Objective. To examine the association of physician burnout with the career engagement and the quality of patient care globally. Design. Systematic review and meta-analysis. Data Sources. Medline, PsycINFO, Embase, and CINAHL were searched from database inception until May 2021. Eligibility criteria for selecting studies. Observational studies assessing the association of physician burnout (including a feeling of overwhelming emotional exhaustion, feelings of cynicism and detachment from job defined as depersonalisation, and a sense of ineffectiveness and little personal accomplishment) with career engagement (job satisfaction, career choice regret, turnover intention, career development, and productivity loss) and the quality of patient care (patient safety incidents, low professionalism, and patient satisfaction). Data were double extracted by independent reviewers and checked through contacting all authors, 84 (49%) of 170 of whom confirmed their data. Random-effect models were used to calculate the pooled odds ratio, prediction intervals expressed the amount of heterogeneity, and meta-regressions assessed for potential moderators with significance set using a conservative level of P<0.10. Results. 4732 articles were identified, of which 170 observational studies of 239 246 physicians were included in the meta-analysis. Overall burnout in physicians was associated with an almost four times decrease in job satisfaction compared with increased job satisfaction (odds ratio 3.79, 95% confidence interval 3.24 to 4.43, I (2)=97%, k=73 studies, n=146 980 physicians). Career choice regret increased by more than threefold compared with being satisfied with their career choice (3.49, 2.43 to 5.00, I (2)=97%, k=16, n=33 871). Turnover intention also increased by more than threefold compared with retention (3.10, 2.30 to 4.17, I (2)=97%, k=25, n=32 271). Productivity had a small but significant effect (1.82, 1.08 to 3.07, I (2)=83%, k=7, n=9581) and burnout also affected career development from a pooled association of two studies (3.77, 2.77 to 5.14, I (2)=0%, n=3411). Overall physician burnout doubled patient safety incidents compared with no patient safety incidents (2.04, 1.69 to 2.45, I (2)=87%, k=35, n=41 059). Low professionalism was twice as likely compared with maintained professionalism (2.33, 1.96 to 2.70, I (2)=96%, k=40, n=32 321), as was patient dissatisfaction compared with patient satisfaction (2.22, 1.38 to 3.57, I (2)=75%, k=8, n=1002). Burnout and poorer job satisfaction was greatest in hospital settings (1.88, 0.91 to 3.86, P=0.09), physicians aged 31-50 years (2.41, 1.02 to 5.64, P=0.04), and working in emergency medicine and intensive care (2.16, 0.98 to 4.76, P=0.06) ; burnout was lowest in general practitioners (0.16, 0.03 to 0.88, P=0.04). However, these associations did not remain significant in the multivariable regressions. Burnout and patient safety incidents were greatest in physicians aged 20-30 years (1.88, 1.07 to 3.29, P=0.03), and people working in emergency medicine (2.10, 1.09 to 3.56, P=0.02). The association of burnout with low professionalism was smallest in physicians older than 50 years (0.36, 0.19 to 0.69, P=0.003) and greatest in physicians still in training or residency (2.27, 1.45 to 3.60, P=0.001), in those who worked in a hospital (2.16, 1.46 to 3.19, P<0.001), specifically in emergency medicine specialty (1.48, 1.01 to 2.34, P=0.042), or situated in a low to middle income country (1.68, 0.94 to 2.97, P=0.08). Conclusions. This meta-analysis provides compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organisations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care. Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency.
Commentaire du Dr Marius Laurent (PAQS)
- Les auteurs de cette revue systématique nous montrent que les médecins souffrant de burn-out sont jusqu’à quatre fois plus susceptibles d’être peu satisfaits de leur travail et plus de trois fois plus susceptibles d’avoir l’intention de quitter leur emploi ou de regretter leur choix de carrière. Ils sont deux fois plus susceptibles d’être impliqués dans des incidents liés à la sécurité des patients et davantage encore de recevoir un score de satisfaction médiocre de la part de ces derniers. Faut-il voir dans ces liens bien démontrés un lien de cause à effet, et si c’est le cas, faut-il s’interroger sur le sens de ce lien ? L’explosion des burn-out dans les métiers de soins est impressionnante. Pratiquement inconnue il y a vingt ans (les premiers articles qui font l’objet de cette revue datent d’environ 2005), cette pathologie fait la une de l’actualité surtout depuis la pandémie. Je suppose qu’elle existait bien auparavant, et portait d’autres noms moins spécifiques dans le domaine des dépressions réactionnelles. Les métiers de la santé changent, je ne suis pas sûr que la charge de travail s’accroisse, mais elle change de caractère. Il y a des lustres que je n’ai plus croisé de médecin contraint de prester des gardes résidentes dans un service aigu de son hôpital une nuit sur trois sans récupération digne de ce nom, mais la nature de son travail change et donc aussi ses sources de stress et de fatigue. S’il dispose de davantage de moyens thérapeutiques, il fait face aussi de ce fait à une plus grande obligation de résultat. Les instants de détente dans la journée sont rares, l’attention est constante et l’impératif de rentabilité a envahi tout le secteur des soins. Les obligations administratives se multiplient, leur but étant prioritairement comptable : avait-on bien le droit de faire cet examen et donc de percevoir la rétribution (par l’hôpital aussi), de sorte que l’outil informatique mis à sa disposition est rarement d’une aide quelconque dans son travail clinique quand il n’est pas un obstacle. En même temps, les motivations à faire ce métier changent : la priorité des individus est souvent mise, non sur produire plus, mais sur profiter davantage de ce qu’on gagne, ce qui crée une tension avec le gestionnaire hospitalier. Si le burn-out est associé à un mal-être professionnel, il le provoque souvent. Mais parfois ce mal-être n’est-il pas préexistant, et dès lors, la cause du burn-out plutôt que son effet.
Hodkinson A, Zhou A, Johnson J, et al. Associations of physician burnout with career engagement and quality of patient care : systematic review and meta-analysis. Br Med J 2022;378:e070442. Doi : 10.1136/bmj-2022-070442.