172 respondents returned their questionnaires, but 4 of these did not complete the Basic Bio-Data Section and were excluded from the analysis, leaving 168 valid responses out of the dispatched 300 (56.0 % response rate). This rate is considered modest as most online surveys generally have poor response rates [
27], and it surpasses the 154 minimum estimated sample size for the study. Despite the expected low response rates with online questionnaires, this study opted for this method for a number of advantages conferred by the online approach over postal or direct surveys [
28]. Firstly, cost was a key consideration given that the survey was self-funded. In addition, the ease of dispatch, collation and follow-up, as well as the convenience for the respondents (important in getting them to respond given the usually busy schedule of doctors) were other key considerations. In any case, the rate from this survey was better than that from a 2012 survey of European GPs, which recorded a 41 % response rate [
29], but is poorer than most other similar studies, including that Canada (78 %) [
3], the UK (70 to 83 % range) [
10,
25,
30,
31], France (64 %) [
32], and Switzerland (66 %) [
33]. However, all the cited studies depended on postal or directly administered questionnaires, and, as already noted, these generally tend to fare better than the online ones [
27].
The basic response characteristics are summarized in Table
1, and include Gender, Age, Specialty, Marital Status, Family Setting, Postgraduate Vocational Status, Hours worked/week, Duration in After-hours, and Country of Primary Degree. At 19.6 %, the proportion of females involved in AHHC in Australia is much less than the 43 % involved in regular-hour general practice [
17]. A majority of the respondents were career GPs (84.4 %), with the rest being in other specialties (Physicians, Surgeons, Anesthetists, etc.). Just over half (53.6 %) were in the 40–60 age bracket, with 41.1 % being aged 39 or less and only 5.4 % being over 60 years of age.
Table 1
Summary of the basic statistics of the doctors involved in after-hours, house calls in Australia
Gender Valid = 168 | Male | 135 | 80.4 |
Female | 33 | 19.6 |
Age Range (Yrs) Valid = 168 | 39 or less | 69 | 41.1 |
40-60 | 90 | 53.6 |
Over 60 | 9 | 5.4 |
Vocational/Registration status Valid = 137 | Vocationally registered (Fellows) | 61 | 44.5 |
Non-vocationally registered (Non-fellows) | 76 | 55.5 |
Primary degree Valid = 160 | Australian-trained | 45 | 28.1 |
Overseas: New Zealand | 6 | 3.8 |
Overseas: other | 109 | 68.1 |
Specialty Valid = 160 | General Practice | 135 | 84.4 |
Medical | 7 | 4.4 |
Surgical | 2 | 1.3 |
Emergency Department | 6 | 3.8 |
Others (Paediatricians, Anaesthetists, etc.) | 10 | 6.3 |
Location of Service Valid = 160 | Adelaide | 51 | 31.9 |
Brisbane Area (Brisbane and Sunshine Coast) | 36 | 22.6 |
Gold Coast | 23 | 14.4 |
Melbourne Area (Melbourne, Geelong and Canberra) | 31 | 19.4 |
Sydney | 17 | 10.6 |
Other (unfixed location) | 2 | 1.3 |
Duration In After-Hours Valid = 160 | <= 2 years | 80 | 50.0 |
2–10 years | 54 | 33.8 |
>10 years | 26 | 16.3 |
Hours worked/week Valid = 160 | <24 h/week | 62 | 38.8 |
24 to 37.5 h/week | 47 | 29.4 |
>37.5 h/week | 51 | 31.9 |
Marital status Valid = 168 | Married | 140 | 83.3 |
Single | 12 | 2.4 |
De facto (Co-habitation & civil partnership) | 10 | 6.0 |
Separated | 4 | 2.4 |
Widowed | 2 | 1.2 |
Family setting Valid = 168 | Lives with own kids | 115 | 68.5 |
Have kids/live with none | 17 | 10.1 |
No kids/Live with none | 36 | 21.4 |
The rest of the results are presented and discussed according the three Burnout parameters identified on the Analysis Section above.
Burnout parameter 1: frequency percentages
i.
Emotional Exhaustion (EE)
Table
2 summarizes the frequencies of experiences in the three different dimensions of Burnout. Just under 1-in-5 (19.8 %) and nearly 1-in-4 (23.4 %) of the respondents recorded high-level and moderate-level burnouts respectively on the EE Dimension, leaving well over half (56.8 %) with low-level burnout. Unfortunately, no AHHC study had ever been published to look at Burnout in this regard, but comparisons made to regular-hours, office-based GPs show these AHHC rates are generally more favourable. For instance, a study of 158 office-based, regular-hour Canadian Family Physicians published in 2008 showed 47.9 % of high-level burnout on EE, with a 28.9 % of low burnout [
3]. Apart from Canada, findings from a survey of in-hour GPs based in Switzerland [
33], the United Kingdom [
31], Iran [
34] and the entire Europe [
29] showed high-level burnouts of 33, 46, 27.3 and 43 % respectively, all higher than the levels in the AHHC doctors reported in this survey. The only Australian study to show relevance was a 1991 survey of regular-hour GPs in in South Australia, which showed that one-third of the 966 surveyed doctors had significant job stress [
31]. However, the particular dimension for that survey were not reported.
Table 2
Frequencies, Means and Averages of experiences in the various dimensions of Stress among after-hours, house call doctors in Australia
1. Frequencies of Emotional Exhaustion (EE) |
Low = Never (409) + Few-times-per-year (301) | 710 | 56.8 % |
Medium = Once-per-Month-or-less (126) + Few-times-per-month (167) | 293 | 23.4 % |
High = Once-per-Week (101) + Few-times-per-week (88) + Everyday (58) | 247 | 19.8 % |
Totals for EE (TEE) | 1,250 | 100.0 % |
2. Frequencies of Depersonalization (DP) |
Low = Never (504) + Few-times-per-year (109) | 613 | 87.6 % |
Medium = Once-per-month-or-less (29) + Few-times-per-month (15) | 44 | 6.3 % |
High = Once-per-week (10) + Few-times-per-week (25) + Everyday (8) | 43 | 6.1 % |
Totals for DP (TDP) | 700 | 100.0 % |
3. Frequencies of Personal Accomplishment (PA) |
High (Low PA) = Never (7) + Few-times-per-year (38) | 45 | 4.0 % |
Medium = Once-per-month-or-less (22) + Few-times-per-month (85) | 107 | 9.6 % |
Low (High PA) = Once-per-week (72) + Few-times-per-week (304) + Everyday (588) | 964 | 86.4 % |
Totals for PA (TPA) | 1116 | 100.0 % |
4. Averages and Means |
Dimension | Total Mean Scores | Average Scores (out of 6) | Interpretation |
aEmotional exhaustion, EE (9 items) | 15.97 | 1.77 | Low-level Stress |
bDepersonalization, DP (5 items) | 3.15 | 0.63 | Low-level Stress |
cPersonal accomplishment (8 items) | 40.39 | 5.05 | Low-level Stress |
Still on percentage rates, the respective rates for the nine individual items of EE are summarized on Table
3. These items include experiences of the following when dealing with patients: “feeling emotionally drained”, “feeling used up”, “feeling fatigued in the mornings”, “driving round is a strain”, “feeling burned out”, “feeling frustrated”, “working too hard”, “stressed working with people”, and “feeling at the end of the rope”. From the Table
3, it is obvious majority of the respondents (between 4-in-10 to just over 8-in-10 practitioners) reported either “a few” or “no” feelings of any of the EE items over the entire 12-month surveyed, while a minority (between 1-in-10 to 3-in-10) expressed a “daily” to “once-a-week” feelings of these same experiences.
Table 3
Response rates to “Emotional Exhaustion” items among after-hours, house call doctors in Australia
1 | Feeling emotionally drained (Valid 140) | 60 (42.8) | 49 (35.0) | 31 (22.1) | 2.20 (1.92–2.48) | 0.14 |
2 | Feeling Used Up (Valid 140) | 55 (39.2) | 43 (30.7) | 42 (30.0) | 2.47 (2.16–2.78 | 0.16 |
3 | Feeling fatigued in the mornings (Valid 140) | 65 (46.4) | 44 (31.4) | 31 (22.1) | 2.24 (1.93–2.55) | 0.16 |
4 | Driving round is a strain (Valid 139) | 68 (49.0) | 39 (28.1) | 32 (23.0) | 2.02 (1.70–2.35) | 0.16 |
5 | Feeling burned out (Valid 139) | 83 (59.7) | 26 (18.8) | 30 (21.6) | 1.76 (1.45–2.08) | 0.16 |
6 | Feeling frustrated (Valid 139)) | 85 (61.2) | 30 (21.2) | 24 (17.3) | 1.61 (1.31–1.91) | 0.15 |
7 | Working too hard (Valid 137) | 83 (60.6) | 26 (19.0) | 28 (20.4) | 1.73 (1.42–2.04) | 0.16 |
8 | Stressed working with people (Valid 138) | 98 (71.0) | 23 (16.6) | 17 (12.3) | 1.22 (1.93–2.55) | 0.14 |
9 | Feeling at the end of the rope (Valid 140) | 113 (81.9) | 13 (9.4) | 12 (8.7) | 0.72 (0.46–0.97) | 0.13 |
| TOTALS (%) | 710 (56.8) | 293 (23.4) | 247 (19.8) | 15.97 | |
Explanations for these low-level and infrequent feelings of emotional exhaustion among the respondents may be related to the way the AHHC services is organized by the NHDS. Private correspondences with the management of the company revealed that, even though most weekday (and night) schedules commence at 6 pm, the involved doctors work in shifts, with majority starting by 6 pm and finishing by 1 am (or earlier in most cases) of the next morning. A fresh set of doctors, who did not start with the others at 6 pm, take over from 1 am, and then work till 8 am of the same morning. The Weekends and public holidays are slightly different, with the practitioners working 10-h shifts, which are split into two blocks of 5-h, with a 2-h break in between. This time schedule will no doubt allow most practitioners to have good rests overnight or in the daytime as the case might be, thereby limiting burnout with regards to most items of the EE dimension. Burnout may further be limited by the fact the NHDS allow most of their doctors to negotiate schedules that are convenient for them. The doctors are also allowed to get involved full-time or part-time. These flexibilities will allow the doctors to work take up shifts that suit them and these will no doubt minimize burnout in the industry. A final possible explanation may be linked to the fact that the doctors are allowed to use chauffeurs or chaperones if so desired, and most of the driving to see patients are at less busy times of the day or nights, when the roads are not very congested. These may limit the burnouts related to driving around or feeling fatigued. In fact, such a measure has indeed been found to be associated with reduced burnout [
26] and increased satisfaction [
35] when working in AHHC, findings which substantiate these theories. It is important to note that these explanations are theories, and a well-designed qualitative study may be useful in exploring these, as well as other possibilities.
On the DP Dimension, only 6.1 % of the respondents reported have high-level burnout, while 6.3 % indicated moderate levels. 87.6 % of burnouts on this scale were low-level (Table
2). These rates compared favorably with a Canadian study [
3], which recorded 46.3 % high burnout and 30.6 % low burnout on DP respectively. The rates also appear better when compared to results from studies in Switzerland [
33], the UK [
31], Iran [
34] and Europe [
29], with reports of 28, 42, 94.7 and 35 % high-level burnouts respectively. These studies are all in regular-hour GP practices, as no previous study had ever been published on AHHC in this regard, and so caution should be applied when interpreting these comparisons.
Table
4 summarizes the frequencies of the experiences of the five individual items on the DP dimension. As a reminder, these items include feelings of “treating patients impersonally” “being callous to patients” “not caring what happened to patients” “becoming emotionally hardened” and “feeling blamed by the patients”. The table that 8-in-10 to 9-in-10 respondents have either never experienced these feelings at all, or have only had a few experiences of them over the 12-month period under survey. On the other hand, less than 1-in-10 practitioner admits to having these feelings on a daily or at least once-weekly basis in the same period.
Table 4
Response rates to “Depersonalization” items among after-hours, house call doctors in Australia
1 | Treats patients Impersonally (Valid 140) | 114 (85.0) | 11 (7.9) | 10 (7.2) | 0.66 (0.42–.91) | 0.12 |
2 | Became Callous to Patients (Valid 140) | 122 (86.9) | 12 (8.6) | 6 (4.3) | 0.58 (0.35–.80) | 0.11 |
3 | Became Emotionally Hardened (Valid 140) | 123 (87.9) | 9 (6.4) | 8 (5.7) | 0.68 (0.45–.90) | 0.11 |
4 | Does not care what happens to Patients (Valid 140) | 129 (92.1) | 5 (3.6) | 6 (4.3) | 0.41 (0.21–.68) | 0.10 |
5 | Feels blamed by Patients (Valid 140) | 120 (85.9) | 7 (5.0) | 13 (9.3) | 0.82 (0.56–.07) | 0.13 |
| TOTALS (%) | 613 (87.6) | 44 (6.3) | 43 (6.1) | 3.15 | |
The possible reasons for these low-level and infrequent feelings of depersonalizations may be related to the lack of the need for continuity of patient-care required of doctors involved in AHHC. This is so because, most follow-ups after AHHC consultations are with the patients’ regular GPs, meaning that the major responsibilities of care in the service are passed on to these GPs, which, in most cases are office-based, regular-hour practitioners. With this burden off the AHHC doctors, it will not come as a surprise that the level of burnout associated with the DP items mentioned above are less on these doctors, as those with ongoing care of their patients would be expected to be more vulnerable to these feelings.
iii.
Personal Accomplishment (PA)
In accordance with the DP dimension, the respondents reported a very high percentage of low-level burnout (equivalent to high-level achievement) on the PA dimension (86.4 %), leaving 4.0 and 9.6 % respectively on the high and moderate levels (Table
2). Compared to previous studies of regular-hour doctors, the closest low-level burnout on the PA dimension was a study of GPs in Iran, with a 73.7 % rate [
34], but low-level burnout in other countries appear much lower. Examples include results from Switzerland (20 %) [
33], the UK (34 %) [
31] and the entire Europe (32 %) [
29]. These comparisons show that the AHHC in Australia have a lower level of burnout but higher perceived achievements relative to the regular-hour GP jobs in these countries.
An analysis of the frequencies of the experiences of the eight individual items in the PA dimension, summarized in Table
5, indicate very high percentages for each. The concerned items are the feelings of “being effective with the patients’ problems”, “having positive influences on the patients”, “easily creating relaxed atmospheres with them”, and “being calm with their emotional problems”. Other items include the feeling of “easily of understanding the patients”, “feeling energetic”, “feeling exhilarated when dealing with patients”, and a feeling of an “accomplishment of worthwhile things while on the job”. As shown in in Table
5, between 7-in-10 and 9-in-10 practitioners experienced these feelings daily or at least once-per-week, while a handful (less than 1-in-10) of them either did not report experiencing these feelings at all, or reported them only a few times a year.
Table 5
Response rates to Perceived Personal Accomplishment items among after-hours, house call doctors in Australia
1 | Easily Understands Patients (Valid 140) | 5 (3.4) | 13 (9.3) | 122 (87.2) | 5.25 (5.03–5.48) | 0.11 |
2 | Effective with Patient’s problems (Valid 138) | 1 (0.7) | 4 (2.9) | 133 (96.4) | 5.58 (5.45–5.72) | 0.07 |
3 | Positively Influence patients (Valid 139) | 4 (2.9) | 10 (7.2) | 125 (89.9) | 5.15 (4.94–5.35) | 0.10 |
4 | Feels Energetic (Valid 140) | 7 (5.0) | 25 (17.8) | 108 (77.1) | 4.61 (4.35–4.86) | 0.13 |
5 | Easily creates relaxed atmosphere (Valid 140) | 1 (0.7) | 11 (7.8) | 128 (91.4) | 5.42 (5.23–5.60) | 0.09 |
6 | Feels Exhilarated (Valid 139) | 11 (7.9) | 19 (13.7) | 109 (78.4) | 4.52 (4.24–4.80) | 0.14 |
7 | Accomplished worthwhile things (Valid 140) | 12 (8.6) | 20 (14.3) | 108 (77.2) | 4.58 (4.30–4.87) | 0.14 |
8 | Calm with emotional problems (Valid 140) | 4 (2.9) | 5 (3.6) | 131 (93.6) | 5.28 (5.09–5.48) | 0.10 |
| TOTALS (%) | 45 (4.0) | 107 (9.6) | 964 (86.4) | 4039 | |
The real reasons behind the findings on the PA dimension is not very clear. Most of the items reflect how the doctors feel they relate to the patients. The high levels recorded in these might be related to the independence enjoyed by the doctors involved in this service, given that they mostly work alone. Such independence may allow them display a more personal and relaxed consultation when seeing these patients. In addition, private discussions with the NHDS indicate that the doctors involved in AHHC do not see as many patients per hour compared to those in regular-hour office jobs, meaning that they are likely to spend more per patient. This may result in a higher level of time spent in understanding, calming, and influencing their patients. This explanation is merely a theory, and a new survey may be the best way to explore these findings. However, the high level regarding a feeling by doctors that they had “accomplished more worthwhile things” while in AHHC may be related to the fact that they get paid at a higher rate per consultation compared to their office-based colleagues [
15], meaning that they might have more disposable income than their other colleagues.
Burnout parameters 2: total means
i.
Emotional Exhaustion (EE) and Depersonalization (DP)
A Maslach Mean Total Scores of 15.97 was recorded on the EE Dimension, while On Depersonalization (DP), it was 3.15 (Table
2). These both indicate that burnout for the EE and DP dimensions were in the low-level ranges, concurring with findings from Parameter 1. Again, these scores appear to be better than scores from office-based studies of GPs in Southern Californian (which reported with means of 24.4 for EE and 9.4 for DP) [
9] as well as those from Switzerland (which recorded means of 22.3 for EE and 7.4 to DP) [
33]. As can be seen, these two cited studies are both in the moderate burnout range, but caution is advised while comparing these results given the differences in the working conditions and the countries involved. Even though the exact reasons for these findings are not obvious, the same explanations given for the findings on the EE and DP dimensions using the “burnout parameter 1” section may still apply, but further studies may be required for full exploration.
ii.
Personal Accomplishment (PA)
A score of 40.39 was recorded for this dimension, consistent with low level of burn-out and a high-level feeling of personal accomplishment (Table
2). This is similar to the level from the already-cited a survey of office-based family practitioners in Southern California (40.1) [
9], and GPs in Switzerland (39.4) [
33]. These indicate that the perceived achievements of GPs involved in AHHC in Australia are not only high, but are comparable to those elsewhere.
Burnout parameters 3: average means
An analysis of the Average Mean Score for each Dimension, the third Parameter used by this study to assess Burnout, also revealed similar findings as the second and first. For reference, the Maslach Study Sample recorded Average Means (out of 6) of 2.47 EE; 1.42 for DP and 4.57 for PA [
25]. However, findings from this study regarding AHHC doctors (Table
2), found Means of 1.77 for EE and 0.63 for DP, indicating lower averages of burnout on these dimensions relative to the Maslach Reference Means. It equally recorded a higher value for PA (5.05) relative to the Maslach Reference, indicating a higher level of perceived personal accomplishment (low burnout) among the AHHC doctors. Only one other study was found in the literature reporting its findings with this same Parameter. A 1995 study of GPs in Northampton, UK [
25], found Means of 2.9, 1.95 and 4.36 respectively for EE, DP and PA which indicate higher level burnout in the surveyed British doctors. Explanations for these interesting findings are in line with those already proffered under the “burnout parameter 1”, but as already indicated, future studies may be needed for full exploration.
Overall, the foregoing discussion have revealed that burnout levels are relatively low among primary care practitioners involved in after-hours house calls in Australia. The reasons behind these are not clear, given that this study was not designed to answer this question, but the voluntary nature of the job in Australia might be a factor, given that those engaged in the service might be those that really enjoy doing it. In addition, the flexibility of the NHDS to their staff, allowing them to choose where to work, what hours to do, and so on, might equally be a factor. However, given the significant nature of the findings of this work, it is hoped that future studies will take up the challenge of unravelling the real reasons behind these relatively low-level burnouts. It should be noted that, even though it was not reported in this paper, a related article regarding the same study population [
26] have established that reduced burnout in AHHC is significantly associated with the adoption of self-protection measures while on the job, as well as the attainment of postgraduate fellowships (vocational registration), working less than 24 h per week, being in legally recognised partnerships, and being male, while increased burnout in AHHC was linked to being under 40 years of age, obtaining primary medical degrees from Australia (as opposed to overseas), and practitioners who have general practice as a career (as against being in other specialties).