Sense of meaning as a predictor of burnout in emergency physicians in Israel: a national survey

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Abstract

INTRODUCTION

Burnout is a syndrome involving mental and psychological exhaustion, a reduced sense of accomplishment and self-esteem, and depersonalization in individuals whose work involves dealing with people [1-4]. The syndrome develops as a response to an inability to cope effectively with prolonged stress at work [5].

While burnout has adverse effects in every occupational setting, it is particularly detrimental to physicians [6,7]. Burnout in physicians is associated with poor mental and physical health, guilt, poor judgment, drug abuse, decreased satisfaction with work, sleep disturbances, hypertension, posttraumatic stress disorder, anxiety, alcoholism, and myocardial infarction [4,8-11]. The specific emotional and physical challenges of emergency medicine (EM) render burnout a particularly acute problem for this specific population [11].

A comprehensive review conducted in 2013 identified only seven studies that examined burnout in emergency physicians (EPs) [4]. To the best of our knowledge, no studies have been conducted to examine burnout in EPs in Israel. Based on the few studies conducted, the following three clusters were found to increase burnout: 1) dissatisfaction with institutional/structural settings (e.g., specialty services); 2) work overload (e.g., an increased number of shifts per month and working hours per week); and 3) emotional issues (e.g., high levels of anxiety due to concern regarding adverse clinical outcomes) [7,12,13]. Factors such as support from others, academic activity, and work/leisure balance potentially increase resilience to burnout [4,14,15].

Sense of meaning is a central factor that may be associated with burnout. A sense of meaning has long been established as an essential factor in coping with difficult conditions [16]. Burnout can be characterized as a symptom of an inadequate level of existential meaning manifesting as reduced vitality on both somatic and psychological levels [17]. Moreover, some reports have indicated that a sense of meaning derived from work was associated with positive outcomes such as increased well-being, enhanced motivation, and happiness [18]. Nevertheless, to the best of our knowledge, no studies have examined the significance of existential meaning derived from work as a protective factor against burnout in physicians. Some evidence regarding this relationship was found in studies examining other professionals (e.g., teachers and managers) [19,20]. In light of these findings, the present study examined the impact of existential meaning on burnout in EPs.

EM is a relatively new specialty in Israel; there are 28 general emergency departments (EDs) in the country. Physician staffing is variable, with regular emergency staff consisting of EM-trained physicians, and full-time non-EM-trained physicians, most of whom are trained in internal medicine or general surgery. After-hours care is provided mainly by residents in medicine, surgery, and orthopedics, who treat patients in the ED under the supervision of EPs. In total, there are approximately 300 physicians working in each ED on a full- or part-time basis, approximately 150 of whom hold board certification in EM. Residency training is available in two tracks: as a primary or secondary specialty (after board certification in internal medicine, surgery, anesthesiology, family medicine, or pediatrics). There are currently approximately 80 EM residents in training nationally.

The aim of the current study was to explore burnout levels and delineate the contributive and protective factors for burnout in EPs in Israel. This is particularly important in a local context, as a series of reforms and institutional changes implemented in the mid-1990s (associated with budget cuts and a general decline in the social status of doctors) led to an increase in burnout levels in physicians in Israel [21].

The hypotheses of the present study were as follows: 1) There is a high level of burnout in EP’s, mainly due to large workloads. 2) A sense of existential meaning derived from work is a significant factor in countering and coping with burnout. 3) Negative emotions, such as worry or anxiety, increase burnout levels. 4) Factors contributing to well-being, such as work satisfaction and good work-family balance, are significant factors in countering burnout.

METHODS

Survey content

The scale included demographic variables and information regarding training types, work and leisure time, involvement in malpractice suits and mental and physical health including mood and signs of depression and anxiety. The questionnaire included primarily closed-ended questions, with responses provided using the five-point ordinal polytomous Likert scale (with a “not applicable” option), with several open-ended questions and a space for general comments at the end. The specific content of the questionnaire items (originally in Hebrew) is shown in Table 1.

Table 1.

Survey questionnaire

RESULTS

Demographic characteristics

Table 2 presents some of the demographic characteristics of physicians who participated in the study; 49, 14, and 7 were specialists, EM residents, and residents in EM as a super specialty (i.e., board certified in another specialty), respectively. 70% were male, aged 41 to 60 years, married, and had >25 years of experience in medicine (for results concerning the other variables included in the survey see Supplementary Table 1).

Table 2.

Participants’ demographic characteristics

Burnout

In total, 61%, 51%, and 17% of respondents exhibited high emotional exhaustion, high depersonalization, and a low sense of personal accomplishment, respectively. In addition, 71.4% reported experiencing at least one burnout symptom based on a high emotional exhaustion or depersonalization score. Responding physicians’ burnout characteristics are summarized in Table 3.

Table 3.

Physicians’ burnout characteristics

Predictors of burnout

A series of nonparametric Mann-Whitney tests were performed to determine the differences between burnout groups (burned out and not burned out) according to the test variables. The test variables for which scores differed significantly between groups were as follows: smoking frequency (P<0.05), satisfaction with work (P<0.001), work-life balance (P<0.05), extent to which work provides meaning (P<0.05), social support (P<0.05), feeling depressed (P<0.001), lack of interest in daily activities (P<0.05), preoccupying thoughts (P<0.05), stress (P<0.001), and worry (P<0.001). All correlations were in the expected direction (Table 4).

Table 4.

Results of Mann-Whitney tests performed to identify differences between burnout groups (burned out, not burned out) according to test variables

Logistic regression analysis, including the significant variables outlined above as potential predictor variables, was performed to identify variables that were independently predictive of a disposition toward burnout (measured via the MBI). Two variables predicted burnout: 1) degree of worry (β=3.678, P<0.01; 95% confidence interval [CI], 6.28 to 1.08) and 2) extent to which work provides meaning (β=-3.144, P<0.05; 95% CI, -6.24 to -0.045).

DISCUSSION

The aim of the current study was to determine burnout rates in full-time EPs in Israel and identify the variables that explain these rates, both positively and negatively. In addition, we examined the sense of meaning, which is a crucial variable that has received no attention in the literature on burnout in EPs.

Significant burnout was reported by 71% of respondents. These rates are significantly higher relative to those observed for physicians in other specialties (up to 39%) [7] and EPs in China (25.4%) [11] but similar to those observed for EPs in the US (60% to 65%) [12].

Interestingly, high burnout levels were observed in participants who reported strong feelings of competency and work satisfaction, and 82% of participants reported medium or high competency levels (personal accomplishment), which was a similar finding to those of previous studies [15].

The main variables that were associated with burnout were work-life balance, satisfaction with work, a sense of existential meaning derived from work, social support, depressive symptoms, worry, stress, and preoccupying thoughts. Some of these variables correspond to the findings of previous studies. For example, work-life balance has repeatedly been found to predict burnout in internal medicine physicians, surgeons, and residents [23-26]. Israel has a strong pronatalist culture, which stresses the significance of family life; accordingly, work-life balance was a significant factor in decreasing burnout levels, which was also reported in another Israeli study [27]. Satisfaction with work was a protective factor against burnout, and distress and worry were associated with increased burnout [26,28,29]. As in other studies, there was no significant relationship observed between participants’ demographic characteristics and burnout levels [12,13].

Two other factors significantly predicted burnout: worry, which was also associated with burnout in previous studies [29], and meaning derived from work. While previous studies reported that a sense of competence and work satisfaction predicted burnout, to the best of our knowledge, no studies have identified the existential meaning derived from work as a significant protective factor against burnout in physicians. Individuals may feel professionally competent and satisfied with their work without necessarily achieving personal fulfillment or a sense of meaning in life.

The psychoanalytic-existential approach assumes that the root of career burnout lies in the human need to believe that our lives are meaningful and what we do—and consequently, who we are—are important and significant [30]. Frankl [16] suggested that the striving to find meaning in one’s life is the primary motivational force in man. Becker [31] posited that work is a frequently chosen path to existential significance for many people.

The assumption that people experience burnout when they feel that their work is no longer significant has been supported in the past [32]. Nevertheless, some studies have reported that medical students emphasized factors other than a sense of meaning as important in choosing a career in EM. These factors include diversity in clinical pathology, emphasis on acute care, previous employment in an emergency setting, and flexibility in both practice location and work schedule in final-year medical students [33]; and hospital orientation, medical lifestyle, and varied scope of practice in entry-level medical students [34].

In contrast to these findings, the results of the current study suggest that a sense of meaning was an important influential factor in work satisfaction and burnout in the later stages of EPs’ careers. In the early stages of professional training, it may be difficult to envisage the ways in which one’s future medical practice should be developed to maximize individual happiness. Although less emphasis is placed on the aspects of EPs work concerning a sense of meaning in the early stages of their careers, a shift in focus is expected in later stages, as they may be exposed to unanticipated factors. For instance, while some research has suggested that entry-level medical students are less likely to report that social orientation was an important factor in their interest in EM [34], the results of the current study show a shift in emphasis toward meaningful relationships and the provision of meaningful assistance in the later stages of EPs’ careers. This shift in emphasis may contribute to the high levels of burnout observed in full-time EPs in this and previous studies.

Considering the high price of burnout, there is clearly a need to develop interventions to counter burnout. In addition to factors that have previously been associated with burnout, the current findings highlighted the importance of existential meaning as a protective factor against burnout. This finding could guide the development of specific intervention programs that focus on methods of increasing the sense of meaning that physicians derive from their work. This is important, as burnout intervention programs often focus primarily on the objective aspects of work (e.g., workload or payment).

In view of the centrality of the meaning derived from work, it is surprising that so few studies have examined the processes involved in enhancing meaningfulness at work [18]. Furthermore, despite serious consequences, few studies have assessed interventions designed to reduce burnout levels and enhance the meaning derived from work [22]. These studies were characterized by small sample sizes and focused mainly on individual, rather than organizational interventions. Nevertheless, there is growing evidence that interventions designed to enhance the meaning derived from work decrease the incidence of burnout in physicians [35,36]. For instance, physicians’ ability to focus on the most meaningful aspects of their work is strongly negatively associated with burnout [35]. Mindfulness-based interventions have been associated with significant improvements in burnout scores and mental well-being in a broad range of healthcare providers [37].

The analysis of responses to the open-ended questions could offer preliminary directions for future research, such as examination of the centrality of meaning derived from the emotional aspects of medicine (e.g., forging relationships with other staff members and patients and their families). Further exploration of the involvement of the process of enhancing existential meaningfulness in EPs necessitates in-depth interviews that could facilitate the examination of different aspects of physicians’ sense of existential meaning and how it develops over time and in different career stages. Specifically, identifying meaningfulness enhancing tactics may allow those tactics to be taught to burned-out physicians, decreasing their burnout levels.

The strengths of the present study include the broad and varied sample recruited from several medium and large hospitals, which increased the generalizability of the results [4]. The study’s limitations include the sample size and response rate and the intentionally limited breadth of the questions.

Supplementary Material

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Notes