Burnout Syndrome in Lung Transplant Physicians

Abstract

Objective: Burnout syndrome is common in physicians, but little is known about burnout in lung transplant physicians specifically. The purpose of this study was to explore burnout and its relationship to job factors and depression in lung transplant physicians.

Design: A cross-sectional study that included lung transplant pulmonologists and surgeons was performed via electronic survey.

Setting: The lung transplant physicians surveyed practiced worldwide.

Methods: The survey incorporated questions about demographics and job characteristics as well as the Maslach Burnout Inventory and Patient Health Questionnaire-2. Burnout was defined by high emotional exhaustion or depersonalization.

Participants: Ninety physicians worldwide completed the survey.

Results: Of the 90 physicians who completed the entire survey, 44 (48.9%) had burnout with 38 (42.2%) having high emotional exhaustion, 15 (16.7%) having high depersonalization, and 9 (10.0%) with both. Of the respondents, 14 (15.6%) had high risk of depression, and of these, 13 also had high emotional exhaustion. There was a positive correlation between depression score and emotional exhaustion score (P=0.67, P<0.001). Depression was more common in surgeons compared with pulmonologists (35.7% versus 11.8%, P=0.02). There was a trend toward more burnout by emotional exhaustion in physicians with more versus less work experience (68.4% versus 31.6%, P=0.056).

Conclusions: Emotional exhaustion is common in lung transplant physicians and is associated with depression and a negative impact on life.

Burnout syndrome (BOS) is a pathological syndrome resulting from a prolonged response to chronic occupational stress that develops in individuals with no history of psychologic or psychiatric disorders.^1,2 Burnout has three key dimensions: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Exhaustion occurs when work-related demands lead to depletion of energy and generalized fatigue; people feel drained and used up.^1,3 DP is a negative or excessively detached attitude toward work and is self-protective against the overload of exhaustion.¹ Finally, reduced PA refers to a tendency to negatively evaluate work with feelings of incompetency and lack of productivity.^1,3

In a survey of physicians in the United States performed in 2011, approximately 45% of physicians met the criteria for burnout.⁴ A subsequent study showed a 10% increase in the prevalence of burnout among US physicians over the next three years,⁵ suggesting burnout is an increasing problem. There was significant variability in the rate of burnout by medical specialty, with specialties at the frontline of access to care, including emergency medicine, general internal medicine, and family medicine, demonstrating the highest rates of burnout. Other risk factors for burnout include workload, sleep deprivation, work-life balance, patient characteristics, and alignment of personal and organizational values.^1,6

In addition to an increased risk of burnout, physicians also have an increased risk for depression compared to the general population.⁷ However, while burnout is considered a work-related syndrome, depression affects all aspects of life. In a study of depression-burnout overlap in Austrian physicians, approximately 10% of physicians had major depression, and 50% had burnout. Symptoms of depression and burnout were highly correlated.⁸ The majority (87.5%) of depressed physicians also had burnout symptoms.

Lung transplantation is a highly specialized medical field offering treatment for end-stage lung disease. Despite having the reward of saving lives, transplant physicians have many risk factors for burnout including dealing with critical illness, high workload, patients with high expectations, and unpredictable hours with frequent night calls. However, little is known about burnout in lung transplant physicians. The purpose of this study was to explore burnout and its relationship to job factors and depression in lung transplant physicians.

Materials and Methods

Study Design

A cross-sectional survey of lung transplant physicians in the United States, Canada, Australia, and Europe was performed in September 2019. Lung transplant programs in the United States were identified by listing in the Scientific Registry of Transplant Recipients (srtr.org). Online searches were performed to identify the lung transplant programs in Canada, Australia, and Europe. Manual online search was performed to identify the medical director at each lung transplant program. If a medical director could not be found, the surgical director of lung transplantation was identified. An introductory, informational email was sent to each transplant director with request to forward a second recruitment email to the transplant pulmonologists and lung transplant surgeons within the program. This second email contained a link to an electronic study survey. Two additional reminder emails were also sent to the transplant program directors over a one-month time period. This study was approved by the Institutional Review Board of Baylor College of Medicine. Completion of the survey was considered consent to participate in the research, and all responses were anonymous.

Measures

Sociodemographic and Professional Data

Survey participants were asked 12 questions that assessed sociodemographic variables and professional characteristics. Sociodemographic data included gender, age, and geographic area of practice. Professional data included individual information including type of lung transplant physician (pulmonologist versus surgeon), years working in lung transplant, allocation of time at work, average number of hours worked per week, average hours per week devoted to direct patient care, and whether call was required and, if so, how often. Center information was also obtained including number of lung transplants performed annually and the total number of lung transplant patients being managed by the center. At the end of the survey, participants were asked if their work in lung transplant negatively affected their well-being. This question was graded on a 6-point Likert scale ranging from strongly agree to strongly disagree.

Burnout

The Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS) was used to assess burnout.⁹ The MBI-HSS is a validated instrument comprising 22 items that capture the three dimensions of burnout. Responses are measured on a Likert scale frequency rating from 0 (never) to 6 (every day). Items were summed for each dimension. In addition, an average score for each dimension was obtained by taking the summed score and dividing by the total number of questions in that domain. Burnout was defined as either high EE or high DP using cutoffs previously defined (≥ 27 for emotional exhaustion and ≥ 13 for depersonalization).^10,11

Depression

The Patient Health Questionnaire-2 (PHQ-2) is a screening tool for depression as a “first-step” approach¹² and was incorporated into the study survey. It comprises two items about the frequency of depressed mood and anhedonia over the last 2 weeks. Responses are measured on a Likert scale frequency rating from 0 (not at all) to 3 (nearly every day). Major depressive disorder is likely if the score is ≥3, and therefore participants were considered depressed if score was ≥3 and not depressed if score was <3.

Data Analysis

Descriptive statistics were run for all variables. Data were summarized as mean ± SD for parametric variables and median (interquartile range, IQR) for non-parametric variables. Spearman’s correlations were used to determine the relationships between variables. Kruskal-Wallis test or chi-square test was also used to determine associations among variables. A P value of <0.05 was considered statistically significant for all two-sided tests. Statistical analysis was performed using STATA version 11 (StataCorp, College Station, TX).

Results

The initial email was sent to 83 directors of lung transplantation. There were 95 lung transplant physicians who started the survey, and 90 physicians who completed the survey. The percentage of recruited physicians who answered the email is unknown, since each program was asked to forward the email to physicians within the program. Sociodemographic data of respondents are shown in Table 1. The majority of the survey respondents identified as male (80%), pulmonologists (84.4%), and were from the United States (73.3%). Respondents were mainly age 35-54 years-of-age (76.7%).

Table 1.

Demographic characteristics of participating lung transplant physicians (N=90)

Characteristic	n (%)
Gender
Female	18 (20)
Male	72 (80)
Type of transplant physician
Pulmonologist	76 (84.4)
Surgeon	14 (15.6)
Age
< 35	3 (3.3)
35-44	28 (31.1)
45-54	41 (45.6)
55-64	14 (15.6)
>65	4 (4.4)
Geographic location
Australia	7 (7.8)
Canada	9 (10.0)
Europe	8 (8.9)
United States	66 (73.3)

The professional characteristics of the group are presented in Table 2. Almost half of the respondents (48.9%) worked at transplant centers that performed at least 50 lung transplants per year and followed more than 300 lung transplant recipients at a given time (21.1% with 301-500 lung transplant recipients and 30.0% with more than 500 lung transplant recipients). Just over half the respondents had more than 10 years of experience (56.7%) and spent the most time (on average, 52.5 ± 22.9 percent of the time) on the clinical care of lung transplant patients and clinical care of non-lung-transplant patients (20.4 ± 20.3% of the time). Almost all respondents worked on average more than 40 hours per week, with 54.4% working more than 60 hours per week. Approximately half (47.7%) spent 20-40 hours on direct patient care. Almost all respondents (97.8%) were required to take call, with the majority taking call at least 11 weeks per year (47.7% with 11-20 weeks of call and 35.2% with greater than 20 weeks of call). In response to the question whether work in lung transplant negatively affected the respondent’s wellbeing, 11.1% strongly agreed, 14.4% agreed, 30.0% somewhat agreed, 7.8% neither agreed nor disagreed, 8.9% somewhat disagreed, 15.6% disagreed, and 12.2% strongly disagreed.

Table 2.

Work and center characteristics of lung transplant physicians (N=90)

Characteristic	n (%)
Center average number of lung transplants per year,
<10	1 (1.1)
10-19	8 (8.9)
20-29	10 (11.1)
30-39	13 (14.4)
40-49	14 (15.6)
≥ 50	44 (48.9)
Center total number of lung transplant recipients
≤50	2 (2.2)
51-100	11 (12.2)
101-200	16 (17.8)
201-300	15 (16.7)
301-500	19 (21.1)
>500	27 (30.0)
Work experience in years
≤ 5	16 (17.8)
6-10	23 (25.6)
11-20	33 (36.7)
>20	18 (20.0)
Time (%) spent on the following (mean ± SD)
Clinical care of lung transplant patients	52.5 ± 22.9
Clinical care of non-lung-transplant patients	20.4 ± 20.3
Clinical or basic research	11.6 ± 12.3
Administration	12.8 ± 9.4
Teaching/education	7.3 ± 4.8
Average hours spent working each week
<20	0 (0.0)
20-40	1 (1.1)
41-60	40 (44.4)
61-80	39 (43.3)
>80	10 (11.1)
Work hours per week dedicated to patient care
<20	19 (21.1)
20-40	43 (47.7)
41-60	17 (18.9)
61-80	7 (7.8)
>80	4 (4.4)
Work involves call
Yes	88 (97.8)
No	2 (2.2)
Number of weeks on call per year
1-2	2 (2.3)
3-5	1 (1.1)
6-10	12 (13.6)
11-20	42 (47.7)
>20	31 (35.2)

The results of the MBI-HSS and the PHQ-2 are shown in Table 3. Based on the MBI-HSS, 44 respondents (48.9%) had burnout. Of these, 38 respondents (42.2%) had burnout based on EE score (≥27), and 15 respondents (16.7%) had burnout based on DP score (≥13). There were 9 respondents (10.0%) who had burnout by both EE and DP criteria, 6 respondents who had burnout by DP alone (6.7%), and 29 respondents who had burnout by EE alone (32.2%). The median score on the PHQ-2 was 1 (interquartile range 0, 2). There were 14 respondents (15.6%) at high risk for depression based on PHQ-2. Of the 14 respondents with high risk of depression, 13 had burnout based on EE cutoff, and 6 had burnout based on DP cutoff.

Table 3.

Burnout and depression parameters of participants (N=90)

Maslach Burnout Index Total Score by Domain, mean ± SD
Emotional Exhaustion	25.9 ± 11.7
Depersonalization	8.0 ± 5.6
Personal Accomplishment	33.9 ± 5.2
Maslach Burnout Index Mean Score by Domain, mean ± SD
Emotional Exhaustion	2.9 ± 1.3
Depersonalization	1.6 ± 1.1
Personal Accomplishment	4.9 ± 0.7
Burnout by Maslach Burnout Index based on domain, n (%)
Emotional Exhaustion	38 (42.2)
Depersonalization	15 (16.7)
Patient Health Questionnaire-2, Total Score [median (interquartile range)]	1 (0,2)
Depression by PHQ-2, n (%)
Yes	14 (15.6)
No	76 (84.4)

There was significant positive correlation between DP and EE (ρ=0.52, P<0.001). There were significant negative correlations between PA and the other two domains (PA and DP, ρ=−0.26, P=0.01; PA and EE: ρ=−0.38, P<0.001). There were significant positive correlations between PHQ-2 total score and EE total score (ρ=0.67, P<0.001) as well as DP total score (ρ=0.44, P<0.001). There was a significant negative correlation between PHQ-2 total score and PA total score (ρ=−0.43, P<0.001). Gender, age, type of job, transplant volume, and work hours were not associated with differences in burnout. There was a trend toward a difference in burnout by EE score in physicians with more versus less work experience (31.6% with ≤10 years of experience and 68.4% with >10 years of experience, P=0.056). There was also a trend toward greater burnout by EE score depending on the type of job (64.3% in surgeons and 38.2% in pulmonologists, P=0.07). High risk of depression was also more prevalent in surgeons compared to pulmonologists (35.7% versus 11.8%, P=0.02).

Of the 14 respondents at high risk for depression, all 14 at least somewhat agreed that work in lung transplant negatively affected the respondent’s wellbeing. Of the 44 respondents with burnout, 36 (81.8%) at least somewhat agreed that work in lung transplant negatively affected the respondent’s wellbeing.

Discussion

This study found that lung transplant physicians have a high prevalence of burnout at 49% and a lower prevalence of depression at 16%. Emotional exhaustion is the most common manifestation of burnout in transplant physicians and is also common in those with depression. More experienced transplant physicians have a trend toward higher EE than less experienced physicians. Transplant surgeons have more depression and a trend toward greater EE compared with transplant pulmonologists.

Previous studies of transplant physicians have focused on transplant surgeons and not just within the specific field of lung transplantation. Surveys of United States transplant surgeons incorporating the MBI-HSS found mean EE scores of 23.37, mean DP scores of 6.32, and mean PA scores of 36.66.¹³ Another study of European transplant surgeons, of which the majority were liver and kidney transplant surgeons, found similar mean scores of 20.6 for EE, 6.7 for DP, and 35.1 for PA.¹⁴ Mean scores for EE and DP were slightly higher in this study compared with these prior studies. This study included both transplant surgeons and pulmonologists, indicating that factors related to the transplant field rather than specialty training may be a major factor leading to burnout.

High EE was the most common reason for burnout. Emotional exhaustion may be one of the first signs that there is a problem with a person’s job.¹ In surveys of United States physicians, high EE was found to be more common than either high DP or a low sense of PA.^4,5 Gender may also influence burnout experience. One study of general practitioners found that burnout in women was triggered by EE, but in men, the first sign of burnout was DP.¹⁵ A higher prevalence of burnout based on EE compared with DP in this study indicates that while transplant physicians experience fatigue, many are still able to remain engaged with people and their job. The rate of burnout in transplant physicians is similar to prior reported rates in frontline specialities⁴ and critical care physicians (reported at 55%¹⁶), but higher than the 32% of burnout reported in pulmonary and critical care trainees.² Transplant physicians care for patients in both the inpatient and outpatient settings and often have primary responsibility for care of their patients, making them similar to both critical care physicians and frontline workers.

A bi-directional association between burnout and depression has been previously observed in both cross-sectional and longitudinal studies.¹⁷ In the current study, PHQ-2 score was correlated with all three burnout domain scores. However, the strongest association was with EE. In addition, almost all respondents with high risk of depression had burnout by EE, but only half had burnout by DP. This is consistent with prior studies that have demonstrated EE has the strongest link to depression, with weaker correlations of depression with DP or PA.^17,18 Surgeons were more likely to have depression than pulmonologists, but there was no difference in burnout based on job type. Although burnout has typically been associated with job-related factors, while depression is associated with generic factors such as family history, substance abuse, or problems with friends or family, threats and stresses in professional life can also increase risk of depression.¹⁹ Surgeons had higher risk of depression as well as a trend toward more burnout by EE. However, the specific personal or professional factors leading to this finding were not determined.

Work experience has previously been linked to burnout. In a cross-sectional study of 7288 physicians from all specialties, middle career physicians were more likely to have high EE and burnout compared with early or late career physicians.²⁰ However, high DP was most common in early career physicians and decreased over time.²⁰ The authors hypothesized that multiple factors led to higher burnout in middle career physicians, including dissatisfaction with work-life balance, long work hours, and frequent call. In comparison, transplant physicians had a trend toward high EE score in those with more work experience compared with those with less work experience. This finding may suggest that the effects of working in the field of lung transplantation accumulate over time, leading to greater exhaustion. The high prevalence of burnout in transplant physicians may also be related to the nature of the work, which was not specifically investigated in this study.

The study has several limitations. First, it is unclear what percentage of lung transplant physicians worldwide responded to this survey, since recruitment for participation in this study was done via the transplant directors. It is also possible that those physicians with burnout or depression were more or less likely to respond to the survey, thus biasing the results of the study. In addition, multiple cutoffs exist for the MBI, and therefore, changes in cutoffs could affect the prevalence of burnout in this study. Finally, this was a cross-sectional study, and therefore, information cannot be gathered regarding burnout over time.

Emotional exhaustion is common in lung transplant physicians, is associated with depression, and has a negative impact on life. More information is needed to determine if certain characteristics such as resilience allow retention in the field of lung transplantation despite high burnout levels. Methods to counteract burnout may also be necessary to help encourage the recruitment and retention of transplant physicians. In addition, strategies to recruit more physicians into lung transplant may help to alleviate the burden on current transplant physicians.