Emotional exhaustion and stress in doctors are linked

BMJ 2002; 324 doi: (Published 22 June 2002) Cite this as: BMJ 2002;324:1475
  1. Susan Mayor
  1. London

    Emotional exhaustion and stress have been found to be directly associated in the results of a longitudinal study of UK doctors published last week (Lancet 2002;359:2089-90).

    The study was designed to assess the causal relation between stress and burnout in doctors, based on the recognition that these linked problems are common in healthcare professionals.

    One of the research team, Professor Chris McManus, professor of psychology and medical education, University College London, explained: “Despite being common in health workers—15-20% of UK doctors show significant stress—the development and causal relations of burnout and stress are unclear, in part due to an absence of adequate longitudinal studies.”

    To resolve these unknowns, a stratified sample of 800 doctors was selected at random from the UK Medical Directory—a list of all registered doctors in the country—and their stress levels were followed over three years. The group selected included equal numbers of men and women and of hospital doctors and family practitioners who qualified in five year bands between 1950-9 and 1990-4. One in five doctors in each age, sex, and type of practice had qualified outside the United Kingdom.

    The stress levels of the doctors taking part in the study were assessed by using the 12 item version of the general health questionnaire. Burnout was measured with the Maslach burnout inventory, which includes subscales of emotional exhaustion, depersonalisation (cynicism), and personal accomplishment (professional efficacy). The 551 doctors who completed the questionnaires in 1997 were asked to complete them again three years later, in 2000; 382 (69%) of them responded.

    Results showed a reciprocal causation between exhaustion and stress. The largest causal effects in the model showed a causal cycle in which high levels of emotional exhaustion caused stress (standardised regression coefficient, b=0.189) and high levels of stress caused emotional exhaustion (b=0.175).

    “Emotional exhaustion is probably the key precursor of stress,” Professor McManus explained. “Doctors who become emotionally exhausted become stressed. This then leads to them becoming more emotionally exhausted and even more stressed.” High levels of personal accomplishment increased stress levels (b=0.080).

    In contrast, depersonalisation—treating patients as objects rather than as people—lowered stress levels (b=0.105).

    The authors suggested that this might have occurred through a Freudian type of “ego defence” mechanism. Professor McManus warned: “The key part of the equation is emotional exhaustion. We have got to find a way to reduce this. Reduced workload would help.”

    He suggested that the current emphasis on encouraging doctors to care more about patients as individuals and to reach higher personal achievements, without adequate time and support, was adding to stress and burnout in doctors.

    The survey was funded by the General Medical Council as a part of its audit of the performance procedures. Professor McManus explained that it was the first study of its kind to look at stress levels over time.

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