INTRODUCTION

Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment1. In recent years, doctors’ burnout has become a major public health issue in most Western countries. Its prevalence is quite high in many countries, in residents as well as experienced physicians and regardless of the specialty2. In one recent US study, 54.4% of a cohort of 6880 physicians had experienced at least one symptom of burnout3.

Doctors’ burnout has important harmful effects on the healthcare system. It appears to increase the risk of medical errors by residents4 as well as their elders5 and impair the professionalism of doctors6 as well as their productivity (availability at work, sick leaves)7. It thus costs hospitals and communities dearly8.

Consequences for doctors can also be serious, increasing their risk of suicide9, even though they are at higher risk than the general population for depression and for traffic accidents10.

The scientific literature on this subject is abundant. This quantitative literature has generated several narrative and systematic reviews as well as meta-analyses that have made it possible, in particular, to describe the correlates of doctor burnout across regions and specialties11 and its impact on their productivity7, to list the factors, internal and external, that can cause this burnout12, and to assess the effectiveness of different interventions, focused on either the individual or the organisation13. Accordingly, young physicians, women, and those in more isolated practices appear to be at greater risk of burnout. Similarly, common personal characteristics of doctors, ones that favored their academic success, such as their perfectionism, compulsiveness, guilt, and self-denial, may predispose them to burnout, as do the current changes in healthcare environments and in hospital administration, by creating substantial external pressures12.

To our knowledge, there is no systematic review of the qualitative literature on physician burnout. Qualitative methods are especially relevant in this context, aiming as they do to describe and understand complex phenomena in greater depth. They are a tool of choice for focusing on the views of the physicians of how they live, conceive, and understand burnout in their own professional field. Because qualitative studies are usually conducted with small samples and in specific context, there may often be concern about the generalizability of their results.

The objective of this study was to explore physicians’ perspectives on burnout by applying a metasynthesis approach, including a systematic literature review and analysis of qualitative studies on the subject14,15.

METHODS

Study Design

This metasynthesis relies on our six-stage approach16,17,18,19,20 inspired by the model of meta-ethnography21 and the procedures of the thematic synthesis22. It complies with the ENTREQ reporting guidelines23.

Our approach consisted of six successive stages:

  1. 1.

    Defining the research question, the subjects, and the types of studies to be included

  2. 2.

    Identifying and selecting the studies

  3. 3.

    Assessing the quality of the studies selected

  4. 4.

    Analyzing the studies, identifying their themes, and translating these themes between the studies

  5. 5.

    Generating the themes of the analysis and structuring the synthesis

  6. 6.

    Writing the synthesis

The thematic analysis contained two phases: one descriptive, which defined and compared the themes, and the other interpretive, which developed original ideas drawn from the review.

Search Strategy and Selection Criteria

We conducted a systematic search in four databases according to a search algorithm specific to each base: Medline, PsycINFO, EMBASE, and SSCI through June 30, 2018. Preliminary research had identified several articles from which we selected key words. The research group used existing literature reviews to determine a list of key words, a mix of free-text terms and thesaurus terms, referring to burnout, physicians, and medical residents, and qualitative research, to collect studies indexed in the databases. Our search strategy is available as supplementary material (supplementary material online, Table S1).

Inclusion criteria were qualitative research regarding burnout from the physicians’ perspective (medical doctors, residents, trainees), published in peer-reviewed journals, in English or French language. Exclusion criteria were quantitative or mixed studies, reviews, commentaries, editorials, theses, and non-peer-reviewed journal articles. We discussed potential articles at meetings of our research group, composed of specialists in qualitative research and physicians. We decided to include all studies related to physicians’ burnout without requiring that it necessarily be the principal object of the study.

Extensive lateral searches—systematic checking of reference lists, hand searching of key journals and the PubMed sidebar of related articles—also sought to identify papers that might have eluded our algorithms. Three authors (AM, LBC, and JS) independently screened the papers retrieved, initially by title, then by abstract, and finally by full text.

After collecting the references and eliminating duplicates, two authors (JS and LBC) subsequently read the titles and abstracts to assess their relevance to our target subject and methodology. The database indexing of qualitative studies was rather poor, and most of the references collected were actually quantitative studies. They were eliminated at this step. When the abstract was not sufficient, we read the entire article. Disagreements were resolved during meetings of the research group. The potentially relevant articles were then read in full, and a second selection made to keep only the article that met our inclusion criteria.

Assessment of Article Quality

We assessed the quality of included articles using the Critical Appraisal Skills Program (CASP)24. It comprises 10 questions: two screening questions about the aims of the research and appropriate use of a qualitative methodology and eight questions covering research design, sampling strategy, data collection, researcher’s reflexivity, ethical issues, data analysis, the findings, and the value of the research. Two authors (JS and AM) performed this assessment independently and then discussed the results within the research group until we reached agreement. Given the lack of consensus about the role and function of study quality assessment as part of systematic reviews, we did not exclude any study from the analysis based on our evaluation. However, results are as reliable as they are based on the studies with high methodological quality. We therefore performed a secondary sensitivity analysis by excluding from the synthesis studies in the lowest quartile of methodological quality15.

Data Analysis

Our analysis began with an attentive reading and then repeated readings of the titles, abstracts, and texts of each article. One researcher (AM) extracted the formal characteristics of the studies, and three (JS, AM, and LBC) independently extracted and analyzed the first-order results (that is, the study results) and the second-order results (authors’ interpretations and discussions of the results) in a form of a summary for each study selected; these independent analyses were then compared and discussed at the research meetings.

Thematic analysis followed the five-stage approach (supplementary material online, Table S2). Thematic analysis made it possible to develop themes inductively, from our study data. The work of translation involved comparing and assembling the themes obtained by the analysis of each article to retain the key themes that capture similar ideas in the different articles and then to develop overarching concepts about the research question. The high level of rigor of the results was obtained by triangulation of both the data sources and the analyses: three independent analyses and monthly research meetings to discuss the results. NVivo 11 software was used to manage data, facilitate the development of themes, and verify the researchers’ contribution to the findings.

RESULTS

Presentation of Studies

Of the 2807 articles initially retrieved (after duplicates were removed), 33 articles covering data from more than 1589 medical doctors (68 residents and 1521 physicians) were included in this metasynthesis (Fig. 1).

Figure 1
figure 1

Flow of information through the different phases of study selection. From Moher et al. 64

The median sample size was 22 (range, 7 to 676). These 33 studies came from 15 countries, 22 of them from English-speaking countries. Data were collected mostly through interviews (28). Table 1 describes the characteristics of the studies we included.

Table 1 Main Characteristics of the Studies

The quality appraisal showed that the overall quality of the studies was high (Table 2 and supplementary material online, Table S3). The principal flaw was that several papers failed to address the role of the researchers’ contribution to the findings and/or interpretations. Secondary analysis without the 8 studies with the lowest quality score on CASP (< 18/20) 25,28,33,38,40,48,51,54 did not change the results.

Table 2 CASP Summary

Description of the Themes

Two themes emerged from the analysis: (1) the stress factors promoting burnout—ranked as organizational, then contextual and relational, and finally individual—factors and (2) the protective factors, which were above all individual but also relational and organizational. Table 3 presents quotations from participants and from the authors of the primary studies for each theme. Table 4 gives a list of all the stress and protective factors found in the studies.

Table 3 Quotations
Table 4 List of Stress and Protective Factors

It is important to note that none of these studies directly explored the experience of burnout from the point of view of doctors. Several studies provided descriptive elements of doctor burnout that matched the clinical descriptions in the literature: feelings of exhaustion, chronic fatigue, decreased motivation, mood swings, irritability, low tolerance for stress, apathy, vulnerability to psychosomatic symptoms, and sadness25,26.

The Stress Factors Associated with the Onset of Burnout

The doctors included in these studies reported numerous stress factors that could promote the onset of burnout.

Organizational Factors

The physicians in these studies recognized organizational difficulties as the stress factors contributing the most to burnout27.

Nearly all the studies reported aspects of burnout associated with the organization of work. The doctors noted especially workloads that were too high25,26,28,29,30,31,32,33,34 and especially the load of paperwork29,35,36 and insufficiently diversified work37.

The theme of time recurred repeatedly: the doctors reported workdays that were too long, the constant need to do things faster32,38,39,41,41, as well as a lack of time29,32,37, in particular to spend with patients, for continued education, and to have a social life26,34. Heavy workloads and lack of time were directly related to the difficulty many of these doctors had in finding a balance between their personal and working lives21,32,40,41.

Finally, they described problems with those above them in the hospital chain of command27,29,36,42, lack of continuing education25,32,34, and the lack or unreplaced absence of healthcare personnel 27,30,32,43.

Doctors underlined the importance of context: both the social context and that of their medical practice. Accordingly, age, sex, and skin color could generate stressful situations. The young physicians reported stress that they considered inherent in their lack of knowledge and experience42,44,45; women described inequalities in terms of opportunity, recognition, and credibility34,44 as well as sexual harassment in the workplace34. Finally, some authors pointed out the experiences of discrimination and racism endured by black doctors35.

Physicians also reported some particular workplaces or situations that were especially stressful. These included all types of situations associated with isolation29,31,46. Similarly, three medical situations were noted: (i) directly facing death28,47,48 or the end of life49,50; (ii) risk-taking, especially in surgery51,41; and (iii) the complexity of situations with comorbidity or entanglement with social factors28.

Finally, participants very frequently raised the issue of poor working conditions28,29,52, which could involve either material conditions, such as inadequate equipment32,51 or the precarity of some doctors’ status, associated with substantial concern about their future29,32,34.

Relational Factors

Doctors reported fairly frequently that relational difficulties between professionals caused substantial stress. These could concern disagreements or differences of opinions between providers28 or a vague definition of their respective roles34. The younger physicians described difficult relationships with senior doctors: they described communication problems, even misunderstanding between them30,42.

Many doctors also described inordinate emotional investment with patients and their relatives: too much empathy28,33,41,48, even self-sacrifice26. They also complained about the lack of recognition from both patients and family29,33,36.

Individual Factors

The doctors participating in these studies reported very few stress factors directly related to themselves. Some authors insisted on the burden of personal responsibility29,41,51. Some underlined the dimensions of decision-making48,52, others responsibility for complications41, and still others the effects of disciplinary measures for medical errors53. They also reported feelings of guilt41,51 or helplessness 28,49, as well as doubts about their abilities32,35.

Connections Between Stress Factors

The studies reveal a ranking of and connections between the stress factors that can promote the onset of burnout. Organization was the most recurrent level mentioned in the studies, then relation, and finally individual factors. A structure of experience, within a timeline, can be drawn from this hierarchy. This suggests that a doctor experiences organization as the first level being affected, then relational aspects, and finally himself or herself (Fig. 2).

Figure 2
figure 2

Connection between factors.

The Protective Factors

Most studies also reported protective factors that mirrored the stress factors and could help to prevent physician burnout.

Individual Factors

Regardless of the associated stress factors, most articles reported individual protective factors. We found three that were especially important: (i) self-knowledge, (ii) self-care, and (iii) a realistic vision of one’s work.

To protect oneself and cope with stress, doctors underlined the importance of knowing oneself well39,54. This involved knowing their abilities and their needs26,55, but especially their limitations26,39,50,55,57,57. It required increasing their reflexivity and self-consciousness37,55,58 and recognizing and naming their emotions39,41.

It was also very important for physicians to take care of themselves26,35,37 and to make time for a personal life35,50,58 especially for leisure activities34,55,56,58. Some studies underlined the importance of physical well-being through a healthy diet and physical activity56,58. For psychological well-being, physicians mentioned different avenues towards calmness or letting go28: religious beliefs and spiritual practices, meditation, or philosophy26,35,51,56,58, or potential recourse to psychological help53. Others also underlined the benefits of humor56.

Finally, a realistic vision and realistic expectations of their work was also protective37,56,57. The doctors highlighted the importance of making choices: ranking tasks, setting priorities, setting achievable objectives, and making compromises and not committing to too many activities28,30,37,55. This also meant willingness to refuse tasks and responsibilities37,55. It also involve accepting what they could not change58 and not being able to do everything for each patient39.

Relational Factors

Many studies considered that good professional relationships were an essential protective factor26,30,53,56,58. The physicians underlined especially the importance of dialogue and emotional support between colleagues26,30,39,49,50,55,57,57,39. They also prioritized teamwork to avoid isolation57, to enable group decision-making37,51, and especially to ensure a feeling of safety and satisfaction at work39. Finally, they mentioned the benefits of supervision44,26.

Strategies to keep relationships with patients at an appropriate distance were frequently reported as a protective factor32,58. Some explained that they considered each patient as a whole and listened to them so that they were able to hear their story39, see the person behind the symptoms58, and explore their expectations and their preferences28. Surgeons, on the other hand, reported it was necessary to dehumanize patients—to consider only their body parts or organs—to be able to act49.

Some physicians also mentioned protective factors associated with the physician-patient relationship: remembering patients they had cared for56 and whose funeral they had attended49. Finally, they were sensitive to their patients’ gratitude to them44.

Most physicians reported that their friendships and families played a major protective role26,55,58. They insisted especially on the importance of spending time with them26,55, receiving family support26,35,51, and having an understanding life partner26.

Organizational Factors

Finally, and to a lesser degree, the studies underlined that better organization of work protected doctors from stress. This involves increasing the number of doctors in each department30, setting up protocols for management or strategies to increase productivity30,51, and good leadership30.

We also find here the question of time and the importance of organizing and managing one’s time50,55,58, especially of having enough time to see patients58, and of a long-term permanent job39.

Finally, several authors underlined the protective role of diversification of activities (teaching, supervision, and research)37,41,50,55,56.

Connections Between Protective Factors

Contrary to the connections of the stress factors, here, the first, and most, recurrent level mobilized for protection was personal and individual, then the relations mentioned less often, and finally the organization. The structure of experience, as shown in Fig. 2, would be here that doctors first protected themselves individually, by their personal actions, thoughts, and personal qualities. They mobilized then relational aspects, and at last the contextual and organizational level aspects.

DISCUSSION

Our research found no qualitative study that explicitly explored physicians’ experiences of burnout. When this point was considered in the studies included in this metasynthesis, it always involved descriptions or definitions of burnout but never access to experience. Future qualitative research is thus necessary to explore in depth the subjective experience of physicians who have experienced burnout.

Our research found that qualitative studies about physicians’ burnout mostly explored contributing and protective factors. Some factors have been already broadly investigated while others have been mentioned in only one study (Table 4)—for instance, self-sacrifice or the impact of medical errors—further research should specifically explore the latter. Furthermore, this metasynthesis provides access to the ranking and connections between the different types of factors, but no study directly addressed this important issue. The individual and organizational levels are abundantly described in the literature, simultaneously for risk factors59 and interventions13. On this subject, a recent meta-analysis13 found mainly interventions with an individual focus (mindfulness, stress management, small-group discussions, self-care training, and communication skills training), and few interventions focusing on organization (rotation length, various modifications to clinical work processes, and shortened resident shifts) of similar effectiveness in reducing burnout scores. The authors concluded that interventions combining these two levels are needed13.

Our results suggest that doctors identify numerous organizational factors at the origin of potential burnout, but envision protecting themselves individually above all. This is similar to the personality features often associated with images of physicians, such as perfectionism and denial of personal vulnerability, already described as factors predisposing them to burnout12,45 and which would also induce them to seek solely individual solutions. We also think that physicians do not know whom they should address—or how—about organizational factors. A recent study considered the loss of a feeling of control as a major contributor to doctors’ burnout60 and some authors have put forward their loss of autonomy in their practices to “unknown and invisible forces.”6 In other words, doctors may no longer control what happens for or to them at the organizational level and this factor may, besides contributing to burnout, prevent them from acting on it at that level.

The second level of response in our two themes concerns the group and interpersonal relationships, both in the workplace and in their personal lives. The literature also highlights the importance of socialization at work as a protective factor12. The importance of this relational and group dimension is consistent with numerous reports on the sociology of work and of social psychology, which have shown the entanglement between individual and group in institutions61. The group at the hospital, we think, represents an original axis of protection and intervention for battling burnout in healthcare professionals generally and doctors in particular. That is, burnout must be thought of as an individual experience that takes place within a group. A doctor’s experience of burnout must not be considered in individual problem but on the contrary be integrated into the group dimension. Some authors have insisted on the distinction between depression and burnout62,63; considering burnout only as an individual experience is equivalent to confusing it with depression, that is, an experience of distress belonging only to the depressed individual.

Strengths and Limitations

This metasynthesis integrates the experience of 1589 doctors from 15 different countries. The method we applied is rigorous, has been tested in medical research21, and meets the criteria of the ENTREQ guidelines23. We analyzed 33 articles, all published in peer-reviewed journals and mostly of good quality. Our method is well adapted to the synthesis of a large number of qualitative studies and enabled us to reach a much broader perspective than any of the initial studies.

Nonetheless, certain aspects of this metasynthesis limit the generalization of its conclusions. A qualitative metasynthesis collects only partial data from the participants and depends on the researchers’ interpretations of the data. Moreover, although the review assembled articles from diverse cultural areas, English-speaking countries are overrepresented as we restricted our selection to articles in that language and ours, for practical reasons. We might have excluded studies from language other than French and English and therefore reinforced this overrepresentation. Finally, this work focused only on qualitative literature and did not integrate studies about interventions. It would be very useful to study which factors are linked with which interventions so to elicit what the contributing factors left aside are.

CONCLUSION

This metasynthesis provides access to what doctors identify as contributing factors to burnout and how they envision protecting themselves from it. Relational factors should be addressed as an original axis of protection and intervention for battling doctors’ burnout.