONS
The evidence on burnout in orthopaedic surgeons is preliminary, and key methodological limitations have been noted. Large scale prospective studies are warranted to assess the
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determinants and effects of burnout in orthopaedic surgeons, in order to guide interventions
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against this occupational health hazard.
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Low personal High depersonalization achievement (%) (%) NR NR
Overall burnout rate (%)^
37.0
25.9
37.0
25.0
33.3
33.3
11.4
NR
16.2
45 NR
35 NR
43 NR
45 32
NR 32 28.4 40.0 36
NR 56 24.8 34.5 27
NR 18 10 29.6 4
51.6 56 28.4 40.0 36
50.7
59.4
17.4
59.4
Setting
Cohort
High emotional exhaustion (%)
Zheng et al. 2017 25
China
202 surgeons
NR
27 residents
29.6
11 staff surgeons
33.3
Netherlands
105 trainees
16.2
Australia US
51 trainees 155 general orthopaedic surgeons 345 Trauma surgeons 384 residents 264 faculty members 30 surgeons 110 current chairs or chiefs 69 surgeons
Sargent et al. 2009
US
21
Serbia US
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Lesic et al. 2009 22 Saleh et al. 2007 24
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Sadat-Ali et al. 2005 Eastern province, Saudi 23 Arabia Table 1. Prevalence of burnout among orthopaedic surgeons *NR= not reported
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van Vendeloo et al. 2014 19 Arora et al. 2014 20 Balch et al. 20116
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Simons et al. 2016 16 US Army Medical Centre
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Study
^Burnout rate is defined as the presence of high emotional exhaustion or high depersonalization by the Maslach Burnout Inventory.
85.1
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Family factors
Working environment
Career
Positively associated with burnout
• Female 28 • Racial minorities 28 • Harassment and discrimination 28 • Financial concerns 29 • Alcohol and drug abuse 29
• Work-family conflict 27, 29 • Lack of spousal support/poor marital relationship 24, 27 • Significant others on military service 16
• Sleep deprivation 21 • Working in large residency programmes 21 • Excessive work/long work hours 24, 29 • Nights on-call per week 25 • Perception of stress in work 29 • Stress in workplace relationships 29
• Regret in choosing medicine 16 • Current residents 21 • Anxiety about clinical competence 29 • Worry about competition from other orthopaedic surgeons 29
Negatively associated with burnout
• High self-efficacy 24 • Time for hobbies 21, 29
• Physician father 29 • Good relationship with mother 29 • Satisfaction from talking to friends and family 29 • Spends personal time with spouse 29 • Spouse work long hours 29 • Good marriage quality 21,
• Perceived support from faculty 29 • Satisfaction from talking with colleagues 29 • Frequent contacts with mentor 21 • Standard working hours 26 • Research duties on top of clinical duties 25
• Completed residency for more than 10 years 21 • Job satisfaction 30
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29
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• Parenthood 29, 30
Table 2. Factors associated with burnout
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Personal factors
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China
Netherlands
Saudi Arabia
Serbia
US
6
5
6
5
5
5
2
3
1.5
2
1
1
4
2
4.5
3
4
4
Structured training
Yes
Variable
Yes
Yes
Yes
Yes
Continuous
Yes
Variable
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Minimal duration of training programme (years) Basic surgical
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training/ Rotation to other surgical
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specialties Orthopaedic
assessment
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training
Yes
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Exit examination
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Australia
Table 3. Brief overview of Orthopaedic training pathways
(Board certification is voluntary)
ACCEPTED MANUSCRIPT 216 articles identified through database search
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200 articles were excluded - 25 articles: not in English language - 19 articles: not original research articles - 142 articles not relevant to topic - 12 articles did not assess orthopaedic surgeons - 2 articles did not use validated scales for burnout assessment 16 articles remained, with full text accessed for eligibility
14 articles included in qualitative synthesis
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2 articles were excluded in panel discussion - Articles assessed burnout in surgeons in general, without specific analysis for orthopaedic surgeons
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FIGURE 1. PRISMA flow diagram of studies included into the systematic review