The Prevalence of Stress and Burnout among Doctors

Abstract

Aim: In light with the recent high turnover among medical practitioners in the United States with stress and being considered as some of the contributing factors, the proposed research intends to assess the prevalence of stress and burnout among doctors and the main contributory factors.

Methodology: a questionnaire survey will be given to 100 medical practitioners (61 males, 39 females) who will have worked over 5 years at different types of hospitals or multiple departments within the United States. The survey will include a burnout evaluation (Maslach Burnout Inventory (MBI)), stress (Job Stressor Scale), irrational beliefs (Japanese Irrational Belief Test), and automatic thoughts (Automatic Thoughts Questionnaire-Revised), in addition to the intention to resign.

Findings: The anticipated stressors that lead to burnout include: conflict with other medical practitioners, medical practitioner role conflict, workload, and conflict with patients. The anticipated irrational beliefs related to burnout include: problem avoidance, dependence, and helplessness. A two-way ANOVA will show a significant interaction of the above factors with emotional exhaustion, but no significant interaction with depersonalization plus a sense of accomplishment.

Conclusion: the proposed research will conclude that stress and burnout among medical practitioners can be prevented in addition to the number of medical practitioners quitting their profession by changing irrational beliefs to rational beliefs and improving negative automatic thoughts to positive automatic thoughts.

INTRODUCTION

Background

A major concern in health care services over the past couple of years has been the inability to retain doctors (Shanafelt et al., 2012). The presence of stress and burnout among doctors as a likely contributory factor to the delivery of poor quality care in an already burdened health care system has become a topic of interest. Burnout refers to a negative, persistent, work-related state of mind, which is characterized by exhaustion plus, most of the times, it is accompanied by stress, decreased motivation, a feeling of reduced effectiveness, and dysfunctional attitudes and behaviors in the place of work (Shanafelt et al., 2012). It can basically be defined by three elements, including emotional exhaustion, low personal accomplishment and depersonalization.

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A majority of the researches conducted globally have argued that the between 22% and 66% of doctors report experiencing burnout (Regehr et al., 2014). In the United States, studies are normally small in size plus most have used different measuring instruments, which limit extrapolation of the findings and comparisons across studies (Regehr et al., 2014). A nationwide survey among randomly selected medical practitioners (N = 300) conducted in 2014 documented high levels of stress and burnout (Dyrbye et al., 2014). A cross-sectional research carried out on depression among doctors working in Arizona State Hospital found out that 2% of the doctors reported severe feelings of anxiety and depression; a further 21% reported moderate symptoms; and another 47% were symptom-free (Toh et al., 2012). According to Shanafelt et al. (2016), burnout, with a lifetime prevalence of 14%, appears to be common in doctors as in the general American population. Furthermore, the life time prevalence of mood disorders in the United States in the general population, between 2010 and 2014, was 10.2% (Shanafelt et al., 2016). 

According to research, common issues that contribute to burnout among doctors comprise of excessive workload, bad organizational work culture, equipment issues, inappropriate training for being a medical practitioner, long working hours, management problems, lack of support systems, and little vacation time (Dewa et al., 2014). Burnout has also been linked to absent days from work, decreased job satisfaction, inability to stay at one place of work, and most importantly, suboptimal patient care (Kravits et al., 2010). On an international scale, another multi-country, cross-sectional survey carried out in 10 EU member states involving over 23,000 medical practitioners working in medical and surgical wards reported high levels of burnout in different countries: Switzerland (15%), Netherlands (10%), Spain (29%), Norway (24%), Ireland (41%), Poland (40%), Germany (30%), Belgium (25%), Finland (25%) and England (42%) (Dyrbye & Shanafelt, 2011). The intention to quit the profession was overly high among the medical practitioners.

Another study published by Shanafelt and Dyrbye (2012) reported that over 40% of medical practitioners experience burnout on a day to day basis, plus 25% of these individuals would not recommend the profession to anyone. Working as a doctor is a challenging task and a hospital setting offers a breeding ground for stress and burnout to medical doctors. The proposed research will study the magnitude of this problem so as to motivate the development of an action plan for doctors working in a stressful hospital setting. The proposed study will assess the prevalence of stress and burnout among doctors and the main contributory factors.

Research Problem

Unlike other industries wherein dissatisfied workers can, at any moment, obtain relief by finding new jobs, doctors’ workplace conditions are normally filled with a lot of protocols, which make it overly hard to leave; such protocols involve time and costs linked to re-licensure and re-credentialing, financial and emotional links to the hospital and other physicians, and the extensive investment in training and education (Ro et al., 2010). With the high prevalence rate of stress and burnout that was reported earlier in this proposal, it implies that a significant number of doctors are not performing to their level best, which also creates problems when it comes to ensuring the best possible health outcomes among patients (Contag et al., 2010).

Furthermore, the number of literature carried out on a nationwide scale on the prevalence of stress and burnout together with the contributory factors within the United States are overly limited. A majority of the studies carried out on this topic have focused one or two hospitals (Contag et al., 2010). Also, there a many studies that have focused on a single state, but with the different regulations in different states and conditions of working backed with states that experience more at risk communities with regards to health care, this can limit one’s understanding of how stress and burnout affects doctors (Dyrbye et al., 2011). It is important to carry out a nationwide research that will add to the literature focusing on the entire country. The propose research intends to achieve this by randomly selecting doctors across the United States and interviewing them in order to understand how stress and burnout affects their work and the main contributory factors to reported burnout cases.

Proposed Aims and Objectives

In light of the above discussed research problem, the proposed research will be guided by the following aim

• To understand the magnitude of stress and burnout among doctors

The above aim will be guided by the following objectives

• To explore different contributory factors in hospital setting
• To compare rates of stress and burnout in doctors working different amount of time, plus at different levels of experience
• To study the impact of stress and burnout on perceived patient care
• To study doctors’ level of resilience, and
• To recommend the development of an action plan to help doctors working in stressful hospital settings

Proposed Methodology

The proposed study will essentially assume a descriptive approach into fulfilling the abovementioned research objectives. A descriptive approach normally involves studying the target population and understanding how different variables concerning the target population influence one another. Also, the proposed research will employ a mixed methodology in order to fulfill the above stated objectives. The mixed methodology will involve qualitative and quantitative approaches. The qualitative approach will essentially be achieved through a literature review that will aid in coming up with different hypotheses that will be tested. The quantitative approach, on the other hand, will be achieved through analyzing the responses of each and every respondent. 100 medical practitioners will randomly be selected and sent to questionnaires that will require them to respond to issues regarding burnout, stress, irrational beliefs, and automatic thoughts, in addition to the intention to resign.

Propose Theoretical Framework

The proposed research will be guided by Maslach’s theory of burnout. According to Maslach, burnout arises from a mismatch between a worker and the demands of the job. Therefore, for burnout not to arise, the worker and the demands of the job have to match (Hu et al., 2012). According to Maslach’s theory, stress and burnout comprise of three dimensions, including inefficacy, cynicism/depersonalization, and emotional exhaustion (Maslach et al., 1981). Emotional exhaustion is signs such as frustration, moodiness, agitation, etc. Depersonalization, on the other hand, creates a distance or some sort of detachment between workers. Finally, inefficacy refers to a sense of reduced personal accomplishment. Doctors who experience burnout can have a sense of inefficacy, which makes them feel worthless at their place of work thus reducing their performance levels. This theory considers six factors, which can lead to a mismatch between a worker and his/her job; they include: (1) workload, (2) lack of control, (3) reward, (4) fairness, (5) community, and (6) values (Maslach et al., 1981). 

Proposed Structure

Following the approval of this research proposal, the actual research will include five different chapters. Chapter one will be the introduction. It will expound on the research background earlier discussed, research problem, aims and objectives of the research, the proposed methodology, significance of the research, theoretical approach, and research delimitations. Chapter two will present the literature behind the research discussing different topics under stress and burnout with a special emphasis on medical practitioners. This will be done with the main intention of synthesizing the findings, which will help in coming up with different hypotheses that will be tested later on in the research. Chapter three will comprise of the research methodology. This chapter will include: (1) research design, (2) research approach, (3) research philosophy, (4) research strategy, (5) target population, (6) sample size, (7) data collection methods, (8) data analysis methods, and (9) the ethical approach of the research. Chapter four will present the results of the primary research. This will involves grouping the findings into different themes that are method to either validate or invalidate the hypotheses. This chapter will also compare the findings to past literature. The final chapter five will conclude the research by summarizing the findings, discussing the implications of the research, research limitations and suggestions for further research.

PROPOSED METHODOLOGY

This section will explain the methodology that will be applied in the proposed research. It will comprise of three sections: the first section will describe the nature of the research participants while the second section will explain the materials that will be applied in collecting data. The third and last section will explain the research process that will be applied.

Proposed Hypothesis

Before we discuss the methodology that the proposed research will apply, it is important to first understand the different hypotheses that are going to be tested. The first hypothesis is that the negative physical and emotional aspects of a medical job lead to emotional stress. This is characterized by high feelings of moodiness, agitation and frustration among medical practitioners. It causes medical practitioners to act in a way that is not in line with their work and those who go through this cannot effectively cope with the demands of their medical work (Gleichgerrcht & Decety, 2013). According to the researchers, the more a medical practitioner goes through such situations, the higher their chances of experiencing stress and burnout (Shanafelt et al., 2016).

The second hypothesis that the proposed thesis will test is that high job demands and disengagement of medical practitioners lead to depersonalization. This hypothesis was derived from Privitera’s et al. (2014) study who argued that depersonalization tends to create more distance and detachment from one’s job, which is coupled with different negative feelings concerning the work. In their study, the researchers were warning against view people as objects rather than human beings. Viewing people as objects leads to more detachment, which can be rectified by viewing them as human beings who require careful treatment.

Finally, the third hypothesis that the proposed thesis will test is that stress and burnout lead to a sense of reduced personal accomplishment and inefficacy. An overall sense of unworthiness and incompetence is experienced at after someone self-evaluates their job performance (Ohue et al. 2011). In light of this, this hypothesis will profess that burnout has a negative effect on job performance, relations with colleagues, turnover, which might result into conflict.

Therefore, the three hypotheses that will be tested include:

H1: negative physical and emotional aspects of a medical job lead to emotional stress

H2: high job demands and disengagement of medical practitioners lead to depersonalization among medical practitioners

H3: stress and burnout lead to a sense of reduced personal accomplishment and inefficacy

Research Participants

The proposed research will make use of working medical practitioners who have worked in different hospital levels for at least five years and above. This was to ensure that the survey includes practitioners with at least some years of experience. A random sampling method will be applied in selecting the medical practitioners. As it was earlier stated, the research intended to add to the literature that covers a nationwide audience by surveying medical practitioners from different hospitals in different states. Therefore, the random sampling that will be applied will give different medical practitioners an equal chance to be selected for the research. Random sampling will eliminate any systematic bias that might affect the proposed research (Shanafelt et al., 2012).

Since the proposed research intends to paint a nationwide picture of how stress and burnout is affecting medical practitioners, choosing doctors from one hospital or one state means that one is choosing to overlook factors that affect doctors in other hospitals or states within the U.S. A randomized method of sampling will allow one to gather data from different types of doctors in different hospitals, and furthermore, different states. This will allow one to easily understand the general contributory factors to stress and burnout among medical practitioners in the United States.

It is important to note that the intended number of respondents will be N = 100. Even though 100 medical practitioners will be an insignificant representation of the number of doctors in the whole of United States, this figure was deemed fit due to data manageability purposes. The proposed study lacks the general resources and time to conduct a large-scale research. Nonetheless, all research protocol will be adhered to in order to ensure that the findings echo the views of all the research participants.

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Materials

The proposed study will be rooted on the use of self-report questionnaires. The details of the survey instruments and all their measurement scales are explained below:

• Personal Factors

The burnout of medical practitioners had been linked to age, sex, department of work, marital status, educational background, and clinical experience (Regehr et al., 2014). Therefore, the proposed study will collect these data from the research participants to see how they correlate to burnout.

• Burnout

The Maslach Burnout Inventory (MBI) by Maslach (1981) will be used in evaluating burnout, which comprises of three factors, including emotional exhaustion, personal accomplishment, and depersonalization. The scale is made up 17 questions and its users select one of five answers ranging from “always yes” to “no”. Greater scores on emotional exhaustion and depersonalization and lesser scores of personal accomplishments imply a greater tendency of burnout.

• Stressors

The Job Stressor Scale (JSS) that was developed by Higashiguchi et al. (1998) will be applied in evaluating stress. It comprises of 33 items describing potential stressful situations for medical practitioners, which are divided into seven subscales: (1) conflict with other medical practitioners, (2) medical practitioner role conflict, (3) conflict with none-medical staff, (4) dealing with dying and death, (5) quantitative workload, (6) qualitative workload, and (7) conflict with patients. Higher scores imply higher burden of the stressor.

• Automatic Thoughts

The Japanese Automatic Thoughts Questionnaire-Revised (ATQ-R) that was developed by Kodoma et al. (1994) will also be applied in the proposed research. The instrument has 38 questions, including 15 items for negative evaluation, 10 positive evaluation, and 13 for self-blame. Users select one in five answers ranging from “definitely yes” to “definitely no”. greater scores show that the individuals have strong automatic thoughts.

• Irrational Beliefs

The Japanese version of the Irrational Belief Scale was applied in measuring irrational beliefs. It was developed by Mori et al. (1994), which comprises of 20 questions, which test on self-expectation, ethical blame, dependence, problem avoidance, and helplessness. Users select one in five answers ranging from “definitely yes” to “definitely no”. greater scores show that the individuals have strong irrational beliefs.

• Intention to Design

The research participants will also be asked whether they intent to resign at the time of the study, based on categories developed by Tsuchie and Nakamura (1993). These categories include: whether or not they would like to switch departments or hospitals, and whether or not they want to continue working as medical practitioners.

Procedure

An α-coefficient will be calculated to assess the reliability of the answers on each and every scale. Correlations between burnout and the traits of the participants will be assessed by a t-test, as well as a one-way ANOVA. The relationships between stresses and burnouts will be examined using multiple linear regression analysis, seven Job Stressor Scale subscales applied as the dependent variables, as well as three MBI subscales applied as the dependent variables. Likewise, the relationships between burnout and irrational beliefs will be assess using multiple linear regressions with five Irrational Belief Scale subscales as the independent variables, as well as three MBI subscales as the dependent variables. The relationship of burnout and positive and negative automatic thoughts will be assessed by dividing the participants into groups of high and low “positive automatic thoughts” and into groups with high and low “negative automatic thoughts,” which will be based on a median score. After this, a two-way ANOVA will be conducted by applying the three MBI sub-scales. “Self-negation” and “suture negation” will be applied as negative automatic thoughts.

Based on the findings of the analysis of the stressors, automatic thoughts, and irrational beliefs, the hypothetical model will be examined with a covariance structure analysis with related variables. To study the hypothetical model, comparisons will be made of direct and indirect implications and of the three models wherein burnout will affect cognition. The models with high conformance will be chosen using the Goodness of Fit Index (GFI), Comparative Fit Index (CFI), Adjusted GFI, Akaike’s Information Criterion (AIC), and Root Mean Square Error of Approximation (RMSEA). A logistic multiple linear regressions will later be applied to assess the relationship between burnout and the intention to resign using the MBI subscales as the independent variables and the items of intention to resign as the dependent variables.

Stress and Limitations

The main strength of the proposed research will be the method of selecting the participants. As it was earlier stated, a randomized approach gives different types of medical practitioners a fair chance of being included in the research. A randomized approach will reduce any bias expected with collecting information/data for a research. This will make the findings appear more reliable.

Also, the use of a questionnaire will provide a standard and quick way of gathering information. This is because respondents will only have to tick appropriate answers to the questions asked plus they will not be worried about their confidentiality because they will not be asked to fill in their personal names or any information that can be linked back to them.

The main limitation of the proposed research will be the sample size. 100 doctors will limit the ability to generalize the findings of the research to the entire number of medical practitioners in the United States. Researchers usually advise that one uses a sample size of 30% of the entire target population (Dewa et al., 2014). This would imply interviewing tens of thousands of medical practitioners in order for the findings to be generalized to the entire target population. Nonetheless, this cannot be possible due to the limited resources for the proposed research. Also, such a large-scale study will require a lot of time to complete. Nonetheless, in order to maintain the credibility of the research, factual information will be presented with regards to how each and every respondent responded to the survey questions.

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RESULTS

This section will involve a dummy analysis of the proposed research in order for the reader to understand how the data will be analyze and interpreted in order to turn them into results so that the researcher can come up with the conclusions.

Gender Difference Analysis

In this section, it will be assumed that the number of males and females who took part in the research were 61 and 39 respectively making the total population (N) 100. Initially, a Mann-Whitney test will be carried out to see if there is any statistical difference on burnout according to sex. It is anticipated that the test will not confirm any statistical difference on burnout according to sex. The cut-off scores will be derived for each MBI scale rooted on one standard deviation below/above the sample mean. For example, a score of >22 will be identified for emotional exhaustion; a score for ≥ will be identified for depersonalization; and a score of >23 will be identified for personal accomplishments. The study will record the percentage of the participants who report high and low emotional exhaustion, depersonalization and personal accomplishments.

Individual Scales Reliability and Descriptive Statistical Values

We can assume that the α-coefficient for the difference subscales will be as follows: ATQ-R (automatic thoughts), 0.75-0.93; JIBT (irrational beliefs), 0.71-0.85; MBI (burnout), 0.75-0.85; and NJSS (stressors), 0.71.0.92. In case the coefficient of reliability for all scales is close to the acceptable value, as well as to the reliability of the original scale as the figures displayed above, it will be assumed that each scale will be showing internal consistency.

Factors Affecting Burnout

According to review of past literature and the hypotheses developed for the proposed research, it is anticipated that for emotional exhaustion, considerable differences will be found for age, sex, marital status and work department. In nearly all studies reviewed, the scores for females appear to be considerably higher compared to male medical practitioners. Also, the scores for people aged between 20 to 25 years will also be greater compared to older medical practitioners. Also, it is anticipated that the score of the single participants will be higher compared to married participants. The department in which the medical practitioners worked is considered to also have a considerable effect in their level of stress and burnout. Departments such as gynecology and obstetrics will have greater scores compared to those in less demanding departments. It is important to remember that the above claims are made from the review of the findings of past literature such as (CITATION) on the same subject matter.

For depersonalization, a considerable difference is expected for clinical experience. A multiple comparison is expected to show that the scores of the medical practitioners with less than 3 years of experience are higher compared to those with more clinical experience. With regards to personal accomplishment, a considerable difference is expected between departments. For instance, in Kravits’ et al. (2010) study, the researchers found higher scores for nurses working in the outpatient and pediatrics department compared to the previous departments that were mentioned (gynecology and obstetrics).

Relationship between Stressors, Automatic Thoughts, and Irrational Beliefs Affecting Burnout

With regards to stressors, the emotional exhaustion subscale of burnout is expected to show positive correlations with quantitative workload, qualitative workload, and conflict with patients. The depersonalization subscale is expected to reveal positive correlations with conflict with other medical practitioners, quantitative workload, qualitative workload, and a negative correlation with conflict with other medical practitioners. The personal accomplishment subscale is expected to show a negative correlation with quantitative workloads, and qualitative workload. It will show a positive correlation with conflict with other medical practitioners.

For irrational beliefs, emotional exhaustion that is related to burnout is expected to show positive correlations with helplessness and depersonalization. Personal achievement, on the other hand, is expected to show negative correlations with helplessness and dependence.

The scores for positive and negative thoughts will be grouped into high and low levels using the respective median scores as the point of cut-off. A two-way ANOVA will be conducted for the cells defined by a combination of the main levels so as to study the interactional and main effects of positive and negative automatic thoughts on each the MBI subscale. It is expected that the observations will indicated higher effects of positive automatic thoughts for larger negative automatic thoughts; it will also indicate higher effects for negative automatic thoughts for inferior positive automatic thoughts for all the subscales. The two-way ANOVA will show that the interactional effect of positive and negative automatic thoughts was not significant for personal accomplishment and depersonalization. However, the proposed research will also study the main implications of positive and negative automatic thoughts separately wherein it is expected that the two will be highly significant. For emotional exhaustion, the interactional effect for positive and negative automatic thoughts is expected to be positive. Because of this, the proposed research will also study the effects of one factor (“positive” or “negative”) on emotional exhaustion for every level of another factor (“negative” or “positive”).

On one hand, it is expected that the effect of positive automatic thoughts will be highly significant for the greater level of negative automatic thoughts and hardly significant for the lower level of negative automatic thoughts. The effect of negative automatic thoughts, on the other hand, will be highly significant for the lower level of positive automatic thoughts, and not significant for greater levels of positive automatic thoughts.

Relationship between the Intention to Resign and Burnout

An examination of the relationship between the intention to resign and burnout among the medical practitioners will show that wanting to quit working as a medical practitioner positively correlates with emotional exhaustion and depersonalization. Wanting to quit, however, will negatively correlates with personal accomplishment. Wanting to switch departments or hospitals will positively correlate with emotional exhaustion. Wanting to continue working as a medical practitioner, on the other hand, will negatively correlate with emotional exhaustion and depersonalization, and positively correlate with personal accomplishment. It is expected that a significant odds ratio will be derived from these relationships.

DISCUSSION

The expected findings of the research will be that stress and burnout are prevalent among medical practitioners and that increased emotional exhaustion, inefficacy, and depersonalization can work to increase these problems among the targeted population. It is expected that a very high percentage of medical practitioners will be experiencing stress and burnout as shown by the dummy high scores in the results section. In order for the results to stand out, over half of the medical practitioners will be having high scores on emotional exhaustion, which will suggest that over half of the medical practitioners working in the United States feel emotionally overextended and stressed by their work. Past studies have also uncovered similar finding including (Dyrbye & Shanafelt, 2011) who concluded that over half of the doctors how work in a primary care setting experience stress and burnout. It is, however, important to note that Dyrbye and Shanafelt (2011) surveyed doctors working only in district and community level hospitals. Their study did not focus on different kinds of medical practitioners as the proposed study will. The proposed study is expected to draw a bigger picture that different kinds of medical practitioners in the United States experience stress and burnout. The findings of the proposed research are also expected to echo Shanafelt and Dyrbye (2012) research who found out that almost half (42%) of the doctors in the United States are unhappy with themselves, which has contributed to their dissatisfaction with their jobs, as well as their accomplishments.

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One of the implications of this is that, in some studies, medical practitioners have reported dehumanized and callous perceptions of their respective patients as they perceive they are the lead causes of their stress and burnout (Ro et al., 2010). In the proposed research, the depersonalization of medical practitioners will be tested and the anticipated high score will reveal that stress and burnout can lead to the depersonalization of doctors, which goes hand in hand which the findings of Ro et al. (2010) who argue that doctors become distant of unattached from their patients as a result of stress and burnout. Such a result of the anticipated research will lead to the recommendation of policymakers to deal with work issues of these medical practitioners, and develop a system, which would effectively enhance work motivation and job satisfaction.

The proposed research is also expected to finding greater mean scores for stress and burnout when contrasted to mean scores in smaller studies of medical practitioners within the United States. In addition, the proposed research will suggest greater rates of stress among medical practitioners in the national primary care settings than tertiary care settings. The discussion part of the proposed research will involve comparing studies that focused on a smaller population and those that focused on tertiary care settings to the findings of the proposed study, which will focus on bigger hospitals across the United States.

According to Contag et al. (2010), the opposite of burnout is engagement, which is essentially characterized by low stress, low depersonalization, as well as high personal achievement. The authors surveyed doctors in a tertiary care setting in the United States and claimed that 76% of their medical practitioners reported feelings of low stress, low depersonalization, as well as high personal achievement because of the different measures the hospital had taken to ensure that their doctors are highly motivated. A thorough database research did not reveal any study wherein a majority of the doctors in a large-scale hospital are highly motivated to work; however, a majority of them reveal greater cases of stress and burnout among the medical practitioners. Therefore, this study will seek to confirm whether this is true or false by comparing the findings of the findings of past studies.