Psycho-Oncology

Psycho-Oncology 17: 570–576 (2008)

Published online 12 October 2007 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1269

Stress and burnout in colorectal and vascular surgical

consultants working in the UK National Health Service
A. Sharma1, D. M. Sharp2, L. G. Walker2 * and J. R. T. Monson1
1
Academic Surgical Unit, University of Hull, Cottingham, Hull, UK
2
Institute of Rehabilitation, University of Hull, Hull, UK

* Correspondence to: Institute Abstract

of Rehabilitation, University of
Hull, 215 Anlaby Road,
Kingston upon Hull, HU3 2PG,
UK. E-mail: L.G.Walker@
hull.ac.uk
Received: 5 February 2007
Revised: 17 July 2007
Accepted: 28 July 2007
Background: It has been suggested that dealing with cancer is associated with increased stress
and burnout in health-care professionals. The aim of this study is to examine the prevalence of
psychiatric morbidity and burnout in surgeons working in the National Health Service (NHS),
and the putative relationship between psychiatric morbidity, burnout and the amount of cancer-
related work.
Methods: All consultant colorectal and vascular surgeons identified from their professional
societies were sent a booklet consisting of questions about cancer-related and specialty-specific
work load, job satisfaction and socio-demographics. It also included the General Health
Questionnaire (GHQ-12), the Maslach Burnout Inventory (MBI) and the Coping
Questionnaire.
Logistic regression analysis was used to identify independent predictors of psychiatric
morbidity (GHQ), burnout (MBI) and retirement intentions.
Results: Five hundred and one questionnaire booklets were completed and returned (response
rate 58.7%). The mean age of respondents was 47 years (range 31–65). The majority of the
surgeons were male (460, 92%).
One hundred and sixty-three (33%) surgeons scored in the positive range of the GHQ, and
154 (32%) had high burnout on at least one subscale of the MBI. Three hundred and eighty-
three (77%) surgeons stated that they intended to retire before the statutory retirement age.
Level of work satisfaction and perceived adequacy of training in communication and
management skills were significantly negatively correlated with GHQ and MBI scores.
Surgeons who planned to take early retirement or wished to retire as soon as they could afford
to were more likely to have psychiatric morbidity and/or burnout. Surgeons who were married
or cohabiting were less likely to have psychiatric morbidity, and younger surgeons were more
likely to have higher levels of depersonalization (DP). Work satisfaction was negatively
correlated with psychiatric morbidity and all three burnout scales.
Colorectal surgeons had a greater cancer-related workload than vascular surgeons
(48.6 vs 7.5%, respectively, U ¼ 2667; p50:005). However, there were no significant
differences between the two groups in psychiatric morbidity, personal accomplishment
and emotional exhaustion. Vascular surgeons, however, had significantly higher levels of DP
ðp ¼ 0:04Þ:
Conclusion: Levels of psychiatric morbidity, burnout and work dissatisfaction are worryingly
high in colorectal and vascular surgeons and are likely to impact adversely on patient
satisfaction and service quality. The number of surgeons intending to retire early is also a cause
for concern both in terms of the overall number of trained surgeons in the NHS and in the
balance between senior and junior surgeons. Apart from DP, these indicators of stress, however,
were unrelated to cancer workload.
Copyright # 2007 John Wiley & Sons, Ltd.
Keywords: surgeons; stress; burnout; coping; oncology; cancer

Introduction significant psychiatric morbidity. At approximately

There is evidence to suggest that job-related stress
and professional ‘burnout’ is increasing, and it has
been suggested that this may be due to changes in
the National Health Service (NHS) [1–3]. In a
survey of 882 UK consultants in 1996, Ramirez
et al. [2] found that 27% were likely to have
the same time, Wall et al. [4] studied a sample of
11 000 NHS employees and found a 27% pre-
valence of minor psychiatric disorders in compar-
ison with a prevalence of 18% in general
population. The most important sources of stress
were work overload, feeling badly managed and
resourced, managerial responsibilities and dealing

Copyright # 2007 John Wiley & Sons, Ltd.

Stress and burnout in surgeons
with patients’ suffering, while perceived good
relationships with patients, relatives and staff and
professional esteem made the greatest contribution
to overall job satisfaction [2].
In 1996, Ramirez et al. [2] found that stress and
burnout in surgical oncologists was significantly
lower than in medical oncologists and radiologists.
They suggested that surgeons were protected from
burnout and psychiatric morbidity because they
were able to exercise a significant amount of
control over their own work and also by receiving
positive and immediate feedback from patients.
Lack of perceived control has been shown to be a
good predictor of burnout [5].
Since the first survey by Ramirez 10 years ago,
there have been significant changes within the NHS
[6]. Some of these involve a target-driven culture
and loss of autonomy. In addition to changes
affecting all workers, some changes have affected
certain specialties and may have differentially
increased the risk of psychiatric morbidity and
burnout [7].
Recently, in a research letter, Ramirez et al.
reported a 10-year follow up of stress and burnout.
Over this period they found a significant increase in
psychiatric morbidity and emotional exhaustion
(EE) for surgical oncologists [7]: psychiatric
morbidity in this group had increased from 22 to
33%, burnout had increased from 27 to 41% and
job satisfaction had decreased from 68 to 65%.
It has also been suggested that dealing with
cancer is associated with increased stress and
burnout in health-care professionals [8,9]. In a
study of oncologists in the USA, more than half of
the respondents reported experiencing burnout in
their professional lives [8]. However, other studies
have not found any significant difference in
psychiatric morbidity and burnout in oncologists
compared with other physicians [2,7,10].
Colorectal surgeons care for a mixed group of
patients ranging from benign disorders with
excellent prognosis to colorectal cancer with wide-
spread metastases and extremely poor outlook.
The proportion of cancer work performed can vary
between consultants and may influence stress and
burnout. Vascular surgeons also have a varied case
mix with elective and acute cases; they may also
have similar on-call commitments as other general
surgeons, but they have very limited involvement
with cancer. Both the groups in our study were
employed in the NHS. It is of interest, therefore, to
compare psychiatric morbidity, burnout, job satis-
faction and retirement intentions in vascular
surgeons and colorectal surgeons.
The aims of this study, therefore, are to evaluate
the point prevalence of psychiatric morbidity,
burnout and job satisfaction in colorectal and
vascular surgeons in the UK and examine socio-
demographic and psychosocial factors that might
influence them.
Copyright # 2007 John Wiley & Sons, Ltd.
571
Methods
Respondents and procedure
Ethical approval for the study was obtained from
Hull and East Riding Local Research Ethics
Committee (reference 04/Q1104/29, 29th June
2004). Permission to reproduce copyrighted ques-
tionnaires (GHQ-12 and the MBI) was obtained.
A list of all consultant colorectal surgeons, who
were current members of the Association of
Coloproctology of Great Britain and Ireland
practicing in the NHS1, and a list of all current
vascular surgeons, who were members of the
Vascular Society of Great Britain and Ireland
practicing in the NHS1 was obtained from the
respective societies. Questionnaire booklets were
professionally printed to enable optical character
recognition and automated scoring of responses.2
Booklets were sent to surgeons by post, with a
covering letter explaining the purpose of the survey
and a request to return the survey within 10 days.
A stamped-addressed envelope was enclosed. Be-
cause responses were anonymous, a reminder letter
was sent to all surgeons two weeks later thanking
those who had returned the Booklet and requesting
that those who had not responded to do so as soon
as possible. Data collection was completed in April
2005.
Questionnaire
Participants completed a questionnaire booklet
that contained the following:
1. Socio-demographic questions about age, gender,
place of work (district general hospital,
university hospital or both), marital status,
percentage of clinical work involving patients
with cancer and percentage of clinical work
involving patients with colorectal/vascular
problems.
2. The General Health Questionnaire (GHQ) (12
item version): The GHQ has been validated
against a clinical psychiatric interview and is
widely used to screen for psychiatric morbidity
[11]. The GHQ-12 is self-administered and takes
about 5 minutes to complete. The questionnaire
enquires about the experience of psychological,
social and somatic symptoms over the past few
weeks. Each item is measured on a four-point
scale. Each of the 12 items is assigned a score of
0 (less or no more than usual) or 1 (rather or
much more than usual), giving a maximum score
of 12. A cut-off score of 4 or above indicates a
high probability that the individual suffers from
a clinically significant level of distress
(‘Caseness’/psychiatric morbidity).
3. The Maslach Burnout Inventory (MBI) is com-
monly used to measure three key aspects of
professional burnout}EE, depersonalisation
Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
572
(DP) and personal accomplishment (PA) [12].
Each of the attributes is rated on a seven-point
scale, and the total score for each subscale is
categorised as low, average or high. High
burnout is characterised by high scores on the
exhaustion and DP scales and low scores on the
accomplishment scale [13].
4. The Coping Questionnaire is used to measure
coping strategies used by people to deal with
work-related stress. This has been used
previously in a study of work-related stress in
police officers, prison officers, psychiatric nurses
and firemen [14,15].
5. Other ad hoc questions include level of job satis-
faction, retirement intentions, perception of
adequacy of communication and management
training.
6. Additional comments.
Scoring and interpretation of questionnaires
Optical character recognition was used for compi-
lation of data. Unreadable questionnaires were
read manually and all data were entered in an SPSS
database. Written comments were entered manu-
ally into an Excel database for each group.
Statistical analysis
Data were analysed using the Statistical Package
for the Social Sciences (SPSS, version 11.5,
Chicago, IL). Spearman’s correlation coefficient
was used to examine the relationships between
psychiatric morbidity and burnout with demo-
graphic characteristics, training in communication,
management, emotional problems and coping
strategies. The Chi square and Mann–Whitney
tests were used to compare psychiatric morbidity
and burnout levels in colorectal and vascular
surgeons and between surgeons with more or less
than 50% cancer workload, as appropriate. Logis-
tic regression was used to identify factors indepen-
dently predictive of psychiatric morbidity, burnout
and retirement intentions.
Table 1. Comparison of colorectal and vascular surgeons}demographic characteristics
Colorectal surgeons
Response rate 253/455 (55.6%)
Age 47.7 (range 32–65)
Gender}male 227 (89.7%)
Marital status}married/cohabiting 246/252 (97.6%)
Place of work DGH}173 (68.7%)
UH}69 (27.4%)
Both}10 (4%)
Cancer workload 48.6% (5–90%)
Specialty-specific workload 77.7% (20–100%)
Copyright # 2007 John Wiley & Sons, Ltd.
A. Sharma et al.
Results
The booklet was sent to 853 surgeons (455 color-
ectal, 398 vascular). Five hundred and one ques-
tionnaire booklets were returned, giving a response
rate of 58.7%. The response rates of colorectal and
vascular surgeons did not differ significantly (55.6
vs 62.3%, w2 ¼ 3:123; p ¼ 0:08).
The mean age of respondents was 47.4 years (SD
7.4, range 31–65). The majority of the surgeons
were male (460, 92%). Marital status was available
for 498 respondents (99.4%). Four hundred and
seventy-six respondents were either married or
cohabiting (95.6%). Three hundred and three
consultants were working in a district general
hospital (61%), 164 in a university hospital
(33%), and 30 (6%) said their work involved
working in both a DGH and a university hospital.
The mean cancer workload was 28.2% (SD 26.4,
range 0–90%).
Colorectal and vascular surgeons differed sig-
nificantly in terms of marital status (97.6 vs 94.3%,
respectively, w2 ¼ 4:083; p ¼ 0:04), place of work
(w2 ¼ 13:462; p50:005) and cancer workload (48.6
vs 7.5%, U ¼ 2667; p50:005). The differences in
age and gender were not statistically significant.
The average proportion of colorectal cases out of
the total workload for colorectal surgeons was
77.7% (SD 19.4, range 20–100%), whereas the
average amount of vascular workload for vascular
surgeons was 74.6% (SD 25.9, median 80%, range
20–100%, Table 1).
GHQ-12 scores were available for 499 surgeons
(99.6%) and MBI scores were available for 486
(97%) surgeons. The mean GHQ score was 2.9 (SD
3.4), the MBI EE, DP and PA scores being 21.1
(SD 11.5), 6.0 (SD 5) and 36.9 (SD 6.6),
respectively. There was no significant difference
between the total GHQ and MBI scores of color-
ectal and vascular surgeons.
GHQ scores were divided into normal (0–3) and
high (54) as recommended in the GHQ manual
[16]. MBI scores were divided into ‘low and high’
levels of burnout using standard scores for health-
care professionals (Table 2). One hundred and
sixty-three (32.9%) surgeons scored high on the
Vascular surgeons Chi square/Mann–Whitney, p value
248/398 (62.3%) w2 ¼ 3:123; p ¼ 0:08
47.1 (range 31–65) U ¼ 30081; p ¼ 0:52
233 (94.3%) w2 ¼ 2:444; p ¼ 0:12
230/246 (94.3%) w2 ¼ 4:083; p ¼ 0:04
DGH}130 (53.1%) w2 ¼ 13:462; p ¼ 0:001
UH}95 (38.8%)
Both}20 (8.2%)
7.5% (0–60%) U ¼ 2667; p50:005
74.6% (20–100%) U ¼ 30732:5; p ¼ 0:8
Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
Stress and burnout in surgeons
Table 2. Comparison of the presence or absence of psychiatric morbidity and burnout in colorectal and vascular surgeons
Colorectal surgeons (%)
GHQ scores Normal
High
MBI EE scores Low burnout
High burnout
MBI DP scores Low burnout
High burnout
MBI PA scores Low burnout
High burnout
Total
GHQ. Using the MBI, 154 (31.7%) had high EE,
103 (21.2%) had high levels of DP and 140 (28.8%)
had feelings of low PA on the MBI (Table 2).
Vascular surgeons were found to have significantly
higher levels of DP (w2 ¼ 4:06; p ¼ 0:04); there
were no significant differences in psychiatric
morbidity, PA or EE levels.
Three hundred and eighty-three surgeons (76.9%
of colorectal surgeons and 77.9% of vascular
surgeons, p ¼ 0:8) stated that they intended to
retire before the statutory retirement age and 343
(64.7% of colorectal surgeons and 73.7% of
vascular surgeons, p ¼ 0:06) said they would retire
as soon as they could afford to.
One hundred and fifty-eight (32.3%) consultants
thought they had not received adequate training in
communication skills, and 226 (43.5%) indicated
that they had insufficient training in management
skills. No significant difference was found between
vascular and colorectal surgeons. In terms of
coping with work-induced stress, no significant
differences were found between the two groups of
surgeons.
Younger respondents had higher DP scores
(U ¼ 16796; p ¼ 0:02) and surgeons who were
married or living with partners had lower levels
of psychiatric morbidity (w2 ¼ 5:9; p ¼ 0:01) and
DP (w2 ¼ 0:68; p ¼ 0:04).
In terms of coping with self-perceived work-
related stress, surgeons with psychiatric morbidity
and a high score on any of the three MBI scales
coped by changing their food consumption (by
eating more or less, p50.005), increasing their
alcohol consumption (p50.005), tending to take
work home (p50.005), keeping things to them-
selves (p50.005), taking stress out on family or
friends (p50.005), engaging less in sports
(p50.005) and recreation (p50.005) and mixing
less with friends (p50.005) in response to an
increase in work-related stress. On the other hand,
surgeons who scored in the normal range of the
GHQ and low on the burnout scales reported that
they coped by taking things easier (p50.005),
talking things over with family (p50.005), increas-
ing level of sports (p ¼ 0.02) and recreation
(p50.005) and mixing more with friends
Copyright # 2007 John Wiley & Sons, Ltd.
573
Vascular surgeons (%) p value
176 (69.8) 157 (64.3) w2 ¼ 1.698
76 (30.2) 87 (35.7) p ¼ 0.193
166 (68.9) 166 (67.8) w2 ¼ 0.071
75 (31.1) 79 (32.2) p ¼ 0.790
199 (82.6) 184 (75.1) w2 ¼ 4.060
42 (17.4) 61 (24.9) p ¼ 0.04
177 (73.4) 169 (69) w2 ¼ 1.181
64 (26.6) 76 (31) p ¼ 0.277
241 245
(p50.005) in response to stress. Surgeons with
normal GHQ scores and low burnout scores
reported greater job satisfaction (p50.005) and
indicated that they were less likely to retire before
retirement age (p50.005) or achieving affordability
(p50.005). Surgeons with low burnout and/or
normal GHQ scores considered their training in
management skills to have been adequate, whereas
those with high burnout and/or psychiatric mor-
bidity considered their training to have been
inadequate (p50.005). Surgeons reporting low
PA and high DP considered their training in
communication to have been inadequate
(p50.005).
Logistic regression analysis showed that several
factors independently predicted the presence or
absence of psychiatric morbidity and burnout. Low
job satisfaction was identified as most predictive of
psychiatric morbidity and all aspects of burnout.
Intention to retire early was an independent
predictor of high psychiatric morbidity, low PA
and high EE. Living with a partner was shown to
be protective against psychiatric morbidity. Eating
less or more and poor social coping were also
independent predictors of psychiatric morbidity
and burnout (Tables 3–6).
Discussion
This national study set out to investigate the
prevalence of psychiatric morbidity and burnout
in colorectal and vascular surgeons and to examine
the influence of demographic factors and coping
strategies.
Five hundred and one colorectal and vascular
surgeons returned the study booklet. This repre-
sents 56% of the colorectal surgeons and 62% of
the vascular surgeons who were identified by their
professional societies.
Overall, 33% of the surgeons (30% colorectal
and 36% vascular surgeons) scored 4 or above in
the GHQ, which suggests that they were currently
experiencing clinically significant psychiatric mor-
bidity. Ramirez et al. reported GHQ-12 caseness
(GHQ score 54) of 22% in surgical oncologists in
Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
574 A. Sharma et al.

Table 3. Logistic regression analysis showing independent related to impaired work performance, more days
predictors of psychiatric morbidity of missed work and poorer physical health in
Independent Coefficient (B) Significance (p) military personnel [17]. In addition to their own
covariates suffering, high psychiatric morbidity can have wide
ranging implications on families and friends. The
Marital status
1.527 0.01
Eat less 0.493 0.03
other concern is the high rate of suicide among
Take work home 0.679 0.01 doctors in the UK. Ramirez et al. [10] quote
Mix less with friends 0.715 0.003 reports from the BMA in which suicide stands out
Satisfaction with work
1.285 50.005 as a prominent cause of death among medical
Intention to retire before the 1.087 0.01 practitioners.
statutory retirement age In terms of burnout, 31% scored in the
‘significant range’ for EE, 21% for DP and 29%
for PA. The proportions of surgeons in the two
specialties were similar for EE and PA, but the
Table 4. Logistic regression analysis showing independent
predictors of burnout (personal accomplishment) proportion of vascular surgeons scoring higher on
DP was significantly higher (17 vs 25%). There are
Independent Coefficient (B) Significance (p) differences in the level of burnout found in Ramirez
covariates
study and this study; Ramirez et al. used the EE
Keep things to myself 0.470 0.02 component of burnout in the 2002 results. The level
Satisfaction with work
0.727 50.005 of EE increased from 27 to 41% between 1994 and
Intention to retire before the 0.945 0.01 2002 in their study. In this study, however, the level
statutory retirement age of EE was significantly lower, being 31.1% in
Training in communication
0.186 0.02
colorectal and 32.2% in vascular surgeons
(w2 ¼ 6:9; p ¼ 0:03).
According to Maslach et al. [12], burnout is
Table 5. Logistic regression analysis showing independent associated with long-term job-related stress: ‘what
predictors of burnout (emotional exhaustion) started out as important, meaningful and challen-
Independent Coefficient (B) Significance (p) ging work becomes unpleasant, unfulfilling and
covariates meaningless. Energy turns into exhaustion, invol-
vement turns into cynicism and efficacy turns into
Eat less 0.532 0.02
Take things easier
0.513 0.03
ineffectiveness’. Burnout is thought to be specific to
Keep things to myself 0.513 0.04 work context and is situation specific rather than
Talk with professional
0.403 0.05 general depression. The symptoms are also present
Take sleeping tablets 1.787 0.02 in normal persons who did not suffer from
Mix less with friends 0.665 0.007 psychopathology before and the emphasis is on
Satisfaction with work
1.123 50.005 the mental and behavioural symptoms rather than
Intention to retire before the 0.818 0.05 on physical ones.
statutory retirement age
Training in management skills
0.194 0.02
Burnout is associated with stress-related ill-
nesses, lower productivity and intention to retire
early, all of which have significant adverse man-
power implications for the NHS [12,18]. Burnout
has also been shown to be associated with
Table 6. Logistic regression analysis showing independent
predictors of burnout (depersonalisation) substance misuse and interpersonal difficulties,
both of which have significant implications for
Independent covariates Coefficient (B) Significance (p) safety in the workplace for colleagues and patients
Eat more 0.571 0.008 [19,20].
Take it out on family 0.941 50.005 The notion that working with cancer per se
Talk with family
0.869 50.005 confers high risk of stress and burnout is not
Mix less with friends 0.555 0.01 supported by the present study. Neither psychiatric
Satisfaction with work
0.600 0.005 morbidity nor burnout levels were higher in
surgeons with a higher cancer workload.
Three-fourth of surgeons wanted to retire early
1994 increasing to 33% in 2002. Their 2002 result is and a similar number said they would retire as soon
similar to this study (w2 ¼ 1:69; p ¼ 0:43; Graph- as they could afford to. If this stated intention is
pad, InStat software. This picture is less than translated into the actual behaviour it is likely that
satisfactory with significant ramifications for the the NHS is going to lose the most experienced
quality of care that these individuals can deliver. group of surgeons prematurely. To offset this to a
Stress at work has been shown to be related to high degree it does appear that those likely to say that
burnout levels in health-care professionals [2]; they are most likely to retire early also have
work stress has also been shown to be significantly significant psychiatric morbidity and are burnt out.

Copyright # 2007 John Wiley & Sons, Ltd. Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
Stress and burnout in surgeons
Multivariate analysis indicated that job dissatis-
faction was an independent predictor of psychiatric
morbidity and burnout. However, given the cross-
sectional design of the present study, it is not
possible to say what is the cause and what is the
effect. It could be that because people have
psychiatric morbidity they are not satisfied, or
alternatively, because of their dissatisfaction they
develop psychiatric morbidity. Training in com-
munication and management was also predictive of
burnout. There is evidence in medical literature to
suggest that communication skills training can
improve attitude of clinicians towards patients,
thus reducing DP [21].
Several coping strategies were found to be
independent predictors of psychiatric morbidity
and burnout. People with poor social strategies
(taking work home, mixing less with friends) had
higher stress and burnout levels. All these re-
sponses can increase adverse consequences domes-
tically and in turn lead to reduction of social
support that might otherwise act as a buffer to
psychosocial stress.
One of the limitations of this study is the
response rate of approximately 60%, these re-
sponse rates are lower than the 80% response rates
obtained by Ramirez et al. in their previous
national surveys of oncologists and radiologists
[2,22]; however, they are similar to those obtained
in many other similar postal studies [8,23]. One
previous study has shown that non-responders are
likely to have higher levels of psychiatric morbidity
[4]; however, due to the anonymous nature of the
questionnaire used in this study, there is no data on
the characteristics of the non-responders.
There are several implications for the work force
planning of NHS which are highlighted in this
study. A significant number of surgeons with
psychiatric morbidity, high levels of burnout and
intention to retire early could lead to a future work
force crisis. Several of our respondents wrote in the
additional comment section about the feeling of
loss of control within the NHS}we started by
pointing out that loss of controls upsets doctors.
There is a concern that the NHS has been subjected
to radical change in the last two decades which is
reflected in a loss of autonomy and perceived
interference in clinical freedom. While there may be
advantages in these changes in terms of standards
and guidelines for care as well as better account-
ability, it has to be recognized that the process may
not have been managed in a manner that is
sensitive to the implications and effects on the
workforce.
Conclusion
Levels of psychiatric morbidity, burnout and work
dissatisfaction are worryingly high in colorectal
Copyright # 2007 John Wiley & Sons, Ltd.
575
and vascular surgeons and are likely to impact
adversely on patient satisfaction and service
quality.
There are several implications for the work force
planning of NHS which are highlighted in this
study. A significant number of surgeons with
psychiatric morbidity, high levels of burnout and
intention to retire early could lead to a future work
force crisis.
Notes
1. Royal College of Surgeons of England, 35-43 Lincoln’s
Inn Fields, London, WC2A 3PE.
2. Kendata Peripherals Limited, Nutsey Lane, Totton,
Southampton, SO40 3N.
References
1. Editorial: Burnished or burnt out: the delights and
dangers of working in health. Lancet 1994;344:1583–
1584.
2. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory
WM. Mental health of hospital consultants: the effects
of stress and satisfaction at work. Lancet 1996;347:
724–728.
3. Graham J, Potts HW, Ramirez AJ. Stress and burnout
in doctors. Lancet 2002;360:1975–1976.
4. Wall TD, Bolden RI, Borrill CS, Carter AJ, Golya DA,
Hardy GE, Haynes CE, Rick JE, Shapiro DA, West
MA. Minor psychiatric disorder in NHS trust staff:
occupational and gender differences. Br J Psychiatry
1997;171:519–523.
5. Freeborn DK. Satisfaction, commitment, and psycho-
logical well-being among HMO physicians. West J Med
2001;174:13–18.
6. Crown Copyright. The NHS Plan. 2000.
7. Taylor C, Graham J, Potts HW, Richards MA, Ramirez
AJ. Changes in mental health of UK hospital con-
sultants since the mid-1990s. Lancet 2005;366:742–744.
8. Whippen DA, Canellos GP. Burnout syndrome in the
practice of oncology: results of a random survey of
1,000 oncologists. J Clin Oncol 1991;9:1916–1920.
9. Ullrich A, FitzGerald P. Stress experienced by physi-
cians and nurses in the cancer ward. Soc Sci Med
1990;31:1013–1022.
10. Ramirez AJ, Graham J, Richards MA et al. Burnout
and psychiatric disorder among cancer clinicians. Br J
Cancer 1995;71:1263–1269.
11. Goldberg DP, Cooper B, Eastwood MR, Kedward HB,
Shepherd M. A standardized psychiatric interview for
use in community surveys. Br J Prev Soc Med
1970;24:18–23.
12. Maslach C, Schaufeli WB, Leiter MP. Job burnout.
Annu Rev Psychol 2001;52:397–422.
13. Maslach C, Jackson SE, Leiter MP. Maslach Burnout
Inventory Manual (3rd edn). Consulting Psychologists
Press, Inc.: Palo Alto, CA, 1996.
14. Alexander DA, Walker LG. Is my stress greater than
yours? A comparison of policemen and firemen. Int J
Police Sci Manag 2000;2:303–312.
15. Alexander DA, Walker LG. The methods used by
Scottish police officers to cope with work-induced stress.
Stress Med 1994;10:131–138.
Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon
576
16. Goldberg D, Williams P. A User’s Guide to the General
Health Questionnaire. NFER-Nelson Publishing Co:
Berkshire, UK, 1988.
17. Pflanz SE, Ogle AD. Job stress, depression, work
performance, and perceptions of supervisors in military
personnel. Mil Med 2006;171:861–865.
18. Greenglass ER, Burke RJ. Hospital restructuring and
burnout. J Health Hum Serv Adm 2002;25(1):89–114
19. McCall SV. Chemically dependent health professionals.
West J Med 2001;174(1):50–54.
20. Gundersen L. Physician burnout. Ann Intern Med
2001;135(2):145–148.
Copyright # 2007 John Wiley & Sons, Ltd.
A. Sharma et al.
21. Fallowfield L, Lipkin M, Hall A. Teaching senior
oncologists communication skills: results from phase I
of a comprehensive longitudinal program in the United
Kingdom. J Clin Oncol 1998;16:1961–1968,
22. Graham J, Ramirez AJ, Field S, Richards MA. Job
stress and satisfaction among clinical radiologists. Clin
Radiol 2000;55:182–185.
23. Asai M, Morita T, Akechi T et al. Burnout and
psychiatric morbidity among physicians engaged in
end-of-life care for cancer patients: a cross-sectional
nationwide survey in Japan. Psycho-Oncology 2007;
16(5):421–428.
Psycho-Oncology 17: 570–576 (2008)
DOI: 10.1002/pon