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Psycho-Oncology

Psycho-Oncology 17: 570–576 (2008)


Published online 12 October 2007 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1269

Stress and burnout in colorectal and vascular surgical


consultants working in the UK National Health Service
A. Sharma1, D. M. Sharp2, L. G. Walker2 * and J. R. T. Monson1
1
Academic Surgical Unit, University of Hull, Cottingham, Hull, UK
2
Institute of Rehabilitation, University of Hull, Hull, UK

* Correspondence to: Institute Abstract


of Rehabilitation, University of
Hull, 215 Anlaby Road, Background: It has been suggested that dealing with cancer is associated with increased stress
Kingston upon Hull, HU3 2PG, and burnout in health-care professionals. The aim of this study is to examine the prevalence of
UK. E-mail: L.G.Walker@ psychiatric morbidity and burnout in surgeons working in the National Health Service (NHS),
hull.ac.uk and the putative relationship between psychiatric morbidity, burnout and the amount of cancer-
related work.
Methods: All consultant colorectal and vascular surgeons identified from their professional
societies were sent a booklet consisting of questions about cancer-related and specialty-specific
work load, job satisfaction and socio-demographics. It also included the General Health
Questionnaire (GHQ-12), the Maslach Burnout Inventory (MBI) and the Coping
Questionnaire.
Logistic regression analysis was used to identify independent predictors of psychiatric
morbidity (GHQ), burnout (MBI) and retirement intentions.
Results: Five hundred and one questionnaire booklets were completed and returned (response
rate 58.7%). The mean age of respondents was 47 years (range 31–65). The majority of the
surgeons were male (460, 92%).
One hundred and sixty-three (33%) surgeons scored in the positive range of the GHQ, and
154 (32%) had high burnout on at least one subscale of the MBI. Three hundred and eighty-
three (77%) surgeons stated that they intended to retire before the statutory retirement age.
Level of work satisfaction and perceived adequacy of training in communication and
management skills were significantly negatively correlated with GHQ and MBI scores.
Surgeons who planned to take early retirement or wished to retire as soon as they could afford
to were more likely to have psychiatric morbidity and/or burnout. Surgeons who were married
or cohabiting were less likely to have psychiatric morbidity, and younger surgeons were more
likely to have higher levels of depersonalization (DP). Work satisfaction was negatively
correlated with psychiatric morbidity and all three burnout scales.
Colorectal surgeons had a greater cancer-related workload than vascular surgeons
(48.6 vs 7.5%, respectively, U ¼ 2667; p50:005). However, there were no significant
differences between the two groups in psychiatric morbidity, personal accomplishment
and emotional exhaustion. Vascular surgeons, however, had significantly higher levels of DP
ðp ¼ 0:04Þ:
Conclusion: Levels of psychiatric morbidity, burnout and work dissatisfaction are worryingly
high in colorectal and vascular surgeons and are likely to impact adversely on patient
satisfaction and service quality. The number of surgeons intending to retire early is also a cause
for concern both in terms of the overall number of trained surgeons in the NHS and in the
balance between senior and junior surgeons. Apart from DP, these indicators of stress, however,
Received: 5 February 2007 were unrelated to cancer workload.
Revised: 17 July 2007 Copyright # 2007 John Wiley & Sons, Ltd.
Accepted: 28 July 2007
Keywords: surgeons; stress; burnout; coping; oncology; cancer

Introduction significant psychiatric morbidity. At approximately


the same time, Wall et al. [4] studied a sample of
There is evidence to suggest that job-related stress 11 000 NHS employees and found a 27% pre-
and professional ‘burnout’ is increasing, and it has valence of minor psychiatric disorders in compar-
been suggested that this may be due to changes in ison with a prevalence of 18% in general
the National Health Service (NHS) [1–3]. In a population. The most important sources of stress
survey of 882 UK consultants in 1996, Ramirez were work overload, feeling badly managed and
et al. [2] found that 27% were likely to have resourced, managerial responsibilities and dealing

Copyright # 2007 John Wiley & Sons, Ltd.


Stress and burnout in surgeons 571

with patients’ suffering, while perceived good Methods


relationships with patients, relatives and staff and
professional esteem made the greatest contribution Respondents and procedure
to overall job satisfaction [2].
Ethical approval for the study was obtained from
In 1996, Ramirez et al. [2] found that stress and
Hull and East Riding Local Research Ethics
burnout in surgical oncologists was significantly
Committee (reference 04/Q1104/29, 29th June
lower than in medical oncologists and radiologists.
2004). Permission to reproduce copyrighted ques-
They suggested that surgeons were protected from
tionnaires (GHQ-12 and the MBI) was obtained.
burnout and psychiatric morbidity because they
A list of all consultant colorectal surgeons, who
were able to exercise a significant amount of
were current members of the Association of
control over their own work and also by receiving
Coloproctology of Great Britain and Ireland
positive and immediate feedback from patients.
practicing in the NHS1, and a list of all current
Lack of perceived control has been shown to be a
vascular surgeons, who were members of the
good predictor of burnout [5].
Vascular Society of Great Britain and Ireland
Since the first survey by Ramirez 10 years ago,
practicing in the NHS1 was obtained from the
there have been significant changes within the NHS
respective societies. Questionnaire booklets were
[6]. Some of these involve a target-driven culture
professionally printed to enable optical character
and loss of autonomy. In addition to changes
recognition and automated scoring of responses.2
affecting all workers, some changes have affected
Booklets were sent to surgeons by post, with a
certain specialties and may have differentially
covering letter explaining the purpose of the survey
increased the risk of psychiatric morbidity and
and a request to return the survey within 10 days.
burnout [7].
A stamped-addressed envelope was enclosed. Be-
Recently, in a research letter, Ramirez et al.
cause responses were anonymous, a reminder letter
reported a 10-year follow up of stress and burnout.
was sent to all surgeons two weeks later thanking
Over this period they found a significant increase in
those who had returned the Booklet and requesting
psychiatric morbidity and emotional exhaustion
that those who had not responded to do so as soon
(EE) for surgical oncologists [7]: psychiatric
as possible. Data collection was completed in April
morbidity in this group had increased from 22 to
2005.
33%, burnout had increased from 27 to 41% and
job satisfaction had decreased from 68 to 65%.
It has also been suggested that dealing with Questionnaire
cancer is associated with increased stress and
Participants completed a questionnaire booklet
burnout in health-care professionals [8,9]. In a
that contained the following:
study of oncologists in the USA, more than half of
the respondents reported experiencing burnout in 1. Socio-demographic questions about age, gender,
their professional lives [8]. However, other studies place of work (district general hospital,
have not found any significant difference in university hospital or both), marital status,
psychiatric morbidity and burnout in oncologists percentage of clinical work involving patients
compared with other physicians [2,7,10]. with cancer and percentage of clinical work
Colorectal surgeons care for a mixed group of involving patients with colorectal/vascular
patients ranging from benign disorders with problems.
excellent prognosis to colorectal cancer with wide- 2. The General Health Questionnaire (GHQ) (12
spread metastases and extremely poor outlook. item version): The GHQ has been validated
The proportion of cancer work performed can vary against a clinical psychiatric interview and is
between consultants and may influence stress and widely used to screen for psychiatric morbidity
burnout. Vascular surgeons also have a varied case [11]. The GHQ-12 is self-administered and takes
mix with elective and acute cases; they may also about 5 minutes to complete. The questionnaire
have similar on-call commitments as other general enquires about the experience of psychological,
surgeons, but they have very limited involvement social and somatic symptoms over the past few
with cancer. Both the groups in our study were weeks. Each item is measured on a four-point
employed in the NHS. It is of interest, therefore, to scale. Each of the 12 items is assigned a score of
compare psychiatric morbidity, burnout, job satis- 0 (less or no more than usual) or 1 (rather or
faction and retirement intentions in vascular much more than usual), giving a maximum score
surgeons and colorectal surgeons. of 12. A cut-off score of 4 or above indicates a
The aims of this study, therefore, are to evaluate high probability that the individual suffers from
the point prevalence of psychiatric morbidity, a clinically significant level of distress
burnout and job satisfaction in colorectal and (‘Caseness’/psychiatric morbidity).
vascular surgeons in the UK and examine socio- 3. The Maslach Burnout Inventory (MBI) is com-
demographic and psychosocial factors that might monly used to measure three key aspects of
influence them. professional burnout}EE, depersonalisation

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
572 A. Sharma et al.

(DP) and personal accomplishment (PA) [12]. Results


Each of the attributes is rated on a seven-point
scale, and the total score for each subscale is The booklet was sent to 853 surgeons (455 color-
categorised as low, average or high. High ectal, 398 vascular). Five hundred and one ques-
burnout is characterised by high scores on the tionnaire booklets were returned, giving a response
exhaustion and DP scales and low scores on the rate of 58.7%. The response rates of colorectal and
accomplishment scale [13]. vascular surgeons did not differ significantly (55.6
4. The Coping Questionnaire is used to measure vs 62.3%, w2 ¼ 3:123; p ¼ 0:08).
coping strategies used by people to deal with The mean age of respondents was 47.4 years (SD
work-related stress. This has been used 7.4, range 31–65). The majority of the surgeons
previously in a study of work-related stress in were male (460, 92%). Marital status was available
police officers, prison officers, psychiatric nurses for 498 respondents (99.4%). Four hundred and
and firemen [14,15]. seventy-six respondents were either married or
5. Other ad hoc questions include level of job satis- cohabiting (95.6%). Three hundred and three
faction, retirement intentions, perception of consultants were working in a district general
adequacy of communication and management hospital (61%), 164 in a university hospital
training. (33%), and 30 (6%) said their work involved
6. Additional comments. working in both a DGH and a university hospital.
The mean cancer workload was 28.2% (SD 26.4,
range 0–90%).
Colorectal and vascular surgeons differed sig-
Scoring and interpretation of questionnaires
nificantly in terms of marital status (97.6 vs 94.3%,
Optical character recognition was used for compi- respectively, w2 ¼ 4:083; p ¼ 0:04), place of work
lation of data. Unreadable questionnaires were (w2 ¼ 13:462; p50:005) and cancer workload (48.6
read manually and all data were entered in an SPSS vs 7.5%, U ¼ 2667; p50:005). The differences in
database. Written comments were entered manu- age and gender were not statistically significant.
ally into an Excel database for each group. The average proportion of colorectal cases out of
the total workload for colorectal surgeons was
77.7% (SD 19.4, range 20–100%), whereas the
average amount of vascular workload for vascular
Statistical analysis
surgeons was 74.6% (SD 25.9, median 80%, range
Data were analysed using the Statistical Package 20–100%, Table 1).
for the Social Sciences (SPSS, version 11.5, GHQ-12 scores were available for 499 surgeons
Chicago, IL). Spearman’s correlation coefficient (99.6%) and MBI scores were available for 486
was used to examine the relationships between (97%) surgeons. The mean GHQ score was 2.9 (SD
psychiatric morbidity and burnout with demo- 3.4), the MBI EE, DP and PA scores being 21.1
graphic characteristics, training in communication, (SD 11.5), 6.0 (SD 5) and 36.9 (SD 6.6),
management, emotional problems and coping respectively. There was no significant difference
strategies. The Chi square and Mann–Whitney between the total GHQ and MBI scores of color-
tests were used to compare psychiatric morbidity ectal and vascular surgeons.
and burnout levels in colorectal and vascular GHQ scores were divided into normal (0–3) and
surgeons and between surgeons with more or less high (54) as recommended in the GHQ manual
than 50% cancer workload, as appropriate. Logis- [16]. MBI scores were divided into ‘low and high’
tic regression was used to identify factors indepen- levels of burnout using standard scores for health-
dently predictive of psychiatric morbidity, burnout care professionals (Table 2). One hundred and
and retirement intentions. sixty-three (32.9%) surgeons scored high on the

Table 1. Comparison of colorectal and vascular surgeons}demographic characteristics


Colorectal surgeons Vascular surgeons Chi square/Mann–Whitney, p value

Response rate 253/455 (55.6%) 248/398 (62.3%) w2 ¼ 3:123; p ¼ 0:08


Age 47.7 (range 32–65) 47.1 (range 31–65) U ¼ 30081; p ¼ 0:52
Gender}male 227 (89.7%) 233 (94.3%) w2 ¼ 2:444; p ¼ 0:12
Marital status}married/cohabiting 246/252 (97.6%) 230/246 (94.3%) w2 ¼ 4:083; p ¼ 0:04
Place of work DGH}173 (68.7%) DGH}130 (53.1%) w2 ¼ 13:462; p ¼ 0:001
UH}69 (27.4%) UH}95 (38.8%)
Both}10 (4%) Both}20 (8.2%)
Cancer workload 48.6% (5–90%) 7.5% (0–60%) U ¼ 2667; p50:005
Specialty-specific workload 77.7% (20–100%) 74.6% (20–100%) U ¼ 30732:5; p ¼ 0:8

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
Stress and burnout in surgeons 573

Table 2. Comparison of the presence or absence of psychiatric morbidity and burnout in colorectal and vascular surgeons
Colorectal surgeons (%) Vascular surgeons (%) p value

GHQ scores Normal 176 (69.8) 157 (64.3) w2 ¼ 1.698


High 76 (30.2) 87 (35.7) p ¼ 0.193
MBI EE scores Low burnout 166 (68.9) 166 (67.8) w2 ¼ 0.071
High burnout 75 (31.1) 79 (32.2) p ¼ 0.790
MBI DP scores Low burnout 199 (82.6) 184 (75.1) w2 ¼ 4.060
High burnout 42 (17.4) 61 (24.9) p ¼ 0.04
MBI PA scores Low burnout 177 (73.4) 169 (69) w2 ¼ 1.181
High burnout 64 (26.6) 76 (31) p ¼ 0.277
Total 241 245

GHQ. Using the MBI, 154 (31.7%) had high EE, (p50.005) in response to stress. Surgeons with
103 (21.2%) had high levels of DP and 140 (28.8%) normal GHQ scores and low burnout scores
had feelings of low PA on the MBI (Table 2). reported greater job satisfaction (p50.005) and
Vascular surgeons were found to have significantly indicated that they were less likely to retire before
higher levels of DP (w2 ¼ 4:06; p ¼ 0:04); there retirement age (p50.005) or achieving affordability
were no significant differences in psychiatric (p50.005). Surgeons with low burnout and/or
morbidity, PA or EE levels. normal GHQ scores considered their training in
Three hundred and eighty-three surgeons (76.9% management skills to have been adequate, whereas
of colorectal surgeons and 77.9% of vascular those with high burnout and/or psychiatric mor-
surgeons, p ¼ 0:8) stated that they intended to bidity considered their training to have been
retire before the statutory retirement age and 343 inadequate (p50.005). Surgeons reporting low
(64.7% of colorectal surgeons and 73.7% of PA and high DP considered their training in
vascular surgeons, p ¼ 0:06) said they would retire communication to have been inadequate
as soon as they could afford to. (p50.005).
One hundred and fifty-eight (32.3%) consultants Logistic regression analysis showed that several
thought they had not received adequate training in factors independently predicted the presence or
communication skills, and 226 (43.5%) indicated absence of psychiatric morbidity and burnout. Low
that they had insufficient training in management job satisfaction was identified as most predictive of
skills. No significant difference was found between psychiatric morbidity and all aspects of burnout.
vascular and colorectal surgeons. In terms of Intention to retire early was an independent
coping with work-induced stress, no significant predictor of high psychiatric morbidity, low PA
differences were found between the two groups of and high EE. Living with a partner was shown to
surgeons. be protective against psychiatric morbidity. Eating
Younger respondents had higher DP scores less or more and poor social coping were also
(U ¼ 16796; p ¼ 0:02) and surgeons who were independent predictors of psychiatric morbidity
married or living with partners had lower levels and burnout (Tables 3–6).
of psychiatric morbidity (w2 ¼ 5:9; p ¼ 0:01) and
DP (w2 ¼ 0:68; p ¼ 0:04).
In terms of coping with self-perceived work- Discussion
related stress, surgeons with psychiatric morbidity
and a high score on any of the three MBI scales This national study set out to investigate the
coped by changing their food consumption (by prevalence of psychiatric morbidity and burnout
eating more or less, p50.005), increasing their in colorectal and vascular surgeons and to examine
alcohol consumption (p50.005), tending to take the influence of demographic factors and coping
work home (p50.005), keeping things to them- strategies.
selves (p50.005), taking stress out on family or Five hundred and one colorectal and vascular
friends (p50.005), engaging less in sports surgeons returned the study booklet. This repre-
(p50.005) and recreation (p50.005) and mixing sents 56% of the colorectal surgeons and 62% of
less with friends (p50.005) in response to an the vascular surgeons who were identified by their
increase in work-related stress. On the other hand, professional societies.
surgeons who scored in the normal range of the Overall, 33% of the surgeons (30% colorectal
GHQ and low on the burnout scales reported that and 36% vascular surgeons) scored 4 or above in
they coped by taking things easier (p50.005), the GHQ, which suggests that they were currently
talking things over with family (p50.005), increas- experiencing clinically significant psychiatric mor-
ing level of sports (p ¼ 0.02) and recreation bidity. Ramirez et al. reported GHQ-12 caseness
(p50.005) and mixing more with friends (GHQ score 54) of 22% in surgical oncologists in

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
574 A. Sharma et al.

Table 3. Logistic regression analysis showing independent related to impaired work performance, more days
predictors of psychiatric morbidity of missed work and poorer physical health in
Independent Coefficient (B) Significance (p) military personnel [17]. In addition to their own
covariates suffering, high psychiatric morbidity can have wide
ranging implications on families and friends. The
Marital status 1.527 0.01
Eat less 0.493 0.03
other concern is the high rate of suicide among
Take work home 0.679 0.01 doctors in the UK. Ramirez et al. [10] quote
Mix less with friends 0.715 0.003 reports from the BMA in which suicide stands out
Satisfaction with work 1.285 50.005 as a prominent cause of death among medical
Intention to retire before the 1.087 0.01 practitioners.
statutory retirement age In terms of burnout, 31% scored in the
‘significant range’ for EE, 21% for DP and 29%
for PA. The proportions of surgeons in the two
specialties were similar for EE and PA, but the
Table 4. Logistic regression analysis showing independent
predictors of burnout (personal accomplishment) proportion of vascular surgeons scoring higher on
DP was significantly higher (17 vs 25%). There are
Independent Coefficient (B) Significance (p) differences in the level of burnout found in Ramirez
covariates
study and this study; Ramirez et al. used the EE
Keep things to myself 0.470 0.02 component of burnout in the 2002 results. The level
Satisfaction with work 0.727 50.005 of EE increased from 27 to 41% between 1994 and
Intention to retire before the 0.945 0.01 2002 in their study. In this study, however, the level
statutory retirement age of EE was significantly lower, being 31.1% in
Training in communication 0.186 0.02
colorectal and 32.2% in vascular surgeons
(w2 ¼ 6:9; p ¼ 0:03).
According to Maslach et al. [12], burnout is
Table 5. Logistic regression analysis showing independent associated with long-term job-related stress: ‘what
predictors of burnout (emotional exhaustion) started out as important, meaningful and challen-
Independent Coefficient (B) Significance (p) ging work becomes unpleasant, unfulfilling and
covariates meaningless. Energy turns into exhaustion, invol-
vement turns into cynicism and efficacy turns into
Eat less 0.532 0.02
Take things easier 0.513 0.03
ineffectiveness’. Burnout is thought to be specific to
Keep things to myself 0.513 0.04 work context and is situation specific rather than
Talk with professional 0.403 0.05 general depression. The symptoms are also present
Take sleeping tablets 1.787 0.02 in normal persons who did not suffer from
Mix less with friends 0.665 0.007 psychopathology before and the emphasis is on
Satisfaction with work 1.123 50.005 the mental and behavioural symptoms rather than
Intention to retire before the 0.818 0.05 on physical ones.
statutory retirement age
Training in management skills 0.194 0.02
Burnout is associated with stress-related ill-
nesses, lower productivity and intention to retire
early, all of which have significant adverse man-
power implications for the NHS [12,18]. Burnout
has also been shown to be associated with
Table 6. Logistic regression analysis showing independent
predictors of burnout (depersonalisation) substance misuse and interpersonal difficulties,
both of which have significant implications for
Independent covariates Coefficient (B) Significance (p) safety in the workplace for colleagues and patients
Eat more 0.571 0.008 [19,20].
Take it out on family 0.941 50.005 The notion that working with cancer per se
Talk with family 0.869 50.005 confers high risk of stress and burnout is not
Mix less with friends 0.555 0.01 supported by the present study. Neither psychiatric
Satisfaction with work 0.600 0.005 morbidity nor burnout levels were higher in
surgeons with a higher cancer workload.
Three-fourth of surgeons wanted to retire early
1994 increasing to 33% in 2002. Their 2002 result is and a similar number said they would retire as soon
similar to this study (w2 ¼ 1:69; p ¼ 0:43; Graph- as they could afford to. If this stated intention is
pad, InStat software. This picture is less than translated into the actual behaviour it is likely that
satisfactory with significant ramifications for the the NHS is going to lose the most experienced
quality of care that these individuals can deliver. group of surgeons prematurely. To offset this to a
Stress at work has been shown to be related to high degree it does appear that those likely to say that
burnout levels in health-care professionals [2]; they are most likely to retire early also have
work stress has also been shown to be significantly significant psychiatric morbidity and are burnt out.

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
Stress and burnout in surgeons 575

Multivariate analysis indicated that job dissatis- and vascular surgeons and are likely to impact
faction was an independent predictor of psychiatric adversely on patient satisfaction and service
morbidity and burnout. However, given the cross- quality.
sectional design of the present study, it is not There are several implications for the work force
possible to say what is the cause and what is the planning of NHS which are highlighted in this
effect. It could be that because people have study. A significant number of surgeons with
psychiatric morbidity they are not satisfied, or psychiatric morbidity, high levels of burnout and
alternatively, because of their dissatisfaction they intention to retire early could lead to a future work
develop psychiatric morbidity. Training in com- force crisis.
munication and management was also predictive of
burnout. There is evidence in medical literature to
suggest that communication skills training can Notes
improve attitude of clinicians towards patients,
thus reducing DP [21]. 1. Royal College of Surgeons of England, 35-43 Lincoln’s
Several coping strategies were found to be Inn Fields, London, WC2A 3PE.
independent predictors of psychiatric morbidity 2. Kendata Peripherals Limited, Nutsey Lane, Totton,
and burnout. People with poor social strategies Southampton, SO40 3N.
(taking work home, mixing less with friends) had
higher stress and burnout levels. All these re-
sponses can increase adverse consequences domes-
tically and in turn lead to reduction of social
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Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon