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Background: Numerous studies around the world has already suggested that burnout among doctors is a global phenomenon. However, studies for burnout in doctors are relatively limited in Chinese communities when compared to the West. As risk factors, barriers to intervention and strategies combatting burnout in different parts of the world can vary a lot due to different social culture and healthcare system, study with a focus at doctors in China from a cultural perspective is a worthful endeavor. Methods: Systematic searches of databases were conducted for papers published in peer-reviewed journals from 2006 to 2016. Selection criteria included practicing doctors in Mainland China and publications written in English or Chinese. Keywords searched including “burnout”, “doctors” and “China” in 3 electronic databases has been undergone. Traditional understanding of “work attitude” and “doctors’ humanity” from ancient Chinese literature has also been retrieved. Results: Eleven full papers, including 9302 participants, were included in this review. The overall prevalence of burn- out symptoms among doctors in China ranged from 66.5 to 87.8%. The review suggested that negative impact of burnout include association with anxiety symptoms and low job satisfaction at the individual doctors’ level, and prone to committing medical mistakes affecting patient safety and higher turnover intention at the society/organizational level. Burnout was higher among doctors who worked over 40 h/week, working in tertiary hospitals, on younger age group within the profession (at age 30-40), and with negative individual perception to work and life. Conclusions and implications: The overall prevalence and adverse impact of burnout among doctors in China echo with the findings from Western studies. Young doctors and doctors working in tertiary hospitals are more at risk of burnout, probably related to shift of social culture related to the loss of medical humanities and a weak primary healthcare system. Potential strategies of managing burnout in Chinese doctors should therefore take consideration from the Chinese cultural perspective, with renaissance of medical humanities and strengthening the primary health- care system in China. 3-dimensional construct consisting of emotional exhaus- Background tion, depersonalization, and reduced personal accom- The initial description of burnout first appeared in the plishment. The Maslach Burnout Inventory (MBI) has mid-1970s in the United States . Most publications been widely used in research studies as a gold standard of for burnout studies since then have targeted on human measurement. Consequences of burnout have been well service workers, with doctors fall into the high risk cat- studied including adverse outcomes on patient care [3, egory of professionals suffering from burnout due to 4], professionalism , doctors’ own health and safety [6, their exposure to high levels of stress in their daily work. 7] and the viability of healthcare systems, such as reduc- Maslach and Jackson  well conceptualized burnout as a tions in doctor’s professional work effort [ 8, 9]. In a recent survey of US physicians found that 54.4% of *Correspondence: email@example.com the respondents reported at least one symptom of burn- University Health Service, The Hong Kong Polytechnic University, Hong out in 2014 . An earlier survey from rural British Kong, China Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lo et al. Asia Pac Fam Med (2018) 17:3 Page 2 of 13 Columbia showed that 80% of physicians suffered from with one-third of doctors experienced conflict and thou - moderate-to-severe emotional exhaustion, 61% suffered sands have been injured . from moderate-to-severe depersonalization, and 44% moderate-to-low feelings of personal accomplishment Literature review on traditional Chinese culture . A burnout prevalence rate of 28.9% was reported on working amongst the responding cohort of UK Oto-rhino-laryn- “Culture is a vague and elusive concept most individuals gologists . A cross-sectional study on burnout among seldom explain or consciously think about and evaluate, French GPs in training reported 16.0% with high levels of and yet it is imperative.” . Confucianism is the lead- emotional exhaustion, 33.8% with high score for deper- ing culture and social value for traditional Chinese. It sonalization, and 38.9% had high score for low personal was developed from the teachings of the Chinese phi- accomplishment . A study on burnout in Australian losopher Confucius (551–479 BC) who considered him- specialist anaesthetists reported that 20% with high emo- self a re-transmitter of the values of the Zhou dynasty, a tional exhaustion, 20% with high levels of depersonali- golden age in ancient China. Harmony is the core value zation and 36% with low levels of personal achievement in Confucian Chinese culture. To maintain harmony, respectively among the respondents . The overall the way of governing the society and families by Confu- prevalence of high personal burnout was 50% in New cianism is to have good compliance to rites (Li), a sys- Zealand’s senior doctors and dentists, with many attrib- tem of ritual norms and propriety that determines how uting their feelings of burnout to work conditions . a person should properly act in everyday life, and is one Studies for burnout in doctors were relatively lim- of the basic Confucian ethical concepts and practices. ited in Asian regions when compared to the West. In a In a society governed by Li, every person is expected cross-sectional study in Yemen, 63.2% of respondent doc- to behave according to the Li assigned to his respec- tors showed high emotional exhaustion, 19.4% showed tive social role or status. A good compliance to Li can high depersonalization, and 33.0% showed low personal maintain the “face” of an individual. Hu , a renowned accomplishment . The reported burnout rate among anthropologist in Chinese culture, stresses that “face” doctors in Malaysia indicated a rate of 36.6% . A is not only limited to reputation achieved through suc- cross-sectional survey on burnout among public doc- cess and ostentation, such as wealth, which is recognized tors in Hong Kong reported 31.4% of the respondents externally, but also includes the respect of the group for satisfied the criteria for high burnout . The over - a man with good moral reputation. It is both a social all burnout rate of doctors in China was reported range sanction for enforcing moral standards and an internal- from 66.5%  to 76.9%  with high burnout ranged ized sanction. If an individual is not compliant to Li, the from 12.1%  to 25.4% . As the number of studies behaviour of this individual is considered as incorrect is limited and most of them are cross-sectional studies and inappropriate. This individual loses “face” and will performed in Asia, simple direct comparison of burnout then lead to a perception of shame. Shame in Chinese condition is difficult. The alarming figures quoted in the also carries two levels of meaning, namely the external available studies may suggest an underestimated problem perception which requires the presence of others, and below the tip of the iceberg. the internal awareness by self, which does not require Numerous studies over the world has already suggested the presence of others . Hence, “… the superior man that burnout among doctors is a global phenomenon. must be watchful over himself when he is alone” i.e. good Estimate of burnout in doctors often yields high figures compliance to Li, even when not being observed by oth- and varies among countries, across time, specialties or ers, which is well documented in the chapter of Da Xue, sector of work, i.e. public/private or rural/urban . Book of Rites (Liji) . Otherwise, the individual will Hence, an in-depth research and discussion on burnout have a self-awareness of shame. This is a form of inter - management should take reference at the specific doc - nalized sanction. tors’ group working, in similar locality and setting, with The Chinese attitude of studying and working has also consideration to their own values and culture. been well documented in the Book of Rites, stating that Regarding to China, having an enormous population “…the scholar learns extensively, but never allows his base of 1.4 billion (equivalent to 19% of the world pop- researches to come to an end; he does what he does with ulation) , doctors in China experience long working all his might, but is never weary.” The attitude of working hours with tremendous workload. Healthcare has been or the sense of mission of fulfilling the role of one’s duty is one of the important themes of deepening reform, men- reflected clearly from the Later Memorial for the case to tioned in China’s National People’s Congress in 2014 , go to war (Post Chu Shi Biao), submitted by Zhuge Liang, as deterioration of the doctor-patient relationship has chancellor-regent of the Shu Han in the Three Kingdoms become a huge problem in China’s healthcare system, period (220-280 AD), to Shu’s second emperor. The most Lo et al. Asia Pac Fam Med (2018) 17:3 Page 3 of 13 famous and historic quote from this report is: “I strive to Table 1 Search criteria do my best until I die.”. One possible deduction regarding Prevalence terms to work attitude from Chinese is, to use all one’s effort to AND complete one’s duty without complaining even when no Factor terms one is observing, is perceived as an appropriate behav- Filters Published between January 2006 and December iour with high moral value, i.e. good compliance to Li and preservation of “face”. On the contrary, if an individual Practising doctors English or Chinese languages complains or shows any sign of unable to cope while ful- Working Experience filling one’s assigned duty, he may be viewed as incompe - tent, and be perceived as ‘inappropriate behaviour’ with assigned low moral value, i.e. non-compliance to Li and Titles of the abstracts were screened for appropriate- loss of “face”. To the best understanding, the concept of ness by the first author. The first and second author fur - work-life balance has not been well illustrated in historic ther reviewed the abstracts with close reference to the and contemporary Chinese culture. inclusion and exclusion criteria (presented in Table 2) to To the best understanding, this is the first systematic eliminate studies not meeting the selection criteria. Full review of cross-sectional surveys on the current burn- texts of criteria-met articles were retrieved. Reference out condition of doctors in China. No other review has lists of the identified papers were scanned through and provided an overview of the influence of the traditional searched to maximize the search. Chinese understanding of “work” and “doctors’ integ- Studies were considered methodologically strong or rity” with reference to doctor’s burnout. With different weak based on: social culture and healthcare system, risk factors, barri- ers to prevention or intervention, the future strategies of • Design Longitudinal and prospective studies were tackling burnout in different parts of the world should considered as methodologically stronger than cross- also vary; this is also the first review paper discussing sectional and exploratory studies. the acceptance of burnout by Chinese doctors from a • Representativeness Studies with populations of > 100 traditional Chinese cultural perspective, including the respondents, studies with response rates > 75% and potential impact of Confucianism, shift of social culture multisite studies were considered as stronger. and diminishing trend of humanity in medicine in China. • Instruments Studies that used valid and reliable ques- Discussion on the strategic management of burnout is tionnaires (α > 0.60) were considered stronger than based on the observation of cultural shift and conflicting studies that used questionnaires for which validity values among Chinese young doctors, the major work- and reliability were not sufficient or not reported; force in the coming decades for the healthcare system in likewise, studies that reported on cut-off scores were China. considered stronger. This study reviews current knowledge on burnout • Statistics Studies that used more advanced statistical among doctors in China, addressing the following three analyses were considered as stronger than those that research questions: used descriptive statistics only. • What do we know about the prevalence of burnout Relevant information from ancient Chinese literature among doctors in China? was also retrieved, enabling a deeper understanding on • What is the adverse impact or conditions associated the social expectation of being a doctor in the traditional with burnout in China? Chinese culture and the role of humanities in medicine. • What are the predictive factors of burnout among doctors in China, with specific reference to the tradi - Results tional Chinese understanding of doctor’s role? Regarding the search of doctors’ burnout with reference to peer-reviewed journals, the search process resulted Methods in a total of 54 articles respectively by 3 electronic data- A comprehensive search in January 2017 was conducted bases: PubMed (32), Medline (13) and PsycINFO (9). by searching keywords including “burnout”, “doctors” and As the total number of articles was manageable by ini- “China” in 3 electronic databases: PubMed, Medline, and tial search, year of publication and language limitation PsycINFO. In addition, manual review on the reference were not applied at the preliminary search. After elimi- list of included papers has been performed as well. The nation of duplicates, the search result was 38. The titles search strategy for the literature search is summarized in and abstracts of the studies were reviewed again by Table 1. Lo et al. Asia Pac Fam Med (2018) 17:3 Page 4 of 13 Table 2 Selection criteria Criteria Included Excluded Publication Published in peer-reviewed scientific journals Book chapters, editorials, dissertations, theses and conference type Reporting original research results abstracts Ancient Chinese literature referring to doctor’s integrity and “Grey” literature (for example, policy advocacies, media or journal concept of work comments) Written in English or Chinese Study Cross-sectional study design Qualitative studies design Quantitative studies providing doctor-specific burnout data Studies not providing burnout related data/measurement using burnout measures with validity support from commonly accepted sources of evidence Population Practising doctors Non-doctors (medical students, and non-doctor health care provid- Practice in Mainland China ers such as nurses and traditional Chinese medicine practitioners Age were excluded) Practice not within China (Hong Kong SAR, Macau SAR and Taiwan were excluded due to different medical systems) considering the inclusion and exclusion criteria. The flow Regarding the Chinese literature related to work atti- diagram of article selection is presented in Fig. 1. tude and doctors’ humanity, the Four Books and Five There were 13 abstracts meeting the criteria. However, Classics have been reviewed. These are the Chinese clas - two papers could not be assessed after attempt using sic texts illustrating the core value and belief systems in interlibrary loan service. As a result, eleven full papers Confucianism. “Great Learning” and “Analects” of the were included in this review, with majority (8 out of 11) Four Books and the “Book of Rites” of Five Classics are published within 5 years. All concerned papers were pub- chosen for the present review. In addition, two texts of lished in English with the exception that two were written traditional Chinese medical books, “On the Absolute Sin- in Chinese. The characteristics of the searched studies cerity of Great Physicians” and the preface of the “Medical are presented in Tables 3 and 4. Book—Pei Yizhong” are included for the present review. Records identified through database Duplicate record searching n = 54 removed n = 16 Records screened on title & Abstract n = 38 Full-text articles Records excluded n = 25 assessed for eligibility n = 13 Not be assessed after Total studies included in attempt using synthesis interlibrary loan service n = 11 n = 2 Fig. 1 Flow diagram of article selection Included Eligibility Screening Identification Lo et al. Asia Pac Fam Med (2018) 17:3 Page 5 of 13 Table 3 Characteristics of included studies Author/year Study name Design/data collec- Population/charac- Regions No. of centers Training status/spe- Measuring instru- Findings tion wave and year teristics cialty ment Zhou 2016  Cross-sectional survey n = 1274 Heilongjiang 2 Trained 15-item CMBI Score 1–7 Multi but not specified Wen 2016  Cross-sectional survey n = 1537 Sichuan, Chongqing, 46 Not stated 15-item CMBI-GS Weighed sum score Gansu, Guizhou, Multi but not specified equation Guangdong, Shanxi, Hunan, Zhejiang, Yunnan, Ningxia Jin 2015  Cross-sectional survey n = 135 Shanghai 2 Intern 15-item CMBI-GS Score 1–7 Not stated Xiao 2014  Cross-sectional survey n = 205 Beijing 3 Not stated 15-item CMBI-GS 6 pt Emergency Wang 2014  Cross-sectional survey n = 457 Shanghai 21 From junior to senior 19-item CMBI-HSS Score 1–7 Multi Wu 2013  Cross-sectional survey n = 1618 Liaoning 7 From junior to senior 16-item CBMI-GS Score 0–6 Not stated Cui 2013  Cross-sectional survey n = 510 Beijing, Xian, Shanghai, ≥ 10 From junior to senior 16-item CMBI-GS Score 0–6 Jiangsu, Zhejiang, Multi Guangdong, Fujian, Hubei, Hunan, Inner Mongolia Wang 2012  Cross-sectional survey n = 1011 Liaoning 6 From junior to senior 15-item CMBI-GS Score 0–6 Not stated Zhang 2011  Cross-sectional survey n = 1451 Hubei 67 From junior to senior 15-item CMBI Score 1–5 Multi Wu 2008  Cross-sectional survey n = 543 Henan 3 Not stated 16-item CMBI-GS Score 0–6 Multi Zhu 2006  Cross-sectional survey n = 561 Not stated 3 From junior to senior 16-item CMBI-GS Score 1–7 Multi but not specified Lo et al. Asia Pac Fam Med (2018) 17:3 Page 6 of 13 Table 4 Summary of findings of the included studies Author/year Prevalence of burnout Adverse impact Predictive factors of burnout of burnout Individual Society Workload Work setting Sociodemographic Individual perception Zhou 2016  ✓ Wen 2016  76.9% (some or serious) ✓ ✓ ✓ Jin 2015  ✓ Xiao 2014  25.4% (high) ✓ Wang 2014  66.5% (mild or severe) ✓ ✓ ✓ ✓ Wu 2013  12.1% (high burnout) ✓ ✓ ✓ Cui 2013  81.8–87.8% (medium or above) ✓ ✓ Wang 2012  ✓ Zhang 2011  ✓ Wu 2008  ✓ ✓ ✓ Zhu 2006  ✓ ✓ ✓ Findings from the Chinese classic texts: social expectation Buddha respectively, he should not become a doctor mis- of being a doctor in the traditional Chinese culture leading others. Being a doctor is a sacred mission. It is To understand burnout phenomenon among Chinese not a technique serving as a tool to gain one’s living . doctors, an important underlying concept is the status This has been echoed by Qiu Fazu (1914–2008), regarded of doctor in Chinese culture. It is probably superficial as the “Father of Modern Chinese Surgeons”, in one of his if the meaning of status is just limited to the levels of famous motto. wealth or official ranking in the society. Looking back to the few 1000 years of Chinese history, doctors in histori- Research question one: what do we know about the cal record with high honour are those considered hav- prevalence of burnout among doctors in China? ing high moral value such as Sun Simiao (581–682 AD), Five studies investigated the prevalence of burnout a famous traditional Chinese medicine doctor of the Sui among doctors in China. and Tang dynasty. He was titled as “China’s King of Medi- A multi-center cross-sectional survey in 2016 inter- cine” for his significant contributions to Chinese medi - viewed 1537 doctors working in multi-specialties from cine and tremendous care to his patients. Apart from 10 provinces in China reported 76.9% suffering from this, he is known for the text “On the Absolute Sincer- some or serious burnout symptoms . Another cross- ity of Great Physicians,” often called “The Chinese Hip - sectional survey in 2014 interviewed 205 doctors work- pocratic Oath,” which comes from the first chapter of his ing in the Emergency unit of three large general hospitals very important medical textbook “Essential Formulas for in Beijing reported 25.4% exhibited high levels of career Emergencies Worth a Thousand Pieces of Gold”. The fol - burnout . A cross-sectional survey published in lowing is an excerpt of the text, highlighting the impor- 2014 interviewed 457 doctors working in multi-special- tance of having high moral standard as a good Chinese ties from 21 hospitals in Shanghai revealed 60.6% were doctor: experiencing a mild degree of burnout and 5.9% were experiencing a severe degree of burnout . Another A Great Physician should not pay attention to cross-sectional survey in 2013 interviewed 1618 doctors status, wealth or age; neither should he question from 7 teaching hospitals in Liaoning province reported whether the particular person is attractive or unat- the prevalence of high degree burnout was 12.1% . tractive, whether he is an enemy or friend, whether A multi-center cross-sectional survey in 2013 inter- he is a Chinese or a foreigner, or finally, whether he viewed 510 doctors working in multi-specialties from 10 is uneducated or educated. He should meet every- areas in China reported 84.9% suffering from medium or one on equal grounds. He should always act as if he higher level of emotional exhaustion, 87.8% with moder- were thinking of his close relatives . ate degree of depersonalization and 81.8% with at least moderate degree of diminished personal accomplishment The preface of a medical book written by Pei Yizhong, . The training status or year of work experience of the a doctor in Ming dynasty stated that: If the talent and respondents ranged from junior to senior doctors in the morality of a person are not comparable to fairy and Lo et al. Asia Pac Fam Med (2018) 17:3 Page 7 of 13 studies of Wang, Wu and Cui, but it was not specified in Research question three: what are the predictive factors the studies of Wen and Xiao. Doctors from multi-special- of burnout among doctors in China? ties were interviewed in the studies of Wen, Wang and All studies attempt to find out the risk and/or protective Cui, only doctors from the Emergency unit was inter- factors of burnout. viewed in the study of Xiao, and the specialty informa- Regarding to the workload factor, a multi-center study tion was not specified in the study of Wu. Different MBI from 10 provinces of China revealed that work hours per versions were used in these five studies with some differ - week and number of patient for daily service were posi- ences in scoring and grading of burnout. The remaining tively correlated with burnout score (both p < 0.001) The studies did not report on the burnout figures/prevalence. average work hours per week were 54.1 ± 10.7 and the average number of daily service patients was 27.8 ± 25.1, Research question two: what is the adverse impact or with doctors reported 60 or more work hours per week conditions associated with burnout in China? was independently associated with higher incidence of Four studies reported on the adverse impact or condi- medical mistakes . A multi-center study in Shang- tions associated with burnout in China. hai reported that burnout was higher among doctors At the individual doctors’ level, a cross-sectional survey who worked 40–60 h/week or over 60 h/week than those in 2016 interviewed 1274 doctors working from multi- who worked up to 40 h/week (OR = 3.63, p < 0.001; specialties in Heilongjiang showed that there is a strong OR = 4.54, p < 0.001) . A multi-center study in Liaon- positive correlation between job burnout and anxiety ing reported that 61.9% of respondents working > 40 h/ symptoms in doctors and the prevalence of anxiety symp- week, and these doctors had significantly higher emo - toms in their study was 31% . The correlation analysis tional exhaustion and cynicism scores and lower pro- from another cross-sectional survey conducted in the fessional efficacy scores than respondents who worked Emergency unit in Beijing showed a negative correla- fewer hours . tion between job satisfaction and emotional exhaustion Regarding to the work setting/environment factor, a and cynicism, and a positive correlation with reduced multi-center study in Shanghai reported that burn- personal accomplishment. The two subscales (anxiety out was higher among doctors who worked on shift subscale and depression subscale) of the psychological (OR = 2.85, p < 0.01). The study also suggested that hos - distress and the three subscales (emotional exhaustion, pital type closely correlates to job burnout. Burnout was cynicism and personal accomplishment) of burnout higher among doctors who worked in hospitals of Grade were correlated significantly with intrinsic and extrinsic II or Grade III than those who worked in Grade I hospi- job satisfaction in the sampled population, but the cor- tals (OR = 2.55, p < 0.001; OR = 3.62, p < 0.001) . A relations between personal accomplishment and extrinsic multi-center study from 10 provinces of China revealed job satisfaction were not significant. The study concluded that the proportions of doctors with serious burnout were that burnout and job satisfaction among Emergency doc- 10.9, 17.3, and 23.7% (p < 0.001) in primary, secondary, tors are at a moderate level, and burnout is negatively and tertiary hospitals respectively. Similarly, the burnout associated with higher job satisfaction . score was highest in tertiary hospitals (2.6 ± 1.1), fol- At the organizational/society level, a multi-center study lowed by secondary (2.4 ± 1.1) and primary (2.0 ± 1.2) from 10 provinces of China revealed that doctors who hospitals . A multi-center cross-sectional survey reported serious burnout were independently associ- from 10 areas in China also supported that doctors work- ated with higher incidence of medical mistakes over the ing in tertiary hospitals (F = 2.34, p = 0.04) or emergency course of the last year, ranged from incomplete or incor- department (p < 0.05) suffered from higher degree of rect items in patients’ records, to medication errors and burnout . In general, the physical work environment delayed treatments . Another cross-sectional survey was one of the major predictors for emotional exhaustion interviewed 1451 doctors working in multi-specialties reported in a cross-sectional survey conducted in 2006. from urban state-owned medical institutions in Hebei The study also revealed that surgeon and doctors working studied the relationship between job satisfaction, burn- in the internal medicine wards scored significantly higher out and turnover intention in 2011, showed turnover in job burnout than their colleagues (p < 0.05) . The intention, which significantly and negatively related to all findings of higher burnout in surgeon and physician, and job satisfaction subscales, positively related to each sub- having physical work environment as significant predic - scale of burnout syndrome. The study concluded that job tor for emotional exhaustion were supported by another satisfaction had both significant direct effects and indi - cross-sectional study conducted in 2008 . A multi- rect effects through occupational burnout as a mediator center study in Liaoning revealed that 47.2% of doctors on turnover intention . reported serious dissatisfaction with their relationship with patient; this was one of the most salient factors Lo et al. Asia Pac Fam Med (2018) 17:3 Page 8 of 13 related to high emotional exhaustion, and cynicism and On the other hand, burnout was negatively associated low professional efficacy scores . with higher job satisfaction in a study among emergency Regarding to the sociodemographic factor, higher level doctors . A study in Liaoning reported that Psycho- of burnout was shown in doctors of younger age in three logical Capital was a mediator between work-family cross-sectional surveys: The prevalence of burnout conflict and burnout, suggesting that it might be a posi - cases was significantly higher among doctors under the tive resource to reduce the negative effect of work-fam - age of 35 . The score of exhaustion was significantly ily conflict on burnout of doctors in China . Coping higher in the 30–40 year age group than that in any other resources were inversely correlated with the three dimen- groups in study conducted in 2008 . This age group sionalities of job burnout (p < 0.05) in the study con- also scored highest in exhaustion in a study conducted ducted in Henan . in 2006 . Higher level of burnout was also shown in doctors with less work experience in two cross-sectional Discussion surveys: The prevalence of burnout cases was signifi - The result to research question one echoed with previ - cantly higher in those worked for less than 5 years . ous Western review studies [40, 41]: that burnout among The degree of burnout was higher among doctors under doctors has reached epidemic levels, with overall preva- 10-year seniority (p = 0.01) . The burnout preva - lence of burnout symptoms among doctors in China lence was higher among doctors with a family income ranged from 66.5%  to 87.8% . of less than 1000 CNY/month/person than among those The result to research question two suggested nega - with an income of more than 3000 CNY/month/person tive impact of burnout among doctors in China including (OR = 5.63, p < 0.05) . The burnout prevalence was association with anxiety symptoms and low job satisfac- higher among unmarried doctors compared with mar- tion at the individual doctors’ level, prone to committing ried doctors (OR = 1.76, p < 0.05) in a study conducted medical mistakes affecting patient safety and higher turn - in Shanghai . Similar findings of higher emotional over intention at the society/organizational level. The exhaustion (t = 2.12, p = 0.03), higher depersonalization finding of these negative impacts also shared the same (t = 2.06, p = 0.04) and lower personal accomplishment conclusions with previous Western studies. (t = − 3.38, p = 0.00) were found in unmarried doc- However, this search reveals that studies focus on tors when compared with married doctors in a survey burnout among doctors in China is small in number conducted in 10 areas of China . On the other hand, when compared to the West, despite the significant work-family conflict was associated with burnout among prevalence and negative impacts of burnout among doc- Chinese doctors in a cross-sectional study conducted in tors in China. Interestingly, with long working hours, Liaoning . tremendous workload, deterioration of the overall doc- Regarding to the individual perception to work and tor-patient relationship with one-third of doctors expe- life, a cross-sectional study in Shanghai concluded that rienced conflict and thousands to have been injured low job control, low reward and over-commitment were , what are the reasons to enable this profession with some of the most significant predictors of burnout . high burnout and low morale continue to sustain the Similar findings were reported in a study in Liaoning sug - service delivery to the society? Burnout, which is a phe- gesting that variables that predicted burnout including nomenon raise from the West, has been translated in high over-commitment, high psychological job demands, Chinese literature, with meaning closed to “fatigue” and low reward, low decision authority, low supervisor and “over-worked”. Chan  and Lo  first pointed out co-worker support . Occupational stress was sig- that existing Chinese translation may have limitation as nificantly positively related to all burnout dimensions they stressed more on the physical and under-describe (p < 0.05) in a study conducted in Henan. The study the psychological and spiritual aspects of burnout. They also noted that main significant predictors of burnout introduced a new Chinese translation of burnout (Rán included role overload, role insufficiency, responsibil - jié) which implies a 3-dimensional burnout, namely phys- ity, and social support . Another study in 2006 sug- ical, psychological and spiritual levels [42, 43]. Hence, a gested that major predictors to burnout included role deeper level of analysis regarding the cultural perspec- overload, role insufficiency, responsibility, social support, tive is performed to explore the psychological, social and leisure activities and self-care . A statistically signifi - spiritual levels of burnout for Chinese doctors. The main cant negative correlation between organizational justice discussion would focus on the reflection from the results and job burnout (r = − 0.298, p = 0.000) was observed to research question three as explored from the Chinese in a cross-sectional survey with 135 medical interns in cultural perspective. Shanghai . Lo et al. Asia Pac Fam Med (2018) 17:3 Page 9 of 13 Cultural reflection phenomenon explains our review findings that doctors In the present systematic literature review, most burn- working in tertiary hospitals in China are more over- out literature mainly focused on reporting the alarm- loaded and have higher burnout prevalence. This phe - ing figures of prevalence and discussion on the adverse nomenon, however, is uncommon in the Western world consequences of burnout. Factors contributing to doc- especially in Europe, despite the similar presence of high tor’s burnout were discussed in a generalized manner technology and sub-specialization in tertiary hospital. with minimal address to specific cultural consideration. Strengthening primary health care has been a central Potential strategies to tackle burnout have been proposed health policy for years in Europe. The concept of having a in a generic way without tailor-made to doctors from dif- holistic family doctor coordinating the health triage sys- ferent parts of the world. Literature in the present review tem has been well implanted, expressed in the health has neither made any attempt to explore the burnout seeking behaviour. With a strong primary healthcare sys- phenomenon from the cultural or moral perspectives, tem, doctors working in the tertiary hospitals in the West nor to account for the apparently high elasticity of Chi- are likely to be proportionally unloaded. Patients seek nese doctors despite the adverse condition. medical opinion from their own family doctor in their With specific reference to the Chinese context, ‘Chi - communities first, with regular and long-lasting doctor- nese doctors’ consist of both qualities of “Chinese” and patient relationship, in contrast to the one-off encounter “doctors”. The Chinese attitude to working or fulfilling between patient and a sub-specialist, with their relation- one’s duty is to stand all the hardship without complain- ship ceased once the relevant medical problem was ing tiredness or fatigue until the end of his life. This is resolved. regarded as compliance to rites (Li) with moral respect. Another impact violating the traditional doctor-patient This inherited traditional working attitude may result in relationship in China is the shift of healthcare concept a self-expectation of maintaining a higher moral standard from delivering a medical mission to maintaining a medi- than the social norm, to stand all the hardship without cal business . Shifting the doctor-patient relation- complaining, hence prone to burnout. Although Chinese ship to business model is driving the doctors away from doctors can sense that they are overloaded or burnout, his mission of helping patients, relieving patients from the Chinese culture of standing all the hardship without sufferings with passion. In addition, medicine becomes complaint may account for the high elasticity of this high a transaction between a “medical service provider” and burnout population and the sustainability of the medical a “customer” who pays for this service. The concept service despite the adverse condition. of “customer” has reinforced the patients’ beliefs that “whoever can afford a higher charge would get a higher Shift of social culture and loss of humanity in medicine quality medical service”. This “medical service provider- In the past several decades, there is a world trend of customer relationship” is clearly different from the “tra - diminishing humanity in medicine. China is no excep- ditional doctor-patient relationship” which was well tion. Doctors are expected to be in pace with the rapid documented in ancient China medical textbooks such as growing research findings, following clinical guidelines the afore-mentioned “On the Absolute Sincerity of Great issued by international authorities in their daily practice. Physicians”. This changing relationship could be one of While the emergence of evidence-based guidelines and the root causes for the current negative perception to sub-specialization ensures highly standardized treat- work and life, as one of our major finding addressed to ment, what people may have overlooked, is the impact research question three. of the over-emphasis on “specialization” on the existing doctor-patient relationship, which has a fundamental Impact of cultural shift and conflicting values on Chinese role affecting the functioning of any helping professional young doctors . One of the major findings in this review is that, young In the present review, the untrusting and distancing doctors in China, especially for those younger than doctor-patient relationship is one of the salient factors for doctors’ burnout. In China, it is commonly found that patients may have doubts upon the general practitioners, The first author had a discussion with general practitioners from Den- or doctors practising in small-scale community hospitals mark, Sweden, New Zealand and UK during a visit to a general practice clinic in Copenhagen, at the World Family Doctors’ Conference in 2016. with no specialization; the lack of relatively high technol- The primary health care policy is very mature in Europe, with each citi- ogy was associated with less competence in medical zen enrolled to the care of his own family doctor in the community with treatment. This untrusting doctor-patient relationship long-term relationship. The citizen cannot attend tertiary hospitals directly except in emergency. Hence, the overloading phenomenon for doctors has driven the patients to visit different specialists for working in tertiary hospitals is not commonly seen as what happening in problems of different organs in the body. This China. Lo et al. Asia Pac Fam Med (2018) 17:3 Page 10 of 13 40 years old, have higher prevalence of burnout. Analyses the society’s script, facing stressors like finding a home have been raised in previous literatures, that it may be and mate, establishing a family or circle of friends, and/or explained by the fact that, young doctors serving as train- getting a good job . ees or junior posts in general are more overloaded, more One may wonder how the Chinese doctors can stand likely to work more than 60 h/week, less rewarded with for these tremendous hardships without complaining. In monthly wage less than $RMB 2000 and having less fact, the art of achieving a good balance between work working experience. According to the first author’s front - and social life, especially in the life stage of young doc- line training experience, young doctors from different tors, seems neither addressed in the Chinese culture nor provinces in China do show disagreement and feel in the medical education. Medical students are taught to uncomfortable about the current “medical service pro- become good doctors in medical schools. The definition vider-customer relationship” in general. One young doc- of a “good” doctor that includes a high moral standard tor from Xi-an expresses desperate feeling when doctors in traditional Chinese culture has been well documented are commonly reminded by the “patient” during the start and implanted into the heart of Chinese. The medical of the medical consultation, that his family is very professionals have to bridge the traditional high moral wealthy and demand for the best medical treatment. This standard and nowadays patients’ demands. To strive an implies patients have assumed doctor was of low moral art of work-life balance, is to formally include medical standard and would only provide good medical service to humanities in the medical curriculum in medical school wealthy people. The young doctor perceives himself as a in China and other parts of the world. This is what we “good” doctor with high moral duty and feels not being advocated in the present review as the “renaissance of respected. Another young doctor from Shanghai sadly medical humanities”. suggests that one way to manage angry patients in order In this review study, unsatisfactory doctor-patient rela- to avoid complaint, is having no physical nor verbal tionship was found to be one major predisposing fac- defence even when being beaten or blamed by “patients”. tor for burnout among doctors in China. It may be too She drops tears in the doctor-patient communication superficial to regard this as the root-cause, because this skill workshop when describing her way of managing is only a sign of an underlying problem, i.e. loss of medi- angry patients, because she is very frustrated with the cal humanities. The original motivation driving a doc - current low social status of Chinese doctors. tor to stand all the hardship, in order to relieve patients’ It comes to a point of psychological struggling, when sufferings; humanity as the major reason of maintain - young Chinese doctors primed with the Confucian Chi- ing harmony between doctor and his patients, was well nese culture, expecting high moral respect from the pub- documented in ancient Chinese medical textbooks and lic initially, become very disappointed after discovering historical record. Hence, by organizing workshops to the reality of the current social environment. Before a enhance doctors’ communication skill can polish the tool new rationalisation to these young doctors is being for- of delivering medical service, but it is insufficient to tar - mulated, they may be prone to burnout at the psycho- get at the root-cause, i.e. loss of medical humanities. logical and spiritual levels, with depression and anxiety Medical humanities may have partial overlapping to symptoms; and may even responded by giving up the the art of medicine, but it is not identical. It comprises medical career, explaining the high turnover rate of med- not only communication skills, professional judgement ical graduates noted by the major research findings in and illness management, but also the unmeasurable this review study. Furthermore, young doctors belong to deeply immersed hearts of empathy, dual respect, genu- early to mid-adulthood of the life stages, somewhat have ineness, self-awareness and reflective practices. Medical to accomplish their many responsibilities according to humanities are not a technical skill that can be acquired by attending lectures and passing relevant examinations, it is a long process of the growth and maturation of a doc- 2 tor, requires years of role-modelling and guided practice. The first author was appointed as Honorary Professor of the First Affili- ated Hospital of the Xi-an Medical School providing training on commu- While both undergraduate and postgraduate medical nication skill and medical humanities. During her stay in August 2016, education reform by strengthening medical humanities in the first author led a hot discussion with more than 100 local doctors in a the curriculum is important, public education to achieve communication skill workshop began by the question on why doctors felt frustrated when repeatedly reminded by patients that they were wealthy and renaissance in medical humanities in the society cannot could pay for the drug with the highest charge. be neglected. If the social culture is skeptical of virtue, The first author conducted a workshop in June 2016 in Hong Kong, pro- glorifies success by monetary measurement, disvalues viding communication skill training to a group of doctors coming from dif- altruism and self-actualization, it is impractical to expect ferent provinces of China. One of the case scenarios for demonstration was how to manage angry patients. Doctors from the floor were invited to share our young doctors to maintain the mission of doctoring their ways of management in daily practices first, before the author shared in an adverse social environment. While improving the her own experience with them. Lo et al. Asia Pac Fam Med (2018) 17:3 Page 11 of 13 remuneration package and working environment of doc- promotion of family doctors and disease prevention, can tors in China are very important, returning moral respect hopefully triage and reduce patients attending tertiary to doctors from the society is one of the most crucial hospitals directly, hence decreasing the workload of doc- needs for burnout prevention. Promotion of humanities tors working in the tertiary hospital setting; promotion may not be only beneficial to the medical profession and of medical humanities to both the medical discipline the sustainability of the healthcare system, but also to the and the general population is crucial to combat burn- genuine harmony of the Chinese society. out among doctors and maintain the sustainability of the medical system in a society built upon with Chinese Strategies of managing burnout among Chinese doctors culture. Western literature [40, 41] suggests that interventions for burnout can be classified into doctor-individual level and Limitation of the review organizational level. The former usually involves mind - Although each of the 11 studies were multi-centred, had fulness techniques or cognitive behavioural techniques population of more than 100 respondents, and response to enhance job competence and improve communica- rates > 75%, all of them belong to cross-sectional and tion skills, personal coping strategies, stress management exploratory studies which may have lower level of evi- and self-care training, etc. The later involves reduction of dence when compared with such as Randomized Con- workload, changes in work schedule or more ambitious trolled Trials (RCTs) by using the evidence-based changes to the operation of practices and whole health practice hierarchies. However, by applying a set of scien- care organizations, with improvement to teamwork, tific criteria on qualitative studies exploring on a human - changes in work evaluation, supervision to reduce job istic research topic can be limiting and may not be able demand, enhance job control, and increasing the level to reflect the genuine picture. Another problem is that, of participation in decision making . A recent meta- although most studies used the MBI as burnout meas- analysis suggests that these recent intervention programs urement tool, it is difficult to make direct comparisons for burnout in doctors were associated with small benefits between the various studies as different versions of the that may be boosted by adoption of organization-directed MBI were used, and information on the content, num- approaches, supporting that burnout is a problem of the ber of items, scoring methods and cut-off scores are var - whole health care organization, rather than individu- ied. Doctors participated in these studies are also largely als . However, these findings and suggestions are not diversified from different specialities, work settings, and specific to Chinese doctors and without consideration to years of training, etc. with insufficient documentation in the cultural perspectives. Whether these interventions some of the studies. This affects the strength of the con - can be directly applied to the Chinese locality is subject clusions resulted from the review. Furthermore, although to question. One of the major factors for low utilization studies published in Chinese have also been included in and high dropout rates in Chinese mental health services, the search process, some Chinese studies which do not known as the stigmatization of mental illness, have long have English abstracts may not be included in the West- been recognized in previous literatures . This is prob - ern databases used in this review process and probably be ably more significant among Chinese medical doctors, missed out. whose self-perception belongs to a higher moral standard and are thus more resilient to hardship when compared Future research direction with majority of Chinese people. For instance, personal It is encouraging to see that most of the studies were counselling or stress management workshops may have carried out in the past 5 years, suggesting that burnout been shown by Western studies to be effective in burnout among doctors are getting more attention in the field and management, the Chinese work culture encouraging peo- looking for a way out. It would be of interest to investi- ple to stand all the hardships without complaining may gate whether East Asian countries (e.g. Korea, Taiwan, cause Chinese doctors unwilling to seek for help due to Japan) influenced by Confucian teaching would have their compliance to Li and preserving to ‘face’. 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