Regarding the Chinese literature related to work attitude and doctors’ humanity, the Four Books and Five Classics have been reviewed. These are the Chinese classic texts illustrating the core value and belief systems in Confucianism. “Great Learning” and “Analects” of the Four Books and the “Book of Rites” of Five Classics are chosen for the present review. In addition, two texts of traditional Chinese medical books, “On the Absolute Sincerity of Great Physicians” and the preface of the “Medical Book—Pei Yizhong” are included for the present review.
Findings from the Chinese classic texts: social expectation of being a doctor in the traditional Chinese culture
To understand burnout phenomenon among Chinese doctors, an important underlying concept is the status of doctor in Chinese culture. It is probably superficial if the meaning of status is just limited to the levels of wealth or official ranking in the society. Looking back to the few 1000 years of Chinese history, doctors in historical record with high honour are those considered having high moral value such as
Sun Simiao (581–682 AD), a famous traditional Chinese medicine doctor of the
Sui and
Tang dynasty. He was titled as
“China’s King of Medicine” for his significant contributions to Chinese medicine and tremendous care to his patients. Apart from this, he is known for the text “
On the Absolute Sincerity of Great Physicians,” often called “
The Chinese Hippocratic Oath,” which comes from the first chapter of his very important medical textbook “
Essential Formulas for Emergencies Worth a Thousand Pieces of Gold”. The following is an excerpt of the text, highlighting the importance of having high moral standard as a good Chinese doctor:
A Great Physician should not pay attention to status, wealth or age; neither should he question whether the particular person is attractive or unattractive, whether he is an enemy or friend, whether he is a Chinese or a foreigner, or finally, whether he is uneducated or educated. He should meet everyone on equal grounds. He should always act as if he were thinking of his close relatives [
31].
The preface of a medical book written by
Pei Yizhong, a doctor in
Ming dynasty stated that: If the talent and morality of a person are not comparable to fairy and Buddha respectively, he should not become a doctor misleading others. Being a doctor is a sacred mission. It is not a technique serving as a tool to gain one’s living [
32]. This has been echoed by
Qiu Fazu (1914–2008), regarded as the “
Father of Modern Chinese Surgeons”, in one of his famous motto.
Research question one: what do we know about the prevalence of burnout among doctors in China?
Five studies investigated the prevalence of burnout among doctors in China.
A multi-center cross-sectional survey in 2016 interviewed 1537 doctors working in multi-specialties from 10 provinces in China reported 76.9% suffering from some or serious burnout symptoms [
20]. Another cross-sectional survey in 2014 interviewed 205 doctors working in the Emergency unit of three large general hospitals in Beijing reported 25.4% exhibited high levels of career burnout [
22]. A cross-sectional survey published in 2014 interviewed 457 doctors working in multi-specialties from 21 hospitals in Shanghai revealed 60.6% were experiencing a mild degree of burnout and 5.9% were experiencing a severe degree of burnout [
19]. Another cross-sectional survey in 2013 interviewed 1618 doctors from 7 teaching hospitals in Liaoning province reported the prevalence of high degree burnout was 12.1% [
21]. A multi-center cross-sectional survey in 2013 interviewed 510 doctors working in multi-specialties from 10 areas in China reported 84.9% suffering from medium or higher level of emotional exhaustion, 87.8% with moderate degree of depersonalization and 81.8% with at least moderate degree of diminished personal accomplishment [
33]. The training status or year of work experience of the respondents ranged from junior to senior doctors in the studies of Wang, Wu and Cui, but it was not specified in the studies of Wen and Xiao. Doctors from multi-specialties were interviewed in the studies of Wen, Wang and Cui, only doctors from the Emergency unit was interviewed in the study of Xiao, and the specialty information was not specified in the study of Wu. Different MBI versions were used in these five studies with some differences in scoring and grading of burnout. The remaining studies did not report on the burnout figures/prevalence.
Research question two: what is the adverse impact or conditions associated with burnout in China?
Four studies reported on the adverse impact or conditions associated with burnout in China.
At the individual doctors’ level, a cross-sectional survey in 2016 interviewed 1274 doctors working from multi-specialties in Heilongjiang showed that there is a strong positive correlation between job burnout and anxiety symptoms in doctors and the prevalence of anxiety symptoms in their study was 31% [
34]. The correlation analysis from another cross-sectional survey conducted in the Emergency unit in Beijing showed a negative correlation between job satisfaction and emotional exhaustion and cynicism, and a positive correlation with reduced personal accomplishment. The two subscales (anxiety subscale and depression subscale) of the psychological distress and the three subscales (emotional exhaustion, cynicism and personal accomplishment) of burnout were correlated significantly with intrinsic and extrinsic job satisfaction in the sampled population, but the correlations between personal accomplishment and extrinsic job satisfaction were not significant. The study concluded that burnout and job satisfaction among Emergency doctors are at a moderate level, and burnout is negatively associated with higher job satisfaction [
22].
At the organizational/society level, a multi-center study from 10 provinces of China revealed that doctors who reported serious burnout were independently associated with higher incidence of medical mistakes over the course of the last year, ranged from incomplete or incorrect items in patients’ records, to medication errors and delayed treatments [
20]. Another cross-sectional survey interviewed 1451 doctors working in multi-specialties from urban state-owned medical institutions in Hebei studied the relationship between job satisfaction, burnout and turnover intention in 2011, showed turnover intention, which significantly and negatively related to all job satisfaction subscales, positively related to each subscale of burnout syndrome. The study concluded that job satisfaction had both significant direct effects and indirect effects through occupational burnout as a mediator on turnover intention [
35].
Research question three: what are the predictive factors of burnout among doctors in China?
All studies attempt to find out the risk and/or protective factors of burnout.
Regarding to the workload factor, a multi-center study from 10 provinces of China revealed that work hours per week and number of patient for daily service were positively correlated with burnout score (both p < 0.001) The average work hours per week were 54.1 ± 10.7 and the average number of daily service patients was 27.8 ± 25.1, with doctors reported 60 or more work hours per week was independently associated with higher incidence of medical mistakes [
20]. A multi-center study in Shanghai reported that burnout was higher among doctors who worked 40–60 h/week or over 60 h/week than those who worked up to 40 h/week (OR = 3.63, p < 0.001; OR = 4.54, p < 0.001) [
19]. A multi-center study in Liaoning reported that 61.9% of respondents working > 40 h/week, and these doctors had significantly higher emotional exhaustion and cynicism scores and lower professional efficacy scores than respondents who worked fewer hours [
21].
Regarding to the work setting/environment factor, a multi-center study in Shanghai reported that burnout was higher among doctors who worked on shift (OR = 2.85, p < 0.01). The study also suggested that hospital type closely correlates to job burnout. Burnout was higher among doctors who worked in hospitals of Grade II or Grade III than those who worked in Grade I hospitals (OR = 2.55, p < 0.001; OR = 3.62, p < 0.001) [
19]. A multi-center study from 10 provinces of China revealed that the proportions of doctors with serious burnout were 10.9, 17.3, and 23.7% (p < 0.001) in primary, secondary, and tertiary hospitals respectively. Similarly, the burnout score was highest in tertiary hospitals (2.6 ± 1.1), followed by secondary (2.4 ± 1.1) and primary (2.0 ± 1.2) hospitals [
20]. A multi-center cross-sectional survey from 10 areas in China also supported that doctors working in tertiary hospitals (F = 2.34, p = 0.04) or emergency department (p < 0.05) suffered from higher degree of burnout [
33]. In general, the physical work environment was one of the major predictors for emotional exhaustion reported in a cross-sectional survey conducted in 2006. The study also revealed that surgeon and doctors working in the internal medicine wards scored significantly higher in job burnout than their colleagues (p < 0.05) [
36]. The findings of higher burnout in surgeon and physician, and having physical work environment as significant predictor for emotional exhaustion were supported by another cross-sectional study conducted in 2008 [
37]. A multi-center study in Liaoning revealed that 47.2% of doctors reported serious dissatisfaction with their relationship with patient; this was one of the most salient factors related to high emotional exhaustion, and cynicism and low professional efficacy scores [
21].
Regarding to the sociodemographic factor, higher level of burnout was shown in doctors of younger age in three cross-sectional surveys: The prevalence of burnout cases was significantly higher among doctors under the age of 35 [
19]. The score of exhaustion was significantly higher in the 30–40 year age group than that in any other groups in study conducted in 2008 [
37]. This age group also scored highest in exhaustion in a study conducted in 2006 [
36]. Higher level of burnout was also shown in doctors with less work experience in two cross-sectional surveys: The prevalence of burnout cases was significantly higher in those worked for less than 5 years [
19]. The degree of burnout was higher among doctors under 10-year seniority (p = 0.01) [
33]. The burnout prevalence was higher among doctors with a family income of less than 1000 CNY/month/person than among those with an income of more than 3000 CNY/month/person (OR = 5.63, p < 0.05) [
19]. The burnout prevalence was higher among unmarried doctors compared with married doctors (OR = 1.76, p < 0.05) in a study conducted in Shanghai [
19]. Similar findings of higher emotional exhaustion (t = 2.12, p = 0.03), higher depersonalization (t = 2.06, p = 0.04) and lower personal accomplishment (t = − 3.38, p = 0.00) were found in unmarried doctors when compared with married doctors in a survey conducted in 10 areas of China [
33]. On the other hand, work-family conflict was associated with burnout among Chinese doctors in a cross-sectional study conducted in Liaoning [
38].
Regarding to the individual perception to work and life, a cross-sectional study in Shanghai concluded that low job control, low reward and over-commitment were some of the most significant predictors of burnout [
19]. Similar findings were reported in a study in Liaoning suggesting that variables that predicted burnout including high over-commitment, high psychological job demands, low reward, low decision authority, low supervisor and co-worker support [
21]. Occupational stress was significantly positively related to all burnout dimensions (p < 0.05) in a study conducted in Henan. The study also noted that main significant predictors of burnout included role overload, role insufficiency, responsibility, and social support [
37]. Another study in 2006 suggested that major predictors to burnout included role overload, role insufficiency, responsibility, social support, leisure activities and self-care [
36]. A statistically significant negative correlation between organizational justice and job burnout (r = − 0.298, p = 0.000) was observed in a cross-sectional survey with 135 medical interns in Shanghai [
39].
On the other hand, burnout was negatively associated with higher job satisfaction in a study among emergency doctors [
22]. A study in Liaoning reported that Psychological Capital was a mediator between work-family conflict and burnout, suggesting that it might be a positive resource to reduce the negative effect of work-family conflict on burnout of doctors in China [
38]. Coping resources were inversely correlated with the three dimensionalities of job burnout (p < 0.05) in the study conducted in Henan [
37].