Advertisement

European Journal of Pediatrics

, Volume 178, Issue 5, pp 681–693 | Cite as

Occupational well-being in pediatricians—a survey about work-related posttraumatic stress, depression, and anxiety

  • Minouk Esmée van SteijnEmail author
  • Karel Willem Frank Scheepstra
  • Gulfidan Yasar
  • Miranda Olff
  • Martine Charlotte de Vries
  • Maria Gabriel van Pampus
Open Access
Original Article

Abstract

The objective of this study was to study mental health, coping, and support after work-related adverse events among pediatricians. Physicians are frequently exposed to adverse events. It makes them at risk for posttraumatic stress disorder (PTSD), depression, and anxiety disorders. Besides the personal impact, physicians could pose a threat towards patients, as mental health problems are associated with medical errors. A questionnaire was sent to all members of the Pediatric Association of The Netherlands in October 2016. The questionnaire focused on adverse events, coping, and support. The Hospital Anxiety and Depression Scale and the Trauma Screening Questionnaire were included for evaluation of anxiety, depression, and posttraumatic stress. Four hundred ten questionnaires (18.9%) were eligible for analysis. Seventy-nine % (n = 325) of the respondents experienced adverse events, with “missing a diagnosis” having the most emotional impact and “aggressive behavior” as the most common adverse event. Nine (2.2%) pediatricians scored above the cut-off value on the Trauma Screening Questionnaire, indicative of PTSD. In total, 7.3% (n = 30) and 14.1% (n = 58) scored above the cut-off values in the Hospital Anxiety and Depression Scale, indicative of depression and anxiety. Only 26.3% reported to have a peer support protocol available for emotional support following adverse events.

Conclusion: Pediatricians experience a considerable amount of adverse and potentially traumatizing events associated with significantly higher mental health problems compared to the general high-income population. Aggression towards pediatricians seems to be a common problem. Protocolled (peer) support should be implemented.

What is known:

Physicians are frequently exposed to adverse events. It makes physicians at risk for depression, anxiety, and posttraumatic stress.

Physicians who are affected by these events pose a threat towards patients, as mental health problems are associated with medical errors.

What is new:

Pediatricians experience a considerable amount of adverse and potentially traumatizing events associated with significantly higher mental health problems.

It is advised that (peer) support after adverse events is protocolled and education on coping strategies is implemented, to improve mental well-being of pediatricians.

Keywords

Adverse events Mental health Occupational stress Work-related posttraumatic stress disorder Work-related depression Work-related anxiety Workplace aggression 

Abbreviations

DSM-IV

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition

EJ

Eva Jacobs

GY

Gulfidan Yasar

HADS

Hospital Anxiety and Depression Scale

MdV

M.C. de Vries

NVK

Pediatric Association of The Netherlands

PTSD

Posttraumatic stress disorder

TSQ

Trauma Screening Questionnaire

Introduction

Physicians are frequently exposed to adverse events, such as medical errors, patient safety incidents, violence, and complaints. Adverse events may lead to mental health problems including posttraumatic stress disorder (PTSD) [1, 2]. Apart from this personal impact, diminished occupational well-being among physicians is linked to decreased professionalism, more medical errors and poorer patient outcomes [3, 4, 5, 6]. The Canadian Medical Education Directives for Specialists 2015 (CanMEDS 2015) specify that physicians should take responsibility for their own health and well-being and that of their colleagues in order to provide optimal patient care [7]. Therefore, it is important to identify which events are risk factors for physicians to develop mental health problems. Furthermore, it is important to know what kind of support is needed to cope with these events.

The 1-year prevalence of mood disorders (major depression, bipolar disorder, and dysthymia) among Dutch citizens with a high income is 3.0%, and the 1-year prevalence of anxiety disorders is 6.0% [8]. In physicians, the prevalence of both depression and anxiety disorders can be as high as 29% and 24%, respectively [9, 10]. Also, physicians have an elevated risk of developing PTSD as they are more frequently exposed to adverse events during their career [11]. Pediatricians experience repetitive stress when dealing with sick children and their emotional and desperate parents, which may be extra stressful compared to other specialties [12]. Physicians’ way of coping and their personal resilience might be important in preventing depression, anxiety, and PTSD. Therefore, the aim of this study was to examine work-related stressors and associated mental health problems in pediatricians as well as their ways of coping and received emotional support in their institute.

Materials and methods

A cross-sectional questionnaire was conducted with members of the Pediatric Association of The Netherlands (NVK).

Among the members of the NVK are residents, attending, non-practicing, and retired pediatricians. At the time of the questionnaire, there were 2160 members in total. All members received an invitation from the NVK for an online questionnaire and three reminders over the course of a 3-month period from October 2016. The questionnaire was sent through SurveyMonkey® using an anonymous (non-traceable) link.

The questionnaire consisted of 56 questions and contained two validated screening instruments, the Trauma Screening Questionnaire (TSQ) and the Hospital Anxiety and Depression Scale (HADS, Appendix) [13, 14, 15, 16]. The first draft of the questionnaire was reviewed by members of the Childbirth and Psychotrauma Research (CAPTURE) group of the hospital OLVG in Amsterdam, The Netherlands, as well as by MdV. Furthermore, this questionnaire was conducted with gynecologists in 2014 and with orthopedic surgeons in 2016 (accepted for publication) [17]. The questionnaires were kept very similar to make it possible to compare the different specialties.

The TSQ is a ten-item screening instrument based on items from the PTSD Symptom Scale-Self Report and has five items concerning re-experiencing and five items concerning arousal. Answers can be “yes” or “no” [18]. The cut-off score indicative of PTSD symptoms is six [14, 15]. Only respondents who answered yes to experiencing a traumatic event at least 4 weeks ago filled out the TSQ. Within 4 weeks after an adverse event, an acute stress reaction might trigger complaints comparable to those found with PTSD. However, if the complaints exist for more than 4 weeks, the complaints are more likely to be due to PTSD.

The HADS is a 14-item screening instrument for depression and anxiety, where both subscales contain seven questions each. Each question contains an answer consisting of a four-point Likert scale. The cut-off value of the Dutch version for clinically relevant depressive symptoms (HADS-D) or anxiety symptoms (HADS-A) is equal to or bigger than eight. The total HADS cut-off value for psychological distress is equal to or bigger than 12.

Further questions were added to the questionnaire to explore demographics (age, employment, working experience, sub-specialism), assess adverse events at work, way of coping with adverse events and how pediatricians learned to cope, satisfaction with current support, and if and how the current support system should change (Appendix).

Statistical analysis was performed with IBM Statistical Package for the Social Sciences (SPSS, version 22). Only completed questionnaires were analyzed. Open questions were categorized by two independent contributors (GY and EJ), the overall inter-rater agreement was calculated with Cohen’s kappa. Demographic data and multiple-choice questions were analyzed using descriptive statistics, and P values were calculated with binomial tests. Differences in categorical outcomes between residents and attending physicians were tested with either chi-square tests (χ2) or Fisher’s exact. In continuous data, independent t or Mann-Whitney U tests were used. A two-sided P value of 0.05 or smaller was considered statistically significant.

This study was exempted from ethical approval by the Medical Research Ethics Committees United (MEC-U) and registered under the number W18.096.

Results

Population characteristics

A total of 456 questionnaires (21.1%) were completed, of which 410 questionnaires (18.9%) were eligible. Figure 1 shows the inclusion diagram.
Fig. 1

Inclusion diagram of selecting the questionnaires

Table 1 shows the baseline characteristics of the respondents, compared with the members of the NVK, the reference group. Gender and the amount of residents were comparable between respondents and the reference group; however, there were more attending pediatricians, less retired pediatricians, and less pediatricians with a management function in our sample (Table 1). Table 2 shows the baseline characteristics divided in the subgroups resident, attending, retired, and non-practicing.
Table 1

Baseline characteristics respondents and NVK

 

Responding pediatricians (n = 410)

Composition of membership NVKa (n = 2160)

P value

Gender

 Male

134 (32.7)

759 (35.1)

0.17

 Female

276 (67.3)

1402 (64.9)

0.17

Position

 Resident

74 (18.0)

377 (17.5)

0.41

 Attending physician

307 (74.9)

1307 (60.5)

< 0.001

 Retired

23 (5.6)

254 (11.8)

< 0.001

 Non-practicing

6 (1.5)

222 (10.3)

< 0.001

Age (in years)

 20–29

19 (4.6)

 

 30–39

108 (26.3)

 

 40–49

115 (28.0)

 

 50–59

110 (26.8)

 

 60–69

46 (11.2)

 

 ≥ 70

12 (2.9)

 

Years in practice

 ≤ 5

40 (9.8)

 

 6–10

71 (17.3)

 

 11–15

57 (13.9)

 

 16–20

79 (19.3)

 

 21–25

57 (13.9)

 

 26–30

49 (12.0)

 

 > 30

57 (13.9)

 

All values shown in n (%), P values calculated with binomial tests

– unknown, NVK Pediatric Association of The Netherlands

aNon-respondents plus respondents

Table 2

Baseline characteristics in subgroups

 

Total (n = 410)

Resident (n = 74)

Attending (n = 307)

Retired (n = 23)

Non-practicing (n = 6)

Gender

 Male

134 (32.7)

11 (14.9)

103 (33.6)

16 (69.6)

4 (50.0)

 Female

276 (67.3)

63 (85.1)

204 (66.4)

7 (30.4)

4 (50.0)

Age (in years)

 20–29

19 (4.6)

19 (25.7)

0 (0)

0 (0)

0 (0)

 30–39

108 (26.3)

55 (74.3)

53 (17.3)

0 (0)

0 (0)

 40–49

115 (28.0)

0 (0)

114 (37.1)

0 (0)

1 (16.7)

 50–59

110 (26.8)

0 (0)

106 (34.5)

0 (0)

4 (66.7)

 60–69

46 (11.2)

0 (0)

34 (11.1)

12 (52.2)

0 (0)

 ≥ 70

12 (2.9)

0 (0)

0 (0)

11 (47.8)

1 (16.7)

Years in practice

 ≤ 5

40 (9.8)

37 (50.0)

3 (1.0)

0 (0)

0 (0)

 6–10

71 (17.3)

40 (50.0)

34 (11.1)

0 (0)

0 (0)

 11–15

57 (13.9)

0 (0)

56 (18.2)

0 (0)

1 (16.7)

 16–20

79 (19.3)

0 (0)

76 (24.8)

2 (8.7)

1 (16.7)

 21–25

57 (13.9)

0 (0)

54 (17.6)

1 (4.3)

2 (33.3)

 26–30

49 (12.0)

0 (0)

47 (15.3)

1 (4.3)

1 (16.7)

 > 30

57 (13.9)

0 (0)

37 (12.1)

19 (82.6)

1 (16.7)

Complaints at disciplinary boarda

46 (11.2)

1 (1.4)

39 (12.7)

4 (17.4)

2 (33.3)

All values shown in n (%)

aPediatricians who received complaints at the disciplinary board

Selected quotes of the respondents are added in Table 3 to visualize the events they experience as adverse, divided in aggression by parents and death of a patient.
Table 3

Quotes of pediatricians*

Aggression

 “During two periods in my career I was stalked, they phoned me, also during the night, either hanging up or telling me they knew where my family lived.”

---------------------------------------------------------------------------------------------------------------------------

 “We admitted a physically abused patient whose parents had severe psychiatric problems. I reported them to the Child Care and Protection Board and afterwards there were letters in the room of the patient telling me something would happen to me. These parents even went to my parents’ house.”

---------------------------------------------------------------------------------------------------------------------------

 “I was held hostage twice, once by a desperate father, once by a drug-addicted father.”

---------------------------------------------------------------------------------------------------------------------------

 “I was threatened by parents during cardiopulmonary resuscitation, they kept yelling at me: ‘You killed my child!’.”

---------------------------------------------------------------------------------------------------------------------------

 “I was threatened by parents with a gun after a patient died.”

---------------------------------------------------------------------------------------------------------------------------

 “At the outpatient clinic there was a big, strong father who grabbed me by the throat and pushed me in the corner”

Death of a patient

 “The death of a patient due to a mistake with medication.”

---------------------------------------------------------------------------------------------------------------------------

 “The sudden death of a neonate whom I treated for half a year. It was hard to keep control during resuscitation and it took a long time for me to regain confidence during acute situations.”

---------------------------------------------------------------------------------------------------------------------------

 “A neonate who could not be intubated by anyone and who died.”

---------------------------------------------------------------------------------------------------------------------------

 “I sent a neonate with mild respiratory complaints back home. A day later he was presented with severe cardiomyopathy and despite maximum resuscitation at the ER, he died.”

---------------------------------------------------------------------------------------------------------------------------

 “Failed resuscitation of a neonate when my supervisor was not present.”

---------------------------------------------------------------------------------------------------------------------------

 “The death of a toddler due to drowning when my own children were toddlers. The parallelism and vulnerability had a huge emotional impact.”

Question 23: Can you briefly describe the adverse event(s)?

These quotes are selected from all the answers

Work-related stressors

The following events were experienced as high emotional impact stressors at work by the respondents (multiple answers possible): missing a diagnosis (71.2%, n = 292), suspicion of child abuse (49.3%, n = 202), doubts about making the right decision (48.3%, n = 198), death of a patient (38.0%, n = 156), and critically ill children (26.3%, n = 108; Fig. 2). Almost 80% (n = 325) of the respondents indicated that they actually perceived an event as an adverse event, of which 277 described this event. Aggressive behavior of parents towards the physician was most commonly named as an adverse event (42.5%, n = 118).
Fig. 2

Top 10 events pediatricians describe as an adverse event (n = 410), multiple answers possible

Posttraumatic stress disorder

Table 4 shows the outcomes of the TSQ. Among the respondents, 79.3% experienced an adverse event at work, of which 34.9% (n = 143) reported having experienced this event during their work more than 4 weeks ago.
Table 4

HADS and TSQ scores

 

Total (n = 410)

Resident (n = 74)

Attending (n = 307)

Retired (n = 23)

Non-practicing (n = 6)

P value**

Experienced potential psychotraumatic event at work as a physician

325 (79.3)

     

Depression

 HADS-D score above cut-off

30 (7.3)

1 (1.4)

27 (8.8)

1 (4.3)

1 (16.7)

0.03

Anxiety

 HADS-A score above cut-off

58 (14.1)

9 (12.2)

47 (15.3)

0 (0)

2 (33.3)

0.49

Combined anxiety and depression

 Combined HADS score above cut-off

79 (19.3)

13 (17.6)

63 (20.5)

1 (4.3)

2 (33.3)

0.57

PTSD

 Traumatic experience (criterion A)

143 (34.9)

23 (31.1)

111 (36.2)

7 (30.4)

2 (33.3)

 

 TSQ score above cut-offa

9 (6.3)

2 (8.7)

6 (5.4)

1 (14.3)

0 (0.0)

0.63

All values shown in n (%)

HADS Hospital Anxiety and Depression Scale, HADS-D Hospital Anxiety and Depression Scale—Depression, HADS-A Hospital Anxiety and Depression Scale—Anxiety, TSQ Trauma Screening Questionnaire

**χ2 test between residents and attending

aMeasurements based on the following: total n = 143, resident n = 23, attending n = 111, retired n = 7, and non-practicing n = 2

The mean score of the TSQ was significantly lower in the group of participants where a peer support protocol was present for adverse events (0.77 ± 1.06) compared to the group where no protocol was present or where it was not used (1.62 ± 2.10, P = 0.02).

Depression and anxiety

Outcomes of the HADS are shown in Table 4. Attending pediatricians have significantly more depressive symptoms according to the HADS-D compared to residents (P = 0.03).

Coping

The most common coping strategies after adverse events were (multiple answers possible) seeking support from colleagues (86.1%, n = 353), seeking support from friends and family (73.2%, n = 300), seeking some other form of distraction (32.7%, n = 134), or doing sports (22.4%, n = 92). Respondents learned their coping strategies (multiple answers possible) during residency (58.3%, n = 239), as an attending (55.1%, n = 226), during clerkships (20.2%, n = 83), and 21.0% (n = 86) reported to having never learnt to cope with adverse events.

Of the respondents, 41.0% (n = 168) has seriously considered quitting their job at some point in their career. Most common reasons for this were (multiple answers possible) disbalance between work and private life (75.0%, n = 126), high workload (68.5%, n = 115), disutility (working outside of working hours; 44.6%, n = 75), too much stress (38.7%, n = 65), and too much responsibility (37.5%, n = 63; Fig. 3). Furthermore, 6.6% (n = 27) considered quitting because of a complaint to the disciplinary board.
Fig. 3

Top 10 possible reasons pediatricians describe to stop working (n = 168). Multiple answers possible

Six percent (n = 26) of the respondents admitted that they were dealing with adverse events by drinking more alcohol and 1.2% (n = 5) by taking new medication. Professional psychological help was sought by 9.8% (n = 44) and 16.1% (n = 66) stifled emotions.

After being exposed to a work-related adverse event, 18.5% (n = 76) of the respondents adjusted their work. Most common ways to do this were (multiple answers possible) performing more diagnostic tests (51.9%, n = 40), calling a colleague earlier (36.4%, n = 28), work less (33.8%, n = 26), and starting treatment faster (20.8%, n = 16). Over time, 40.5% (n = 166) of the respondents reported to have become more defensive.

Support

Of the respondents, 26.3% (n = 108) indicated that there was a protocol for support in the case of an adverse event in their current working environment, 34.2% indicated that there was no protocol, and the remainder did not know whether there was a protocol. Furthermore, 50.2% (n = 206) thought that a culture change is necessary concerning coping with adverse events. When asked what the standardized support system involved (multiple answers possible), respondents indicated that discussing the situation with the present team (71.2%, n = 292) and self-initiated peer support with direct colleagues (64.9%, n = 266) were used. Of the respondents, 16.3% (n = 67) indicated that there was no support system at all and 41.5% (n = 170) confided that there is not enough opportunity to discuss adverse events and express emotions.

According to the respondents, the preferred form of support would be (multiple answers possible) discussing the situation with the present team (76.3%, n = 313), peer support from direct colleagues (72.0%, n = 295), and professionally organized peer support (43.2%, n = 178). Even though 28.5% (n = 117) would prefer to get help from a psychologist or coach, only 9.8% (n = 40) actually sought out this kind of help.

Discussion

The aim of this study was to examine work-related stressors and associated mental health problems in pediatricians as well as their ways of coping and received emotional support in their institute. First of all, among pediatricians, work-related stressors during their career were high. Suspicion of child abuse and critically ill children are two topics that distinguish pediatricians from other specialties and why this specific specialty can have high emotional burden. Notable is the high prevalence of aggressive behavior towards pediatricians, as stated in the quotes. Therefore, we think that it is necessary to not only develop a better support system after an adverse event but to also implement ways to teach pediatricians to cope with aggression. For example, certain training programs (conflict management and de-escalation (CMD)) focus on how to cope with aggression [19, 20]. Another stressor may be a complaint to the disciplinary board. This has a high impact on psychological well-being and is associated with defensive practice [21]. More than half of the pediatricians who received a complaint at the disciplinary board seriously considered quitting their job. More work-years corresponded with a higher chance to receive a complaint. Whether the non-practicing group stopped working because of complaints at the disciplinary board cannot be answered because of the small numbers. The amount pediatricians who received a complaint to the disciplinary board is low compared to gynecologists [17].

The point prevalence of PTSD in The Netherlands is 1.3%, making that the point prevalence of work-related PTSD is expected to be even lower [8]. In our questionnaire, when pediatricians experienced a traumatic event, we found a high point prevalence of symptoms indicative of work-related PTSD (2.2%). However, compared to the study of Ruitenburg et al., who found a prevalence of PTSD complaints of 15% in hospital physicians, the percentage we found seems low. Nonetheless, the study of Ruitenburg et al. used a much lower threshold than is normally used to assess PTSD complaints and does not use Criterion A [10]. Furthermore, we found more respondents with depressive and anxiety symptoms as compared to 1-year prevalences found in the general Dutch high-income population [8].

After experiencing an adverse event, a little over a quarter of all respondents indicated that there was a protocol regarding adverse events, but over half of the respondents do think a culture change is needed. Therefore, pediatricians have the need for a better support system. When more than half of the pediatricians perceive that care surrounding adverse events is not sufficient, this could lead to unnecessary stress. Physicians might experience more barriers than non-physicians to seek out professional help for mental health problems due to their fear of losing their license, denial of problems, and embarrassment [22]. When physicians are unfit, this may have a negative impact on their practice [23], whereas occupational well-being can positively contribute to patient satisfaction and the quality of interpersonal aspects of care [6]. In this questionnaire, coping strategies applied by the pediatricians were similar to coping strategies of gynecologists in the study by Baas et al. [17]. Almost 20% of the respondents adjusted their job and 40% seriously considered quitting their job completely. This is consistent with the findings of Hawkins et al. [24], who also found that physicians reduce work hours, retire, or quit medicine altogether because of a high work strain. Reported alcohol use to cope with adverse events seems to be quite low in our respondents with only 6%, especially since Hyman et al. found percentages of 6% (daily use) up to 25% (occasional use) of substances [25].

Thus far, little research has been done on this topic, specifically concerning mental health problems in relation to institutional or peer support. This study, which included validated questionnaires, allowed for detailed data collection. Allowing respondents to fill out examples of their experiences gives further insight in the way they experience their problems.

Limitations of the study are the response rate, with 18.9% lower than the average e-mail response rate of 25–30% [26]. Reasons for the low response rate could not only be the heavy workload of pediatricians but also the fact that the questionnaire was spread through a non-personal email account from the NVK, which people may not always read. With 410 completed questionnaires, however, we have a representative cohort comparable to the reference group. Another limitation is the risk of participation bias, because as with any questionnaire, pediatricians who are involved with this topic are more likely to participate. Concerning depression and anxiety, screening rates are generally an overestimation, especially when using self-report questionnaires. However, these are point prevalences, so when compared to 12-month prevalences, it can be an underestimation. Furthermore, depression and anxiety are not merely work-related.

In conclusion, work-related stressors in Dutch pediatricians are high and can subsequently lead to posttraumatic stress disorder. Parental aggression towards pediatricians seems to be a common problem, something that should be addressed, for example with CMD training programs [19]. In this study, the amount of pediatricians with PTSD complaints was higher compared to prevalences found in the general population and the same applies to depression and anxiety symptoms. There is no national standardized support after adverse events for pediatricians, while other occupations where there is an occupational hazard do have such support (e.g., in the police, military, firefighters). It is advised that evidence-based support (e.g., peer support) after adverse events is protocolled and education on coping strategies is implemented, to improve mental well-being of pediatricians.

Notes

Acknowledgments

We would like to thank all members of the Pediatric Association of The Netherlands (NVK) who participated in this questionnaire for their interest in this topic. Furthermore, we would like to thank the Pediatric Association of The Netherlands (NVK) for their help. Lastly, we would like to thank Eva Jacobs (EJ) for categorizing all answers.

Authors’ contributions

Dr. M.G. van Pampus, K.W.F. Scheepstra and M.E. van Steijn conceptualized and designed the study, drafted the initial manuscript and reviewed and revised the manuscript.

G. Yasar collected data, carried out the initial analysis and reviewed and revised the manuscript.

Prof. dr. M.C. de Vries and prof. dr. Olff reviewed and revised the manuscript for important intellectual content.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Compliance with ethical standards

This study was exempted from ethical approval by the Medical Research Ethics Committees United (MEC-U) and registered under the number W18.096.

Financial disclosure statement

The authors have no financial relationships relevant to this article to disclose.

Conflict of interest

The authors declare that they have no conflicts of interest.

References

  1. 1.
    Kessler RC, Aguilar-Gaxiola S, Alonso J, Benjet C, Bromet EJ, Cardoso G, Degenhardt L, de Girolamo G, Dinolova RV, Ferry F, Florescu S, Gureje O, Haro JM, Huang Y, Karam EG, Kawakami N, Lee S, Lepine JP, Levinson D, Navarro-Mateu F, Pennell BE, Piazza M, Posada-Villa J, Scott KM, Stein DJ, ten Have M, Torres Y, Viana MC, Petukhova MV, Sampson NA, Zaslavsky AM, Koenen KC (2017) Trauma and PTSD in the WHO world mental health surveys. Eur J Psychotraumatol 8:1353383CrossRefGoogle Scholar
  2. 2.
    de Vries GJ, Olff M (2009) The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands. J Trauma Stress 22:259–267CrossRefGoogle Scholar
  3. 3.
    Brazeau CM, Schroeder R, Rovi S, Boyd L (2010) Relationships between medical student burnout, empathy, and professionalism climate. Acad Med 85:S33–S36CrossRefGoogle Scholar
  4. 4.
    Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag J (2010) Burnout and medical errors among American surgeons. Ann Surg 251:995–1000CrossRefGoogle Scholar
  5. 5.
    de Oliveira GS Jr, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, McCarthy RJ (2013) The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesth Analg 117:182–193CrossRefGoogle Scholar
  6. 6.
    Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM (2015) A systematic review of the impact of physicians’ occupational well-being on the quality of patient care. Int J Behav Med 22:683–698CrossRefGoogle Scholar
  7. 7.
    Frank SL Jr, Sherbino J (eds) (2015) CanMEDS 2015 Physician Competency Framework. Royal College of Physicians and Surgeons of Canada, OttawaGoogle Scholar
  8. 8.
    de Graaf R, ten Have M, van Gool C, van Dorsselaer S (2012) Prevalence of mental disorders and trends from 1996 to 2009. Results from the Netherlands mental health survey and incidence Study-2. Soc Psychiatry Psychiatr Epidemiol 47:203–213CrossRefGoogle Scholar
  9. 9.
    Bernburg M, Vitzthum K, Groneberg DA, Mache S (2016) Physicians’ occupational stress, depressive symptoms and work ability in relation to their working environment: a cross-sectional study of differences among medical residents with various specialties working in German hospitals. BMJ Open 6:e011369CrossRefGoogle Scholar
  10. 10.
    Ruitenburg MM, Frings-Dresen MH, Sluiter JK (2012) The prevalence of common mental disorders among hospital physicians and their association with self-reported work ability: a cross-sectional study. BMC Health Serv Res 12:292–298CrossRefGoogle Scholar
  11. 11.
    Skogstad M, Skorstad M, Lie A, Conradi HS, Heir T, Weisaeth L (2013) Work-related post-traumatic stress disorder. Occup Med (Lond) 63:175–182CrossRefGoogle Scholar
  12. 12.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA, American Psychiatric Association, Washington, DCCrossRefGoogle Scholar
  13. 13.
    Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370CrossRefGoogle Scholar
  14. 14.
    Brewin CR, Rose S, Andrews B, Green J, Tata P, McEvedy C, Turner S, Foa EB (2002) Brief screening instrument for post-traumatic stress disorder. Br J Psychiatry 181:158–162CrossRefGoogle Scholar
  15. 15.
    Dekkers AM, Olff M, Naring GW (2010) Identifying persons at risk for PTSD after trauma with TSQ in the Netherlands. Community Ment Health J 46:20–25CrossRefGoogle Scholar
  16. 16.
    Mouthaan J, Sijbrandij M, Reitsma JB, Gersons BP, Olff M (2014) Comparing screening instruments to predict posttraumatic stress disorder. PLoS One 9:e97183CrossRefGoogle Scholar
  17. 17.
    Baas MAM, Scheepstra KWF, Stramrood CAI, Evers R, Dijksman LM, van Pampus MG (2018) Work-related adverse events leaving their mark: a cross-sectional study among Dutch gynecologists. BMC Psychiatry 18:73CrossRefGoogle Scholar
  18. 18.
    Foa EB, Riggs DS, Dancu CV, Rothbaum BO (1993) Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Trauma Stress 6:459–473CrossRefGoogle Scholar
  19. 19.
    Hemati-Esmaeili M, Heshmati-Nabavi F, Pouresmail Z, Mazlom S, Reihani H (2018) Educational and managerial policy making to reduce workplace violence against nurses: an action research study. Iran J Nurs Midwifery Res 23:478–485CrossRefGoogle Scholar
  20. 20.
    Rosenman ED, Vrablik MC, Charlton PW, Chipman AK, Fernandez R (2017) Promoting workplace safety: teaching conflict management and de-escalation skills in graduate medical education. J Grad Med Educ 9:562–566CrossRefGoogle Scholar
  21. 21.
    Bourne T, Vanderhaegen J, Vranken R, Wynants L, De Cock B, Peters M, Timmerman D, Van Calster B, Jalmbrant M, Van Audenhove C (2016) Doctors’ experiences and their perception of the most stressful aspects of complaints processes in the UK: an analysis of qualitative survey data. BMJ Open 6:e011711CrossRefGoogle Scholar
  22. 22.
    Brooks E, Early SR, Gendel MH, Miller L, Gundersen DC (2018) Helping the healer: population informed workplace wellness recommendations for physician well-being. Occup Med (Lond) 68(4):279–281Google Scholar
  23. 23.
    Wallace JE, Lemaire JB, Ghali WA (2009) Physician wellness: a missing quality indicator. Lancet 374:1714–1721CrossRefGoogle Scholar
  24. 24.
    Hawkins M (2016) 2016 Survey of America’s physicians. Practice patterns & perspectives. The Physicians Foundation, MemphisGoogle Scholar
  25. 25.
    Hyman SA, Shotwell MS, Michaels DR, Han X, Card EB, Morse JL, Weinger MB (2017) A survey evaluating burnout, health status, depression, reported alcohol and substance use, and social support of anesthesiologists. Anesth Analg 125:2009–2018CrossRefGoogle Scholar
  26. 26.
    Yun GW, Trombo CW (2000) Comparative response to a survey executed by post, e-mail, & web form. Journal of Computer-Mediated Communication 6(1)Google Scholar

Copyright information

© The Author(s) 2019

OpenAccessThis 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.

Authors and Affiliations

  1. 1.Department of Obstetrics and GynecologyOLVGAmsterdamThe Netherlands
  2. 2.Department of Obstetrics and Gynecology, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
  3. 3.Department of Psychiatry, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
  4. 4.Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
  5. 5.Arq Psychotrauma Expert GroupDiemenThe Netherlands
  6. 6.Department of Medical Ethics and Health LawLeiden University Medical CenterLeidenThe Netherlands
  7. 7.Department of PediatricsLeiden University Medical CenterLeidenThe Netherlands

Personalised recommendations