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Burnout among obstetricians and paediatricians: a cross-sectional study from China
  1. Junying Ye1,2,
  2. Huan Wang3,4,
  3. Hao Wu1,
  4. Liaosha Ye5,
  5. Qi Li6,
  6. Xiang-yu Ma7,
  7. Xiaodong Yu4,
  8. Hua Zhang2,
  9. Xu Luo3
  1. 1 Xinqiao Hospital, Army Medical University, Chongqing, China
  2. 2 Chongqing Health Center for Women and Children, Chongqing, China
  3. 3 Department of Medical Administration, Southwest Hospital, Army Medical University, Chongqing, China
  4. 4 Department of Medical Administration, The 987 Hospital of PLA, Baoji, Shanxi Province, China
  5. 5 Department of Medical Administration, The Army General Hospital, Beijing, China
  6. 6 Department of Foreign Languages, School of Basic Medical Sciences, Army Medical University, Chongqing, China
  7. 7 Department of Epidemiology, Army Medical University, Chongqing, China
  1. Correspondence to Dr Hao Wu; ewuhao{at}163.com

Abstract

Objectives Hospitals devoted to maternal and child health represent unique healthcare institutions in China. Healthcare professionals in these hospitals attend to health services for women and children, and also provide technical services and support for district maternal and children’s healthcare as well as family planning. However, few studies have examined occupational burnout among doctors employed in these hospitals. This research addresses the gap in the literature.

Methods A cross-sectional survey of obstetricians and paediatricians from 11 maternal and child health hospitals across China was conducted May through June 2017. A total of 678 people completed a self-administered questionnaire. The survey included questions about demographics, doctor–patient relationships and networks of support as well as characteristics designed to capture the occurrence of burnout, such as emotional exhaustion, cynicism and professional efficacy. T-test, variance and multiple regression analyses were used to examine the data.

Results The research revealed that 56.6% of obstetricians and paediatricians exhibited signs of occupational burnout. Poor doctor–patient relationships and high average number of weekly hours worked contributed to burnout. Additionally, low family support corresponded to physicians’ low sense of professional efficacy.

Conclusions Several factors have contributed to occupational burnout among paediatricians and obstetricians at maternal and child health hospitals in China, including lack of family support, poor doctor–patient relationships and heavy workloads.

  • Chinese doctors
  • burnout
  • maternal and child health care hospital
  • maslach burnout inventory-general survey

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Strengths and limitations of this study

  • The research topic is relatively new: the job burnout of doctors in provincial maternal and child healthcare hospitals in China has scarcely been the key focus; the influences of China’s comprehensive two-child policy on the burnout among obstetricians and paediatricians also opens up a new area of research.

  • The result shows, for the first time, that 56.6% of obstetricians and paediatricians in Chinese provincial maternal and child healthcare hospitals exhibited signs of occupational burnout. Poor doctor–patient relationships and high average number of weekly hours worked contributed to burnout.

  • This information may raise concerns about the occupational health of obstetricians and paediatricians in China, and inspire the government to increase the training of relevant professionals.

  • A major limitation is that, due to lack of research in this field, this paper only made a preliminary study of the status quo, wanting a more in-depth study, such as interviews, questionnaire surveys and consultation from professionals.

Introduction 

China has made great progress on maternal and child health in the past two decades. From 1990 to 2015, the country lowered infant mortality by nearly 70% and maternal mortality 75%.1 Much of this success was possible due to a multipronged strategy that emphasised investments in antenatal and delivery care, effective referral systems for women at high risk and a commitment to the professionalisation of maternity care.2 Hospitals devoted to maternal and child health represent unique healthcare institutions in China. The professionals in these hospitals attend to health services for women and children, and also provide technical services and support for district maternal and children’s healthcare as well as family planning. These hospitals are now playing an increasingly significant role in Chinese women and children’s healthcare. For example, our previous survey showed that the number of deliveries in Chongqing Health Center for Women and Children was about 13 000 in 2017, ranking the first among all health institutions in Chongqing, and it was 44.5% higher than that of the second place.

However, the increasing workload, to some extent, limits the development of these hospitals. It is generally known that China has suffered from a shortage of obstetricians in recent years. With the implementation of China’s two-child policy, there was much speculation about the impact the change would have on the services provided to mothers and infants. The number of babies born in 2016 represented an increase of 8.7 million from the previous year. Despite the fact that 53% of 2016 newborn babies come from two-child families, the population of obstetricians and paediatricians has not increased at the same rate.3 In addition, as a result of the new policy, more older women have decided to have another child. Many of them would require assisted reproductive services due to their age, and the same doctors who provide services might go on maternity leave to have their second child.4 Consequently, doctors have been treating a greater number of high-risk births, and their workloads have increased. Furthermore, the expectations of patient’s family members have intensified, creating greater pressure on them in doctor–patient relationships. All the factors mentioned above may increase the risk of serious job burnout among doctors.

As a previous research showed, in comparison with other professions, doctors are more likely to suffer from burnout. The researchers have attributed this likelihood to the fact that doctors are often held to high standards, are less likely to seek support when they need help and perform work that is often emotionally intense.5 As a matter of fact, interest in occupational burnout among healthcare professionals began nearly half a century ago.6 Freudenberger’s early work in clinics devoted to people struggling with drug addiction noted that staff frequently suffered from the gradual onset of a lack of motivation and commitment, which was accompanied by both mental and physical symptoms.7 The identification of burnout symptoms typically involved three dimensions: emotional exhaustion, cynicism and a low sense of professional achievement.8 The burnout was shown to trigger a variety of personal problems for the medical professional, such as physical illnesses, work absenteeism and/or domestic conflict, and also negatively impact medical decisions and doctor–patient relationships.9 Currently, there is a growing interest in the factors that contribute to burnout and possible strategies to mitigate the impact. For instance, a 2011 study from the USA separated the factors into several aspects: external, job-related and personal life factors.10

Research on job burnout among hospital doctors emerged later in China and never reached the same level of interest it enjoyed in other countries. To date, the research has focused on the identification of burnout among general hospital doctors, the factors contributing to job burnout11 and its impact on medical service delivery.9 Despite the country’s sustained commitment to create a strong Maternal and Child Health Initiative over the past 20 years, there has not been research on the occupational burnout among the medical professionals working in maternal and child healthcare hospitals. Our research was designed to address this gap in the literature and to further an understanding of the challenges China faces in its efforts to provide quality healthcare services to mothers and children. A cross-sectional survey was developed, focusing on the personal character traits of doctors, doctor–patient relationships and the levels of support doctors received from their families. Finally, a means to measure burnout and strategies to mitigate its impacts are proposed.

 Subjects and methods

A cross-sectional survey was administered to obstetricians and paediatricians across the country from May until June 2017.

Subjects

We launched a research project on the job burnout among doctors in maternal and child healthcare hospitals, and invited some provincial hospitals of this kind to participate in the survey. The reason for choosing provincial maternal and child health hospitals is that they have more perfect systems in paediatric and obstetric departments compared with those of the general hospitals, and also they undertake more delivery workload, both of which may better reflect the current situation of job burnout among paediatricians and obstetricians in China. To ensure the consistency of the samples, we formulated the following inclusion criteria: (1) The maternal and child healthcare hospitals chosen must be at provincial level; (2) according to the evaluation criteria of the third-class maternal and child healthcare hospitals, the number of beds in use should be no less than 300, and the beds in departments of obstetrics and paediatrics should account for not less than 90% of the total number. Besides, hospitals with imperfect systems were excluded as some maternal and child healthcare hospitals could only provide outpatient services but not hospitalisation services because of the decisions made by the administrative departments of higher levels.

A sample was then obtained from 11 maternal and child health hospitals located in Jiangsu, Guangdong, Hubei, Shanxi, Gansu, Xinjiang, Chongqing, Yunnan, Sichuan, Guizhou and Liaoning. A total of 750 questionnaires, along with a consent form, were distributed by mail to 750 paediatricians and obstetricians from the selected hospitals. By the end of June, 710 doctors had returned and 678 had completed the questionnaire—an effective response rate of 90.4%. A total of 131 male (19.3%) and 547 female doctors (80.7%) responded. Approximately half (49.9%) of the respondents were paediatricians.

Questionnaire

The questionnaire captured the participants’ demographics and employment, information about doctor–patient relationships, details about the family support enjoyed by doctors and indicators of occupational burnout.

Demographic and employment information was captured through questions addressing sex, age, marital status, education level, region, professional title, department and average number of hours worked weekly.

The question about age permitted one of four possible responses: 29 years of age or younger, 30–39 years of age, 40–49 years of age, and 50 years of age or older. Departments are divided into obstetrics and paediatrics because these two departments are the most important ones in maternal and child healthcare hospitals, with the beds accounting for more than 90% of the total number. Due to the different means by which certification to practice medicine in China may be obtained, questions regarding education permitted one of four responses: junior college degree, undergraduate degree, master’s degree and doctorate. Participants also could choose one of four occupational titles: resident, attending physician, associate chief physician and chief physician. Possible responses to marital status were unmarried, married, divorced or widowed. Place of employment was limited to regions: Eastern, Central, Western and Northeastern China. Finally, the normal working hours of Chinese doctors are 40 hours a week (8 hours a day, 5 days a week), so we take 10 hours as a grade to indicate the number of average hours worked weekly: 40 hours or less, 41–50 hours, 51–60 hours, and 61 hours or more.

A Chinese adaptation of the Difficult Doctor–Patient Relationship Questionnaire-10, originally developed by Steven Hahn and his colleagues,12 was used to measure doctor’s perceptions of doctor–patient relationships.13 There were 10 questions that focused on the following areas: physicians’ subjective experiences, patients’ behaviours, and symptoms. Responses were scored on a six-point Likert scale. The higher the scores, the more difficult the doctor–patient relationship was determined to be. Cronbach’s alpha of the doctor–patient relationship scale was 0.803.

Family support was measured by the Perceived Social Support Scale-Family,14 adapted for research in China by Xiangdong Wang in 1999.15 This was a questionnaire that consisted of questions in two categories: My family can help me concretely; I am able to obtain emotional help and support from my family when I need it and I can talk to my family about my problems. Responses were scored on a seven-point scale from completely disagree to completely agree. Higher scores indicated greater levels of perceived support. Cronbach’s alpha was 0.869.

The Chinese version of the Maslach Burnout Inventory–General Survey (MBI-GS) was chosen to identify occupational burnout.16 The MBI-GS has been translated and revised to ensure that the questions could be administered to Chinese subjects in a culturally and linguistically appropriate fashion.17 Previous studies on Chinese nurses and doctors that used the revised survey found it to be an effective tool.18 19 The research consisted of three subscales: emotional exhaustion (EE, five items), cynicism (CY, four items) and sense of achievement by professional efficacy (PE, seven items). EE was defined as feeling emotionally overwhelmed and exhausted by work; CY was defined as doubting the value of one’s work or its contribution to anything; PE described a feeling of reduced competence and lack of success/achievement in one’s work with other people. Each question was ranked on a six-point scale from never to always. The possible minimum and maximum scores were 0 to 30 for EE, 0 to 24 for CY and 0 to 42 for PE. In accordance with the Chinese adaptation of the MBI-GS, the cut-off points were as follows: a low score for EE was less than 9, average was 9 to 13 and high was greater than 13; a low score for CY was less than 3, average was 3–9 and high was greater than 9; a low score for PE was greater than 30, an average score was 18–30 and a high score was less than 18.20 Individuals with a high score in one or more of these three domains were considered to exhibit burnout symptoms. Those with high EE and CY scores combined with a low PE score were identified as having a high degree of occupational burnout.17 Cronbach’s alpha coefficients for EE, CY and PE were 0.95, 0.92 and 0.88, respectively.

Statistical analysis

Data were analysed using SPSS V.17 software. T-tests and variance analyses were employed to test and compare the scores among doctors with different demographics. Additionally, an analysis was conducted to identify any existing correlation between occupational burnout and demographic variables, family support and doctor–patient relationships. Finally, a multiple regression analysis was performed to examine the factors related to occupational burnout.

Harman single-factor analysis was used to test for homology.21 A factor analysis of all items in the scale was created to determine the principal component in the non-rotation and identify the amount of homologous variance. An amount of less than 50% of the key value indicated that common method variance was not problematic. Bartlett’s and Kaiser–Meyer–Olkin (KMO) tests were used to examine scores from the family support, doctor–patient relationships and occupational burnout scales. Bartlett’s test approached 0, indicating suitability for factor analysis. KMO values were 0.823, 0.847 and 0.913, respectively. SPSS was used to test common variance; the cumulative percentage of the first principal component was 31.98% (less than 50%), which proved that the common method variance was not severe.

Patient and public involvement statement

This study is just for doctors, no patient and public involved.

Results

The subjects’ distribution by demographics and employment situations is illustrated in table 1. Among the 678 samples included, women accounted for the vast majority (80.7%); men accounted for only 19.3%. The majority of the doctors came from the western region, accounting for 63.7%; only 8.0% came from the eastern region. Paediatricians and obstetricians each accounted for half of the sample. Only 2.9% of the doctors worked less than 40 hours per week, and 39.7% worked more than 60 hours a week. The overall burnout rate was 56.6%.

Table 1

Subject distribution by demographics

Univariate analysis of the MBI-GS scores in relation to demographics and employment situation variables are shown in table 2. Obstetricians and paediatricians evidenced prevalent occupational burnout, demonstrating very high average scores on emotional exhaustion and moderate scores on cynicism. The data indicated that age, department, title, weekly working hours and region correlated with greater emotional exhaustion, whereas education, sex and marital status did not. Doctors aged 40 or younger, with lower levels of education, longer working hours or who came from eastern China exhibited a higher level of emotional exhaustion. Obstetricians evidenced a higher level of emotional exhaustion than paediatricians.

Table 2

Univariate analysis of Maslach Burnout Inventory–General Survey scores, family support and doctor–patient relationships in relation to demographics

Factors such as age, profession, employment position, number of hours worked and place of residence corresponded with higher levels of CY, whereas sex and marital status did not. As doctors’ age increased, they showed higher levels of cynicism. Moreover, longer working hours, lower professional titles and location in eastern or central China also corresponded to higher levels of CY. Obstetricians demonstrated higher levels of cynicism than paediatricians.

Interestingly, sex and region did not impact PE, yet age, marital status, education, professional title, work hours and profession all did. Doctors who were younger and unmarried, had lower professional titles, worked more than 60 hours a week and exhibited lower levels of PE demonstrated a lower sense of achievement on the scales. Interestingly, obstetricians seemed to enjoy a greater sense of achievement. The analyses of family support, doctor–patient relationships and occupational burnout (table 3) revealed that emotional exhaustion was negatively correlated with family support (r=−0.141), yet positively with difficult doctor–patient relationships (r=0.459). CY was negatively correlated with family support (r=−0.188), yet positively with difficult doctor–patient relationships (r=0.570). Moreover, a sense of achievement by professional efficacy proved negatively correlated with family support (r=−0.167), yet positively with difficult doctor–patient relationships (r=0.338).

Table 3

Correlations for Maslach Burnout Inventory–General Survey scores and family support and doctor–patient relationships

A regression analysis of factors that shaped occupational burnout showed that the Durbin-Watson (DW) value was 1.74; collinearity was not evident. Table 4 illustrates the relationship between hours of work, family support, doctor–patient relationships and occupational burnout. Emotional exhaustion was negatively correlated with difficult doctor–patient relationships; the correlation coefficients β were 0.396 and 0.219. There was a significant positive correlation between CY and difficult doctor–patient relationships (p<0.01), with a correlation coefficient β of 0.517. Family support was negatively correlated with a sense of achievement by professional efficacy (p<0.01), with a correlation coefficient β of −0.098. Yet, a significant positive correlation was apparent between family support and doctor–patient relationships (p<0.01), with a correlation coefficient β of 0.298.

Table 4

General linear model analysis of the factors associated with Maslach Burnout Inventory–General Survey scores

Multiple regression analysis provided an indication of the factors that helped to predict occupational burnout, as shown in table 5. Difficult doctor–patient relationships evidenced a greater ability to predict EE, CY and PE (13%, 20% and 7%, respectively). Work hours also served as a predictor of EE and CY (9% and 5%, respectively). However, family support proved to be a less reliable predictor.

Table 5

Factors that impact the variance in Maslach Burnout Inventory–General Survey subscale scores

Discussion

The rate of occupational burnout among obstetricians and paediatricians reached 56.6%. This percentage surpasses the rate of 44% identified in Iran, a country with high levels of burnout22 and parallels the estimated 40%–70% of burnout among US obstetricians.11 Recent research on occupational burnout among physicians in China had indicated much lower rates than those found here among obstetricians and paediatricians. Moreover, the levels of EE, CY and PE of these doctors were higher than those of other medical professionals.20

There could be several explanations for these high rates of burnout among paediatricians and obstetricians, the majority of whom in China are women, as they were in the sample we collected. A study conducted in the USA observed that the burnout rate of female doctors was 1.6 times higher than that of men.23 Yet, the research conducted here did not identify significant differences in burnout rates between men and women doctors. Interestingly, the researchers who conducted the US study noted that women often face additional pressures both at home and on the job. That is, the factor that impacted the level of burnout was not explained by the sex of the professional but rather by the totality of the work for which they were responsible.

The findings also suggested that occupational burnout is greater among doctors with longer working hours. Among the paediatricians and obstetricians sampled, 73% worked more than 50 hours per week.

Another possible explanation for the high incidence of burnout could be directly related to doctor–patient relationships. The greater number of patients in the hospitals devoted to maternal and child health in recent years, without a corresponding increase in the number of doctors, suggests that these professionals have had a much greater workload than they previously did. The amount of time and the energy that may be devoted to each patient would have to be either reduced or maintained through an increase of hours worked. Moreover, there seemed to be a dialectical relationship between poor doctor–patient relationships and burnout, each contributing to the greater likelihood of the other.

There were several limitations to the present study. First, as a cross-sectional study, the research captured the situation of burnout at a single time point. An understanding of the changes over time would have been helpful to identify any direct impacts of the two-child policy and a rapid increase of births in China on doctor burnout in facilities specifically devoted to mothers and children. It would have been interesting to know whether or not the differences in burnout rates among these doctors compared with others throughout the country already existed prior to these changes. That would have helped to further focus on any particularities in these specialisations that could merit further attention in future research devoted to addressing burnout.

Second, the inclusion of all medical professionals working in these facilities, such as nurses, could provide greater insight into the systemic and/or dynamic nature of burnout. An understanding of the prevalence or absence of burnout among all the professions that form part of a medical team could reveal some of the interpersonal dynamics on the job that could contribute to or alleviate the symptoms of burnout.

Third, a larger sample of hospitals throughout the country would strengthen the research. As geographical region did appear to play a role in the presence of burnout, a larger sample from each of the regions would be imperative to better understand those differences.

Finally, the study used the data collected from the Perceived Social Support Scale and doctor-reported information about doctor–patient relationships, both of which rely on self-reporting. To better grasp the entirety of the support potentially available to or enjoyed by doctors, surveys that capture the experiences of other members of their support networks or research methods that promote direct observation would be recommended.

Conclusions

Doctors’ occupational health concerns themselves and also the quality of the services that they are able to provide. Consequently, the high rate of burnout among China’s obstetricians and paediatricians gives cause for concern. There is an urgent need to better understand the mitigating factors that have contributed to this situation and develop feasible solutions in light of China’s current baby boom. The findings from this research have helped to identify several possible areas on which to focus efforts in the coming years.

The shift to a two-child policy by the national government resulted in much higher numbers of births per year. The hospitals devoted to maternal and child health services have experienced a significantly increased demand for their services. Yet, there has not been a corresponding increase in the number of medical professionals available to provide those services. There is an urgent need to fill this gap. The national government could devote the resources necessary to train greater numbers of paediatricians and obstetricians as a means to alleviate the workload currently placed on these doctors.

Regional differences impact burnout in the medical professions. Any efforts to address burnout should remain attentive to the factors underlying these regional differences, especially with regard to the resident population’s needs and the resources devoted to address those needs.

Administrators in medical institutions are uniquely positioned to identify and reduce burnout among doctors in their facilities. In addition to their ability to adjust workloads, they could develop greater opportunities for doctors of all levels to achieve a greater sense of accomplishment in their profession. Such opportunities could include training, research, enhanced career mobility and/or pay incentives for any increase of assigned responsibilities.

Finally, greater public awareness of the challenges that the maternal and child healthcare system currently faces could help alleviate some of the factors that contribute to medical doctor burnout. The government, hospital administrators, researchers and media outlets could all promote an understanding of the current situation. This could remove some of the burden of responsibility that doctors and patients shoulder as they navigate their relationships with one another.

References

  1. 1.
  2. 2.
  3. 3.
  4. 4.
  5. 5.
  6. 6.
  7. 7.
  8. 8.
  9. 9.
  10. 10.
  11. 11.
  12. 12.
  13. 13.
  14. 14.
  15. 15.
  16. 16.
  17. 17.
  18. 18.
  19. 19.
  20. 20.
  21. 21.
  22. 22.
  23. 23.

Footnotes

  • Patient consent for publication Not required.

  • JY and HW contributed equally.

  • Contributors JY and HuW contributed to data collection and analysis, writing and revision. HaW contributed to the design and the writing of the article. LY contributed to data collection. QL contributed to the writing of the article, XM contributed to data analysis. XY contributed to data collection. HZ contributed to data collection and the writing of the article. XL contributed to data collection.

  • Funding This article was funded by Chongqing Decision Consulting and Management Innovation project (no. cstc2016jccxB0077).

  • Competing interests None declared.

  • Ethics approval The Institutional Review Board of Southwest Hospital, China, approved the study proposal as well as the manner in which the informed consent was obtained from all the participants.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We are willing to share the main research data, including the demographic characteristics of the subjects, the doctor–patient relationship score, the job burnout score and the family support score. The data can be obtained by mail within a year after the publication of the article. The data of this issue may be helpful for studying the occupational health and mental health status of Chinese doctors. It is important to note that these shared data are provided only to relevant researchers of universities and public research institutions, and the relevant research documents will be shared after the whole subject is finished.

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