In an article entitled “Burnout, well-being, and self-reported medical errors among physicians,” Owoc et al1 report on the problem of burnout among physicians in Poland. The study aimed to assess burnout and mental well-being, and the associations thereof with negative outcomes such as fatigue, medical errors, and suicidal ideation among Polish physicians. The study used a nonrandomized, observational (ie, cross-sectional) design and enrolled both residents and physicians. To evaluate physician burnout and mental well-being, they used a self-administered questionnaire and validated scales, such as the Maslach Burnout Inventory and the World Health Organization–5 Well-being Index (WHO-5). Using data from 125 residents and physicians (mostly internists and cardiologists), the associations among the study variables were evaluated by Spearman correlation coefficient analysis. Factors related to burnout and medical errors were identified by multiple logistic regression analyses. Burnout was reported by 67% of respondents, the mean WHO-5 score was 40 points, about 70% of the respondents made a medical error in the last 3 months, burnout increased the odds of making an error by more than 5-fold, and about 14% of the physicians experienced suicidal ideation within the last 12 months. The authors concluded that since the level of burnout among respondents was high and its negative consequences could affect the entire healthcare system of Poland, the problem of physician burnout should be urgently addressed.

In recent years, healthcare workers have experienced a marked increase in workload due to technological advances, increased demand for emergency care from an aging society, greater patient rights, and regulatory changes. Due to the nature of healthcare settings, healthcare workers are required to react to the situation like amoeba, constantly changing to meet these increased demands. Emergencies frequently arise, in which healthcare workers are asked to take on more responsibilities than they can reasonably manage within a given period. In addition, healthcare workers frequently take on many roles, collaborate with numerous other agents or departments, and perform clerical work. Schaefer and Moos2 studied work stress and job morale among healthcare workers in healthcare facilities. They found that healthcare workers with higher workloads and scheduling problems were more likely to be dissatisfied with their job, and to experience depression and develop physical problems related to job distress, such as chronic fatigue, poor appetite, and indigestion. An excessive workload had a strong negative effect on the morale of healthcare workers. Increased workload causes numerous psychological problems. Burnout is a psychological syndrome characterized by chronic fatigue, depersonalization, emotional exhaustion, and a sense of reduced accomplishment during daily work.3 Excessive workloads are supposed to lead to burnout in physicians. Numerous studies have been undertaken to evaluate workloads and burnout among physicians in different medical settings. Rosenstein et al4 reviewed 182 studies published between 1991 and 2018, involving 109 628 individuals in 45 countries. Other studies reported burnout prevalence rates of 25% to 60% in physicians with various specialties.5-7 Shanafelt et al8 estimated the prevalence of burnout over time in a large sample of United States (US) physicians: the rate was 45.8% in 2011, 54.4% in 2014, and 43.9% in 2017. Among the 182 studies identified by Rosenstein et al,4 the prevalence rate of overall burnout was estimated to be 67% (n = 122/182), while that of emotional exhaustion was 72% (n = 131/182), that of depersonalization was 68.1% (n = 124/182), and that of a sense of low personal accomplishment was 63.2% (n = 115/182). Thus, physician burnout is clearly a widespread problem in healthcare settings in many countries.

Work factors, personal characteristics, and environmental factors have all shown associations with physician burnout. The work factors include excessive workload, threat of a malpractice suit, long working hours, being frequently on call at night or over the weekend, having to continue working while at home, use of electronic health records, and computerized physician order entry.9 Low control over the work environment and lack of peer or supervisor support are also related to burnout in physicians.9,10 Personal characteristics associated with physician burnout include female gender, less clinical experience, sleep deprivation, inadequate coping strategies or support from outside of the work setting (eg, no spouse, partner, or children), over-commitment to work, work-life imbalance, and personality traits promoting vulnerability to stress (eg, perfectionism, being self-critical, and idealism).10 Specifically, female gender is related to an increased likelihood of fatigue, and female physicians are more likely to experience burnout in association with depersonalization triggered by emotional exhaustion.11 The stress levels of younger physicians are nearly twice those of older physicians.10 Three main types of organizational factors are relevant to burnout: relationship factors (how committed physicians feel to their work), goal-oriented factors (how much autonomy physicians have, how much time pressure there is, and how much emphasis is placed on planning and efficiency) and system-related factors (how clear the expectations are, to what extent rules are used to control behavior, and the pleasantness of the physical setting).12

Owoc et al1 studied burnout among physicians, and the number of errors made during medical practice in Poland. As noted above, these topics are frequently discussed subjects and well-documented by the existing literature. So the opportunities for novel findings are extremely limited. However, the fact that this study is the first one to describe physician burnout in Poland should be taken into account. Physician burnout is suggested to be a particularly serious problem in that country: two-thirds of the respondents made an error in the last 3 months, 10% of which caused major and permanent morbidity (while another 5% caused death). Overall, the study is well-designed, and shows its aims and explains the findings adequately. However, some weaknesses should be highlighted. First, the study included only cardiologists and rheumatologists. Undoubtedly, these 2 residencies could not reflect the real-world data from everyday clinical practice. Thus, the generalizability and external validity of the findings may be limited. Similarly, the exclusion of surgical residents is a particularly significant weakness of this study. Ideally, to produce an unbiased result and make subgroup analysis, and to find out the different characteristics, an equal proportion of surgical and nonsurgical residents should have been included. Additionally, the inclusion of rheumatologists was not ideal, as their residencies are less rigorous compared with other specialists. It is referred that the median age of participants is 32 years old. This indicates that fewer consultants and more residents were included in the study. Residents work more hours and have less experience, and therefore present with burnout symptoms more frequently and make more mistakes in medical practice. This could explain the differences in findings between the present study and previous ones, where comparisons of subjects having different attributes might be misleading. In summary, although it has several methodological problems, the present study shows that physician burnout is a serious problem in Poland, and it is highly probable that the coronavirus pandemic has exacerbated it.

Finally, we refer to the future topic of physician burnout study. More studies are needed to improve clinician well-being and address burnout. Some factors promoting physician burnout should be targets for interventional studies, including sleep deprivation (which is also related to a reduced sense of personal fulfillment among physicians).13 Measures to address sleep deprivation could include limiting the length and frequency of extended shifts, minimizing the number of successive night shifts or nights spent on call, and mandating rest breaks during and after long shifts.13 The likelihood of burnout is high among physicians working in intense clinical settings, including intensive care units (ICUs).9 The effects of mandatory or voluntary days off and breaks on burnout among physicians working in the ICU should be evaluated. Physicians in the US experience less burnout than their European counterparts due to a “safer” culture, excellent career opportunities, and coping methods.14 It may be useful to emulate the safe culture, career opportunities, and problem-solving strategies used in the US. Finally, it is necessary to identify physicians with multiple risk factors who are most at risk of burnout.15 It is not known how the multiple factors associated with burnout interact with each other to increase the likelihood of burnout in physicians. Analyzing higher-order interactions among these factors will help identify high-risk physicians who may benefit from interventions.