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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 8  |  Page : 1063-1069

Burnout among family physicians in Turkey: A comparison of two different primary care systems


1 Department of Public Health, Faculty of Medicine, Ataturk University, Erzurum, Turkey
2 Department of Family Medicine, Faculty of Medicine, Ataturk University, Erzurum, Turkey

Date of Acceptance10-Mar-2019
Date of Web Publication14-Aug-2019

Correspondence Address:
Dr. Y Cayir
Department of Family Medicine, Faculty of Medicine, Ataturk University, 25040, Erzurum
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_355_17

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   Abstract 


Aim: The objective of this study was to determine the prevalence of burnout syndrome and associated factors among family physicians before and after family medicine system (FMS). Materials and Method: The first part of the study was conducted in 2008 (pre-FMS) and the second part in 2012 (post-FMS). Physician's burnout was investigated by using the Maslach Burnout Inventory (MBI). In total, 139 physicians had been participating pre-FMS and 246 physician's post-FMS. Results: The mean pre-FMS emotional exhaustion score was 15.7 ± 5.8, increasing significantly to 17.14 ± 7.5 post-FMS (P = 0.045). Mean pre-FMS and post-FMS depersonalization and reduced personal accomplishment scores were similar (P > 0.05). Age was negatively correlated with depersonalization in this study (P = 0.012) and positively correlated with personal accomplishment (P = 0.001). The primary care physicians in the post-FMS period were older, female physicians had a greater preference for primary care, and the levels of married doctors were higher. In addition, a higher level of physicians also owned their own home and cars compared to the pre-FMS period. A negative correlation has been reported between physicians' burnout levels and home or car ownership in the present study. Conclusion: Our findings suggest that physicians working under the family medicine system, a new primary care model, are at greater risk of emotional exhaustion, but that no change has occurred in terms of personal accomplishment or depersonalization, despite this new system.

Keywords: Burnout, family medicine, Maslach burnout inventory


How to cite this article:
Kosan Z, Aras A, Cayir Y, Calikoglu E O. Burnout among family physicians in Turkey: A comparison of two different primary care systems. Niger J Clin Pract 2019;22:1063-9

How to cite this URL:
Kosan Z, Aras A, Cayir Y, Calikoglu E O. Burnout among family physicians in Turkey: A comparison of two different primary care systems. Niger J Clin Pract [serial online] 2019 [cited 2019 Oct 15];22:1063-9. Available from: http://www.njcponline.com/text.asp?2019/22/8/1063/264410




   Introduction Top


Burnout is defined as a condition involving both physical and emotional exhaustion. It is particularly common among physicians because it usually occurs among personnel whose occupations require interaction with other people.[1] Burnout may seriously affect physicians' performance. It was demonstrated that physicians with burnout tend to create more medical errors that are a common cause of morbidity and mortality in health care.[2] Three sub-dimensions of burnout syndrome have been identified as “emotional exhaustion,” “depersonalization,” and “personal accomplishment.” Emotional exhaustion refers to individuals feeling emotionally overburdened and depleted because of the work they do. Depersonalization refers to the exhibition of attitudes and behavior in a manner devoid of emotion, ignoring the fact that the people receiving services are individuals. Personal accomplishment describes an individual's feelings of sufficiency and success at work. A greater risk of burnout has been reported in occupations involving face-to-face contact with other people, such as medicine, compared to other occupations.[3],[4]

In addition to the difficulties in providing services for unwell individuals, a particularly sensitive group, physicians also have to take decisions in clinically uncertain cases and face the consequences of those decisions. Fear of error makes medicine an even more stressful profession. According to the core competencies defined with the World Organization of Family Doctors (WONCA) tree, which is a schematic description of family physicians' features, family physicians encounter as yet undifferentiated patients. Managing as yet undiagnosed patients with clinically uncertain, undifferentiated symptoms is the greatest difficulty in family medicine.[5] In addition, deficiencies and imbalances in the distribution of services and personnel deriving from the health service may also result in disappointment and tension in family physicians. Work-related tension causes psychological effects such as anxiety, helplessness and depression and somatic effects such as headache, muscular tension, and sleeplessness. This, in turn, gives rise to a decrease in efficiency, lateness at work, absenteeism from fabricated excuses, and even stopping work altogether. Studies have shown that burnout syndrome affects the personal and professional efficiency of 30–40% of family physicians.[6]

Primary health services in Turkey began being provided under the family medicine system (FMS) in 2010. The job titles of primary physician changed at that time. Until 2010, physicians working in this area were known as “general practitioners,” whereas since 2010 they have been described as “family physicians.” Family physicians began providing protective, therapeutic, and rehabilitative health services in family health centers. New job descriptions including health services in the home, cancer screening, and mobile health services were also added.[7],[8] A number of studies have been performed concerning burnout in primary health workers experiencing changes in working conditions and personal rights.[9],[10] However, none of these has compared pre- and post-FMS status in Turkey.

Burnout in primary care workers has significant implications for the individuals concerned, for public health, and for the effectiveness of primary health care services. The objective of this study was to determine the prevalence of burnout syndrome and associated factors among family physicians pre- and post-FMS.


   Materials and Methods Top


Study design and data collection

This cross-sectional study compared two different primary care systems. The first part of the study was conducted between January and December, 2008 (pre-FMS), and the second part between January and December, 2012 (post-FMS). The study was conducted in Erzurum, in the eastern part of Turkey. The total number of the family physician who practiced in 2008 was 190, and it was 252 in 2012. We contacted all physicians listed as currently practicing in the primary care system in Erzurum, pre-FMS and post-FMS, by telephone to invite them to the study. Physicians with a psychiatric diagnosis such as depression or anxiety disorder were excluded. One hundred thirty-nine subjects agreed to take part in the study and pre-FMS and 246 post-FMS. The response rate was 73.1% for pre-FMS, and it was 97.6% for post-FMS. The study was performed at a power of 0.96 with 0.05 deviation at a 95% confidence interval on G-Power software.

The study protocol was approved by the ethics committee of Ataturk University Faculty of Medicine pre-commencement (The number of ethics committee approval: 24.05.2012 / 3 / 11). Informed written consent was obtained from all participants.

The physicians enrolled in the study completed two parts of a self-administered survey. The first section investigated socio-demographic and professional characteristics and the second part determined burnout inventory. Physician burnout was investigated using the Maslach Burnout Inventory (MBI), a previously validated single-item scale involving five potential responses (from “never” to “every day”) permitting the expression of varying levels of burnout. The MBI contains three burnout sub-dimensions; emotional exhaustion (9 items), depersonalization (5 items), and reduced personal accomplishment (8 items). Scores between 0 and 33 indicate a high level of burnout, scores between 34 and 39 moderate burnout, and scores of 40 or more indicate low burnout.[11]

Statistical analysis

All analysis was carried out using SPSS 20 software. Numerical variables are expressed as mean ± SD and categorical variables as numbers (%). Numerical data were checked for normal distribution using the Kolmogorov-Smirnov test. An independent samples t test was used in the comparisons of numerical variables, and a Chi-square test was used to compare categorical variables of pre- and post-FMS period. A Spearman's correlation analysis was performed to evaluate relations between MBI sub-dimensions and various numerical variables. In addition, logistic regression analyses were performed to predict the associated risk factors. Backward Wald model was used in the logistic regression model. Significance was set at P < 0.05.


   Results Top


Three hundred eighty-five primary care physicians took part in the study; 139 had been working pre-FMS and 246 post-FMS. The study sample consisted of 138 women (35.8%) and 247 men (64.2%). The mean age of physicians was 30.00 ± 5.13 years pre-FMS, and 34.05 ± 5.78 year post-FMS (P < 0.05). The demographic characteristics of the physicians are shown in [Table 1] for both groups (pre- and post-FMS).
Table 1: Characteristics of Family Physicians Pre-FMS and Post-FMS

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Sixty-four percent (n = 89) of the physicians in the study worked in urban areas pre-FMS, a figure that declined to 47.6% (n = 129) post-FMS (P = 0.002). The percentage of physicians with administrative duties interviewed pre-FMS was 38.8%, declining to 17.5% post-FMS (P < 0.001). Professional characteristics of the participants are shown in [Table 2].
Table 2: Overview of physician's professional features

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The mean pre-FMS emotional exhaustion score was 15.7 ± 5.8, increasing significantly to 17.14 ± 7.5 post-FMS (P = 0.045). The mean pre-FMS and post-FMS depersonalization and reduced personal accomplishment scores were similar (P > 0.05) [Table 3].
Table 3: Comparison of MBI scores pre-FMS and post-FMS

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A moderate level of burnout in terms of emotional exhaustion was identified in 24.5% of subjects and a high level of burnout in 0.7% pre-FMS emotional exhaustion among physicians' pre-FMS. The post-FMS values for moderate and high burnout in terms of emotional exhaustion were 21.5% and 9.3%, respectively [Table 4]. There was no difference determined between the physicians in the two groups in terms of depersonalization and personal accomplishment, the two other sub-dimensions of burnout syndrome (P > 0.05).
Table 4: Comparison of frequency distribution of the dimensions of MBI

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Age was negatively correlated with depersonalization in this study (r=-0.215, P = 0.012) and positively correlated with personal accomplishment (r = 0.159, P = 0.001). A positive correlation was also determined between total time in the profession and personal accomplishment scores (r = 0.127, P = 0.046). Factors affecting pre-FMS burnout and post-FMS are shown in [Table 5], [Table 6], [Table 7], [Table 8]. Smoking, regularly having a vacation, and thoughts about profession all of three independent variables were considered the full model for logistic regression. The results of the logistic regression analysis show that regularly having vacation and thoughts about profession was statistically significant (P < 0.05). Wald statistics indicate that regularly having vacation was related to having two times more risks and thoughts about profession whose wrong option was related to have 10 times more risks for emotional exhaustion. These two variables significantly predict for emotional exhaustion [Table 9].
Table 5: The relationship between characteristics and burnout scores of pre-FMS physicians

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Table 6: The relationship between characteristics and burnout scores of post-FMS physicians

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Table 7: The relationship between professional characteristics and burnout scores of pre-FMS physicians

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Table 8: The relationship between professional characteristics and burnout scores of post-FMS physicians

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Table 9: Logistic regression of variables

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   Discussion Top


The physicians in this study exhibited a higher level of emotional exhaustion post-FMS. Family physicians are doctors who provide integrated and continuous health services, irrespective of age, sex, or disease. The comprehensive nature of the health service provided by family physicians distinguishes them from physicians providing other levels of care.[12] Research has shown higher levels of burnout among primary care workers than among other physicians. Burnout levels of 68% have been reported among primary care physicians in Spain, whereas primary care physicians have the third-highest burnout levels in America.[13],[14] A British study showed higher burnout scores among primary physicians compared to hospital specialists.[15] Cagan et al. reported low emotional burnout and personal accomplishment scores and high depersonalization scores among primary care physicians in Turkey in the post-FMS period. A particularly high level of emotional burnout has been observed among physicians not working in primary care out of personal choice.[16]

The primary care physicians in the post-FMS period were older; female physicians had a greater preference for primary care; and the levels of married doctors were higher. In addition, a higher level of physicians also owned their own home and cars compared to in the pre-FMS period. A negative correlation has been reported between physicians' burnout levels and home or car ownership in the present study. A clear improvement in primary care physicians' income levels has occurred in Turkey in the post-FMS period compared to the pre-FMS period.[17] There was no difference, therefore, observed in burnout scores, with the exception of emotional burnout, among physicians working post-FMS inspite this being under a new system. We may conclude that this situation in physicians working post-FMS, when an increase took place in home and car ownership, shown to significantly reduce lower burnout scores, enabled them to tolerate a new system better.

In a previous study, workplace culture was determined as an effective factor for burnout among primary care physicians.[18] Physicians working in post-FMS were also able to take more regular exercise in comparison with pre-FMS. We may attribute this to physicians being encumbered with fewer administrative duties in the post-FMS period and to thus being able to set aside more time for themselves. However, we also observed a decrease in regular holiday levels post-FMS. This may be because of days not worked being deducted from salary in the post-FMS system. Emotional burnout was greater among physicians unable to take regular holidays. New measures enabling physicians to take holidays are, therefore, needed in the post-FMS period.

Emotional burnout and depersonalizations scores decreased with age among the primary care physicians in this study, whereas personal accomplishment scores increased. Increased professional experience with age, the acquisition of the ability to take independent decisions and possession of status bestowing satisfaction may have positive effects on burnout.[19] Emotional exhaustion is also known to be related to working under a new system.[4] The greater emotional burnout scores among physicians in the post-FMS period in this study, inspite their greater age, may be because of their operating under such a new system. In fact, changes intended to improve primary care services have imposed greater responsibilities on physicians. Previous studies have reported greater emotional burnout as responsibility increases.[20]

Several factors other than working conditions affect burnout levels in physicians, including age, professional experience, social activities, and marital status.[21] For example, one study of physicians in Taiwan reported greater burnout among married subjects. That study observed no relationship between gender and burnout, but greater burnout was determined when working hours exceeded 13 h in a day.[1] In this study, the level of married physicians was higher post-FMS, and emotional exhaustion levels were similarly greater.

Physicians in the pre-FMS period in this study worked more in urban areas, whereas in post-FMS, there was a greater preference for rural areas. Physicians in the post-FMS period had notably fewer administrative duties. This situation observed post-FMS is compatible with family physician's “access the care” principle.[5] In addition, the primary care physicians in the post-FMS period had a greater length of professional experience. Studies have reported a negative correlation between professional experience and burnout. Greater personal accomplishment has been reported in physicians working in large cities.[16] These findings all explain the absence of greater burnout in physicians' post-FMS, inspite the operation of a new system.

Studies performed in Turkey at various times have observed low levels of burnout among physicians.[10],[22] Our research differs from previous studies in terms of evaluating primary care physicians' pre-FMS and post-FMS. In conclusion, this study's findings suggest that physicians working under the family physician system, a new primary care model, are at greater risk of emotional exhaustion, but that no change has occurred in terms of personal accomplishment or depersonalization, despite this new system.

The most important limitation of this study is that the physicians in the pre-FMS group were not the same individuals as those in the post-FMS group. We were, therefore, unable to compare MBI sub-dimensions in the same physicians. Furthermore, there may be other changes that are not workload, which may have occurred over the 4 years period that could influence likelihood of burnout. However, this is the first trial to compare the burnout scores of physicians working under two different primary care systems in Turkey. Therefore, further investigation should be performed in this issue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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