Assessment of burnout in New Zealand ophthalmology registrars

The medical workforce is prone to burnout and fatigue due to the emotionally demanding nature of the profession, where increased workloads, long hours and understaffing all play a role. It is now well documented that doctors have higher rates of burnout when compared with the general population.¹ Most literature focusses on the senior workforce, highlighting the demands on consultants in New Zealand’s public health system.^2–4 With increased demands on the public health system, there is growing reliance on the junior workforce to maintain service provision. This in turn can result in increased patient load, decreased teaching opportunities and diminished opportunities to progress,^5,6 each of which increases the risk of burnout.⁶

Burnout is a serious concern at an individual level as there are links to increased risk of depression, anxiety, sleep disturbances, suicidal ideation and substance abuse.^5–7 Additionally, these effects are not only limited to the individual but also have downstream consequences, often leading to decreased empathy, increased absenteeism, higher risk of medical error and, ultimately, worse patient outcomes.^5–7

Ophthalmology is a specialty that requires high levels of professionalism, clear communication, emotional intelligence and clinical/surgical competence.^8,9 Most ophthalmic procedures will affect patients’ visual potential and, directly or indirectly, their quality of life.⁹ Complications can result in significant loss of vision and even blindness, which is not only devastating to patients but also has a negative impact on the surgeon and causes further strain on the health system.

Currently, there are no studies published analysing the rates of burnout in training and non-training ophthalmology registrars within New Zealand. However, similar studies in several other first-world countries have shown high rates.^8–10 This study aims to assess the rates of burnout in New Zealand ophthalmology registrars with the hypothesis that the levels of burnout will be comparable to other developed countries with similar ophthalmology training pathways.

Methods

An anonymous, online 53-question survey was sent to New Zealand trainee and non-trainee ophthalmology registrars. To reach this intended group, the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) ophthalmology trainee representative was contacted to be a point of contact for the study. They received the survey sent via email for distribution to the current RANZCO trainees. The non-training ophthalmology registrars were identified via trainees at each hospital with an ophthalmology department, and the non-training registrars also received the same survey via email link.

The survey included questions addressing demographics such as gender preference, age, ethnicity, relationship status and number of years within the specialty. Secondly, there were questions on their respective ophthalmology departments including setting of department, staffing levels and rostering. Thirdly, questions related to lifestyle included sleep patterns, exercise regimes, use of social media and use of alcohol or other substances.

The final section of the survey was the Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS MP), which is a certified tool for assessing burnout.¹¹ Twenty-two questions addressed three facets: emotional exhaustion (EE; measures feelings of being emotionally overextended and exhausted by one’s work), depersonalisation (DP; measures an unfeeling and impersonal response toward patients) and sense of personal accomplishment (PA; measures feelings of competence and successful achievement in one’s work). A score is calculated for each facet and then stratified into either mild, moderate or severe burnout.

View Table 1–3.

Parametric data between trainees and non-trainees were compared using unpaired Student’s t-Tests. Demographic data were compared using the Chi-squared test. A p-value <0.05 was considered statistically significant. A multiple regression analysis was performed under the general linear model to establish associations between independent and outcome variables.

Ethics approval

Ethics approval for this study was obtained from the Academic Committees and Services of University of Otago Medical School. This study also has support from the Ngāi Tahu Research Consultation Committee.

Results

Out of the 35 trainee registrars surveyed, 31 responded, along with 14 out of 30 non-trainee registrars, yielding an overall response rate of 69%. Burnout was identified if respondents had high scores in any of the three facets on the MBI-HSS MP (Table 2). Among the respondents, 55% of trainees (17 out of 31) and 77% of non-trainees (11 out of 14) reported experiencing burnout.

Trainees exhibited moderate levels of burnout, with mean scores of 26.9 for EE, 7.2 for DP and 36.4 for PA. In contrast, non-trainees showed a trend towards higher levels of burnout, with mean scores of 32.1 for EE, 8.9 for DP and 32.6 for PA. A greater proportion of non-trainees fell into the severe range for both EE (64.3% vs 48.4%) and DP (57.1% vs 29%) compared with trainee registrars.

Manageable workload was the only variable found to be statistically significant between training and non-training registrars (p=0.0448, Table 3). Among trainees, 58.1% agreed that their workload was manageable, compared with only 14.3% of non-trainees. Conversely, 57.1% of non-trainees disagreed with the statement, indicating an unmanageable workload, compared with just 19.4% of trainees. These findings suggest a significant association between training status and perceptions of workload manageability, with significant implications for burnout.

Discussion

Burnout is a pervasive syndrome affecting medical professionals across various specialties. It has been well documented that it negatively impacts doctors worldwide, leading to depleted energy, increased mental distance from work, cynicism and diminished professional efficacy.^1,8,12–14 Burnout is particularly prevalent during the demanding stages of medical training.^6,9,15 Despite common perceptions that ophthalmologists experience higher job satisfaction, a less stressful work environment and a generally more favourable lifestyle than other medical professionals,¹⁶ research assessing burnout among ophthalmologists, particularly among registrars, is lacking. Our study reveals that more than half of New Zealand's ophthalmology registrars experience burnout, regardless of their level of training.

Ophthalmology in New Zealand is renowned for its high standards in both clinical practice and professional conduct. These standards are shaped by rigorous training programmes and the exemplary behaviours modelled by RANZCO and its members. The training process, though challenging and often stressful, is essential for preparing practitioners to excel in a specialty that focusses on improving or restoring visual function, a profoundly rewarding privilege shared among ophthalmologists.

Sedhom et al. revealed that 37.8% of 592 practicing ophthalmologists in the United States of America (USA) experienced burnout.⁸ This rate is significantly lower compared with the burnout prevalence observed in our study, which focussed on registrars. In New Zealand, burnout was found—in this study—in 77% of non-trainee and 55% of trainee ophthalmology registrars, averaging 67% across both groups. These rates are comparable with the burnout prevalence among ophthalmology residents in the USA, where 63.3% reported experiencing burnout.¹⁵ Conversely, burnout rates among ophthalmology residents in Saudi Arabia are notably lower at 41%.⁹ Interestingly, when comparing these findings with burnout data from orthopaedic registrars in New Zealand, a similar pattern emerges. In the orthopaedic cohort, 52% of trainees and 50% of non-trainee registrars exhibited moderate to severe levels of burnout on the MBI-HSS MP scale.⁶ These findings indicate that burnout is particularly prevalent among early career stages, regardless of surgical specialty. Thus, addressing the underlying factors contributing to burnout throughout training and equipping future ophthalmologists with effective coping strategies may help mitigate burnout in the present and future.

Securing a place in the ophthalmology training programme is highly competitive, more so than in many other medical specialties. To earn an interview for potential selection, candidates are evaluated using a points-based system with a maximum score of 34. Points are awarded based on several criteria, including Indigeneity, scholarly achievements, regional exposure, ophthalmic work experience and significant PAs. According to the RANZCO 2022–2023 Annual Report, applicants typically work an average of 4.6 years after completing their medical degree before being selected for the programme.¹⁷ In New Zealand, this equates to at least 2.6 years spent as a non-training registrar.

Chambers et al. found that 50% of New Zealand’s senior medical workforce experienced burnout, with rates decreasing with age.² The age group most affected by burnout was those aged 30–39 years. This is particularly concerning given the average age of new trainees entering the 2023 RANZCO programme was 31 years,¹⁷ and 80.7% of the trainees surveyed fell within this age bracket. This is especially concerning for the 30.7% of non-training registrars that fall within this age group, who face heightened pressure to boost their application scores through regional postings and extra academic commitments. These compounded pressures may leave them vulnerable to burnout while striving to secure a place on the training programme. This increased vulnerability is reflected in our study, where non-trainee registrars showed a trend towards higher levels of EE and DP, along with lower levels of PA.

Additional key points warrant mentioning. In our study, 90.2% of trainees and 92.8% of non-trainees reported working more than 50 hours per week. This contrasts with findings from Feng et al., who reported that ophthalmology residents in the USA averaged 67 hours per week (excluding on-call duties) and found a clear association between longer work hours and increased burnout and EE.¹⁵ While our study did not find a significant correlation between the number of hours worked and burnout rates, it did reveal that workload manageability was a more critical factor. Only 58.1% of trainees and 14.3% of non-trainees felt their workload was manageable. Despite shorter workweeks, the intensity and demands of the workload for New Zealand registrars may contribute to heightened burnout.

Furthermore, over 70% of both trainees and non-trainees reported feeling well supported by their senior colleagues and did not report experiencing mistreatment. Senior colleagues play a vital role in providing mentorship, facilitating ongoing professional development, offering constructive feedback and creating opportunities for career advancement.¹⁸ Although the association between senior support and burnout was not statistically significant in our study, existing literature underscores the important role of senior support in reducing burnout.^6,19 Enhancing senior support may thus be a key strategy for mitigating burnout, particularly in settings where such support is currently limited.

This study has a few limitations. With only 45 respondents, our sample size was small compared with similar studies,^9,15 which may have limited our ability to achieve statistical significance when analysing various demographic factors. However, this small sample size was anticipated given the limited number of ophthalmology registrars in New Zealand. Nonetheless, our high response rate of 69% enhances the generalisability of these findings to other medical specialties in New Zealand.

To address these issues and better understand the demographic factors influencing burnout, future research should expand the sample size by including Australian trainees and non-trainees under the RANZCO framework. While work experiences and environments may differ between these groups, their shared participation in the RANZCO training programme could offer valuable insights into the specific factors contributing to burnout. These insights could inform the development of targeted strategies to mitigate registrar burnout.

Being a cross-sectional anonymous survey, this study is affected by survey bias. Respondents are likely to have a vested interest in burnout, which may skew the results toward higher burnout rates compared with non-responders.

Furthermore, burnout is influenced by various factors beyond the work environment, including stress management, personal health and inherent personality traits,^20–22 which were not included in the survey. Future surveys should incorporate questions that assess personality characteristics such as grit, mindfulness and coping skills, which are known to predict wellbeing and offer protection against burnout.²³

Conclusion

This study highlights the significant prevalence of burnout among New Zealand ophthalmology registrars, with non-trainees exhibiting higher levels of EE and DP compared with trainees. Workload manageability emerged as a crucial factor in burnout, with non-trainees facing greater challenges in managing their workload. These findings demonstrate the substantial impact of burnout, particularly on non-training registrars, and highlights the need for targeted interventions to improve workload management and alleviate burnout in this group.