An increasing body of evidence suggests that physician burnout has a detrimental effect on health care delivery worldwide.¹ Burnout among doctors negatively influences recruitment and retention of doctors, effectiveness and efficiency of health systems and, ultimately, patient care.² These are critical issues for the District Health System of South Africa. Maslach’s burnout model defines a syndrome of emotional exhaustion (EE), depersonalisation (DP) and/or a low sense of personal accomplishment (PA) that is related to prolonged occupational stress and frustration and results in reduced effectiveness at work.^2,3 Emotional exhaustion relates to the occupational stress dimension of burnout, while DP is a consequence of EE and refers to job detachment and callousness, which is detrimental to the doctor–patient relationship. Personal accomplishment refers to perceived effectiveness and efficiency at work. Physician burnout results in absenteeism, increased job turnover, cynicism and low job satisfaction². There is also a strong association between burnout and substance abuse, relationship problems and depression.³

There are both contextual and individual factors related to burnout, of which contextual (situational) factors appear to play the predominant role.² Contextual factors include organisational or management structure and style, workload, sleep deprivation, resources, financial compensation, practice setting, patient characteristics, career progression opportunities, work team and community, communication and feedback.^{2, 3} Individual factors include demographics, personality type, external locus of control, job dissatisfaction, and level of social support.^2,3

Globally, burnout rates among doctors range between 25% and 60%.² In 1994, Schweitzer found a 77.8% burnout rate among young doctors working within the South African district health service.⁴ Subsequent South African studies found similarly high levels of burnout.^5,6,7 With regard to the Western Cape Province, Rossouw et al. reported that 76% of doctors working within the provincial primary health care system of the Cape Town Metropole (CTM) experienced clinically significant levels of burnout.⁶ Doctors of all ages and demographic profiles are prone to burnout, but junior doctors (including registrars) are particularly vulnerable and burnout levels are particularly high among doctors working in the primary health care environment.^2,3,4,5,8 No published information is available concerning burnout among district hospital doctors practising in rural areas in the Western Cape. The primary purposes of this cross-sectional study were to determine the prevalence of burnout among doctors working within the Overberg and Cape Winelands district health systems of the Western Cape Province and to compare the findings with those of a normative study⁹ as well as three previous South African studies.^5,6,7 One study, that is, a 2003 national survey by Peltzer and colleagues of 402 doctors randomly selected from the Health Profession Council’s register of 27 551 medical practitioners working in both the private and state sectors, was regarded as a South African normative study. The secondary aim was to identify from the available literature methods for preventing and treating burnout by means of individual-focused approaches and organisational strategies, with special reference to the Western Cape Province of South Africa.

This study revealed a high prevalence of burnout among OB & CW hospital doctors including specialist FPs, MOs and CSMOs. Comparisons with the Maslach⁹ and Peltzer⁵ normative studies revealed that the differences in mean EE and DP scores achieved not only statistical significance, but they are also of meaningful clinical importance as indicated by their widely separated confidence intervals and large effect sizes (Cohen’s d). Interestingly, mean PA did not differ from the Maslach normative mean score and was markedly greater than that of the Peltzer study⁵ which showed a remarkably low score for PA.

Our findings are similar to the recent study by Rossouw and co-workers⁶ among 132 district level doctors in the CTM who demonstrated equally high burnout rates with regard to prevalence and severity. Clearly physician burnout is a problem among urban and rural doctors working within the public sector primary health care system of the Western Cape.

Participants in the Peltzer study⁵ also completed Spielberger’s Job Stress Survey.¹⁴ Job stress predicted EE and DP. The greatest sources of job stress included working overtime, lack of organisational support, inadequate salary, making critical on-the-spot decisions and dealing with crisis situations, factors that have been identified in other publications.¹ Rossouw and co-workers⁶ have listed the 10 most important factors that contribute to burnout in primary health care doctors (Table 5).⁶

Family physicians appear to have fared better than MO’s, considering that the mean scores for EE and PA indicated statistically significantly lower burnout levels than those of the MOs (mean EE 20 vs. 33; PA 33 vs. 39 and Cohen’s d values indicative of large effect sizes). However, the 95% confidence intervals of the differences between the mean values were wide and included trivial differences as well as possibly clinically important differences. Furthermore, the mean DP scores did not achieve statistical significance; therefore, the clinical importance of these findings is uncertain. Certain individual FPs scored high on the EE and DP scales and low on the PA scale (Figure 1). Additional studies of larger sample sizes are required to elucidate any real differences as well as the extent of burnout that may be emerging among FPs. The Western Cape Healthcare 2030 document¹⁵ states that district hospitals will provide a FP-driven service; however, the appearance of signs of burnout among this small sample of family practitioners, whose role is inter alia mentoring of junior doctors, deserves investigation.

The Western Cape Department of Health has outlined its vision for the future in a document entitled ‘Healthcare 2030: The road to wellness’,¹⁵ an ambitious, wide-ranging plan to improve the quality of health care that is based upon ‘patient-centred quality of care’. With regard to human resources, the document recognises that:

In a section entitled ‘Improved Staff Experience’, the document acknowledges the ‘high levels of burnout among staff as a result of heavy workloads and a stressful working environment’ and that:

A goal is repeatedly stated that the Department of Health should become an employer of choice. Various approaches are offered that include improving management systems, a staff recognition system and an employee wellness programme. These intentions are encouraging. Nevertheless, it is noteworthy that whereas long working hours, high workload, working overtime and lack of organisational support feature prominently as causes of burnout in South African and overseas studies, the provision of adequate staff numbers appropriate to the clinical load is not specifically addressed in the document. The findings of previous reports over several decades regarding the plight of South African rural doctors were confirmed in 2004 by De Villiers and De Villiers¹⁶ who interviewed doctors from 20 Western Cape rural hospitals. The authors stated ‘Our findings confirmed that substantial after-hour duties, an excessive workload and a perceived lack of management support impact negatively on rural district hospital doctors’. It is possible that after 12 years the situation may not have improved.

Wallace and colleagues conducted an extensive review of high-quality studies regarding physician wellness¹ and concluded that burnout and psychological distress are highly prevalent among primary care physicians. At the organisational level, excessive burnout, job stress, fatigue and dissatisfaction result in suboptimal patient care, increased clinical errors, reduced productivity and increased staff turnover. At personal level, burnt-out physicians are exposed to increased risks of needle-stick injuries and motor vehicle accidents as well as making serious medical errors.¹⁷ It is with these considerations in mind that the results of these studies need to be considered by district health policymakers. In view of the relationship between physician wellness and patient care outcomes, burnout levels should ideally be no greater than normative values. Considering local service requirements and the nature of the clinical work, it is inevitable that doctors working in district hospitals will at some time experience exhaustion or burnout. However, such high a prevalence of excessive levels of burnout that have appeared among primary health care doctors in the Western Cape is unacceptable and poses a threat to patient care as well as to the physical and mental health of the doctors.

Several studies have investigated the attitudes, behavioural traits and strategies employed by physicians who function successfully in stressful job situations known to result in burnout. Keeton and colleagues investigated factors determining career satisfaction, work–life balance and burnout among 935 physicians practising in specialities that predispose to burnout (general obstetrician–gynaecologists, subspecialty obstetrician–gynaecologists, general internal medicine, general paediatrics, general surgery and family medicine).¹⁷ They concluded that the capacity to exercise some control over work schedule and hours worked is the most important predictor of low burnout and satisfactory work–life balance. Low levels of burnout strongly predicted career satisfaction. A study of 8050 direct patient care physicians demonstrated that professional autonomy was more important than income in determining physician career satisfaction.¹⁸

Various strategies have been proposed to assist health care systems and health care workers develop coping mechanisms and resilience to the stresses that lead to burnout (Table 6).^{16,17,18,19,20,21,22,23,24,25,26} These include mindfulness interventions, mentoring programmes, etc., as well as improvement of the work environment by improving continuity of care, professional autonomy, etc. Recently, West and co-workers conducted a meta-analysis regarding the effectiveness of various interventions to reduce burnout among doctors.²⁷ They included 47 studies consisting of 15 randomised clinical trials (716 physicians) and 37 cohort studies (2914 physicians). Effective organisational approaches included modified duty hour requirements and modifications to clinical work processes. Effective individual-focused strategies included mindfulness-based approaches, stress management training and small group curricula. Structural or organisational interventions were more effective than individual-focused ones. Overall, the incidence of high scores for EE was reduced by 14% (95% CI 11% to 18%) and that of high scores for DP was reduced by 4% (95% CI 0% to 8%).

The weakness of this study is the small sample size, especially the low numbers of FPs. Furthermore, the seven district hospitals situated in the Cape Winelands and Overberg districts are not necessarily representative of the whole group of Western Cape district hospitals. Nevertheless, important statistical and clinical information can be inferred regarding the plight of the doctors we studied, whose predicament appears to be similar to medical personnel in other district hospitals.

This study has shown that there is a high level of burnout among doctors working in rural hospitals in the Cape Winelands and Overberg districts of the Western Cape, similar to doctors working at primary care facilities in the Cape Metropole. The goals of clinician wellness, patient-centred care and better patient outcomes as described in the Health Care 2030 plan of the Western Cape Health are achievable only if the working environments of doctors are improved by reducing workloads, improving working conditions, granting doctors more professional autonomy and by enabling doctors to cope better with the stress related to their occupation. Improvements in working hours and staffing are regrettably long overdue, necessitating a short-term focus on strategies that aim to increase resilience among clinicians by developing coping mechanisms. However, a long-term solution can only be achieved by interventions aimed at improving the work environment. Such interventions should reduce burnout among clinicians, thereby delaying their exit from the public service.