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Family Practice Advance Access originally published online on July 11, 2008
Family Practice 2008 25(4):245-265; doi:10.1093/fampra/cmn038
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© The Author 2008. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.

Burnout in European family doctors: the EGPRN study

Jean Karl Solera, Hakan Yamanb, Magdalena Estevac, Frank Dobbsd, Radost Spiridonova Asenovae, Milica Katicf, Zlata Ozvacicf, Jean Pierre Desgrangesg, Alain Moreauh, Christos Lionisi, Péter Kotányij, Francesco Carellik, Pawel R. Nowakl, Zaida de Aguiar Sá Azeredom, Eva Marklundn, Dick Churchillo, Mehmet Unganp and (European General Practice Research Network Burnout Study Group)

a Institute of Postgraduate Medicine and Primary Care, Faculty of Life and Health Sciences, University of Ulster, Coleraine BT52 1SA, UK (Maltese Co-ordinator)
b Akdeniz University, Faculty of Medicine, Department of Family Medicine, Antalya, Turkey
c Research Unit, Majorca Primary Care Health District Department, Ib-salut, Spain (Spanish Co-ordinator)
d Institute of Postgraduate Medicine and Primary Care, Faculty of Life and Health Sciences, University of Ulster, Coleraine BT52 1SA, UK
e Plovdiv, Bulgaria
f Zagreb, Croatia
g Brittany, France
h Lyons, France
i Crete, Greece
j Budapest, Hungary
k Milan, Italy
l Gdansk, Poland
m Portugal
n Sweden
o Nottingham, UK
p Turkey

Correspondence to Hakan Yaman, Faculty of Medicine, Department of Family Medicine, Akdeniz University, 07059 Antalya, Turkey; Email: hakanyaman{at}akdeniz.edu.tr

Received 16 October 2006; Revised 5 June 2008; Accepted 6 June 2008.


   Abstract
Top
 Abstract
Introduction
 Methodology
 Results
 Discussion
 Conclusions
 Future research
 Declaration
 References
 
Introduction. The aim of this study was to determine the prevalence of burnout, and of associated factors, amongst family doctors (FDs) in European countries.

Methodology. A cross-sectional survey of FDs was conducted using a custom-designed and validated questionnaire which incorporated the Maslach Burnout Inventory Human Services Survey (MBI-HSS) as well as questions about demographic factors, working experience, health, lifestyle and job satisfaction. MBI-HSS scores were analysed in the three dimensions of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA).

Results. Almost 3500 questionnaires were distributed in 12 European countries, and 1393 were returned to give a response rate of 41%. In terms of burnout, 43% of respondents scored high for EE burnout, 35% for DP and 32% for PA, with 12% scoring high burnout in all three dimensions. Just over one-third of doctors did not score high for burnout in any dimension. High burnout was found to be strongly associated with several of the variables under study, especially those relative to respondents’ country of residence and European region, job satisfaction, intention to change job, sick leave utilization, the (ab)use of alcohol, tobacco and psychotropic medication, younger age and male sex.

Conclusions. Burnout seems to be a common problem in FDs across Europe and is associated with personal and workload indicators, and especially job satisfaction, intention to change job and the (ab)use of alcohol, tobacco and medication. The study questionnaire appears to be a valid tool to measure burnout in FDs. Recommendations for employment conditions of FDs and future research are made, and suggestions for improving the instrument are listed.

Keywords. Burnout, Europe, general practice, job satisfaction, job stress.


   Introduction
Top
 Abstract
 Introduction
Methodology
 Results
 Discussion
 Conclusions
 Future research
 Declaration
 References
 
Job-related ‘burn out’ or ‘burnout’ has been identified as an occupational hazard for various professionals involved in people-oriented services. Burnout is a syndrome, with reported symptoms including exhaustion, frustration, anger, cynicism and a feeling of ineffectiveness and/or failure. An important element of the syndrome is a negative impact on job performance.1,2

The predominant multidimensional model of burnout defines it as a psychological response to chronic interpersonal job stressors, characterized by overwhelming exhaustion, feelings of cynicism and detachment from the job.1 Three dimensions of the syndrome are described: emotional exhaustion (EE) is the depletion of one's emotional resources and reflects the basic stress dimension of burnout; depersonalization (DP) usually develops due to the effect of EE and exhibits features of detachment and, eventually, dehumanization; and reduced personal accomplishment (PA) reflects reduced feelings of competence and productivity at work, which are linked to depression.1,2

Factors related to burnout amongst professionals, including doctors, include situational factors [organizational commitment and hierarchy, absence of job resources (e.g. inadequate pay), overload, role conflict and ambiguity, poor career progression and lack of feedback] and individual characteristics (demographic variables, personality characteristics, external locus of control, job satisfaction, job withdrawal and lack of social support), with the effect of the situational factors being stronger.1,3,4

Although burnout has been described in health professionals4–6 and has been reported to be common in family doctors (FDs),5,7–9 there are few published studies, and there is an evident need for further research. This study is an attempt to address this lacuna in the field of research of burnout in FD populations in Europe.

The scale which has demonstrated the strongest psychometric [Psychometrics: the field of study concerned with the theory and technique of psychological measurement, which includes the measurement of knowledge, abilities, attitudes and personality traits. The field is primarily concerned with the study of differences between individuals (http://en.wikipedia.org/wiki/Psychometrics)] properties, has been shown to distinguish job-related neurasthenia from other mental disorders1 and continues to be used most widely by researchers is the Maslach Burnout Inventory—Human Services Survey (MBI-HSS) developed by Maslach and Jackson in the early 1980s.10 It comprises 22 seven-point Likert-type questions on frequency of symptoms (ranging from ‘0 = never’ to ‘6 = every day’). The three dimensions are each measured by subscales: EE on a subscale with nine items and a maximum score of 54, DP on a five-item subscale with a maximum score of 30 and a decreased sense of PA (inverse scale, low scores indicate high burnout) on a subscale with eight items and a maximum score of 48.10 The MBI-HSS has demonstrated good external validity in FDs and similar subscale correlations as in Maslach's normative sample.11

The instrument of choice for this study of burnout is consequently also a questionnaire. Thus, the MBI-HSS was incorporated (unaltered) into a questionnaire designed to measure other factors previously reported to be associated with burnout in FDs.8,12–16 The study instrument (Fig. 1) was based on a similar questionnaire piloted previously in the population of interest.17


Figure 1
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  		FIGURE 1 Questionnaire instrument

 
This cross-sectional study was designed to address two specific research questions.

Study research questions

1) What is the prevalence of burnout in European FDs?
2) Which factors are associated with high levels of burnout in European FDs?


   Methodology
Top
 Abstract
 Introduction
 Methodology
Results
 Discussion
 Conclusions
 Future research
 Declaration
 References
 
Study idea
This study was developed from an original idea to study burnout in Turkish medical and education students presented at a meeting of the World Organization of Family Doctors (WONCA) European region18 and was developed during various meetings of the European General Practice Research Workshop [EGPRW—since renamed ‘European General Practice Research Network’ (EGPRN)] from 1999 to 2002.19,20 Twenty-four EGPRW members from 16 European countries formed an interest group and worked as a team to develop an instrument to collect data on burnout and on factors associated with burnout.

Instrument
Questionnaire design process. A literature search was performed to identify instruments and tools which measure burnout and to identify factors associated with high levels of burnout. The questionnaire instrument was developed on the basis of such literature. It was pilot tested in 2000, the results being published in 2002.17

Translation of the questionnaire instrument. In those countries where the use of an English-language instrument could potentially pose a language barrier, the questionnaire was translated to the native language by the key co-ordinating FD in that country, and the translation process was cross-checked by cross-translation in most cases (see Table 1).


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  		TABLE 1 Details of the study process in each participating country: co-ordinator, translation and mailing procedure, sample selection and response rates

 
Questionnaire instrument structure. The final validated questionnaire instrument (Fig. 1) comprised, in order:
a) a 25-item questionnaire including questions regarding age, gender, marital status, years since qualification as a doctor, years in current workplace, earning, workplace conditions (solo/group, rural/urban setting), working conditions (working hours per week, patients per week, night shifts, weekends worked), intention of changing job, sick leave utilization, sleep patterns, alcohol consumption, smoking and psychoactive medication use;
b) a seven-point Likert-type job satisfaction question and
c) the MBI-HSS.

Data collection procedure
Sampling procedure. The country co-ordinators, one lead FD in each of 12 participating countries who was selected from the burnout study interest group, were tasked to send the questionnaire to a representative sample of their country's FDs.

Sample size. The original target was a sample size of 160 completed questionnaires from each country, calculated to allow the discrimination of a population difference of 10% or more in the mean MBI-HSS burnout scores in any one dimension between two countries to an {alpha}-value of 0.05 with a power (β) of 80%, based on the variability of the data obtained from the pilot study. The inclusion criteria were: practising FDs working in private, or state employment. Retired FDs and those working less than 50% full time in family practice were excluded.

Ethical approval
International ethical approval. Many, but not all, country co-ordinators did apply for and obtain ethical approval in their country.

Data entry
Data coding. Each country co-ordinator coded the data from the returned questionnaires into a custom-designed Microsoft Excel21 spreadsheet template, and these were then imported into SPSS version 1122 by HY.

Missing values. Up to one missing response per dimension of burnout in the MBI-HSS instrument was replaced with the average score of the rest of that respondent's responses for that dimension (rounded to an integer value). If more than two responses were missing for any one dimension, the score for that dimension was replaced with a ‘missing value’ code recognized as such by SPSS.

Coding of burnout outcome variables. MBI-HSS scores were output in the three dimensions of burnout and were then transformed into dummy categorical variables for high, average and low burnout in the dimensions of EE, DP and PA as recommended by Maslach using the cutoff values applicable for doctors, as listed below (Maslach C, personal communication, July 6, 2004).10 However, the burnout outcome variables were re-coded into high and not-high (average or low burnout) for the statistical analyses.

EE: low burnout ≤ 13, average burnout 14–26, high burnout ≥ 27 (The scoring guide actually recommends that average scores for EE range from 19 to 26. Scores in the range from 14 to 18 are thus difficult to classify. For the purposes of the description of rates of burnout found in this study, EE scores in the range of 14 to 18 were classified as average, to avoid unclassified cases. However, all the statistical analyses performed on the data set used the outcome variable of high as against not high burnout in the three dimensions.)
DP: low burnout ≤ 5, average burnout 6–9, high burnout ≥ 10.
PA: high burnout ≤ 33, average burnout 34–39, low burnout ≥ 40 (inverse scale).

Statistical analysis
Validation of questionnaire instrument in each country. The MBI-HSS section of the questionnaire was internally validated by calculating a Cronbach's alpha coefficient for each dimension [for the nine questions which scored for EE, the five for DP and eight for PA in turn against the respective total for each dimension], for each translation of the questionnaire used in the 12 different countries.

Respondents. Descriptive statistics have been used to tabulate the characteristics of the respondents as measured by the questionnaire instrument, including the MBI-HSS scores. Continuous variables which were severely non-normal were re-coded as categorical variables or transformed (income was re-coded as a difference from average for that country, expressed as a proportion of the Organization for Economic Co-operation and Development (OECD) income per capita for that country).

Point prevalence of burnout—research question 1. Descriptive statistics have been used to present the proportion of respondents who scored as high burnout, average burnout or low burnout in each dimension, with the 95% confidence interval (CI).

Factors associated with high burnout—research question 2. The associations between each of the three principal yes/no outcome variables (high burnout present or not in each of the three dimensions of EE, DP and PA) and each variable in the questionnaire were explored.

The statistical significance and strength of the associations between the categorical variables and the burnout outcome variables were analysed using Pearson's chi-square test and Cramer's V [Cramer's V is a chi-square-based measure of the strength of association, which can be used for nominal variables. Values range from 0 (no association) to 1]. The statistical analyses of the distributions of the continuous normal variables within the two categories of the three burnout outcome variables (i.e. high burnout against not high burnout in the three dimensions) were performed using the independent samples t-test. Besides the one-way analysis of associations between the independent variables and the three burnout outcome variables as above, a sensitivity analysis was performed to test the associations in a two-way model with country as a control variable.

A multivariate analysis was subsequently performed using SPSS complex samples logistic regression analysis,22 stratifying samples by country and including as main effects all variables which reached an {alpha} level of at least 0.25 (P ≤ 0.25) in the one-way analysis, with the same burnout outcome variables as the dependent variables. The final model was the one which resulted from a stepwise backward elimination process using the maximum likelihood method. SPSS was used to calculate odds ratios for all independent variables and the 95% CI for the estimate and the {alpha}-value (corrected for multiple comparisons using the sequential Bonferroni method).


   Results
Top
 Abstract
 Introduction
 Methodology
 Results
Discussion
 Conclusions
 Future research
 Declaration
 References
 
Table 1 details the sample selection process and study execution in the 12 countries. A total of 1393 completed and analysable questionnaires were returned from more than 3416 sent (the reported number sent out in Sweden was an estimate), giving a response rate of approximately 41%.

Table 2 lists the Cronbach's alpha coefficients of the MBI-HSS instrument and its elements in each translation of the questionnaire. The worst correlation between a question and the total burnout score per dimension is also tabulated, along with the Cronbach's alpha for the scale if that question were to be deleted. The scores for all three dimensions in the various translations range from good to excellent.


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  		TABLE 2 Cronbach's alpha coefficient of the MBI-HSS instrument scores for each dimension of burnout in each of the versions/translations of the questionnaire used in the 12 countries

 
Table 3 gives the frequency distribution of the categorical variables and describes the distribution of continuous variables for the respondents. The 1393 respondents (758 males, 54.6%) had a mean age of 45.4 years (SD 8.5 years) and had graduated 19 years previously to filling in the questionnaire (SD 8.5 years), worked 46 hours per week (SD 14 hours), saw 150 patients per week (SD 83 patients) and were roughly evenly distributed amongst the 12 countries (somewhat less respondents in Greece at 45, whilst France and England were the only two countries that achieved the target of 160 responses), with 58% of respondents coming from the South of Europe.


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  		TABLE 3 Respondent characteristics (n = 1393) as measured by the questionnaire instrument

 
Burnout point prevalence—research question 1
Table 4a lists the frequency distributions of respondents by degree of burnout (high, average or low) in the three dimensions (EE, DP, PA). Table 4b gives the frequency distribution of respondents by presence of high burnout scores in none (0), one or more of the three dimensions (1, 2 or 3). For both tables, 95% CI of the proportion is tabulated. In all, 43% of respondents scored high for EE (95% CI = 40.5–45.6%), 35.3% for high DP (32.9–37.9%), 32.0% low for PA (29.6–34.5%) and 12% of respondents (10.4–13.8%) scored high for burnout in all three dimensions. Only 35.1% of doctors (32.6–37.7%) did not score high for burnout in any dimension.


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  		TABLE 4a Frequency and cumulative frequency distributions of respondents by degree of burnout (high, average and low) with 95% CI in each of the three dimensions

 


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  		TABLE 4b Frequency and cumulative frequency distributions of respondents by high burnout score in none (0) or any one, any two or all three dimensions (1, 2 or 3) with 95% CI

 
Figure 2 depicts the distribution of respondents by percentage with a high burnout score in each of the three dimensions and in all three dimensions by country and for all countries together (with error bars representing 95% CI for proportions). Bulgarian, Italian and English respondents demonstrated high proportions of high EE burnout, Greek, Italian and English respondents demonstrated high proportions of high DP burnout, whilst Greek and Turkish respondents demonstrated high proportions of high PA burnout.


Figure 2
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  		FIGURE 2 Distribution of the proportions of respondents by high burnout score in each of the three dimensions and in all three dimensions in one respondent, by country and for all countries together (with error bars representing 95% CIs for proportions)

 
Factors associated with high burnout—research question 2
Tables 5a and 5b list the results of the analysis of association between the three dichotomous burnout outcome variables (a categorical yes/no variable for high burnout in each of the three dimensions of EE, DP and PA) and the questionnaire categorical and continuous variables, variable by variable, respectively. Also listed are the results of the analysis of the association between the categorical and continuous variables measured in the questionnaire and the three dichotomous burnout outcome variables, all questionnaire responses from all countries being analysed together (one way; except for the variable controlled for, i.e. country). Finally, Tables 5a and 5b also list the results of the analysis of association between the categorical and continuous variables measured in the questionnaire and the three dichotomous burnout outcome variables, variable by variable, controlling for country (two way). The strongest associations include those between the burnout outcome variables and country, European region, job satisfaction and intention to change job, the (ab)use of tobacco, alcohol and psychotropic drugs, male sex, age, type of work and sick leave utilization.


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  		TABLE 5a Associations between categorical variables in the questionnaire and the three burnout outcome variables (high burnout in each of the three dimensions) explored using Pearson chi-square (or Somer's d) and Cramer's V test (or Spearman correlation) as appropriate

 


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  		TABLE 5b The associations between continuous variables and the three burnout outcome variables (high burnout in each of the three dimensions) explored using the independent samples t-test, one-way ANOVA or two-way ANOVA F-tests, as appropriate

 
Table 6 lists the results of the logistic regression analysis of the categorical and continuous variables measured in the questionnaire controlling for country. The odds ratios, 95% CI and P-values are presented. The three models each correctly classify approximately three-quarters of all cases in the database. The model for high EE burnout correctly classifies two-thirds or respondents as having high burnout, whilst the models for high DP and PA burnout perform considerably better in predicting absence rather than presence of burnout. Again, the highest odds ratios were found for job satisfaction and intention to change job, the (ab)use of tobacco, alcohol and psychotropic drugs, male sex, age, type of work and sick leave utilization.


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  		TABLE 6 Logistic regression analysis, controlling for country

 

   Discussion
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
Conclusions
 Future research
 Declaration
 References
 
In summary, this EGPRN study of burnout in FDs from 12 European countries with a validated tool to measure burnout achieved a response rate of 41%. In all, 43% of respondents scored high for EE burnout, 35% scored high for DP burnout and 32% scored high for PA burnout. Only 35% of respondents did not score high for burnout in any dimension, whilst 21% scored high for burnout in at least two dimensions and 12% scored high for all three. There was a wide variation in the proportions of respondents with high burnout in the various countries. In the 12 countries, between 15% and 68% of respondents scored high for EE burnout, between 12% and 73% for DP burnout, between 12% and 93% for PA burnout, and between 2% and 25% scored high for burnout in all three dimensions. FDs from Southern European countries had significantly lower levels of EE burnout but higher levels of PA burnout. After controlling for country, low job satisfaction, expressed intention to change job, (ab)use of alcohol, tobacco and psychotropic medication, sick leave utilization, younger age, male sex and type of work were associated with high burnout, as previously reported.1

Table 7 summarizes the comparisons between burnout scores and rates reported previously in the literature and the data from this EGPRN study.8,9,17,23–27 Some earlier studies did report lower rates of burnout, but a similar number of recent studies did report similar data. As expected, high burnout was more likely with low job satisfaction and intention to change job.1,5,9,28 Additionally,1,3,4,8,28 high levels of burnout were found to be more likely with certain organizational factors (country of origin, as surrogate for health care system, and type of work) and increased sick leave utilization, and less so with high workload (patients per week and hours per week) and other job stressors (working nights and weekends). Personal factors such as younger age, sex, marital status and number of children were also linked with burnout, but male sex more strongly so.1,28 Academic work type was linked to lower EE, but higher PA burnout, as previously reported.1 Low self-esteem has been previously reported to be associated with burnout.1 In this study, we observed that burnout was more likely with increasing smoking, increased use of alcohol and use of psychotropic medication, which may be manifestations of low self-esteem.9 Other variables, such as income, were surprisingly rather weakly linked with high burnout, whilst others (non-academic type of work, years since graduation, not having further qualifications, increasing smoking) seemed to be linked with high EE burnout, but make high PA burnout less likely; however, such ambiguous findings have been previously described in burnout research in doctors, for example, by Deckard et al.4 Generally, the pattern of associated variables appears similar to that reported by Goehring et al.8 for those variables which were included in both studies.


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  		TABLE 7 Descriptive analysis of previously published studies of burnout in FDs or primary care doctors compared with the EGPRN study

 
The questionnaire was constructed with reference to the current literature at the time and included those variables that had been reported to be associated with, or to cause, burnout. Nonetheless, the possibility exists that other variables may have an important role to play. For example, FDs may be more likely to suffer burnout if they perceive that they have poor control of their place of work,28 but this variable was unfortunately not included in our questionnaire. The rather low response rate in many countries and the consequent failure to achieve the target sample size weaken the power of this study to answer the principal research questions, especially the second one using the regression models. The survey was administered differently in the 12 countries, and also not concurrently. This may have had a variable influence on the non-response rate, potentially introducing bias.

The validity of the questionnaire has been tested in a pilot study, and the results have been published separately by Yaman and Soler.17 In the pilot study, factor analysis confirmed that the three constructs of EE, DP and PA are distinct and identified which items loaded to which dimension. The results were consistent with Maslach's scoring key except for item 16.10 The Cronbach's alpha for EE, DP and PA in the pilot study was all high, at 0.67, 0.66 and 0.70, respectively.17 The MBI-HSS section of the questionnaire has again been validated in the main study using Cronbach's alpha analysis (Table 2). The Cronbach's alpha coefficients for each dimension in each country were, in fact, higher than those found in the pilot study, for most countries (i.e. 0.9 for EE, 0.5 to 0.9 for DP and 0.7 to 0.9 for PA). In general, deleting questions would not improve the internal consistency, with few exceptions. The validity and reliability of the questionnaire appear to be high, based on the analyses and comparisons performed, and the good consistency of the results was obtained between countries and between the pilot and main studies.

The sample size calculation, in retrospect, should have been more precise since the calculated sample would only have achieved enough power to measure the projected differences if the rate of burnout was considerably lower. Additionally, the effect of non-response was not fully considered. The responses from the various European countries were pooled together in the one-way analyses of association; if the variability of burnout rates within the countries is less than that between countries, then an {alpha}-value of 0.05 may be too large to exclude associations due to chance.29

Multicollinearity is present when the independent variables in a multiple regression equation are highly correlated, and this causes a lack of precision of the regression coefficient estimates (here expressed as odds ratios in Table 6). During the logistic regression analysis, interfactor correlation was examined, and in fact, there was only one correlation greater than 0.6, that between age and years since graduation (0.9, data not tabulated).

This is the first reported study investigating the prevalence of burnout in an European FD workforce, designed to investigate the factors associated with high burnout. The limitations of this study include the fact that it is cross-sectional, that it has not been conducted concurrently in all countries, that the cultural and linguistic equivalence of the concept of burnout and the MBI-HSS instrument itself have not been fully investigated in Europe and that the study involved FDs in various European countries and working in different health care systems without measuring the complexity of this environment. The response rate was moderate, but it is quite possible that non-respondents might have scored differently to respondents to the MBI-HSS. However, similar response rates are common in anonymous questionnaire studies. The burnout scores found appeared comparable or high with respect to earlier studies. However, the Italian respondents in this study, which response rate was the highest in this study, scored very high for burnout, suggesting that non-responders may also have high levels of burnout.


   Conclusions
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
 Conclusions
Future research
 Declaration
 References
 
Burnout seems to be a common problem in FDs across Europe, with high levels apparently affecting two-thirds of respondents in this study. In all, 41% of respondents reported high levels of EE, 35% DP and 32% low feelings of PA. There is considerable variation between countries, with doctors from Southern European countries reporting lower rates of EE but also lower feelings of PA.

High burnout was found to be more likely in association with several of the variables under study, especially those relative to respondents’ country of residence and European region, job satisfaction, intention to change job, sick leave utilization, the (ab)use of alcohol, tobacco and psychotropic medication, younger age and male sex.

Future research is needed to explore the problem in depth, develop models to describe the phenomenon and to identify causative factors and effective intervention strategies. Job satisfaction is an important element in such research, and it should be prioritized by EGPRN and WONCA Europe as an action point for research and intervention.


   Future research
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
 Conclusions
 Future research
Declaration
 References
 
Recent research work on burnout aims to develop new theoretical frameworks that explicitly integrate both individual and situational factors, using a model of job–person fit. Maslach and Leiter30 address the challenge by formulating a model that focuses on the degree of match or mismatch between the person and six domains of the job environment, namely workload, control, reward, community, fairness and values. Research has indicated that the greater the mismatch, the greater the potential for burnout.

Future research into the phenomenon should address these factors when studying burnout in FDs, and the focus should be on positive rather than negative states, dealing with job engagement and satisfaction and not just job stress.1 In this regard, the strong relationships found in this study between low job satisfaction and burnout support the notion of focusing future research on improving job satisfaction rather than addressing burnout directly.

Surprisingly, little research has been conducted into interventions for burnout. Although research indicates that it is the organizational attributes that seem to have stronger associations with burnout, most interventions have in the past ironically been centered on changing individuals.1 Various intervention strategies have been studied, some focusing on prevention of burnout and others on treatment when it has already occurred, and results have been varied.1 This is another important area where levels of knowledge should improve. A controlled trial of organizational interventions for FDs to improve job satisfaction should be considered.


   Declaration
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
 Conclusions
 Future research
 Declaration
References
 
Funding: During the course of the main study, financial support to total Euro 8000 was requested and received jointly from European General Practice Research Network and WONCA Europe for the costs incurred by country co-ordinators, and to support the protected time of the study co-ordinators and authors.

Ethical approval: Obtained in most countries individually, and at the University of Malta by the first author for the whole study.

Conflicts of interest: None.


   Acknowledgments
 
We would like to thank Prof. Dr Henk Lamberts and Dr John Beasley for their invaluable advice on the analysis of data and presentation of the results. Author JKS is very grateful to Prof. Isabel Stabile for her invaluable assistance in obtaining ethical approval for this study in Malta. Author HY has been supported by The Akdeniz University Research Foundation. Distribution of work: JKS led the project, developed the research idea and study methodology, presented the research protocol and design at EGPRN meetings, recruited the country co-ordinators, designed the questionnaire, co-ordinated the pilot and main studies, provided data, analysed the data and wrote the manuscript. HY originated and developed the research idea, designed the questionnaire, analysed the data for the pilot and main studies and participated in writing the manuscript. ME provided data, participated in the design and translation of the questionnaire, analysed the data and participated in writing the manuscript. FD developed the research idea and methodology, advised on data analysis and participated in writing the manuscript. In the EGPRN Burnout Study Group, DC provided data, participated in the design of the questionnaire and participated in writing the manuscript; CL provided data, participated in the design and translation of the questionnaire and participated in writing the manuscript; RSA, Z de ASA, FC, JPD, MK, PK, ZO, AM, EM, PRN and MU provided data and participated in the design and translation of the questionnaire.


   Notes
 
Soler JK, Yaman H, Esteva M, Dodds F, Spiridonova Asenova R, Katic M, Ozvacic Z, Desgrange JP, Moreau A, Lionis C, Kotányi P, Carelli F, Nowak PR, de Aguiar Sá Azeredo Z, Marklund E, Churchill D and Ungan M (European General Practice Research Network Burnout Study Group) Burnout in European family doctors: the EGPRN study. Family Practice 2008; 25: 245–265.


   References
Top
 Abstract
 Introduction
 Methodology
 Results
 Discussion
 Conclusions
 Future research
 Declaration
 References
 
1 Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. (2001) 52:397–422.[CrossRef][Web of Science][Medline]

2 Maslach C, Goldberg J. Prevention of burnout: new perspectives. Appl Prev Psychol. (1998) 7:63–74.[CrossRef][Web of Science]

3 Beemsterboer J, Baum BH. "Burnout" definitions and health care management. Soc Work Health Care. (1984) 10:96–109.

4 Deckard GJ, Metarko M, Field D. Physician burnout: an examination of personal, professional and organisational relationships. Med Care. (1994) 32:745–754.[CrossRef][Web of Science][Medline]

5 Deckard GJ, Hicks LL, Hamory BH. The occurrence and distribution of burnout amongst infectious diseases physicians. J Infect Dis. (1992) 165:224–228.[Web of Science][Medline]

6 Gundersen L. Physician burnout. Ann Intern Med. (2001) 135:145–148.[Free Full Text]

7 Chambers R, Wall D, Campell I. Stress, coping mechanisms and job satisfaction in general practitioner registrars. Br J Gen Pract. (1996) 46:343–348.[Web of Science][Medline]

8 Goehring C, Bouvier Gallacchi M, Künzi B, Bovier P. Psychological and professional characteristics of burnout in Swiss primary care practitioners: a cross-sectional survey. Swiss Med Wkly. (2005) 135:101–108.[Medline]

9 Thommasen HV, Lavanchy M, Connelly I, Berkowitz J, Grzybowski S. Mental health, job satisfaction and intention to relocate. Can Fam Physician (2001) B47:737–744.[Abstract/Free Full Text]

10 Maslach C, Jackson SE. Maslach Burnout Inventory (1986) 2nd edn. Palo Alto, CA: Consulting Psychologists Press.

11 Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol. (1986) 42:488–493.[Web of Science][Medline]

12 Howie JGR, Hopton JL, Heaney DJ. Attitudes to medical care, the organization of work, and stress among general practitioners. Br J Gen Pract. (1992) 42:181–185.[Web of Science][Medline]

13 McManus IC, Winder BC, Gordon D. The causal links between stress and burnout in a longitudinal study of UK doctors. Lancet (2002) 359:2089–2090.[CrossRef][Web of Science][Medline]

14 Smith R. Why are doctors so unhappy? BMJ (2001) 322:1073–1074.[Free Full Text]

15 Rowe MM. Hardiness, stress, temperament, coping and burnout in health professionals. Am J Health Behav. (1997) 21:163–171.[Web of Science]

16 Yaman H, Ungan M. Burnout in young doctors. [Turkish]. Türk Psikoloji Derg. (2002) 17(49):37–44.

17 Yaman H, Soler JK. The job-related burnout questionnaire in family practice: a multinational pilot study. Aust Fam Physician. (2002) 31:1055–1056.[Medline]

18 European Society of General Practice and Family Medicine (Wonca Europe). http://www.woncaeurope.org/ (accessed on January, 2007).

19 European General Practice Research Network. http://www.egprn.org. (accessed on January 2007).

20 Yaman H, Ungan M, Soler JK. Frequency of job-related burnout in family physicians working in family practice: proposal for a multinational study of European countries. Paper Presented at the EGPRW Meeting in October 2001 in Gdynia, Poland. www.egprn.org/gdyn2t.htm.

21 Microsoft Corporation. Excel for Windows Version 6 (2000) Redmond, WA: Microsoft Corporation.

22 SPSS Inc. SPSS for Windows Version 11 and Version 13 (2004) Chicago, IL: SPSS Inc.

23 Cathebras P, Begon A, Laporte S, Bois C, Truchot D. Burn out among French general practitioners. Presse Med. (2004) 33:1569–1574.[Web of Science][Medline]

24 Prieto Albino L, Robles Aguero E, Salazar Martinez LM, Daniel Vega E. Burnout in primary care doctors of the province of Caceres. Aten Primaria. (2002) 29:294–302.[Medline]

25 Esteva M, Larraz C, Jimenez F. La salud mental en los mèdicos de familia: efectos de la satisfacciòn y el estrès en el trabajo. Rev Clin Esp. (2006) 206:77–83.[CrossRef][Web of Science][Medline]

26 Grassi L, Magnani K. Psychiatric morbidity and burnout in the medical profession: an Italian study of general practitioners and hospital physicians. Psychother Psychosom. (2000) 69:329–334.[CrossRef][Web of Science][Medline]

27 Kirwan M, Armstrong D. Investigation of burnout in a sample of British general practitioners. Br J Gen Pract. (1995) 45:259–260.[Web of Science][Medline]

28 Linzer M, Visser MRM, Oort FJ, et al. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med. (2001) 111:170–175.[CrossRef][Web of Science][Medline]

29 Altman DG, Machin D, Bryant TN, Gardner MJ. Statistics with Confidence (2000) 2nd edn. London: BMJ Books.

30 Maslach C, Leiter MP. The EGPRN burnout study (1997) San Francisco, CA: Jossey-Bass.


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