Author(s) | Study population | Description of sample | Burnout measure | Quality of care measure | Quality of care outcomes | ||
Medical errors (ME) | Patient satisfaction (PS)/quality of care (QoC) | Communication/attitudes | |||||
Anagnostopoulos et al
31 Greece | Physicians working in three large primary healthcare centres. Patients of participating physicians. Patients selected through systematic random sampling—1:3 consecutive patients. Physician response rate: 85.8% Patient response rate: Not reported | n=30 physicians <10 years practicing: 53% Specialties: General practitioners: 63% Pathologists/internists: 23.3% Male: n=17 Female: n=13 >50 years: 43% 26–50 years: 40% n=300 patients Male: 46% Female: 54% Mean age: 54±15 years | Greek translation of the 22-item Maslach Burnout Inventory (MBI)-Human Services Survey | Patient report: Patient satisfaction assessed using 18-item Consultation Satisfaction Questionnaire (CSQ).52 5-point Likert scale from 1=‘strongly agree’ to 5=‘strongly disagree’. Satisfaction subscales: (1) general, (2) perceived length of consultation, (3) depth of relationship, and (4) professional care provided Overall satisfaction: sum of all items (max score=90) Scale was translated into Greek using back-translation and pilot testing. English version’s psychometric properties tested.52 63 | Correlation between MBI dimensions and PS:
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Halbesleben and Rathert32 USA | Attending physicians of university students who had been hospitalised in past year. Student response rate: Not reported. | n=178 physicians Years practicing: Not reported Specialties: Not reported Male: n=84 Female: n=94 Mean age=46±13 years n=178 patients Male: n=98 Female: n=80 Mean age: 23±5 years | 22-item MBI-Human Services Survey modified to apply to patients rather than general care recipients | Patient report: Patient satisfaction assessed using 22-item SERVQUAL.50 7-point Likert scale from 1=‘strongly disagree’ to 7=‘strong agree’. Psychometric properties tested but subsequent study suggested need for further exploration regarding its validity.51 | Correlation between MBI dimensions and PS:
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Hayashino et al
30 Japan | Members of a panel of 6459 hospital-based physicians recruited through hospital lists and scientific meetings. A randomly selected subsample of 1198 were invited to participate. Response rate: 70% | n=836 physicians Years practicing: Not reported Male: 92% Female: 8% 28–39 years: 23% 40–49 years: 47% 50–59 years: 26% 60–81 years: 4% | 17-item MBI developed for Japanese healthcare professionals based on the MBI-Human Services Survey Used burnout thresholds: EE: >21 DP: >18 PA: >16 | Physician report: Perceived medical errors assessed with questions: ‘Are you concerned that you have made any major medical mistakes in the last year?’ If ‘yes’, asked about number of medical errors that concerned respondent. Psychometric properties not tested. | Association between MBI dimensions and any medical error:
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Klein et al
5 Germany | Physicians in surgery working in >100 beds general hospitals with a general surgical and/or gynaecological ward. Stratified probability sample based on hospital beds. Response rates: Hospital level: 53% Physician level: 36% Physicians in participating hospitals: 65% | n=1311 physicians Mean years practicing: 11 years Male: 60% Female: 40% Mean age=45 ± 8.5 years | Copenhagen Burnout Inventory (CBI). Three scales assessing personal, client and work burnout. This study focused on personal burnout (ie, degree of physical and psychological fatigue and exhaustion). | Physician report: Perceived quality of care assessed using short version of Chirurgisches Qualitässiegel. Created three subscales: (1) psychosocial care, (2) diagnosis/therapy and (3) quality assurance. 5-point Likert scale from 1=‘very good’ to 5=‘bad’. Two questions about frequency of diagnostic and therapeutic errors: ‘I have made mistakes in diagnosis.’ and ‘I have made mistakes in treatment.’ 4-point Likert scale (‘never’ to ‘often’). Psychometric properties not tested for either set of questions. | Adjusted* ORs (95% CI) for probability of error and high burnout score:
| Adjusted* ORs (95% CI) for probability of suboptimal care and high burnout score:
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Rabatin et al
29 USA | Primary care physicians in New York City, Chicago and rural and urban Wisconsin Recruited 1–6 patients/physician with diabetes, hypertension or congestive heart failure. Response rate: Physicians: 59.6% Non-participants did not differ from participants in specialty, age or sex. | n=119 practices n=449 physicians n=1419 patient charts Physician characteristics: Male: n=235 Female: n=187 Mean age: 43±10 years Specialties: Family medicine: 47% General internal medicine: 50% Patient characteristics: Not reported. | Single-item measure: ‘Using your own definition of burnout… (a) I have no symptoms of burnout; (b) Occasionally I am under stress… but I don’t feel burned out; (c) I am definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion; (d) The symptoms of burnout that I’m experiencing won’t go away…; (e) I feel completely burned out and often wonder if I can go on…’ The question correlates with the EE dimension of MBI.42 | Patient chart: Chart audit using a standardised template to retrospectively assess over 18 months for guideline adherence, responsiveness to ‘recurrent abnormalities’ and missed drug interactions. Reliability not reported. | Statistics not reported. No statistically significant differences between physicians with burnout and without. | ||
Ratanawongsa et al
33 USA | Physicians from 15 urban community-based clinics who provided primary care to adult patients enrolled in a randomised controlled trial for hypertensive minority patients. Response rate: Not reported. | n=40 physicians Mean years of practice: 11±7.7 years Male: 47% Female: 53% Mean age: 42±8.7 years Specialties: Internal medicine: 83% Family practice: 15% General practice: 2% n=235 patients Male: 34% Female: 66% Mean age: 59±13.2 years | A 6-item scale derived from the MBI that captures the domains of EE and PA. 5-point Likert scale from 1=‘strongly agree’ to 3=‘neutral’ to 5=‘strongly agree’. Based on terciles, burnout scores were categorised as low, average or high. | Physician report: Physicians completed ‘brief questionnaires indicating the degree to which they knew the patient, their attitudes toward the patient in general, and their attitudes regarding the visit’. Audiotaped encounters analysed for rapport-building communication behaviours using the Roter Interaction Analysis System. Four types of rapport identified: (1) positive, (2) negative, (3) emotional and (4) social. Reliability and predictive validity tested.64 | Adjusted* ORs (95% CI) for probability of PS with high versus low burnout:
| ORs (95% CI) for probability of negative rapport building with medium and high versus low burnout:
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Shanafelt et al
38 USA | American surgeons who were members of the American College of Surgeons who permitted email correspondence. Response rate: 32% | n=7905 physicians Specialties: General: 41% Cardiothoracic: 6% Colorectal: 4% Otolaryngology: 5% Obstetrics/gynaecology: 1% Oncological: 5% Paediatric: 2% Plastic: 4% Transplant: 2% Trauma: 4% Urological: 4% Vascular: 6% Other: 6% Male: 87% Female: 13% Median age (IQR): 51 years (43, 59) | 22-item MBI-Human Services Survey | Physician report: Response to: ‘Are you concerned you have made any major medical error in the last 3 months?’ Psychometric properties not tested. | ORs (95% CI) for perceived medical error with MBI dimensions:
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Shirom et al
39 Israel | Physicians from four health plans specialising in either: ophthalmology, dermatology, otolaryngology, gynaecology (community based), general surgery, cardiology (hospital based). 50% random probability sample drawn from each specialty. Response rate: 63% | n=890 physicians Male: 80% Female: 20% Median age: 52 years | 12-items from the Shirom−Melamed Burnout Measure with three subscales: (1) physical fatigue, (2) cognitive weariness, and (3) emotional exhaustion. | Physician report: Physicians completed a 15-item version of the modified SERVQUAL. 5-point Likert scale from 1=‘to a very small extent’ to 5=‘to a very large extent’. Psychometric properties of the modified version not tested. | Structural equation model examining relationships of autonomy, burnout and QoC:
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Travado et al
34 Italy, Spain, Portugal | Physicians recruited from cancer centres of three hospitals: two general hospitals with a cancer ward and one cancer hospital. Convenience sample Response rate: Not reported. | n=125 physicians Years of practice: 15±9.4 years Male: 47% Female: 54% Mean age: 42±9.7 years | 22-item MBI-Human Services Survey Used Maslach and Jackson6 cut-off scores for no/low burnout, intermediate and high burnout. | Physician report: Communication skills assessed using two scales: (1) Self−Confidence in Communications Skills (SCSS). 12-item scale rating ability to communicate and manage a series of clinical situations. (2) Expected Outcomes of Communication (EOC). 23-item scale assessing extent to which physician perceives result of communication is positive or negative. Psychometric testing not completed.56 | Correlations between MBI burnout dimensions and communication: SCSS
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Weigl et al
36 Germany | Physicians working in one academic children’s hospital who were providing patient care. Response rate: 74% | n=88 physicians Years of practice: 8±6.7 years Male: 47% Female: 53% Mean age: 37±8.6 years | Two subscales of the German version of the MBI-D: EE and DP. High burnout defined as Mean EE score >3.5 and Mean DP >2.5 | Physician report: 2-item perceived quality of care measure: ‘My workload frequently leads to reduced quality of work’ and ‘Adverse work conditions frequently lead to a loss of quality.’ 5-point Likert scale from 1=‘not at all’ to 5=‘a very great extent’. Psychometric properties not tested for the two items taken from the German version of the MBI. | Adjusted* ORs (95% CI) for probability of low QoC with MBI dimensions (low vs high):
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Wen et al
37 China | Physicians practicing in one of 46 hospitals in 10 provinces n=12 tertiary hospitals n=9 secondary hospitals n=25 primary hospitals In the secondary and tertiary hospitals, physicians were selected from >10 clinical departments with >10 people in the age groups:<30 years, 30–39 years, 40–49 years and >50 years. Response rate: 89% | n=1607 total physicians n=192 physicians from primary hospitals n=354 physicians from secondary hospitals n=991 physicians from tertiary hospitals Primary hospital Male: 54% Female: 46% Mean age: 37±9.9 years Education: <high school: 17% Some college: 47% Bachelors’ degree: 35% >Master’s degree: 1.0% Secondary hospital Male: 53% Female: 47% Mean age: 36±9.4 years Education: <high school: 4% Some college: 17% Bachelors’ degree: 73% >Master’s degree: 6% Tertiary hospital Male: 61% Female: 39% Mean age: 36±8.0 years Education: <high school: 1% Some college: 3% Bachelors’ degree: 46% >Master’s degree: 51% | Used 15-item Chinese version of the MBI-General Survey Respondents grouped into three categories: (1) no burnout symptoms; (2) some burnout symptoms; (3) serious burnout symptoms. | Physician report: Physicians were asked if they had made any of the following medical errors: (1) patient was harmed, (2) medication error, (3) treatment delayed and (4) incomplete or incorrect item in the patient record. Psychometric properties not tested. | Adjusted* ORs (95% CI) for probability of any medical error with no burnout symptoms group as reference:
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Weng et al
35 Taiwan | Physicians working in two hospitals. Patients of participating physicians. Physician response rate: Not reported. Patient response rate: 78% | n=110 internists Male: 85% Female: 15% Mean age: 41±6.9 years n=2872 patients Male: 59% Female: 41% | MBI-Human Services Survey | Patient report: Patient satisfaction assessed with two questions: ‘I am satisfied with the care provided by my doctor’ and ‘I would recommend this doctor to my friends and family members’. Single item from the CSQ’s52 General Satisfaction subscale not validated for individual use. Single item about recommendation was correlated with EUROPEP patient satisfaction questionnaire.53 | Correlation between MBI burnout dimensions and PS:
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DP, depersonalisation; EE, emotional exhaustion; PA, personal accomplishment.