Physician wellbeing and burnout in emergency medicine in Switzerland

DOI: https://doi.org/https://doi.org/10.57187/s.3421

Introduction

Burnout is defined as an occupational phenomenon resulting from chronic workplace stress [1]. It is characterised by three dimensions: an emotional component (feeling of energy depletion or exhaustion), a depersonalisation component (increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job) and a personal accomplishment component (reduced professional efficacy) [2]. Burnout is not a disease but rather a state, and it is a risk factor for the development of mental and physical illnesses, such as depression, hypertension, multiple sclerosis and cancer [3].

Among healthcare professionals, emergency physicians are the most at-risk specialist group for burnout, with consequences not only for physician health but also for patient care and the rest of the healthcare system [4, 5]. Burnout is associated with reduced quality of care, decreased patient satisfaction and increased medical complication and error rates, and it leads to reduced productivity, higher staff turnout and attrition, increased costs and the eventual closure of emergency departments [6, 7]. In certain countries, up to 87.9% of emergency physicians are burnt out [8–10].

Clinically, burnout can manifest with a variety of symptoms, such as irritability, anxiety, insomnia, lack of concentration and dissatisfaction. It is often recognised at a late stage, when it has been translated into loss of interest, behavioural problems, reluctance to accept new obligations or postponement of current obligations, and general distancing of oneself from the job [11, 12]. If not addressed, burnout can lead to depression and alcohol and drug abuse [13], which can culminate in suicide, which is not uncommon among emergency physicians [14]. Often, as a means of escape from this vicious cycle, emergency physicians choose to leave the profession, which worsens the situation for remaining physicians [15].

Switzerland has seen an increase in the incidence of burnout in recent decades across all fields of medicine [16]. The recent COVID crisis, as well as the post-pandemic increase in patient flow, has led to an increase in work-related exhaustion [17–20]. No study has yet quantified the situation in Swiss emergency departments, but with a system currently in crisis, and calls for reform from both the Swiss Society of Emergency and Rescue Medicine (SGNOR/SSMUS/SSERM) and emergency physicians throughout the country, there is a need to understand how wellbeing can be improved to ensure the preservation of the safety net for the Swiss population that is emergency medicine.

The following study aimed to review the current state of wellbeing of emergency physicians in Switzerland and to identify factors influencing this wellbeing.

Methodology

Survey design

We designed a survey-type observational study. Eligible study participants were physicians currently practicing in a Swiss emergency department, regardless of training or experience. The survey, which was sent to all 1300 members of the SSERM, was translated into German, French, Italian and English and was also disseminated to non-SSERM members via a modified snowball recruitment method (as SSERM membership is not mandatory to practice emergency medicine in Switzerland). To enable this secondary recruitment method, an explanatory email containing a link to the survey was sent to the heads of all 104 hospital-based emergency departments in Switzerland and was intended to be forwarded to residents and staff currently working in their emergency departments.

The survey was divided into four parts. The first section consisted of socio-demographic questions. The second section included Likert scale questions pertaining to the Maslach Burnout Inventory – Health Services Survey (MBI-HSS) and the Copenhagen Burnout Inventory (CBI), two externally validated instruments used to measure burnout [21]. The MBI-HSS is the most widely used scale to measure burnout among human services workers; in the form of a standardised 22-point questionnaire, it aims to assess three aspects of burnout: depersonalisation, emotional exhaustion and personal accomplishment. The Copenhagen Burnout Inventory (CBI) is another commonly used assessment tool; in the form of a 19-point questionnaire, it also assesses three aspects of burnout: personal (P-CBI), work-related (WR-CBI) and client-related (CR-CBI – i.e. patient-related). In addition to the Maslach Burnout Inventory-Health Services Survey (MBI-HSS) and CBI, the second section of the survey also included Likert scale questions covering the Patient Health Questionnaire (PHQ-9) to screen for depression [22]. A third section contained closed questions on career resilience and on suicidality. Finally, a fourth section focused on the personal experience of each physician, in the form of free-text questions giving the opportunity for respondents to express individualised concerns. This final section was the subject of a secondary analysis, which will not be covered in detail in this paper.

The survey was open for a duration of 4 weeks, between March 23^rd and April 23^rd, 2023, with a reminder email sent out 2 weeks after the survey became available. The link to the e-survey was distributed by email, and data were collected on the Mind Garden^© platform. All responses were kept anonymous, and incomplete surveys were excluded. No financial incentives were offered for responses.

The study protocol was approved by the Swiss Society of Emergency and Rescue Medicine and the Swiss Ethics Committee (BASEC 2022-01519).

Outcomes

The primary outcome measured was the incidence of burnout among emergency medicine physicians using two scores: the MBI (cut-offs: depersonalisation ≥10, emotional exhaustion ≥27, personal accomplishment <34) and CBI (cut-offs: P-CBI, WR-CBI and CR-CBI: ≥50). In addition, we investigated the incidence of depression (using the PHQ-9), suicidality and career resilience. As a secondary outcome, we examined whether age, gender, primary language at work, employment percentage (i.e. part-time), working hours, number of night shifts, post-graduate experience, specialty, relationship status and having children had any influence on the incidence of burnout.

Statistical analysis

Burnout scores for the MBI and CBI were calculated according to the appropriate questionnaire manuals [23, 24]. Standard descriptive statistics were calculated for demographics. Relationships between meeting the threshold for burnout on the MBI and CBI and potential risk factors were assessed using binary logistic regression. As an initial step for the purposeful selection of model variables, univariate analysis of each potential risk factor versus meeting the threshold for burnout on any domain on the MBI was analysed. This was repeated for the outcome of meeting the threshold for burnout on any domain of the CBI. Variables found to be associated (p-value <0.1) with burnout were included as predictors in the initial multivariable model to determine which factors were independently associated with burnout. Backwards stepwise multivariable logistic regression (Wald removal criterion of 0.1) was used to determine the predictor variables independently associated with burnout. Likelihood ratio tests were used to determine the appropriateness of including variables in the multivariable model. Nagelkerke R² was used to determine the variance in burnout explained by the final model. This test was chosen because it is modified to have a maximum value of 1 which, although it has limitations, provides greater ease of interpretation than other methods.

All data analyses were performed in SPSS version 29 (IBM Corp., IBM SPSS Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp).

Results

Of the 685 completed surveys, 74 were missing data and thus excluded; 611 responses were therefore included in our analysis. The majority of respondents were male (321/611, 52.5%), with a median age of 40 years (IQR 32.0–49.0). A substantial proportion of respondents were married (295/611, 48.3%) with children (324/611, 53%), and the median duration of practice was 12 years post-graduation (IQR 5.0–21.0).

Socio-demographic variables

Table 1 summarises the socio-demographic variables identified by our survey.

Maslach Burnout Inventory

Of all participants, 362/611 (59.2%) met at least one of the criteria for burnout according to the Maslach Burnout Inventory (MBI) 279/611 (45.7%) met the depersonalisation cut-off of ≥10 (median score 9.0 [IQR 5.0–13.0]), 208/611 (34.0%) met the emotional exhaustion cut-off of ≥27 (median score 21.0 [IQR 13.0–30.0]) and 128/611 (20.9%) met the personal accomplishment cut-off of <34 (median [IQR] score 39.0 [9.0–48.0]). Figure 1 illustrates the percentage of participants meeting each criterion (of the 362 meeting at least one criterion) and figure 2 illustrates the percentage of participants the MBI burnout criteria, according to each dimension.

Figure 1Violin plot. Total score by domain of the Maslach Burnout Inventory (0 = mean score). Red lines indicate the cut-offs for each Maslach Burnout Inventory domain, with the red arrows indicating those above each threshold. Black circles indicate median scores.

Figure 2Percentage of participants (n = 362) meeting the Maslach Burnout Inventory burnout criteria, according to each dimension.

The initial model-building univariate analyses removed gender and average working hours per week from the model. The multivariable logistic regression model was run with the remaining predictors, and the final model correctly classified 68.2% of cases and explained 23.8% of the variance in burnout. The final multivariable logistic regression model showed that each additional 1 year increase in age was associated with a 3.5% decrease in the odds of meeting any MBI burnout threshold, and for each one-unit increase in the number of in-person night shifts per month a physician was 1.109 times more likely to meet an MBI criterion for burnout. Compared to physicians who had children, those without children were almost twice as likely to suffer from burnout (95% CI 1.09–2.76).

Copenhagen Burnout Inventory

Of all participants, 333/611 (54.5%) met at least one criterion for burnout according to the Copenhagen Burnout Inventory (CBI) 286/611 (46.8%) met the P-CBI cut-off of ≥50 (median score 45.80 [IQR 33.50–58.30]), 254/611 (41.6%) met the WR-CBI cut-off of ≥50 (median score 42.90 [IQR 28.60–57.10]) and 132/611 (21.6.%) met the CR-CBI cut-off of ≥50 (median score 29.20 [IQR 12.50–45.80]). Furthermore, 102/611 (16.7%) met the criteria for all three domains (Personal, Work-Related and Client-Related).

The initial model-building univariate analyses removed average working hours per week and partner working as a healthcare professional from the model. The multivariable logistic regression model was run with the remaining predictors, and the final model correctly classified 65.0% of cases and explained 13.1% of the variance in burnout. The final multivariable logistic regression model showed that each additional one-year increase in age was associated with a 3.8% decrease in the odds of meeting any CBI burnout threshold, and for each one-unit increase in the number of in-person night shifts per month a physician was 1.098 times more likely to meet a CBI criterion for burnout. Compared to physicians without a SSERM specialty, those with an interdisciplinary sub-specialty in hospital emergency medicine (ISP KNM / FAI MUH) were 1.714 times more likely to suffer from burnout (95% CI 1.050–2.797).

Patient Health Questionnaire-9

The median score for the PHQ-9 was 5.00 (IQR 0.0–25.0), with a cut-off of ≤4 indicating minimal depression (and no recommended treatment) [22, 25]. Of all participants, 331/611 (54.2%) physicians met the criteria for mild to severe depression, with 220/611 (36.0%) meeting the criteria for mild depression, 77/611 (12.6%) for moderate depression, 27/611 (4.4%) for moderately severe depression and 7/611 (1.1%) for severe depression.

Consideration of a career change

A total of 432/611 (70.7%) of respondents had considered leaving emergency medicine as a result of their working conditions. Of all participants, 26/611 (4.3%) had considered this once every shift, 44/611 (7.2%) more than once a shift, 42/611 (6.9%) once a week, 43/611 (7.0%) more than once a month, 93/611 (15.2%) once a month, 60/611 (9.8%) more than once a year, 77/611 (12.6%) once a year and 47/611 (7.7%) at least once in their career. In contrast, 179/611 physicians (29.3%) had never considered leaving their profession.

Consideration of suicide

A total of 66/611 respondents (10.8%) had considered suicide at some point in their career; of these, 34/611 (5.6%) had considered this in the previous 12 months.

Discussion

While often accepted as multifactorial, with the intertwining of personal and professional issues, burnout is an occupational phenomenon resulting from chronic workplace stress [1]. Our study demonstrates the repercussions that current working conditions have on physician wellbeing in emergency departments in Switzerland.

In our survey, 59.2% of respondents met at least one criterion for burnout according to the MBI-Health Services Survey, and 54.1% met at least one burnout criterion using the CBI. In addition, more than half exhibited symptoms of mild to severe depression, and close to 20% screened positive for moderate to severe depression, nearly 4 times the incidence in the general population [26]. More worryingly, our study also illustrates the ultimate consequences of these difficult working conditions, with 10.8% of respondents reporting having considered suicide at some point during their career as an emergency physician and nearly half having contemplated this in the 12 months prior to our study. In a profession reluctant to seek help for depression [27, 28] where suicide is not uncommon [14, 29–32], attention needs to be focused on prevention by resolving issues that negatively influence wellbeing.

Our findings are comparable to those of other international studies of burnout in emergency physicians [5, 19]. While certain issues may be specific to individuals and/or individual countries, the similarities among studies suggest that there are common issues shared by all emergency physicians throughout the world and that certain characteristics associated with burnout are inherent to emergency medicine.

Night shifts, commonly accepted as part of the responsibilities of an emergency physician, are strenuous and harmful to their wellbeing [5]. In our study, 36% of respondents reported working ≥5 nights a month. Burnout was also cited as one of the top 10 factors influencing wellbeing in the free-text portion of our survey, and it increased significantly with the frequency of night shifts (MBI: OR 1.18, p <0.001; CBI: OR 1.144, p <0.001).

Working hours were reported as one of the main issues affecting emergency physician wellbeing in the free-text section of our survey. Interestingly, the statistical analysis did not show an increase in burnout when working over 50 hours a week (MBI: OR 1.00, p = 0.93; CBI: OR 1.004, p = 0.515). Similarly, working part time was also not statistically associated with increased burnout (MBI: OR 1.01, p = 0.02; CBI: OR 1.008, p = 0.067). We suggest interpreting these results with caution, as the denominator used was that of a 50-hour week with 10-hour days, which is the standard for all physicians, regardless of medical specialty, in Switzerland [33]. As suggested by other studies [34–36], the 50-hour week is in itself not adapted to emergency medicine, as it does not take into account the strenuous nature and constant (increasing) workflow of emergency departments. As such, it is our opinion that the 50-hour week is in itself a risk factor for burnout, and this has been suggested in a recent review of Danish studies [37]. A comparative analysis between a 50-hour work week and a reduced work schedule for emergency medicine would thus be pertinent; this might be an area for reform.

The number of years of practice and age also seemed to have an effect on burnout. In an inverse relationship, each additional year of practice decreased the risk of burnout (MBI: OR 0.93, p <0.001; CBI: OR 0.950, p <0.001), similarly to age (MBI: OR 0.93, p <0.001; CBI: OR 0.952, p <0.001). This is seemingly counterintuitive, as one would expect that the more time spent in a strenuous work environment, the higher the potential for burnout. However, this interpretation does not consider that, with increasing experience, emergency medicine physicians generally see their share of night shifts decrease in favour of more traditional daytime hours, and clinical responsibilities diminish in favour of diverse non-clinical areas, such as training and emergency department management. Senior physicians are therefore less likely to be regularly exposed to difficult working conditions, and thus less likely to burn out, which could explain the statistical results.

Specific to Switzerland, and our study, language at the place of work was shown to have an influence on burnout, though this was not statistically significant. French-speaking respondents reported more burnout than physicians working in German (MBI: OR 0.647, p = 0.015; CBI: OR 0.52, p <0.001) or Italian (MBI: OR 0.730, p = 0.0244; CBI: OR 0.66, p = 0.128) areas, in a manner similar to that seen in previous studies in Switzerland [16, 38]. Further analysis is needed, as each region, and often each canton, differs in the way emergency departments are organised; this includes (but is not limited to) the type of clinical activity and level of clinical supervision. A follow-up study to this survey aims to incorporate these specificities as variables to better understand their influence on wellbeing.

Our study has therefore demonstrated that current working conditions negatively influence the wellbeing of Swiss emergency physicians. Reform is therefore vital, not only for the health of emergency physicians, but also for the continuity of acute care, which is at risk due to high staff attrition rates, as evidenced by the 40.6% of respondents who reported considering a change in their career at least once a month. In order to reform these working conditions, other parameters that are not assessable using Likert scale questions need to be reviewed. As mentioned previously, our survey included a free-text section, which offered an opportunity for participants to report the challenges they faced. As the subject of a separate analysis, we believe this will help to guide reform and to explain why no other medical specialty sees such high rates of burnout and staff turnover.

Notably, certain factors extrinsic to working conditions had an important influence on burnout. Similar to other studies [10, 39–43], female and non-binary physicians reported higher levels of burnout than their male counterparts (MBI: OR 1.70, p = 0.001; CBI: OR 1.18, p = 0.31) . As with other studies, this seems to be an independent factor [19, 44–46]. Interestingly, having no children was also a contributing factor (MBI: 2.28, p <0.001; CBI: 3.71, p <0.001), as was being single, suggesting the importance of personal resources.

Limitations

While we believe the sample was representative of the population, the modified snowball approach used to distribute the survey introduced bias. Given the unknown total sample size and the infeasibility of estimating the total number of emergency department physicians in Switzerland, the response rate is difficult to estimate. In addition, the survivorship bias mentioned during the discussion limited the study to physicians who are currently practicing. The absence of mandatory membership to the Swiss Society of Emergency and Rescue Medicine makes surveying those who have already left difficult and allows the possibility of recollection bias. All of these issues are due to the absence of a recognised specialist title and dedicated training pathway.

Conclusion

With over half of survey respondents meeting at least one criterion for burnout, 20% screening positive for moderate to severe depression (nearly 4 times the incidence in the general population) and 10.8% having considered suicide at some point during their career, this is the first national study to demonstrate that current working conditions are harmful to the wellbeing of Swiss emergency physicians. In a system in which continuity is regularly questioned (40.6% of survey respondents reported considering a change in their career at least once a month), reform is urgently needed. This study aimed to provide a situational overview and offers insight into what factors affect wellbeing in emergency medicine. Furthermore, it confirmed certain risk factors for burnout previously identified in other international studies, such as night shifts, working hours, seniority, gender and individual resources, and introduced new factors, such as language of practice. In order to evaluate trends and better understand some of these aforementioned factors, regular follow-up studies are required.

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