Global Prevalence of Burnout in orthopaedic surgeons: a meta-analysis

Pandji Winata Nurikhwan1,2, Ahmad Muhsinin3, Yopi Meliandi3

1
Medical Education Department of Medical Faculty, Lambung Mangkurat University, Indonesia
2
Student of Medical Education Master Program of Medical Faculty, Universitas Indonesia,
Indonesia
3
Harapan Insan Sendawar General Hospital, Kutai Barat, Indonesia

Background: The orthopaedic residency program is emotionally, physically and intellectually

challenging, placing orthopaedic surgeons at risk of burnout. Burnout syndrome is associated
with negative impacts both for patients and the surgeon. The aim of this review is to summarize
the available literature on burnout among orthopaedic surgeons and provide recommendations
for future work in this field.

Methods: Records identified through database searching (Science Direct, PubMed and Google
Scholar) with search terms: ‘Burnout’ AND ‘Orthopaedics’; was performed. Inclusion criteria
were orthopaedic surgeon/resident, written in the English language, and using the Maslach
Burnout Inventory as a validated instrument.

Results and Discussion: There were 320 records identified and furthermore 302 were excluded.
After full-text were assessed, 12 Studies included in qualitative synthesis for the systematic
review. Study design found were cross-sectional and cohort, mainly occurred in a developed
country (and one in Nigeria). Burnout rates among orthopaedic surgeons are in the range of 7.7–
100%, This finding has examined and found burnout symptoms were happened in practicing
surgeons, academic leaders, and trainees around the world. Several studies have noted that
surgeons, faculty leaders, and trainees suffer different types of burnout at various rates; therefore,
those roles must be investigated independently

Conclusion: Burnout is highly prevalent among orthopaedic surgeons, there is a need to assess
burnout rates among orthopaedic population sets in other countries and to determine the factors
driving burnout in specific populations. High burnout rates among orthopaedic surgeons may
need to be addressed through implementation of preventative strategies at the surgeon (e.g.
voluntary reduction in work hours), institution (e.g. increase in number of orthopaedic surgeons
to decrease workload/surgeon) and government policy (e.g. workshops to help orthopaedic
surgeons deal with burnout and its effect’.
 Global Prevalence of Burnout in orthopaedic surgeons: a meta-analysis

Pandji Winata Nurikhwan1,2, Ahmad Muhsinin3, Yopi Meliandi3

1
Medical Education Department of Medical Faculty, Lambung Mangkurat University, Indonesia
2
Student of Medical Education Master Program of Medical Faculty, Universitas Indonesia,
Indonesia
3
Harapan Insan Sendawar General Hospital, Kutai Barat, Indonesia

INTRODUCTION

The three main components of burnout are an overwhelming exhaustion, feelings of cynicism or
depersonalization, and a sense of ineffectiveness and lower efficacy. It is also one of the most
common mental health issues faced by medical and surgical residents or trainees who are junior
doctors holding Bachelor of Medicine and Bachelor of Surgery or undergraduate Doctor of
Medicine degrees and who are undergoing supervised medical or surgical specialty training.

The Maslach Burnout Inventory (MBI) scale is a scoring system that has been validated in
multiple physician and non-physician populations, and is considered as the gold-standard for
burnout assessment. The scale consists of 22 seven-point Likert scale questions, which measures
EE, DP and PA separately. In clinical practise and research studies, clinically significant burnout
is defined as the presence of either high level EE or high level DP.

Orthopaedic surgery is a challenging specialty, covering broad anatomy, complex pathologies,

major trauma cases and a wide range of procedures. Orthopaedic surgeons have a heavy
workload and commonly work long hours. The postgraduate orthopaedic training programme is
also notoriously difficult. In the modern medical environment, reduced independent surgical
practice and exposure has made it increasingly difficult to achieve surgical skills, further
steepening the learning curve and putting additional pressure on the already high expectation and
demands of orthopaedics. Given the challenges in practising orthopaedics, the data on burnout in
other medical specialties may not be generalisable to orthopaedic surgeons. While burnout has
been studied in orthopaedic surgeons, a comprehensive review article in this area is lacking.

AIM

Accordingly, we performed a systematic review to summarise and discuss the evidence

regarding the prevalence, determinants, outcome and management of burnout in orthopaedic
surgeons.

METHODS

Literature search
A systematic literature search was conducted in PubMed, Elsevier, and Science Direct to identify
relevant articles published through 30 August 2019. The search terms (“Orthopaedics" [Mesh]
OR “Orthopaedic + Surgeons" [Mesh] OR Orthop*[tiab]) AND (“Burnout, Professional" [Mesh]
OR burnout*[tiab] OR “Stress, Psychological" [Mesh] OR “Mental Fatigue" [Mesh]) were used.

Inclusion/exclusion criteria

The articles retrieved from PubMed were further screened by two independent reviewers.
Articles that were (a) peer-reviewed original research articles; (b) measures burnout directly in
study participants; (c) uses validated scales for burnout assessment; and (d) on orthopaedic
surgeons, were included. There was no limit on place and time of publication. Articles without
English full texts were excluded. Given the high variability in methodology and quality of
studies, no studies were excluded based on methodological factors. The corresponding
limitations of the studies were noted and discussed.

Discrepancy resolution

For discrepancies between reviewers during study review and data collection, a panel discussion
involving all research team members was carried out to achieve consensus.
RESULT

Figure 1. PRISMA flow diagram of studies included into the systematic review meta
analysis
 Table 1. Prevalence of burnout among orthopaedic surgeons

No Author Year Type Country Subject Professional level Overal

Burnout
Rate
1 Alsheikh 2019 Cross- Saudi 142 Residents orthopedic 56,3%
et al sectional Arabia
2 Faivre et 2019 cross- French 441 orthopedic and trauma 172 (39%)
al sectional surgeons
3 Faivre et 2018 cross- French 107 Residents orthopedic 43 (40%)
al sectional
4 Oladeji 2018 cross- Columbia 243 Orthopedic surgery 30.9%
et al sectional residents
5 Zheng et 2018 cohort China 202 orthopedic surgeons 85.1%.
al
6 Shetty et 2017 cross- Indian 299 orthopaedic 69 (23.1%)
al sectional
7 Simon et 2016 cross- AS 58 Resident and staff 7.7%
al sectional surgeon
8 Arora et 2014 cohort Australia 51 Australian orthopaedic 27 (53%)
al trainees
9 Coker et 2012 cross- Nigeria 29 resident doctors and 15(51.7%)
al sectional consultant orthopaedic
surgeons
10 Sargent 2011 cross- AS 648 orthopaedic residents,56% of
et al sectional faculty, and residents,
their spouses or
30% of
significant others working
resident
spouses,
28% of
faculty, and
13%
of working
faculty
spouses
11 Sargent 2009 cross- AS 380 orthopaedic residents 56%of
et al sectional orthopedic and full-time residents,
resident, orthopaedic faculty 28% of
264 full- members full-time
time orthopaedic
orthopaedic faculty
faculty members
members
12 Sargent 2004 cross- AS 46 21 Orthopaedic 100% and
et al sectional resident and 25 full- 2 of 25
 time orthopaedic from
faculty faculty

Random effects
Study Prev (95% CI) % Weight
Alsheikh et al 0.54 ( 0.45, 0.62) 7.4
Faivre et al, 2019 0.39 ( 0.34, 0.44) 7.6
Faivre et al, 2018 0.40 ( 0.31, 0.50) 7.3
Oladeji et al 0.31 ( 0.25, 0.37) 7.5
Zheng et al 0.85 ( 0.80, 0.90) 7.5
Shetty et al 0.23 ( 0.18, 0.28) 7.6
Simon et al 0.07 ( 0.02, 0.15) 7.0
Arora et al 0.53 ( 0.39, 0.67) 6.9
Coker et al 0.52 ( 0.33, 0.70) 6.4
Sargent et al, 2011 0.45 ( 0.41, 0.48) 7.6
Sargent et al, 2009faculty 0.56 ( 0.51, 0.61) 7.6
Sargent et al, 2009resident 0.28 ( 0.23, 0.34) 7.5
Sargent et al, 2004faculty 1.00 ( 0.92, 1.00) 6.0
Sargent et al, 2004resident 0.08 ( 0.00, 0.23) 6.2

Overall 0.44 ( 0.34, 0.55) 100.0

Q=413.25, p=0.00, I2=97%

0 0.2 0.4 0.6 0.8 1

Prevalence

Figure 2. Forest Plot

In forest plot table, it can conclude that the result is heterogeneous (p < 0.0001) with the overall
effect are 0.44.

DISCUSSION

As stated, there are approximate 44% global prevalence occurred. Hence, we try to review and
describe the associated factor. These factors stated in table 3.

Table 2. Factors associated with burnout in orthopaedic

Personal factors Family factors Working environment Career

Female Work-family conflict Sleep deprivation Regret in choosing
medicine
Racial minorities Lack of spousal support/ Working in large Current residents
poor marital relationship residency
programmes
Harassment and Significant others on Excessive work/ long Anxiety about clinical
discrimination military service work hours competence
Financial concerns Nights on-call per Worry about
week competition from
other
orthopaedic surgeons
Alcohol and drug Perception of stress in
abuse work
Stress in workplace
relationships

CONCLUSION

The evidence on burnout occure in orthopaedic surgeons is 44%, but it is still preliminary, and
key methodological limitations have been noted. Large scale prospective studies are warranted to
assess the determinants and effects of burnout in orthopaedic surgeons, in order to guide
interventions against this occupational health hazard.

REFERENCES

 Alsheikh KA, Alhabradi FA, Almalik FF, Alsalim AA, Ahmed FE, Alhandi AA. Burnout
syndrome among orthopedic surgery residents in Saudi Arabia: A multicenter study. J
Musculoskelet Surg Res 2019;3:184-8.
 Faivre G, Marillier G, Nallet J, Nezelof S, Clment I, Obert L. Are French orthopedic and
trauma surgeons affected by burnout? Result of a nationwide survey. Orthopaedics &
Traumatology: Surgery & Research. 2019:105:395-399
 Faivre G, Kielwasser H, Bourgeois M, Panouilleres M, Loisel F, Obert L. Burnout
syndrome in orthopaedic and trauma resident in France: a nationwide survey. 2018: 104:
1291-1295
 Oladeji LO, Ponce BA, Worley JR, Keeney JA. Mentorship in orthopedics: a national
survey of orthopedic surgery residents. Journal of Surgical Education: 2018:75:1606-
1614
 Zheng H, Shao H, Zhou Y. Burnout among Chinese adult reconstructive surgeons:
incidence, risk factors, and relationship with intraoperative irritability. J Arthoplasty.
2018;33:1253e1257. https://doi.org/10.1016/j.arth.2017.10.049, 2017/12/15.
 Shetty SH, Assem Y, Khedekar RG, Asha S, Arora M. Indian orthopaedic surgeons are
less burned out than their western colleagues. Journal of Arthroscopy and Joint Surgery:
2017:4:1-7
 Simons BS, Foltz PA, Chalupa RL, et al. Burnout in U.S. Military orthopaedic residents
and staff physicians. Mil Med. 2016;181:835e839. https://doi.org/10.7205/milmed-d-15-
00325, 2016/08/03.
 Arora M, Diwan AD, Harris IA. Prevalence and factors of burnout among Australian
orthopaedic trainees: a cross-sectional study. J Orthop Surg. 2014;22:374e377.
https://doi.org/10.1177/230949901402200322, 2015/01/01.
 Coker AO, Adewole OA, Shoga MO, Uzodimma CC. Burnout syndrome among
orthopaedic surgeons in Lagos, Nigeria. East and Central Afrrican Journal of Surgery:
2012:17:13-17
 Sargent MC, Sotile W, Sotile MO, et al. Managing stress in the orthopaedic family:
avoiding burnout, achieving resilience. J Bone Joint Surg Am. 2011;93: e40.
https://doi.org/10.2106/jbjs.j.01252, 2011/04/22.
 Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during
orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and
faculty. J. Bone Joint Surg. Am. 2009; 91: 2395–405.
 Sargent MC, Sotile W, Sotile MO, et al. Stress and coping among orthopaedic surgery
residents and faculty. J Bone Joint Surg Am. 2004;86-a:1579e1586, 2004/07/15.
 And more..