Empathy and burnout in Slovenian family medicine doctors: The first presentation of jefferson scale of empathy results

Empathy has been recognised as an important and powerful part of communication in general practice, strengthening the physician-patient relationship (1, 2). Burnout in family medicine doctors (FMDs) at the front line of health care, disrupts this relationship (3, 4, 5, 6). An empathic attitude is described as the capacity to understand what another person is experiencing from within their frame of reference (7). Physicians with empathic attitudes experience greater patient satisfaction and better patient compliance and adherence to treatment (8, 9). In addition, they tend to face fewer medical errors (10), have improved health outcomes (11), report fewer symptoms of burnout and have better well-being (12). The concept of empathy consists of cognitive and affective components (13), with a known moderate correlation between the concepts of sharing understanding and sharing emotion in patient-care (14).

Almost 65% of European FMDs exhibit signs of burnout (3) with various and non-specific symptoms (6). As the response to chronic emotional and interpersonal stressors at work, burnout leads to reduced job performance (15); the physicians’ behaviour can have a detrimental effect on the health of patients and lead to more malpractice suits (16) and patient dissatisfaction (17). In physicians, the heavy workload and the lack of financial and organisational resources are important risk factors for burnout (15, 18), with an intense empathic attitude leading to emotional exhaustion and causing burnout syndrome (19). Some studies determined depersonalisation to be the main reason for a decrease in empathic attitude (20).

In Slovenia, burnout has only been evaluated in family medicine trainees, who scored highly (71%) in at least one burnout dimension (21). This is the first study in Slovenian family medicine focusing on the relationship between empathy and burnout and aiming to assess the extent of burnout and the level of empathic attitude in FMDs, and also to explore their associations with sociodemographic factors, working conditions and health. The Jefferson Scale of Empathy (JSE) for physicians was used as a validated self-assessment tool for the first time in Slovenia (see Additional File).

Most of the responding FMDs were females (78.9% trainees and 83.9% specialists), working in this speciality for 11.2±10.4 years. The majority were married or in an intimate relationship (272 (86.1%)), most of them had children (218 (69%)). At the time of the survey, more FMDs worked in urban (199 (63%)) than in rural (117 (37%)) settings. Approximately half of the participants had to provide emergency care during regular worktime (152 (48.1%)) vs. 164 (51.9%)). A quarter did not work night shifts (75 (23.7%)), the same proportion reported night shifts at least 4 times per month, while one to three night shifts were reported by 166 (52.5%) respondents. Most of the participants examined at least from 40 to 60 patients per a working day (230 (72.8%)), 53 (18.7%) FMDs dealt with 60 or more patients per day and only a minority worked with less than 40 patients per day (33 (10.4%)).

Participants mainly reported no chronic illnesses (230 (72.8%)) and used either none (136 (43%)) or less than six sick leave days in a year (119 (37.7%)). Only 61 (19.3%) needed 6 or more sick leave days per year. Self-assessment of their general health was well (3.5±0.9), the same for mood and emotional state (3.2±0.9).

This study assessed the level of empathic attitude and extent of burnout in Slovenian FMDs, and tested associations between JSEtot and individual burnout dimensions with socio-demographic factors, working conditions and physician health (Tables 2, 3). Psychometric properties of Slovenian MBI and JSE scales are also presented (Table 1), introducing the Slovenian version of JSE as validated and highly recommended instrument.

The participants reported a higher level of burnout when comparing mean values for each dimension with European FMDs (Table 2) (3, 33) and Slovenian family medicine trainees (21). A large cross-national burnout study (34) included Slovenian psychiatry trainees, but used a 16-item MBI-GS scale, which made the comparison very difficult. Another hurdle is different speciality, given that psychiatrists could exhibit even higher burnout and have different work process than FMDs. The positive association between emotional exhaustion and age and work experience (Table 2) was identified, concordant with a Slovenian study of family medicine trainees results (21). Maslach (15) discovered greater burnout in those at the beginning of their careers, but warns of survival bias. With regard to work experience, specialists reported higher burnout scores in all three dimensions, in comparison to trainees (Table 3). This is plausible, considering the situation in the Slovenian healthcare system, with specialists taking on an even higher workload, i.e., an excessive number of patients and extensive bureaucracy (35). The overall higher burnout in specialists (Table 3) could be attributed also to the sampling method.

Slovenian female FMDs reported lower personal accomplishment than males (Table 3), while in an European burnout study (3), a strong association between male gender and a high score in all three burnout dimensions was found. Parenting was associated with higher personal accomplishment scores, whereas living in an intimate partnership was not associated with any dimension of MBI (Table 3). Parenting probably shapes personality more than having a partner, in terms of hardiness, self-esteem, non-avoidant coping style, which are found to protect against burnout (15). An increased tendency to experience burnout in those who are single or not married was reported previously (15), while Park et al. reported of no correlation between MBI and marital status or parenting (36).

The correlation between workload and emotional exhaustion (Table 2), supported by the findings highlighting difficult working conditions in Slovenian primary health care, with 90% of physicians dealing with at least 40 patients and 20% with at least 60 patients per day (Table 2), is concordant with a previous Slovenian study of family medicine trainees and Croatian FMDs (21, 37). An additional burden was demonstrated in those working in rural family medicine clinics (Table 3), which is concordant with the study in which those working in rural settings scored higher on the MBI (28).

Unlike burnout, there are few studies that deal with physicians’ empathy, yet research into this topic is on the rise (38). It is difficult to compare scores for empathic attitude, as different instruments and study populations were in use (39, 40). The FMDs in this study reached a JSEtot (Table 2) comparable to that of medical students (40, 41), but the scores were lower than in doctors in other studies (11, 24). These findings could be attributed to cultural, educational and organisational differences of studied populations. Some other researchers also shortened the scale to improve internal consistency (13, 36). Literature often describes greater empathy in female physicians and medical students (1, 13, 19, 24, 36, 40, 41, 42), but no correlation between gender and empathic attitude was discovered in this study (Table 2).

FMDs with a chronic illness reported higher emotional exhaustion and showed a higher empathic attitude (Table 2). Physical illness affecting burnout has not yet been adequately researched and there is a high possibility of burnout in the presence of a persistent stressor, such as chronic disease (43). The impact of chronic illness on empathic capacity was examined in some qualitative studies, showing greater empathy in those who had experienced illness themselves (44).

More empathic participants felt greater personal accomplishment (Table 2), similarly to studies of Spanish (42) and French (45) FMDs and to family medicine trainees (20); physicians with greater empathic attitudes were reported to be less emotionally exhausted (36). Cognitive component of empathy (Perspective Taking) was associated with greater personal accomplishment (Table 2), similarly to Paro et al. (46), who reported personal accomplishment to be significantly associated with decreasing personal distress and which was found to be a reliable predictor for perspective taking. Some research shows that deficits in perspective taking alone might be a risk for burnout, whereas higher perspective taking and empathic concern might be protective (19, 47).

Given that multiple comparisons bias was additionally addressed by holding alpha error rate at 5% and changing the level of statistical significance (p<0.001), this emphasised the most important results of this study, i.e., a positive association between emotional exhaustion and age and working experience ((r=0.213, p<0.001) and (β=0.28, p<0.001), respectively), and between personal accomplishment and cognitive component of empathy (β=0.35, p<0.001). That is concordant with several previous studies and strengthens the reliability of association between empathy and burnout. Contrary to previous studies, the correlations between age and burnout in FMDs could be explained by the Slovenian health care system organisation.

In this study, organisational issues are shown to be a high risk factor for burnout (Table 2), high workload being an issue in Slovenia as well as in other developed countries (3, 15, 37). The situation in the country, with an aging population, the lack of physicians working in primary care, a decrease in interest in family medicine residencies, and shortage of time for the patient (48), suggests an urgent need for psychological help and support for FMDs, taking into consideration empathic attitude, which is associated with the feeling of personal accomplishment.

This study, being the first in Slovenia to assess burnout and empathic attitude in trainees and specialists in family medicine, and with a satisfactory response rate (56%), opens a new dimension of the physician-patient relationship and emphasises the empathic approach to family medicine. The results from this study could be the starting point for a discussion on the restructuring of curricula for both medical students and family medicine trainees, and support for the work of specialists, since FMDs work in relative isolation in their outpatient clinics and are deprived of peer support, as capacity building was shown to be empowering (49, 50). Additionally, the Slovenian version of JSE is presented and could be applied in further research.

The associations between emotional exhaustion, workload, age and work experience, depict important issues of Slovenian family medicine. Given that the association between burnout and empathy was confirmed, the importance of learning empathic communication and peer-support-based capacity building in FMDs for the prevention of burnout have been shown. There is a need for further intervention studies in medical students and FMDs, in order to evaluate these findings, elaborate peer support interventions and enhance the quality of patient care.