Doctors' Burnout: Explaining the Differences Between Countries

Kerry Dooley Young

February 14, 2019

Administrative burdens and insufficient pay emerged as key contributors to burnout in a Medscape Medical News survey of doctors in six countries.

The survey results echoed other research that previously has identified burnout and depression as major concerns in medicine. For this survey, Medscape looked at the situations of doctors in the United Kingdom, United States, France, Spain, Portugal, and Germany

More than a third to half (36% to 51%) of those surveyed by Medscape reported feeling burnout or depression or both. And of those doctors reporting burnout, 19% to 25% of this group in five of the surveyed countries said their distress was severe enough for them to consider leaving medicine. In Spain, this figure was 9%.

Common Complaints

Despite great variation in the countries' approach to funding and managing healthcare, doctors in the UK, US, France, Spain, Portugal, and Germany shared some common complaints.

In 5 of the 6 countries surveyed, doctors were most likely to say too many bureaucratic tasks were a contributor to burnout. This was cited by 56% of survey respondents from both the United States and Portugal, 52% of those from Germany, 49% from France, and 47% from the UK. While Spanish doctors cited insufficient pay more frequently as a contributor, 47% of them cited too many bureaucratic tasks as a contributor, making it the second most common complaint from respondents from that nation.

Doctors in the US were most likely of this group to also list increased computerisation of their practice through electronic health records (EHRs) as a contributor to burnout. 

A quarter (25%) of respondents from the United States cited this as a factor, compared with 18% of German respondents, 15% of Spanish respondents, 13% of Portuguese respondents, 12% of French respondents and 9% of UK respondents.

The approach taken with EHRs has turned a technology once considered a potential time saver for physicians into a major source of stress for those working in the United States.

The EHRs have made it easier for insurers and others to layer on requirements for performance measurements, without anyone taking a broad look at the cumulative toll, Dr Christine Sinsky, of the American Medical Association, told Medscape Medical News in an interview.

"They were done in a way that didn't take into account the total burden of all of those good ideas," said Sinsky, who serves as AMA's vice president for personal satisfaction. "Some of this has been facilitated by technology. It made it easier for those interested in measurements to demand more measurements."

Another national difference was annual holiday/vacation. The Medscape survey found that doctors working in the United States reported taking far less time off than their European counterparts. A third (33%) of US respondents reported taking 2 weeks or less holiday time each year. In contrast, 16% of UK respondents reported taking this little time off, while only 7% to 9% of their counterparts in the other four countries did.

AMA's Sinsky said the vacation time estimates may be somewhat misleading as a depiction of doctors’ leisure time. Many physicians take hours away from family time and recreation to keep up with administrative demands while on holiday.

"They continue to work their inbox while on vacation. They don't want to burden their colleagues and they don't want to come home to what would clearly be an unmanageable inbox," Sinsky said.

The survey included nearly 20,000 practising doctors who accepted an invitation to complete a 10-minute online survey. The United States provided the overwhelming majority of participants, with 15,543 respondents. Next was Spain (1053), France (968), the United Kingdom (956), Portugal (800) and Germany (615).
 

Economic Crisis

Doctors in Spain and Portugal were far more likely than their counterparts in other countries to cite insufficient compensation as a contributor to burnout.

More than half (56%) of respondents from Spain who reported burnout cited insufficient pay as a factor, as did 43% of those from Portugal. In contrast, this same complaint  was made by 27% of the UK cohort, 26% of the German cohort, 23% of the US cohort and 18% of the French cohort.

The dissatisfaction with compensation in Spain and Portugal likely reflects fiscal policies dictated for these nations after the economic crisis of 2007 to 2011, doctors told Medscape Medical News.

"The increase in the care burden and the decrease in salary were two fundamental elements that promoted emotional exhaustion and depersonalization, basic elements of burnout," Dr Oriol Yuguero, of Spain's University of Leida, told Medscape Medical News in an email exchange.

Dr Gustavo Queirós, a paediatrician from Lisbon said resulting budget cuts have worsened the chronic understaffing in Portugal's primary care units leading many patients to visit the emergency room unnecessarily, many physicians faced longer hours, and overtime pay was cut. Portugal required "brutal sacrifice of the professionals in order to keep running the system," he told Medscape Medical News in an email exchange.

"With some economic recovery, we were expecting that the situation could improve," Queirós said. "But it’s not the case."

Seeking Help

The Medscape survey found that doctors in Spain were least likely to have sought professional care for depression and burnout

Of the respondents from Spain reporting these conditions, 64% said they had no plans to seek professional help.

"Despite burnout, most professionals maintain high levels of quality of care as our research results showed," Yuguero said, referring to a paper he and colleagues published in 2017 in the journal BMC Medical Ethics.

In that paper, Yuguero and colleagues reported that burnout didn't significantly influence quality of care delivery in 22 Spanish primary care centres they studied.

Yuguero told Medscape Medical News that Spain doesn't have enough programs in place to address depression and burnout problems among health professionals. But there has been some progress, he noted.

"In Catalonia, the medical organizations have created tools to help the professionals, and they are very well received," Yuguero said.

In Medscape's survey, doctors in France appeared most willing to look for help. Of those reporting feeling burned out or depressed, 42% said they'd either received professional help in the past, were currently receiving help, or planned to seek it.

Still, almost half (47%) said they had not sought help and didn't plan to, with another 11% declining to answer this question in the survey.

The topic of burnout remains "taboo" among doctors, Dr Ziad Kansoun, told Medscape Medical News in an email exchange. Kansoun, who published research this year on burnout among French doctors, said doctors find it difficult to speak about their own psychological problems.

Some French hospitals are using mindfulness training and other techniques to prevent stress at work, Kansoun said. Other hospitals use a phone line to let doctors discuss burnout.

After the French, doctors in the UK appeared next most likely to seek help (56%).

More than a third (34%) of those reporting feelings of burnout or depression said they had received professional help in the past, were currently receiving help, or planned to seek it.

The UK stood out in the use of social workers or counsellors to help doctors manage their feeling of burnout and depression. More than half (56%) of respondents who reported feeling burnout or depressed said they had sought this kind of counselling.

One of the British Medical Association’s wellbeing support services addresses these issues. It offers a confidential counselling service which is open 24 hours a day, 7 days a week, via phone or video chat. The service is staffed by members of the British Association for Counselling and Psychotherapy, who are bound by strict codes of confidentiality. There are about 3000 calls a year to this service, Tom Rapanakis, BMA’s wellbeing support services manager, told Medscape Medical News, in an interview.

This service offers an immediate form of outreach, even when medical staff work in remote locations, Rapanakis said.

"A doctor who may be isolated and at the end of a difficult day can still talk to someone," he said.

Read a special analysis of the survey for French physicians (in French) here.

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