View Article PDF

It is well documented that burnout and fatigue are common in the medical profession. Most of the available literature is based on assessment of the senior workforce, focussing primarily on consultants.[[1–5]] Recently, there has been a growing concern for the wellbeing of the junior workforce, due to a number of changes in the working environment.[[6–12]] These changes include an increased need for service provision, less teaching time, a diminished opportunity to progress through a chosen career pathway and a general increase in the number of patients (with increasing amounts of significant comorbidities), all potentially leading to a greater manifestation of occupational burnout.[[6–12]]

The consequences of burnout are far reaching, affecting all levels of healthcare. Adverse effects to doctors include increased rates of suicidal ideation and drug abuse, as well as health concerns such as hypertension, anxiety, depression, headaches and other cardiovascular disease.[[1,7]] Healthcare institutions are affected by doctor absenteeism and high turnover rate, as well as poor performance indicators while at work.[[1]] Patient care is often compromised, with an increased risk of medical errors and a decrease in the quality of medical care.[[1,7,13]] Burnout of medical staff has also been shown to decrease the empathy they have for patients. This ultimately affects the overall care of a patient.[[14]]

Occupational burnout is defined as a syndrome composed of three main facets: emotional exhaustion (EE), depersonalisation (DP) and a low sense of personal accomplishment (PA). These are often secondary to the chronic stresses of one’s profession.[[3,4,15]] EE is defined as “the perception of feeling drained or depleted due to excessive emotional or psychological demands”. DP is defined as “the inclination to view another person in an overly detached and impersonal regard”.[[1]] Low PA is defined as “a decline in feelings of competence” and “a tendency to evaluate oneself negatively, in particular, regarding their work with others”.[[16]]

Orthopaedic surgery is a highly skilled and demanding specialty. Surgeons are expected to maintain high standards of professionalism, medical expertise and technical competence.[[5]] The outcome of their work is directly linked to the overall function of their patients. Adverse outcomes have a serious impact on the patient, the surgeon and the healthcare system.[[5]]

Orthopaedic training is considered to be emotionally, physically and intellectually challenging, and can take a substantial toll on trainees and their families. The significant number of clinical hours, along with the time spent studying to reach the level of clinical excellence demanded, can often compromise the wellbeing of trainees. This is detrimental to their personal health and overall job satisfaction, and compromises patient care and safety.[[6,7,9–12]]

The phenomenon of burnout among orthopaedic scheme trainees has been extensively studied and documented in other first world countries that share a similar demand of excellence from their doctors.[[6–8,10–12,17,18]] To our knowledge, there is currently no published study analysing the rates of burnout among New Zealand orthopaedic registrars. The aim of this study was to assess the rates of New Zealand orthopaedic registrar burnout, both at a trainee and non-trainee level. A secondary aim was to establish if there were any specific factors leading to burnout. Our hypothesis was that the burnout rate would be comparable to other first world countries with a similar orthopaedic training programme.

Methods

In August 2021, an email containing a link to a 53-question survey was sent to all (n=62) of the orthopaedic registrars on the New Zealand Orthopaedic Association (NZOA) training programme. Ethics approval was retrospectively obtained from the Health and Disability Ethics Committee (Reference: #2022OOS12773). The survey was conducted anonymously online. A reminder email was sent in weeks two and three to all registrars on the list.

A similar email was sent to the non-trainee orthopaedic registrars. Two methods were employed to ensure the survey reached its intended group. Firstly, all non-trainee registrars who had identified orthopaedics as their current specialty with the Specialty Trainees of New Zealand (STONZ) union received an email. Secondly, a selected orthopaedic registrar was contacted at most of the district health boards (DHBs) and was asked to be a point of contact for the study. If they agreed, a link to the survey was sent to them via email or SMS. They were then asked to distribute the survey link to the rest of the applicable doctors in that department.

The surveys demographic questions addressed gender preference, ethnicity, age, year of the Surgical Education and Training (SET) Programme/number of years the registrar had worked in orthopaedics, current relationship status and, if applicable, work status of their partner and whether they were in the medical profession.

Factors associated with burnout were queried, including number of sleep hours and the exercise regimen of a registrar, as well as use of social media, alcohol and other substances. Registrars were asked whether they could routinely attend health maintenance appointments or if they had ever used professional services for their mental health. Questions about their orthopaedic department including hospital setting, whether the department had a full complement of staff, hours worked, time since their last holiday, manageability of the clinical workload and amount of senior support were also included.

Maslach Burnout Inventory

The final part of the survey was the Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS MP). This is a validated tool used to assess burnout.[[15]] It assesses the three main facets of the syndrome via a Likert-scale set of 22 questions: nine for EE, five for DP and eight for PA. The total score for each facet is then calculated, stratified and ranked into either a mild, moderate or severe form of burnout. This information is summarised in Table 1.[[19]] The level of EE and DP is proportional to burnout; PA is inversely proportional.[[6]] A registrar was considered “burnt out” if they scored in the severe range for either EE or DP. Levels of burnout were calculated in the trainee and non-trainee groups. Potential factors were then assessed to see if there were any statistically significant associations related to each facet of burnout.

Statistics

Parametric data between trainees and non-trainees was compared using unpaired T-testing. Ranked non-parametric data were compared using Mann–Whitney testing. Categorical data were compared using the Chi-squared and Fisher’s Exact test. A p-value <0.05 was considered statistically significant. A multivariate regression analysis was performed to establish associations between variables. Trainees and non-trainees were then grouped, dependent on whether they were exhibiting burnout.

Results

Trainees vs non-trainees

Fifty of the 62 (80.6%) trainees completed the survey. Sixty-six of 70 (estimated number) (94.3%) of non-trainees completed the survey. Overall, trainees exhibited moderate levels of burnout (mean score EE 22.5, DP 8.8, PA 35.9). Non-trainees also exhibited moderate levels of burnout (mean score EE 22.4, DP 8.9, PA 35.9). Fifty-two point two percent of trainees and 50% of non-trainees scored in the severe range for either (or both) EE or DP. This is summarised in Table 2.

Demographic data and relevant associated factors are summarised in Table 3. There were statistically significant differences between trainees and non-trainees with regards to age, relationship status, children, whether their partner was in the medical profession, and if COVID-19 had decreased the participant’s mood. Ninety-five point seven percent of trainees and 87.9% of non-trainees either disagreed or were neutral when asked if they were able to routinely attend health maintenance appointments.

Associations within cohorts

Trainees

In the trainee group, the only significant association noted was an increased level in DP when trainees stated they had not had time away from work for greater than three months (P=0.042).

Non-trainees

The non-trainee group exhibited several associations between parameters. DP was found to be higher in males than females surveyed (P=0.028). It was also increased in departments without a full complement of staff (P=0.020). EE was higher in registrars who slept six hours or fewer (R=0.329, P=0.012) and worked greater than 80 hours per week (R=0.266, P=0.043). EE was lower in trainees with a lower mood due to COVID-19 (R=0.270, P=0.043). DP (P=0.009) and EE (P<0.001) were increased in non-trainees who indicated that they “strongly disagreed” that they were able to routinely attend health maintenance appointments.

Associations of respondents displaying signs of burnout

Respondents displaying signs of burnout exhibited several statistically significant associations. The presence of a senior colleague is highly significant at reducing burnout (P<0.001). A respondent who participates in professional assistance for work-related stress (such as attending professional supervision, or seeing a counsellor, psychologist or psychiatrist) is less likely to be burnt out (P=0.049). A respondent working in a department with a full complement of staff is less likely to be burnt out (P=0.020). A respondent who is able to attend health maintenance appointments is less likely to be burnt out (P=0.050). This is summarised in Table 4.

View Tables 1–4.

Discussion

Burnout is a syndrome that exists in all forms of the medical profession. It has been noted to adversely affect orthopaedic surgeons in other countries with similar healthcare systems, and it is particularly prevalent while doctors are advancing through their training.[[3,6–8,10,11,13,17,18]] Our study shows that New Zealand’s orthopaedic registrars, both trainee and non-trainee, are not statistically different.

Orthopaedic surgery in New Zealand prides itself on its high standards, both in clinical practice and professional behaviour. These standards are developed by the quality of the surgeon’s training and the examples set by their senior colleagues and consultants. It’s accepted that training will include stressful periods and, ultimately, is a necessary process to practice in a field that produces a high level of job satisfaction.[[7,10,11]] Regardless, there is now substantial evidence available that identifies orthopaedic trainees as being particularly vulnerable to burnout during this period. Consideration on how to mitigate these stresses needs to be further investigated and implemented.

New Zealand shares a comparable orthopaedic training scheme and healthcare system to Australia. Both orthopaedic associations follow guidelines set by the Royal Australasian College of Surgeons. A 2014 study by Arora et al. examined burnout in Australian orthopaedic trainees and demonstrated that 53% of respondents were burnt out.[[6]] This is a similar figure to our study, whereby 52.3% of trainees and 50% of non-trainees are burnt out. A 2016 study by Chambers et al. examined burnout in New Zealand’s senior medical staff, finding 50.1% of respondents were burnt out.[[20]] It was also found that respondents aged 30–39 had the highest mean burnout scores. This is particularly alarming considering 89.1% of the trainee respondents are in this age category.

Burnout is difficult to address due to the complex and multifactorial nature of the syndrome. A 2009 study by Sargent et al. documented a number of factors associated with increased EE and DP.[[9]] EE was adversely affected by difficult relationships with senior colleagues, anxiety over clinical competence and high levels of conflict being present between work and personal life. A high level of DP was found with increased work hours and difficult relationships with nursing staff.[[9]]

Strategies to try and combat burnout have been identified. They can be divided into personal and institutional approaches. Personal strategies to combat burnout include spending time with partners, children and extended family and friends, as well as maintaining a social life outside work and maintaining physical fitness.[[8,9,12,21]] A strong and positive maintenance of relationships with colleagues was deemed particularly important.[[12]] On an institutional level, limiting work hours to fewer than 80, providing senior support when required and providing mentorship programmes have been shown to decrease levels of burnout in registrar populations.[[8,9,12,21,22]]

A few important associations were found in our study. Trainees recorded a higher level of DP when they hadn’t had time away from work for three months or more. In the non-trainee group, males had a higher level of DP compared to females. EE and DP were found to be increased in registrars who slept fewer than six hours, worked greater than 80 hours, or were in a department without a full complement of staff. To gain a place on the training programme is extremely competitive with limited places available. To attempt to gain an interview for potential selection, a points-based system is utilised to direct non-trainees in areas of orthopaedic development. This system awards points for specific courses, research published, presentations given, cultural involvement and orthopaedic work experience. The majority of non-trainees will have worked between three to five years as an orthopaedic registrar before being selected to the training programme. Our study noted that over 40% of non-trainee respondents were in their third year or more as orthopaedic registrars. While not directly assessed in this study, the lack of certainty about their future might be a direct contributor to burnout. Anecdotally, many non-trainees will often work long hours (often going above the hours stipulated on their salaried contract) to try and prove themselves. This is an unfortunate situation that may be improved with better personal and institutional strategies in place. When respondents displaying signs of burnout were grouped together, further important associations were noted. The presence of a senior colleague, participation in professional assistance programmes, being able to attend health maintenance appointments and working in a department with a full complement of staff were all found to be important factors in limiting burnout.

A positive change in our medical personnel’s wellbeing necessitates looking for ways to change the current system. A particularly concerning area was the large proportion of respondents (95.7% trainees, 87.9% non-trainees) who were neutral or stated they were unable to routinely attend health appointments. As one of the strategies to prevent burnout is maintenance of physical fitness, we suggest a mandatory implementation of protected time for health-related consultations should be made at a DHB or governing body level. The presence of a senior colleague is highly significant at reducing burnout (P<0.001), leading us to emphasise the importance of implementation of mentoring programmes. Mentoring has been defined in many ways, but essentially equates to a “career friend” who can help a patron through the rigours of a particular activity.[[23]] Mentorship can be formal or informal; it is rewarding for both the mentor and the mentee. The NZOA offers mentorship to its trainees, with regular documented check-ins between surgeons and the registrars working for them. While there is no formal mentoring system set up for non-trainees, a Medical Council of New Zealand (MCNZ) requirement states all non-trainees must register in a recertification programme for their general scope of practice. Inpractice is an independent not-for-profit organisation whose role is to deliver education and continuing professional development programmes, including formulation of professional development plans, continued medical education, peer review sessions, participation in audits and quarterly meetings with a nominated consultant. This programme is important for future career planning and academic development. To help supplement this, we suggest either incorporating further sections that focus on burnout prevention or offer other mentorship programmes at a DHB level as an introductory step forward in this process.

We also endorse the use of professional supervision. This is an ongoing and formal process, whereby a participant is encouraged (in a professional capacity) to undergo critical self-reflection, discuss previous decisions, problems, or concerns in a safe environment.[[24,25]] Participants also practice wellbeing exercises at these sessions. The aim is for continued professional competence and development.[[24,25]] The majority of our respondents (78.3% trainees, 86.2% non-trainees) stated they had not sought professional assistance for work-related stress. These services are available to all medical practitioners in New Zealand. While the usefulness of the service is heavily dependent on the registrar’s willingness and enthusiasm to participate, a potential institutional measure might be an increased promotion of the service, as well as advertising its positive attributes to orthopaedic registrars.

Trainees recorded higher levels of DP when they hadn’t had time away from work for greater than three months. Evidence shows there is a reduction in burnout levels when people take vacations.[[26–28]] After a few weeks from returning to work, stress and burnout levels begin to rise. An institutional change to counteract this may be the implantation of a required stand-down period for trainees and non-trainees every few months to help limit their burnout levels.[[26–28]] A respondent working in a department with a full complement of staff was less likely to be burnt out (P=0.020). It was also found that DP was increased in non-trainees working in a department without a full complement of staff. While occasional understaffing is an accepted part of the job, institutional measures should be in place to facilitate recruitment and hiring in all departments to ensure registrars are not worn out by consistently having to do more than their fair share of duties.

A positive to be taken from the survey is that only a small proportion of registrars were working, on average, over 80 hours a week (2.2% trainee, 5.2% non-trainee). We found the majority fall between the range of 60 to 80 hours. In 2003 the United States restructured their programme so that a resident would not work more than 80 hours a week.[[29]] Follow-up studies from this proved that operating and clinical time were not affected by the change.[[29,30]] However, the overall MBI scores for the surveyed residents made no statistically significant change, with high levels of burnout still being recorded.[[30]] We are not advocating a rigorous limitation of hours but propose a potential future audit and deduction of potential superfluous jobs (such as extra administration to what is normally expected of a medical professional) might decrease this total.

Another positive is that the majority of respondents (73.9% trainee, 79.3% non-trainee) stated they felt well supported by senior colleagues. Again, as previously stated, the presence of a senior colleague is highly significant at reducing burnout (P<0.001), indicating its importance as an institutional strategy for limiting burnout. Additionally, 63% of trainees and 77.2% of non-trainees were neutral or disagreed with the statement that COVID-19 had decreased their mood. Only 6.5% of trainees and 10.5% of non-trainees felt their workload had increased due to COVID-19. This should be closely followed as the situation continues to develop.

Burnout prevention efforts should also be considered. Abelson et al. showed that a key way to reduce attrition in surgical residents was to begin career mentorship while in medical school.[[22]] Interest and technical ability in orthopaedics is not enough to make a surgeon—it takes consistent and focussed application over time to produce the finished product.[[31]] Preparing junior doctors and medical students about the potential rigours they may face prior to, and during, the training programme could prove to be a key component to limiting burnout in the future.

Limitations

There were a few limitations to the study. Firstly, the sample size was small. This meant we were unable to do multivariate analyses. However, we were only assessing burnout among orthopaedic trainees and non-trainees in New Zealand (a specific group with a finite number) and the high response rates of 80.6% and 94.3% makes these results representative of the New Zealand population. Another limitation was the inability to define the total number of non-trainee orthopaedic registrars in New Zealand. While the trainee population has a centralised body in the NZOA, there is no organisation in charge of the non-trainees. There is a chance that not every non-trainee registrar has had the opportunity to complete the survey. The survey was distributed to the population via STONZ or word of mouth. Some of the orthopaedic non-trainees may be associated with the Resident Doctors Association (RDA), another union representing a proportion of New Zealand’s junior doctors. This organisation was not approached to help distribute the survey. The hope is that the survey found these non-trainees via their departmental colleagues passing the survey onto them. As mentioned in the discussion, another limitation is the lack of information regarding non-trainees in their third year or more as orthopaedic registrars. It is very likely that a proportion of this group has attempted (or had multiple attempts) to be selected to the training programme. This uncertainty about their future might be a direct contribution to burnout but wasn’t fully assessed in this study. Recently, the decision has been made by the NZOA selection committee to only allow three attempts at selection. Future studies assessing burnout in this population should take this change, as well as its potential impacts, into account when designing their study. Finally, inherent survey-based biases might be apparent, with registrars submitting answers that potentially under-report how they are feeling, or answers which they feel they are expected to submit.

Conclusion

At least half of trainee and non-trainee orthopaedic registrars currently working in New Zealand are displaying signs of burnout. This is comparable to other first-world nations with similar training programmes. Burnout is a complex syndrome that is difficult to solve with singular changes. We believe burnout could be attenuated by advocacy for registrars attending health maintenance appointments; promotion and utilisation of mentorship/professional supervision services; and implementation/promotion of these programmes to junior doctors and medical students. As has been shown in other countries, if medical staff working within our healthcare system are burnt out, this ultimately leads to adverse health outcomes for the population of New Zealand.[[6,7,9–12]] By improving the lives of our medical personnel, we hope to ultimately make change on a greater level.

Summary

Abstract

Aim

Burnout and fatigue are common in the medical profession. The primary aim was to assess rates of burnout in trainee and non-trainee orthopaedic registrars in New Zealand. A secondary aim was to establish which specific factors are associated with burnout.

Method

In 2021, a 53-question online survey was sent to New Zealand trainee and non-trainee orthopaedic registrars. The survey included questions addressing demographics, modifiable factors known to lead to burnout, information on respective orthopaedic departments, and how respondents had fared with COVID-19. Registrars also completed the Maslach Burnout Inventory—Human Services Survey for Medical Personnel (MBI-HSS MP), a 22-question validated survey that is designed to assess the frequency and intensity of perceived burnout among medical personnel.

Results

Fifty of 62 (80.6%) trainees and 66 of 70 (estimated number) (94.3%) of non-trainees completed the survey. Trainees and non-trainees both exhibited moderate levels of burnout. The trainee mean score emotional exhaustion (EE) 22.5, depersonalisation (DP) 8.8, personal achievement (PA) 35.9; non-trainee mean score EE 22.4, DP 8.9, PA 35.9. Fifty-two point two percent of trainees and 50% of non-trainees scored in the severe range for at least one of EE or DP. Factors shown to reduce burnout are the presence of a senior colleague (P<0.001), participation in professional assistance (P=0.049), working in a department with a full complement of staff (P=0.020) and being able to attend health maintenance appointments (P=0.050).

Conclusion

Our study shows that approximately half of both trainee and non-trainee orthopaedic registrars are exhibiting signs of burnout. This is comparable to other developed nations with a similar healthcare system.

Author Information

Tanushk Luke Brito Martyn MBChB, BSc: Orthopaedic Registrar, Department of Orthopaedic Surgery, Waikato Hospital, Waikato, New Zealand; Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand. Earle Savage BMBS, BPHTY, Pg Cert HAUL: Orthopaedic Surgeon, Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand. Simon Bruce Murdoch MacLean MBChB, FRCS(Tr&Orth), PGDipCE: Orthopaedic Surgeon, Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand.

Acknowledgements

The authors would like to thank STONZ for their research grant in helping to partly fund this project.

Correspondence

Tanushk Luke Brito Martyn MBChB, BSc: Orthopaedic Registrar, Waikato Hospital, 183 Pembroke Street, Hamilton 3240, New Zealand.

Correspondence Email

tanushk.martyn@gmail.com

Competing Interests

Nil.

1) Arora M, Diwan AD, Harris IA. Burnout in orthopaedic surgeons: a review: Burnout in orthopaedic surgeons. ANZ J Surg. 2013 Jul;83(7–8):512-5.

2) van Wulfften Palthe ODR, Neuhaus V, Janssen SJ, Guitton TG, Ring D. Among Musculoskeletal Surgeons, Job Dissatisfaction Is Associated With Burnout. Clin Orthop. 2016 Aug;474(8):1857-63.

3) Hui RWH, Leung KC, Ge S, Hwang AC, Lai GGW, Leung AN, et al. Burnout in orthopaedic surgeons: A systematic review. J Clin Orthop Trauma. 2019 Oct;10:S47-52.

4) Daniels AH, DePasse JM, Kamal RN. Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention. J Am Acad Orthop Surg. 2016 Apr;24(4):213-9.

5) Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners, and Colleagues: AOA Critical Issues. J Bone Jt Surg. 2017 Jul 19;99(14):e78.

6) Arora M, Diwan AD, Harris IA. Prevalence and Factors of Burnout among Australian Orthopaedic Trainees: A Cross-Sectional Study. J Orthop Surg. 2014 Dec;22(3):374-7.

7) Driesman AS, Strauss EJ, Konda SR, Egol KA. Factors Associated With Orthopaedic Resident Burnout: A Pilot Study. J Am Acad Orthop Surg. 2020 Nov 1;28(21):900-6.

8) Barrack RL, Miller LS, Sotile WM, Sotile MO, Rubash HE. Effect of Duty Hour Standards on Burnout among Orthopaedic Surgery Residents. Clin Orthop. 2006 Aug;449:134-7.

9) Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of Life During Orthopaedic Training and Academic Practice: Part 1: Orthopaedic Surgery Residents and Faculty. J Bone Jt Surg-Am Vol. 2009 Oct;91(10):2395-405.

10) Somerson JS, Patton A, Ahmed AA, Ramey S, Holliday EB. Burnout Among United States Orthopaedic Surgery Residents. J Surg Educ. 2020 Jul;77(4):961-8.

11) Strauss EJ, Markus DH, Kingery MT, Zuckerman J, Egol KA. Orthopaedic Resident Burnout Is Associated with Poor In-Training Examination Performance. J Bone Jt Surg. 2019 Oct 2;101(19):e102.

12) Kp W, Ak KP, Jyl O. Orthopaedic Resident Burnout: A Literature Review on Vulnerability, Risk Factors, Consequences and Management Strategies. Malays Orthop J. 2019 Jul 1;13(2):15-9.

13) Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, et al. Burnout syndrome among medical residents: A systematic review and meta-analysis. Junne FP, editor. PLOS ONE. 2018 Nov 12;13(11):e0206840.

14) Reynolds M, McCombie A, Jeffery M, Mulder R, Frizelle F. Impact of burnout on empathy. 2021;134(1530):9.

15) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: Third edition. In: Evaluating stress: A book of resources. Lanham, MD, US: Scarecrow Education; 1997. p.191-218.

16) Schutte N, Toppinen S, Kalimo R, Schaufeli W. The factorial validity of the Maslach Burnout Inventory-General Survey (MBI-GS) across occupational groups and nations. J Occup Organ Psychol. 2000 Mar;73(1):53-66.

17) Faivre G, Kielwasser H, Bourgeois M, Panouilleres M, Loisel F, Obert L. Burnout syndrome in orthopaedic and trauma surgery residents in France: A nationwide survey. Orthop Traumatol Surg Res. 2018 Dec;104(8):1291-5.

18) Simons BS, Foltz PA, Chalupa RL, Hylden CM, Dowd TC, Johnson AE. Burnout in U.S. Military Orthopaedic Residents and Staff Physicians. Mil Med. 2016 Aug;181(8):835-9.

19) Wang J, Wang W, Laureys S, Di H. Burnout syndrome in healthcare professionals who care for patients with prolonged disorders of consciousness: a cross-sectional survey. BMC Health Serv Res. 2020 Dec;20(1):841.

20) Chambers CNL, Frampton CMA, Barclay M, McKee M. Burnout prevalence in New Zealand’s public hospital senior medical workforce: a cross-sectional mixed methods study. BMJ Open. 2016 Nov;6(11):e013947.

21) Balch CM, Shanafelt T. Combating Stress and Burnout in Surgical Practice: A Review. Adv Surg. 2010 Sep;44(1):29-47.

22) Abelson JS, Sosa JA, Symer MM, Mao J, Michelassi F, Bell R, et al. Association of Expectations of Training With Attrition in General Surgery Residents. JAMA Surg. 2018 Aug 1;153(8):712.

23) Patel VM, Warren O, Humphris P, Ahmed K, Ashrafian H, Rao C, et al. What does leadership in surgery entail?: Leadership in surgery. ANZ J Surg. 2010 Dec;80(12):876-83.

24) Wallbank S, Hatton S. Reducing burnout and stress: the effectiveness of clinical supervision. Community Pract. 2011 Jul;84(7):31-5.

25) Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC Health Serv Res. 2017 Dec;17(1):786.

26) Westman M, Eden D. Effects of a Respite From Work on Burnout: Vacation Relief and Fade-Out. J Appl Psychol. 1997 Aug;82(4):516-27.

27) Fritz C, Sonnentag S. Recovery, well-being, and performance-related outcomes: The role of workload and vacation experiences. J Appl Psychol. 2006;91(4):936-45.

28) Etzion D. Annual vacation: Duration of relief from job stressors and burnout. Anxiety Stress Coping. 2003 Jun;16(2):213-26.

29) Froelich J, Milbrandt JC, Allan DG. Impact of the 80-hour Workweek on Surgical Exposure and National In-Training Examination Scores in an Orthopedic Residency Program. J Surg Educ. 2009 Mar;66(2):85-8.

30) Gelfand DV. Effect of the 80-Hour Workweek on Resident Burnout. Arch Surg. 2004 Sep 1;139(9):933.

31) Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: Perseverance and passion for long-term goals. J Pers Soc Psychol. 2007;92(6):1087-101.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

It is well documented that burnout and fatigue are common in the medical profession. Most of the available literature is based on assessment of the senior workforce, focussing primarily on consultants.[[1–5]] Recently, there has been a growing concern for the wellbeing of the junior workforce, due to a number of changes in the working environment.[[6–12]] These changes include an increased need for service provision, less teaching time, a diminished opportunity to progress through a chosen career pathway and a general increase in the number of patients (with increasing amounts of significant comorbidities), all potentially leading to a greater manifestation of occupational burnout.[[6–12]]

The consequences of burnout are far reaching, affecting all levels of healthcare. Adverse effects to doctors include increased rates of suicidal ideation and drug abuse, as well as health concerns such as hypertension, anxiety, depression, headaches and other cardiovascular disease.[[1,7]] Healthcare institutions are affected by doctor absenteeism and high turnover rate, as well as poor performance indicators while at work.[[1]] Patient care is often compromised, with an increased risk of medical errors and a decrease in the quality of medical care.[[1,7,13]] Burnout of medical staff has also been shown to decrease the empathy they have for patients. This ultimately affects the overall care of a patient.[[14]]

Occupational burnout is defined as a syndrome composed of three main facets: emotional exhaustion (EE), depersonalisation (DP) and a low sense of personal accomplishment (PA). These are often secondary to the chronic stresses of one’s profession.[[3,4,15]] EE is defined as “the perception of feeling drained or depleted due to excessive emotional or psychological demands”. DP is defined as “the inclination to view another person in an overly detached and impersonal regard”.[[1]] Low PA is defined as “a decline in feelings of competence” and “a tendency to evaluate oneself negatively, in particular, regarding their work with others”.[[16]]

Orthopaedic surgery is a highly skilled and demanding specialty. Surgeons are expected to maintain high standards of professionalism, medical expertise and technical competence.[[5]] The outcome of their work is directly linked to the overall function of their patients. Adverse outcomes have a serious impact on the patient, the surgeon and the healthcare system.[[5]]

Orthopaedic training is considered to be emotionally, physically and intellectually challenging, and can take a substantial toll on trainees and their families. The significant number of clinical hours, along with the time spent studying to reach the level of clinical excellence demanded, can often compromise the wellbeing of trainees. This is detrimental to their personal health and overall job satisfaction, and compromises patient care and safety.[[6,7,9–12]]

The phenomenon of burnout among orthopaedic scheme trainees has been extensively studied and documented in other first world countries that share a similar demand of excellence from their doctors.[[6–8,10–12,17,18]] To our knowledge, there is currently no published study analysing the rates of burnout among New Zealand orthopaedic registrars. The aim of this study was to assess the rates of New Zealand orthopaedic registrar burnout, both at a trainee and non-trainee level. A secondary aim was to establish if there were any specific factors leading to burnout. Our hypothesis was that the burnout rate would be comparable to other first world countries with a similar orthopaedic training programme.

Methods

In August 2021, an email containing a link to a 53-question survey was sent to all (n=62) of the orthopaedic registrars on the New Zealand Orthopaedic Association (NZOA) training programme. Ethics approval was retrospectively obtained from the Health and Disability Ethics Committee (Reference: #2022OOS12773). The survey was conducted anonymously online. A reminder email was sent in weeks two and three to all registrars on the list.

A similar email was sent to the non-trainee orthopaedic registrars. Two methods were employed to ensure the survey reached its intended group. Firstly, all non-trainee registrars who had identified orthopaedics as their current specialty with the Specialty Trainees of New Zealand (STONZ) union received an email. Secondly, a selected orthopaedic registrar was contacted at most of the district health boards (DHBs) and was asked to be a point of contact for the study. If they agreed, a link to the survey was sent to them via email or SMS. They were then asked to distribute the survey link to the rest of the applicable doctors in that department.

The surveys demographic questions addressed gender preference, ethnicity, age, year of the Surgical Education and Training (SET) Programme/number of years the registrar had worked in orthopaedics, current relationship status and, if applicable, work status of their partner and whether they were in the medical profession.

Factors associated with burnout were queried, including number of sleep hours and the exercise regimen of a registrar, as well as use of social media, alcohol and other substances. Registrars were asked whether they could routinely attend health maintenance appointments or if they had ever used professional services for their mental health. Questions about their orthopaedic department including hospital setting, whether the department had a full complement of staff, hours worked, time since their last holiday, manageability of the clinical workload and amount of senior support were also included.

Maslach Burnout Inventory

The final part of the survey was the Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS MP). This is a validated tool used to assess burnout.[[15]] It assesses the three main facets of the syndrome via a Likert-scale set of 22 questions: nine for EE, five for DP and eight for PA. The total score for each facet is then calculated, stratified and ranked into either a mild, moderate or severe form of burnout. This information is summarised in Table 1.[[19]] The level of EE and DP is proportional to burnout; PA is inversely proportional.[[6]] A registrar was considered “burnt out” if they scored in the severe range for either EE or DP. Levels of burnout were calculated in the trainee and non-trainee groups. Potential factors were then assessed to see if there were any statistically significant associations related to each facet of burnout.

Statistics

Parametric data between trainees and non-trainees was compared using unpaired T-testing. Ranked non-parametric data were compared using Mann–Whitney testing. Categorical data were compared using the Chi-squared and Fisher’s Exact test. A p-value <0.05 was considered statistically significant. A multivariate regression analysis was performed to establish associations between variables. Trainees and non-trainees were then grouped, dependent on whether they were exhibiting burnout.

Results

Trainees vs non-trainees

Fifty of the 62 (80.6%) trainees completed the survey. Sixty-six of 70 (estimated number) (94.3%) of non-trainees completed the survey. Overall, trainees exhibited moderate levels of burnout (mean score EE 22.5, DP 8.8, PA 35.9). Non-trainees also exhibited moderate levels of burnout (mean score EE 22.4, DP 8.9, PA 35.9). Fifty-two point two percent of trainees and 50% of non-trainees scored in the severe range for either (or both) EE or DP. This is summarised in Table 2.

Demographic data and relevant associated factors are summarised in Table 3. There were statistically significant differences between trainees and non-trainees with regards to age, relationship status, children, whether their partner was in the medical profession, and if COVID-19 had decreased the participant’s mood. Ninety-five point seven percent of trainees and 87.9% of non-trainees either disagreed or were neutral when asked if they were able to routinely attend health maintenance appointments.

Associations within cohorts

Trainees

In the trainee group, the only significant association noted was an increased level in DP when trainees stated they had not had time away from work for greater than three months (P=0.042).

Non-trainees

The non-trainee group exhibited several associations between parameters. DP was found to be higher in males than females surveyed (P=0.028). It was also increased in departments without a full complement of staff (P=0.020). EE was higher in registrars who slept six hours or fewer (R=0.329, P=0.012) and worked greater than 80 hours per week (R=0.266, P=0.043). EE was lower in trainees with a lower mood due to COVID-19 (R=0.270, P=0.043). DP (P=0.009) and EE (P<0.001) were increased in non-trainees who indicated that they “strongly disagreed” that they were able to routinely attend health maintenance appointments.

Associations of respondents displaying signs of burnout

Respondents displaying signs of burnout exhibited several statistically significant associations. The presence of a senior colleague is highly significant at reducing burnout (P<0.001). A respondent who participates in professional assistance for work-related stress (such as attending professional supervision, or seeing a counsellor, psychologist or psychiatrist) is less likely to be burnt out (P=0.049). A respondent working in a department with a full complement of staff is less likely to be burnt out (P=0.020). A respondent who is able to attend health maintenance appointments is less likely to be burnt out (P=0.050). This is summarised in Table 4.

View Tables 1–4.

Discussion

Burnout is a syndrome that exists in all forms of the medical profession. It has been noted to adversely affect orthopaedic surgeons in other countries with similar healthcare systems, and it is particularly prevalent while doctors are advancing through their training.[[3,6–8,10,11,13,17,18]] Our study shows that New Zealand’s orthopaedic registrars, both trainee and non-trainee, are not statistically different.

Orthopaedic surgery in New Zealand prides itself on its high standards, both in clinical practice and professional behaviour. These standards are developed by the quality of the surgeon’s training and the examples set by their senior colleagues and consultants. It’s accepted that training will include stressful periods and, ultimately, is a necessary process to practice in a field that produces a high level of job satisfaction.[[7,10,11]] Regardless, there is now substantial evidence available that identifies orthopaedic trainees as being particularly vulnerable to burnout during this period. Consideration on how to mitigate these stresses needs to be further investigated and implemented.

New Zealand shares a comparable orthopaedic training scheme and healthcare system to Australia. Both orthopaedic associations follow guidelines set by the Royal Australasian College of Surgeons. A 2014 study by Arora et al. examined burnout in Australian orthopaedic trainees and demonstrated that 53% of respondents were burnt out.[[6]] This is a similar figure to our study, whereby 52.3% of trainees and 50% of non-trainees are burnt out. A 2016 study by Chambers et al. examined burnout in New Zealand’s senior medical staff, finding 50.1% of respondents were burnt out.[[20]] It was also found that respondents aged 30–39 had the highest mean burnout scores. This is particularly alarming considering 89.1% of the trainee respondents are in this age category.

Burnout is difficult to address due to the complex and multifactorial nature of the syndrome. A 2009 study by Sargent et al. documented a number of factors associated with increased EE and DP.[[9]] EE was adversely affected by difficult relationships with senior colleagues, anxiety over clinical competence and high levels of conflict being present between work and personal life. A high level of DP was found with increased work hours and difficult relationships with nursing staff.[[9]]

Strategies to try and combat burnout have been identified. They can be divided into personal and institutional approaches. Personal strategies to combat burnout include spending time with partners, children and extended family and friends, as well as maintaining a social life outside work and maintaining physical fitness.[[8,9,12,21]] A strong and positive maintenance of relationships with colleagues was deemed particularly important.[[12]] On an institutional level, limiting work hours to fewer than 80, providing senior support when required and providing mentorship programmes have been shown to decrease levels of burnout in registrar populations.[[8,9,12,21,22]]

A few important associations were found in our study. Trainees recorded a higher level of DP when they hadn’t had time away from work for three months or more. In the non-trainee group, males had a higher level of DP compared to females. EE and DP were found to be increased in registrars who slept fewer than six hours, worked greater than 80 hours, or were in a department without a full complement of staff. To gain a place on the training programme is extremely competitive with limited places available. To attempt to gain an interview for potential selection, a points-based system is utilised to direct non-trainees in areas of orthopaedic development. This system awards points for specific courses, research published, presentations given, cultural involvement and orthopaedic work experience. The majority of non-trainees will have worked between three to five years as an orthopaedic registrar before being selected to the training programme. Our study noted that over 40% of non-trainee respondents were in their third year or more as orthopaedic registrars. While not directly assessed in this study, the lack of certainty about their future might be a direct contributor to burnout. Anecdotally, many non-trainees will often work long hours (often going above the hours stipulated on their salaried contract) to try and prove themselves. This is an unfortunate situation that may be improved with better personal and institutional strategies in place. When respondents displaying signs of burnout were grouped together, further important associations were noted. The presence of a senior colleague, participation in professional assistance programmes, being able to attend health maintenance appointments and working in a department with a full complement of staff were all found to be important factors in limiting burnout.

A positive change in our medical personnel’s wellbeing necessitates looking for ways to change the current system. A particularly concerning area was the large proportion of respondents (95.7% trainees, 87.9% non-trainees) who were neutral or stated they were unable to routinely attend health appointments. As one of the strategies to prevent burnout is maintenance of physical fitness, we suggest a mandatory implementation of protected time for health-related consultations should be made at a DHB or governing body level. The presence of a senior colleague is highly significant at reducing burnout (P<0.001), leading us to emphasise the importance of implementation of mentoring programmes. Mentoring has been defined in many ways, but essentially equates to a “career friend” who can help a patron through the rigours of a particular activity.[[23]] Mentorship can be formal or informal; it is rewarding for both the mentor and the mentee. The NZOA offers mentorship to its trainees, with regular documented check-ins between surgeons and the registrars working for them. While there is no formal mentoring system set up for non-trainees, a Medical Council of New Zealand (MCNZ) requirement states all non-trainees must register in a recertification programme for their general scope of practice. Inpractice is an independent not-for-profit organisation whose role is to deliver education and continuing professional development programmes, including formulation of professional development plans, continued medical education, peer review sessions, participation in audits and quarterly meetings with a nominated consultant. This programme is important for future career planning and academic development. To help supplement this, we suggest either incorporating further sections that focus on burnout prevention or offer other mentorship programmes at a DHB level as an introductory step forward in this process.

We also endorse the use of professional supervision. This is an ongoing and formal process, whereby a participant is encouraged (in a professional capacity) to undergo critical self-reflection, discuss previous decisions, problems, or concerns in a safe environment.[[24,25]] Participants also practice wellbeing exercises at these sessions. The aim is for continued professional competence and development.[[24,25]] The majority of our respondents (78.3% trainees, 86.2% non-trainees) stated they had not sought professional assistance for work-related stress. These services are available to all medical practitioners in New Zealand. While the usefulness of the service is heavily dependent on the registrar’s willingness and enthusiasm to participate, a potential institutional measure might be an increased promotion of the service, as well as advertising its positive attributes to orthopaedic registrars.

Trainees recorded higher levels of DP when they hadn’t had time away from work for greater than three months. Evidence shows there is a reduction in burnout levels when people take vacations.[[26–28]] After a few weeks from returning to work, stress and burnout levels begin to rise. An institutional change to counteract this may be the implantation of a required stand-down period for trainees and non-trainees every few months to help limit their burnout levels.[[26–28]] A respondent working in a department with a full complement of staff was less likely to be burnt out (P=0.020). It was also found that DP was increased in non-trainees working in a department without a full complement of staff. While occasional understaffing is an accepted part of the job, institutional measures should be in place to facilitate recruitment and hiring in all departments to ensure registrars are not worn out by consistently having to do more than their fair share of duties.

A positive to be taken from the survey is that only a small proportion of registrars were working, on average, over 80 hours a week (2.2% trainee, 5.2% non-trainee). We found the majority fall between the range of 60 to 80 hours. In 2003 the United States restructured their programme so that a resident would not work more than 80 hours a week.[[29]] Follow-up studies from this proved that operating and clinical time were not affected by the change.[[29,30]] However, the overall MBI scores for the surveyed residents made no statistically significant change, with high levels of burnout still being recorded.[[30]] We are not advocating a rigorous limitation of hours but propose a potential future audit and deduction of potential superfluous jobs (such as extra administration to what is normally expected of a medical professional) might decrease this total.

Another positive is that the majority of respondents (73.9% trainee, 79.3% non-trainee) stated they felt well supported by senior colleagues. Again, as previously stated, the presence of a senior colleague is highly significant at reducing burnout (P<0.001), indicating its importance as an institutional strategy for limiting burnout. Additionally, 63% of trainees and 77.2% of non-trainees were neutral or disagreed with the statement that COVID-19 had decreased their mood. Only 6.5% of trainees and 10.5% of non-trainees felt their workload had increased due to COVID-19. This should be closely followed as the situation continues to develop.

Burnout prevention efforts should also be considered. Abelson et al. showed that a key way to reduce attrition in surgical residents was to begin career mentorship while in medical school.[[22]] Interest and technical ability in orthopaedics is not enough to make a surgeon—it takes consistent and focussed application over time to produce the finished product.[[31]] Preparing junior doctors and medical students about the potential rigours they may face prior to, and during, the training programme could prove to be a key component to limiting burnout in the future.

Limitations

There were a few limitations to the study. Firstly, the sample size was small. This meant we were unable to do multivariate analyses. However, we were only assessing burnout among orthopaedic trainees and non-trainees in New Zealand (a specific group with a finite number) and the high response rates of 80.6% and 94.3% makes these results representative of the New Zealand population. Another limitation was the inability to define the total number of non-trainee orthopaedic registrars in New Zealand. While the trainee population has a centralised body in the NZOA, there is no organisation in charge of the non-trainees. There is a chance that not every non-trainee registrar has had the opportunity to complete the survey. The survey was distributed to the population via STONZ or word of mouth. Some of the orthopaedic non-trainees may be associated with the Resident Doctors Association (RDA), another union representing a proportion of New Zealand’s junior doctors. This organisation was not approached to help distribute the survey. The hope is that the survey found these non-trainees via their departmental colleagues passing the survey onto them. As mentioned in the discussion, another limitation is the lack of information regarding non-trainees in their third year or more as orthopaedic registrars. It is very likely that a proportion of this group has attempted (or had multiple attempts) to be selected to the training programme. This uncertainty about their future might be a direct contribution to burnout but wasn’t fully assessed in this study. Recently, the decision has been made by the NZOA selection committee to only allow three attempts at selection. Future studies assessing burnout in this population should take this change, as well as its potential impacts, into account when designing their study. Finally, inherent survey-based biases might be apparent, with registrars submitting answers that potentially under-report how they are feeling, or answers which they feel they are expected to submit.

Conclusion

At least half of trainee and non-trainee orthopaedic registrars currently working in New Zealand are displaying signs of burnout. This is comparable to other first-world nations with similar training programmes. Burnout is a complex syndrome that is difficult to solve with singular changes. We believe burnout could be attenuated by advocacy for registrars attending health maintenance appointments; promotion and utilisation of mentorship/professional supervision services; and implementation/promotion of these programmes to junior doctors and medical students. As has been shown in other countries, if medical staff working within our healthcare system are burnt out, this ultimately leads to adverse health outcomes for the population of New Zealand.[[6,7,9–12]] By improving the lives of our medical personnel, we hope to ultimately make change on a greater level.

Summary

Abstract

Aim

Burnout and fatigue are common in the medical profession. The primary aim was to assess rates of burnout in trainee and non-trainee orthopaedic registrars in New Zealand. A secondary aim was to establish which specific factors are associated with burnout.

Method

In 2021, a 53-question online survey was sent to New Zealand trainee and non-trainee orthopaedic registrars. The survey included questions addressing demographics, modifiable factors known to lead to burnout, information on respective orthopaedic departments, and how respondents had fared with COVID-19. Registrars also completed the Maslach Burnout Inventory—Human Services Survey for Medical Personnel (MBI-HSS MP), a 22-question validated survey that is designed to assess the frequency and intensity of perceived burnout among medical personnel.

Results

Fifty of 62 (80.6%) trainees and 66 of 70 (estimated number) (94.3%) of non-trainees completed the survey. Trainees and non-trainees both exhibited moderate levels of burnout. The trainee mean score emotional exhaustion (EE) 22.5, depersonalisation (DP) 8.8, personal achievement (PA) 35.9; non-trainee mean score EE 22.4, DP 8.9, PA 35.9. Fifty-two point two percent of trainees and 50% of non-trainees scored in the severe range for at least one of EE or DP. Factors shown to reduce burnout are the presence of a senior colleague (P<0.001), participation in professional assistance (P=0.049), working in a department with a full complement of staff (P=0.020) and being able to attend health maintenance appointments (P=0.050).

Conclusion

Our study shows that approximately half of both trainee and non-trainee orthopaedic registrars are exhibiting signs of burnout. This is comparable to other developed nations with a similar healthcare system.

Author Information

Tanushk Luke Brito Martyn MBChB, BSc: Orthopaedic Registrar, Department of Orthopaedic Surgery, Waikato Hospital, Waikato, New Zealand; Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand. Earle Savage BMBS, BPHTY, Pg Cert HAUL: Orthopaedic Surgeon, Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand. Simon Bruce Murdoch MacLean MBChB, FRCS(Tr&Orth), PGDipCE: Orthopaedic Surgeon, Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand.

Acknowledgements

The authors would like to thank STONZ for their research grant in helping to partly fund this project.

Correspondence

Tanushk Luke Brito Martyn MBChB, BSc: Orthopaedic Registrar, Waikato Hospital, 183 Pembroke Street, Hamilton 3240, New Zealand.

Correspondence Email

tanushk.martyn@gmail.com

Competing Interests

Nil.

1) Arora M, Diwan AD, Harris IA. Burnout in orthopaedic surgeons: a review: Burnout in orthopaedic surgeons. ANZ J Surg. 2013 Jul;83(7–8):512-5.

2) van Wulfften Palthe ODR, Neuhaus V, Janssen SJ, Guitton TG, Ring D. Among Musculoskeletal Surgeons, Job Dissatisfaction Is Associated With Burnout. Clin Orthop. 2016 Aug;474(8):1857-63.

3) Hui RWH, Leung KC, Ge S, Hwang AC, Lai GGW, Leung AN, et al. Burnout in orthopaedic surgeons: A systematic review. J Clin Orthop Trauma. 2019 Oct;10:S47-52.

4) Daniels AH, DePasse JM, Kamal RN. Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention. J Am Acad Orthop Surg. 2016 Apr;24(4):213-9.

5) Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners, and Colleagues: AOA Critical Issues. J Bone Jt Surg. 2017 Jul 19;99(14):e78.

6) Arora M, Diwan AD, Harris IA. Prevalence and Factors of Burnout among Australian Orthopaedic Trainees: A Cross-Sectional Study. J Orthop Surg. 2014 Dec;22(3):374-7.

7) Driesman AS, Strauss EJ, Konda SR, Egol KA. Factors Associated With Orthopaedic Resident Burnout: A Pilot Study. J Am Acad Orthop Surg. 2020 Nov 1;28(21):900-6.

8) Barrack RL, Miller LS, Sotile WM, Sotile MO, Rubash HE. Effect of Duty Hour Standards on Burnout among Orthopaedic Surgery Residents. Clin Orthop. 2006 Aug;449:134-7.

9) Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of Life During Orthopaedic Training and Academic Practice: Part 1: Orthopaedic Surgery Residents and Faculty. J Bone Jt Surg-Am Vol. 2009 Oct;91(10):2395-405.

10) Somerson JS, Patton A, Ahmed AA, Ramey S, Holliday EB. Burnout Among United States Orthopaedic Surgery Residents. J Surg Educ. 2020 Jul;77(4):961-8.

11) Strauss EJ, Markus DH, Kingery MT, Zuckerman J, Egol KA. Orthopaedic Resident Burnout Is Associated with Poor In-Training Examination Performance. J Bone Jt Surg. 2019 Oct 2;101(19):e102.

12) Kp W, Ak KP, Jyl O. Orthopaedic Resident Burnout: A Literature Review on Vulnerability, Risk Factors, Consequences and Management Strategies. Malays Orthop J. 2019 Jul 1;13(2):15-9.

13) Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, et al. Burnout syndrome among medical residents: A systematic review and meta-analysis. Junne FP, editor. PLOS ONE. 2018 Nov 12;13(11):e0206840.

14) Reynolds M, McCombie A, Jeffery M, Mulder R, Frizelle F. Impact of burnout on empathy. 2021;134(1530):9.

15) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: Third edition. In: Evaluating stress: A book of resources. Lanham, MD, US: Scarecrow Education; 1997. p.191-218.

16) Schutte N, Toppinen S, Kalimo R, Schaufeli W. The factorial validity of the Maslach Burnout Inventory-General Survey (MBI-GS) across occupational groups and nations. J Occup Organ Psychol. 2000 Mar;73(1):53-66.

17) Faivre G, Kielwasser H, Bourgeois M, Panouilleres M, Loisel F, Obert L. Burnout syndrome in orthopaedic and trauma surgery residents in France: A nationwide survey. Orthop Traumatol Surg Res. 2018 Dec;104(8):1291-5.

18) Simons BS, Foltz PA, Chalupa RL, Hylden CM, Dowd TC, Johnson AE. Burnout in U.S. Military Orthopaedic Residents and Staff Physicians. Mil Med. 2016 Aug;181(8):835-9.

19) Wang J, Wang W, Laureys S, Di H. Burnout syndrome in healthcare professionals who care for patients with prolonged disorders of consciousness: a cross-sectional survey. BMC Health Serv Res. 2020 Dec;20(1):841.

20) Chambers CNL, Frampton CMA, Barclay M, McKee M. Burnout prevalence in New Zealand’s public hospital senior medical workforce: a cross-sectional mixed methods study. BMJ Open. 2016 Nov;6(11):e013947.

21) Balch CM, Shanafelt T. Combating Stress and Burnout in Surgical Practice: A Review. Adv Surg. 2010 Sep;44(1):29-47.

22) Abelson JS, Sosa JA, Symer MM, Mao J, Michelassi F, Bell R, et al. Association of Expectations of Training With Attrition in General Surgery Residents. JAMA Surg. 2018 Aug 1;153(8):712.

23) Patel VM, Warren O, Humphris P, Ahmed K, Ashrafian H, Rao C, et al. What does leadership in surgery entail?: Leadership in surgery. ANZ J Surg. 2010 Dec;80(12):876-83.

24) Wallbank S, Hatton S. Reducing burnout and stress: the effectiveness of clinical supervision. Community Pract. 2011 Jul;84(7):31-5.

25) Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC Health Serv Res. 2017 Dec;17(1):786.

26) Westman M, Eden D. Effects of a Respite From Work on Burnout: Vacation Relief and Fade-Out. J Appl Psychol. 1997 Aug;82(4):516-27.

27) Fritz C, Sonnentag S. Recovery, well-being, and performance-related outcomes: The role of workload and vacation experiences. J Appl Psychol. 2006;91(4):936-45.

28) Etzion D. Annual vacation: Duration of relief from job stressors and burnout. Anxiety Stress Coping. 2003 Jun;16(2):213-26.

29) Froelich J, Milbrandt JC, Allan DG. Impact of the 80-hour Workweek on Surgical Exposure and National In-Training Examination Scores in an Orthopedic Residency Program. J Surg Educ. 2009 Mar;66(2):85-8.

30) Gelfand DV. Effect of the 80-Hour Workweek on Resident Burnout. Arch Surg. 2004 Sep 1;139(9):933.

31) Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: Perseverance and passion for long-term goals. J Pers Soc Psychol. 2007;92(6):1087-101.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

It is well documented that burnout and fatigue are common in the medical profession. Most of the available literature is based on assessment of the senior workforce, focussing primarily on consultants.[[1–5]] Recently, there has been a growing concern for the wellbeing of the junior workforce, due to a number of changes in the working environment.[[6–12]] These changes include an increased need for service provision, less teaching time, a diminished opportunity to progress through a chosen career pathway and a general increase in the number of patients (with increasing amounts of significant comorbidities), all potentially leading to a greater manifestation of occupational burnout.[[6–12]]

The consequences of burnout are far reaching, affecting all levels of healthcare. Adverse effects to doctors include increased rates of suicidal ideation and drug abuse, as well as health concerns such as hypertension, anxiety, depression, headaches and other cardiovascular disease.[[1,7]] Healthcare institutions are affected by doctor absenteeism and high turnover rate, as well as poor performance indicators while at work.[[1]] Patient care is often compromised, with an increased risk of medical errors and a decrease in the quality of medical care.[[1,7,13]] Burnout of medical staff has also been shown to decrease the empathy they have for patients. This ultimately affects the overall care of a patient.[[14]]

Occupational burnout is defined as a syndrome composed of three main facets: emotional exhaustion (EE), depersonalisation (DP) and a low sense of personal accomplishment (PA). These are often secondary to the chronic stresses of one’s profession.[[3,4,15]] EE is defined as “the perception of feeling drained or depleted due to excessive emotional or psychological demands”. DP is defined as “the inclination to view another person in an overly detached and impersonal regard”.[[1]] Low PA is defined as “a decline in feelings of competence” and “a tendency to evaluate oneself negatively, in particular, regarding their work with others”.[[16]]

Orthopaedic surgery is a highly skilled and demanding specialty. Surgeons are expected to maintain high standards of professionalism, medical expertise and technical competence.[[5]] The outcome of their work is directly linked to the overall function of their patients. Adverse outcomes have a serious impact on the patient, the surgeon and the healthcare system.[[5]]

Orthopaedic training is considered to be emotionally, physically and intellectually challenging, and can take a substantial toll on trainees and their families. The significant number of clinical hours, along with the time spent studying to reach the level of clinical excellence demanded, can often compromise the wellbeing of trainees. This is detrimental to their personal health and overall job satisfaction, and compromises patient care and safety.[[6,7,9–12]]

The phenomenon of burnout among orthopaedic scheme trainees has been extensively studied and documented in other first world countries that share a similar demand of excellence from their doctors.[[6–8,10–12,17,18]] To our knowledge, there is currently no published study analysing the rates of burnout among New Zealand orthopaedic registrars. The aim of this study was to assess the rates of New Zealand orthopaedic registrar burnout, both at a trainee and non-trainee level. A secondary aim was to establish if there were any specific factors leading to burnout. Our hypothesis was that the burnout rate would be comparable to other first world countries with a similar orthopaedic training programme.

Methods

In August 2021, an email containing a link to a 53-question survey was sent to all (n=62) of the orthopaedic registrars on the New Zealand Orthopaedic Association (NZOA) training programme. Ethics approval was retrospectively obtained from the Health and Disability Ethics Committee (Reference: #2022OOS12773). The survey was conducted anonymously online. A reminder email was sent in weeks two and three to all registrars on the list.

A similar email was sent to the non-trainee orthopaedic registrars. Two methods were employed to ensure the survey reached its intended group. Firstly, all non-trainee registrars who had identified orthopaedics as their current specialty with the Specialty Trainees of New Zealand (STONZ) union received an email. Secondly, a selected orthopaedic registrar was contacted at most of the district health boards (DHBs) and was asked to be a point of contact for the study. If they agreed, a link to the survey was sent to them via email or SMS. They were then asked to distribute the survey link to the rest of the applicable doctors in that department.

The surveys demographic questions addressed gender preference, ethnicity, age, year of the Surgical Education and Training (SET) Programme/number of years the registrar had worked in orthopaedics, current relationship status and, if applicable, work status of their partner and whether they were in the medical profession.

Factors associated with burnout were queried, including number of sleep hours and the exercise regimen of a registrar, as well as use of social media, alcohol and other substances. Registrars were asked whether they could routinely attend health maintenance appointments or if they had ever used professional services for their mental health. Questions about their orthopaedic department including hospital setting, whether the department had a full complement of staff, hours worked, time since their last holiday, manageability of the clinical workload and amount of senior support were also included.

Maslach Burnout Inventory

The final part of the survey was the Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS MP). This is a validated tool used to assess burnout.[[15]] It assesses the three main facets of the syndrome via a Likert-scale set of 22 questions: nine for EE, five for DP and eight for PA. The total score for each facet is then calculated, stratified and ranked into either a mild, moderate or severe form of burnout. This information is summarised in Table 1.[[19]] The level of EE and DP is proportional to burnout; PA is inversely proportional.[[6]] A registrar was considered “burnt out” if they scored in the severe range for either EE or DP. Levels of burnout were calculated in the trainee and non-trainee groups. Potential factors were then assessed to see if there were any statistically significant associations related to each facet of burnout.

Statistics

Parametric data between trainees and non-trainees was compared using unpaired T-testing. Ranked non-parametric data were compared using Mann–Whitney testing. Categorical data were compared using the Chi-squared and Fisher’s Exact test. A p-value <0.05 was considered statistically significant. A multivariate regression analysis was performed to establish associations between variables. Trainees and non-trainees were then grouped, dependent on whether they were exhibiting burnout.

Results

Trainees vs non-trainees

Fifty of the 62 (80.6%) trainees completed the survey. Sixty-six of 70 (estimated number) (94.3%) of non-trainees completed the survey. Overall, trainees exhibited moderate levels of burnout (mean score EE 22.5, DP 8.8, PA 35.9). Non-trainees also exhibited moderate levels of burnout (mean score EE 22.4, DP 8.9, PA 35.9). Fifty-two point two percent of trainees and 50% of non-trainees scored in the severe range for either (or both) EE or DP. This is summarised in Table 2.

Demographic data and relevant associated factors are summarised in Table 3. There were statistically significant differences between trainees and non-trainees with regards to age, relationship status, children, whether their partner was in the medical profession, and if COVID-19 had decreased the participant’s mood. Ninety-five point seven percent of trainees and 87.9% of non-trainees either disagreed or were neutral when asked if they were able to routinely attend health maintenance appointments.

Associations within cohorts

Trainees

In the trainee group, the only significant association noted was an increased level in DP when trainees stated they had not had time away from work for greater than three months (P=0.042).

Non-trainees

The non-trainee group exhibited several associations between parameters. DP was found to be higher in males than females surveyed (P=0.028). It was also increased in departments without a full complement of staff (P=0.020). EE was higher in registrars who slept six hours or fewer (R=0.329, P=0.012) and worked greater than 80 hours per week (R=0.266, P=0.043). EE was lower in trainees with a lower mood due to COVID-19 (R=0.270, P=0.043). DP (P=0.009) and EE (P<0.001) were increased in non-trainees who indicated that they “strongly disagreed” that they were able to routinely attend health maintenance appointments.

Associations of respondents displaying signs of burnout

Respondents displaying signs of burnout exhibited several statistically significant associations. The presence of a senior colleague is highly significant at reducing burnout (P<0.001). A respondent who participates in professional assistance for work-related stress (such as attending professional supervision, or seeing a counsellor, psychologist or psychiatrist) is less likely to be burnt out (P=0.049). A respondent working in a department with a full complement of staff is less likely to be burnt out (P=0.020). A respondent who is able to attend health maintenance appointments is less likely to be burnt out (P=0.050). This is summarised in Table 4.

View Tables 1–4.

Discussion

Burnout is a syndrome that exists in all forms of the medical profession. It has been noted to adversely affect orthopaedic surgeons in other countries with similar healthcare systems, and it is particularly prevalent while doctors are advancing through their training.[[3,6–8,10,11,13,17,18]] Our study shows that New Zealand’s orthopaedic registrars, both trainee and non-trainee, are not statistically different.

Orthopaedic surgery in New Zealand prides itself on its high standards, both in clinical practice and professional behaviour. These standards are developed by the quality of the surgeon’s training and the examples set by their senior colleagues and consultants. It’s accepted that training will include stressful periods and, ultimately, is a necessary process to practice in a field that produces a high level of job satisfaction.[[7,10,11]] Regardless, there is now substantial evidence available that identifies orthopaedic trainees as being particularly vulnerable to burnout during this period. Consideration on how to mitigate these stresses needs to be further investigated and implemented.

New Zealand shares a comparable orthopaedic training scheme and healthcare system to Australia. Both orthopaedic associations follow guidelines set by the Royal Australasian College of Surgeons. A 2014 study by Arora et al. examined burnout in Australian orthopaedic trainees and demonstrated that 53% of respondents were burnt out.[[6]] This is a similar figure to our study, whereby 52.3% of trainees and 50% of non-trainees are burnt out. A 2016 study by Chambers et al. examined burnout in New Zealand’s senior medical staff, finding 50.1% of respondents were burnt out.[[20]] It was also found that respondents aged 30–39 had the highest mean burnout scores. This is particularly alarming considering 89.1% of the trainee respondents are in this age category.

Burnout is difficult to address due to the complex and multifactorial nature of the syndrome. A 2009 study by Sargent et al. documented a number of factors associated with increased EE and DP.[[9]] EE was adversely affected by difficult relationships with senior colleagues, anxiety over clinical competence and high levels of conflict being present between work and personal life. A high level of DP was found with increased work hours and difficult relationships with nursing staff.[[9]]

Strategies to try and combat burnout have been identified. They can be divided into personal and institutional approaches. Personal strategies to combat burnout include spending time with partners, children and extended family and friends, as well as maintaining a social life outside work and maintaining physical fitness.[[8,9,12,21]] A strong and positive maintenance of relationships with colleagues was deemed particularly important.[[12]] On an institutional level, limiting work hours to fewer than 80, providing senior support when required and providing mentorship programmes have been shown to decrease levels of burnout in registrar populations.[[8,9,12,21,22]]

A few important associations were found in our study. Trainees recorded a higher level of DP when they hadn’t had time away from work for three months or more. In the non-trainee group, males had a higher level of DP compared to females. EE and DP were found to be increased in registrars who slept fewer than six hours, worked greater than 80 hours, or were in a department without a full complement of staff. To gain a place on the training programme is extremely competitive with limited places available. To attempt to gain an interview for potential selection, a points-based system is utilised to direct non-trainees in areas of orthopaedic development. This system awards points for specific courses, research published, presentations given, cultural involvement and orthopaedic work experience. The majority of non-trainees will have worked between three to five years as an orthopaedic registrar before being selected to the training programme. Our study noted that over 40% of non-trainee respondents were in their third year or more as orthopaedic registrars. While not directly assessed in this study, the lack of certainty about their future might be a direct contributor to burnout. Anecdotally, many non-trainees will often work long hours (often going above the hours stipulated on their salaried contract) to try and prove themselves. This is an unfortunate situation that may be improved with better personal and institutional strategies in place. When respondents displaying signs of burnout were grouped together, further important associations were noted. The presence of a senior colleague, participation in professional assistance programmes, being able to attend health maintenance appointments and working in a department with a full complement of staff were all found to be important factors in limiting burnout.

A positive change in our medical personnel’s wellbeing necessitates looking for ways to change the current system. A particularly concerning area was the large proportion of respondents (95.7% trainees, 87.9% non-trainees) who were neutral or stated they were unable to routinely attend health appointments. As one of the strategies to prevent burnout is maintenance of physical fitness, we suggest a mandatory implementation of protected time for health-related consultations should be made at a DHB or governing body level. The presence of a senior colleague is highly significant at reducing burnout (P<0.001), leading us to emphasise the importance of implementation of mentoring programmes. Mentoring has been defined in many ways, but essentially equates to a “career friend” who can help a patron through the rigours of a particular activity.[[23]] Mentorship can be formal or informal; it is rewarding for both the mentor and the mentee. The NZOA offers mentorship to its trainees, with regular documented check-ins between surgeons and the registrars working for them. While there is no formal mentoring system set up for non-trainees, a Medical Council of New Zealand (MCNZ) requirement states all non-trainees must register in a recertification programme for their general scope of practice. Inpractice is an independent not-for-profit organisation whose role is to deliver education and continuing professional development programmes, including formulation of professional development plans, continued medical education, peer review sessions, participation in audits and quarterly meetings with a nominated consultant. This programme is important for future career planning and academic development. To help supplement this, we suggest either incorporating further sections that focus on burnout prevention or offer other mentorship programmes at a DHB level as an introductory step forward in this process.

We also endorse the use of professional supervision. This is an ongoing and formal process, whereby a participant is encouraged (in a professional capacity) to undergo critical self-reflection, discuss previous decisions, problems, or concerns in a safe environment.[[24,25]] Participants also practice wellbeing exercises at these sessions. The aim is for continued professional competence and development.[[24,25]] The majority of our respondents (78.3% trainees, 86.2% non-trainees) stated they had not sought professional assistance for work-related stress. These services are available to all medical practitioners in New Zealand. While the usefulness of the service is heavily dependent on the registrar’s willingness and enthusiasm to participate, a potential institutional measure might be an increased promotion of the service, as well as advertising its positive attributes to orthopaedic registrars.

Trainees recorded higher levels of DP when they hadn’t had time away from work for greater than three months. Evidence shows there is a reduction in burnout levels when people take vacations.[[26–28]] After a few weeks from returning to work, stress and burnout levels begin to rise. An institutional change to counteract this may be the implantation of a required stand-down period for trainees and non-trainees every few months to help limit their burnout levels.[[26–28]] A respondent working in a department with a full complement of staff was less likely to be burnt out (P=0.020). It was also found that DP was increased in non-trainees working in a department without a full complement of staff. While occasional understaffing is an accepted part of the job, institutional measures should be in place to facilitate recruitment and hiring in all departments to ensure registrars are not worn out by consistently having to do more than their fair share of duties.

A positive to be taken from the survey is that only a small proportion of registrars were working, on average, over 80 hours a week (2.2% trainee, 5.2% non-trainee). We found the majority fall between the range of 60 to 80 hours. In 2003 the United States restructured their programme so that a resident would not work more than 80 hours a week.[[29]] Follow-up studies from this proved that operating and clinical time were not affected by the change.[[29,30]] However, the overall MBI scores for the surveyed residents made no statistically significant change, with high levels of burnout still being recorded.[[30]] We are not advocating a rigorous limitation of hours but propose a potential future audit and deduction of potential superfluous jobs (such as extra administration to what is normally expected of a medical professional) might decrease this total.

Another positive is that the majority of respondents (73.9% trainee, 79.3% non-trainee) stated they felt well supported by senior colleagues. Again, as previously stated, the presence of a senior colleague is highly significant at reducing burnout (P<0.001), indicating its importance as an institutional strategy for limiting burnout. Additionally, 63% of trainees and 77.2% of non-trainees were neutral or disagreed with the statement that COVID-19 had decreased their mood. Only 6.5% of trainees and 10.5% of non-trainees felt their workload had increased due to COVID-19. This should be closely followed as the situation continues to develop.

Burnout prevention efforts should also be considered. Abelson et al. showed that a key way to reduce attrition in surgical residents was to begin career mentorship while in medical school.[[22]] Interest and technical ability in orthopaedics is not enough to make a surgeon—it takes consistent and focussed application over time to produce the finished product.[[31]] Preparing junior doctors and medical students about the potential rigours they may face prior to, and during, the training programme could prove to be a key component to limiting burnout in the future.

Limitations

There were a few limitations to the study. Firstly, the sample size was small. This meant we were unable to do multivariate analyses. However, we were only assessing burnout among orthopaedic trainees and non-trainees in New Zealand (a specific group with a finite number) and the high response rates of 80.6% and 94.3% makes these results representative of the New Zealand population. Another limitation was the inability to define the total number of non-trainee orthopaedic registrars in New Zealand. While the trainee population has a centralised body in the NZOA, there is no organisation in charge of the non-trainees. There is a chance that not every non-trainee registrar has had the opportunity to complete the survey. The survey was distributed to the population via STONZ or word of mouth. Some of the orthopaedic non-trainees may be associated with the Resident Doctors Association (RDA), another union representing a proportion of New Zealand’s junior doctors. This organisation was not approached to help distribute the survey. The hope is that the survey found these non-trainees via their departmental colleagues passing the survey onto them. As mentioned in the discussion, another limitation is the lack of information regarding non-trainees in their third year or more as orthopaedic registrars. It is very likely that a proportion of this group has attempted (or had multiple attempts) to be selected to the training programme. This uncertainty about their future might be a direct contribution to burnout but wasn’t fully assessed in this study. Recently, the decision has been made by the NZOA selection committee to only allow three attempts at selection. Future studies assessing burnout in this population should take this change, as well as its potential impacts, into account when designing their study. Finally, inherent survey-based biases might be apparent, with registrars submitting answers that potentially under-report how they are feeling, or answers which they feel they are expected to submit.

Conclusion

At least half of trainee and non-trainee orthopaedic registrars currently working in New Zealand are displaying signs of burnout. This is comparable to other first-world nations with similar training programmes. Burnout is a complex syndrome that is difficult to solve with singular changes. We believe burnout could be attenuated by advocacy for registrars attending health maintenance appointments; promotion and utilisation of mentorship/professional supervision services; and implementation/promotion of these programmes to junior doctors and medical students. As has been shown in other countries, if medical staff working within our healthcare system are burnt out, this ultimately leads to adverse health outcomes for the population of New Zealand.[[6,7,9–12]] By improving the lives of our medical personnel, we hope to ultimately make change on a greater level.

Summary

Abstract

Aim

Burnout and fatigue are common in the medical profession. The primary aim was to assess rates of burnout in trainee and non-trainee orthopaedic registrars in New Zealand. A secondary aim was to establish which specific factors are associated with burnout.

Method

In 2021, a 53-question online survey was sent to New Zealand trainee and non-trainee orthopaedic registrars. The survey included questions addressing demographics, modifiable factors known to lead to burnout, information on respective orthopaedic departments, and how respondents had fared with COVID-19. Registrars also completed the Maslach Burnout Inventory—Human Services Survey for Medical Personnel (MBI-HSS MP), a 22-question validated survey that is designed to assess the frequency and intensity of perceived burnout among medical personnel.

Results

Fifty of 62 (80.6%) trainees and 66 of 70 (estimated number) (94.3%) of non-trainees completed the survey. Trainees and non-trainees both exhibited moderate levels of burnout. The trainee mean score emotional exhaustion (EE) 22.5, depersonalisation (DP) 8.8, personal achievement (PA) 35.9; non-trainee mean score EE 22.4, DP 8.9, PA 35.9. Fifty-two point two percent of trainees and 50% of non-trainees scored in the severe range for at least one of EE or DP. Factors shown to reduce burnout are the presence of a senior colleague (P<0.001), participation in professional assistance (P=0.049), working in a department with a full complement of staff (P=0.020) and being able to attend health maintenance appointments (P=0.050).

Conclusion

Our study shows that approximately half of both trainee and non-trainee orthopaedic registrars are exhibiting signs of burnout. This is comparable to other developed nations with a similar healthcare system.

Author Information

Tanushk Luke Brito Martyn MBChB, BSc: Orthopaedic Registrar, Department of Orthopaedic Surgery, Waikato Hospital, Waikato, New Zealand; Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand. Earle Savage BMBS, BPHTY, Pg Cert HAUL: Orthopaedic Surgeon, Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand. Simon Bruce Murdoch MacLean MBChB, FRCS(Tr&Orth), PGDipCE: Orthopaedic Surgeon, Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Tauranga Hospital, Bay of Plenty, New Zealand.

Acknowledgements

The authors would like to thank STONZ for their research grant in helping to partly fund this project.

Correspondence

Tanushk Luke Brito Martyn MBChB, BSc: Orthopaedic Registrar, Waikato Hospital, 183 Pembroke Street, Hamilton 3240, New Zealand.

Correspondence Email

tanushk.martyn@gmail.com

Competing Interests

Nil.

1) Arora M, Diwan AD, Harris IA. Burnout in orthopaedic surgeons: a review: Burnout in orthopaedic surgeons. ANZ J Surg. 2013 Jul;83(7–8):512-5.

2) van Wulfften Palthe ODR, Neuhaus V, Janssen SJ, Guitton TG, Ring D. Among Musculoskeletal Surgeons, Job Dissatisfaction Is Associated With Burnout. Clin Orthop. 2016 Aug;474(8):1857-63.

3) Hui RWH, Leung KC, Ge S, Hwang AC, Lai GGW, Leung AN, et al. Burnout in orthopaedic surgeons: A systematic review. J Clin Orthop Trauma. 2019 Oct;10:S47-52.

4) Daniels AH, DePasse JM, Kamal RN. Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention. J Am Acad Orthop Surg. 2016 Apr;24(4):213-9.

5) Ames SE, Cowan JB, Kenter K, Emery S, Halsey D. Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners, and Colleagues: AOA Critical Issues. J Bone Jt Surg. 2017 Jul 19;99(14):e78.

6) Arora M, Diwan AD, Harris IA. Prevalence and Factors of Burnout among Australian Orthopaedic Trainees: A Cross-Sectional Study. J Orthop Surg. 2014 Dec;22(3):374-7.

7) Driesman AS, Strauss EJ, Konda SR, Egol KA. Factors Associated With Orthopaedic Resident Burnout: A Pilot Study. J Am Acad Orthop Surg. 2020 Nov 1;28(21):900-6.

8) Barrack RL, Miller LS, Sotile WM, Sotile MO, Rubash HE. Effect of Duty Hour Standards on Burnout among Orthopaedic Surgery Residents. Clin Orthop. 2006 Aug;449:134-7.

9) Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of Life During Orthopaedic Training and Academic Practice: Part 1: Orthopaedic Surgery Residents and Faculty. J Bone Jt Surg-Am Vol. 2009 Oct;91(10):2395-405.

10) Somerson JS, Patton A, Ahmed AA, Ramey S, Holliday EB. Burnout Among United States Orthopaedic Surgery Residents. J Surg Educ. 2020 Jul;77(4):961-8.

11) Strauss EJ, Markus DH, Kingery MT, Zuckerman J, Egol KA. Orthopaedic Resident Burnout Is Associated with Poor In-Training Examination Performance. J Bone Jt Surg. 2019 Oct 2;101(19):e102.

12) Kp W, Ak KP, Jyl O. Orthopaedic Resident Burnout: A Literature Review on Vulnerability, Risk Factors, Consequences and Management Strategies. Malays Orthop J. 2019 Jul 1;13(2):15-9.

13) Rodrigues H, Cobucci R, Oliveira A, Cabral JV, Medeiros L, Gurgel K, et al. Burnout syndrome among medical residents: A systematic review and meta-analysis. Junne FP, editor. PLOS ONE. 2018 Nov 12;13(11):e0206840.

14) Reynolds M, McCombie A, Jeffery M, Mulder R, Frizelle F. Impact of burnout on empathy. 2021;134(1530):9.

15) Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory: Third edition. In: Evaluating stress: A book of resources. Lanham, MD, US: Scarecrow Education; 1997. p.191-218.

16) Schutte N, Toppinen S, Kalimo R, Schaufeli W. The factorial validity of the Maslach Burnout Inventory-General Survey (MBI-GS) across occupational groups and nations. J Occup Organ Psychol. 2000 Mar;73(1):53-66.

17) Faivre G, Kielwasser H, Bourgeois M, Panouilleres M, Loisel F, Obert L. Burnout syndrome in orthopaedic and trauma surgery residents in France: A nationwide survey. Orthop Traumatol Surg Res. 2018 Dec;104(8):1291-5.

18) Simons BS, Foltz PA, Chalupa RL, Hylden CM, Dowd TC, Johnson AE. Burnout in U.S. Military Orthopaedic Residents and Staff Physicians. Mil Med. 2016 Aug;181(8):835-9.

19) Wang J, Wang W, Laureys S, Di H. Burnout syndrome in healthcare professionals who care for patients with prolonged disorders of consciousness: a cross-sectional survey. BMC Health Serv Res. 2020 Dec;20(1):841.

20) Chambers CNL, Frampton CMA, Barclay M, McKee M. Burnout prevalence in New Zealand’s public hospital senior medical workforce: a cross-sectional mixed methods study. BMJ Open. 2016 Nov;6(11):e013947.

21) Balch CM, Shanafelt T. Combating Stress and Burnout in Surgical Practice: A Review. Adv Surg. 2010 Sep;44(1):29-47.

22) Abelson JS, Sosa JA, Symer MM, Mao J, Michelassi F, Bell R, et al. Association of Expectations of Training With Attrition in General Surgery Residents. JAMA Surg. 2018 Aug 1;153(8):712.

23) Patel VM, Warren O, Humphris P, Ahmed K, Ashrafian H, Rao C, et al. What does leadership in surgery entail?: Leadership in surgery. ANZ J Surg. 2010 Dec;80(12):876-83.

24) Wallbank S, Hatton S. Reducing burnout and stress: the effectiveness of clinical supervision. Community Pract. 2011 Jul;84(7):31-5.

25) Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC Health Serv Res. 2017 Dec;17(1):786.

26) Westman M, Eden D. Effects of a Respite From Work on Burnout: Vacation Relief and Fade-Out. J Appl Psychol. 1997 Aug;82(4):516-27.

27) Fritz C, Sonnentag S. Recovery, well-being, and performance-related outcomes: The role of workload and vacation experiences. J Appl Psychol. 2006;91(4):936-45.

28) Etzion D. Annual vacation: Duration of relief from job stressors and burnout. Anxiety Stress Coping. 2003 Jun;16(2):213-26.

29) Froelich J, Milbrandt JC, Allan DG. Impact of the 80-hour Workweek on Surgical Exposure and National In-Training Examination Scores in an Orthopedic Residency Program. J Surg Educ. 2009 Mar;66(2):85-8.

30) Gelfand DV. Effect of the 80-Hour Workweek on Resident Burnout. Arch Surg. 2004 Sep 1;139(9):933.

31) Duckworth AL, Peterson C, Matthews MD, Kelly DR. Grit: Perseverance and passion for long-term goals. J Pers Soc Psychol. 2007;92(6):1087-101.

Contact diana@nzma.org.nz
for the PDF of this article

Subscriber Content

The full contents of this pages only available to subscribers.
Login, subscribe or email nzmj@nzma.org.nz to purchase this article.

LOGINSUBSCRIBE