Doctors around the world have been subjected to unprecedented challenges since the COVID pandemic, on top of chronic high levels of burnout in many countries. Physicians Anonymous became aware of the extraordinarily high burnout rates in physician colleagues in China after a number of Chinese doctors reached out to us because of the anonymity and safety of the Physicians Anonymous program.
We must profess our ignorance of the pressures in China of being a doctor in China wishing to serve their patients within a challenging system. As the most populous country in the world with a large number of physicians who might be helped, we decided to explore this issue in depth.
According to an article in The Lancet, Hui Wang, a 32-year-old Chinese ophthalmologist in Beijing, experienced sudden cardiac death on June 30 2016, after working with a fever for 6 days in a row. Hui was the father of a 1-year-old. Hui’s wife, also a doctor, donated his corneas to two patients after his death. The emotive circumstances of Hui’s devotion to his work and his family’s selfless donation triggered an outpouring of grief and sympathy online, with commentators raising concerns about burnout in Chinese physicians.
It is not the first case of a doctor collapsing after work in recent years in China. According to a viewpoint published in the Chinese Medical Journal, reports on sudden deaths among Chinese physicians sharply escalated from 2008 to 2015, and most of the deaths, resulting from heavy work load, were male surgeons and anaesthesiologists in tertiary hospitals in large cities. “Sudden deaths among physicians are not rare, and this case series represents the tip of a larger iceberg”, states the article. In fact, the larger iceberg might refer to the physician burnout in China, since DXY (the largest Chinese physicians’ online community) reported that more than two-thirds of Chinese physicians were suffering from burnout in 2018.
While the US and Western average burnout rate is currently around 43-60%, our Chinese colleagues seem to have much higher rates of burnout. Early indications from a 2018 meta-analysis showed an overall burnout symptom prevalence among doctors in China from 66.5 to 87.8%. This review found that burnout was higher among doctors who worked over 40 h/week, working in tertiary hospitals, and in younger doctors aged 30-40.
A 2021 study of 1056 doctors from 8 regions of China found that 72.9% of all respondents reported at least one symptom of burnout. Stresses from the relationship with patients and work tasks were the major indicators associated with job burnout. A much larger 2022 study of 25,000 doctors reported at least one symptom of burnout in 60.8% of healthcare staff, including physicians and nurses.
Chinese trainee doctors (Residents) are not immune – with a reported burnout rate of 71.4%.
Chinese doctors will have been among the first to be hit by the COVID wave back in early 2020. Our knowledge of the virus, treatments, and effective vaccines were all unavailable in the early days of the pandemic. All healthcare staff knew was that there was a new viral illness and the hospitals were full. Several high-profile doctors died having contracted the virus from patients.
The trauma of working at the forefront of healthcare during a new and frightening pandemic cannot be underestimated.
The trauma of working at the forefront of healthcare during a new and frightening pandemic cannot be underestimated. A 2022 survey revealed that 35% of Chinese Emergency Medicine Residents experienced post-traumatic symptoms acutely during the COVID-19 crisis, potentially indicating a high prevalence of acute stress disorder in this population and increased risk of developing PTSD.
An unrelated 2022 survey found that over half of Chinese ER physicians intended to leave. Workplace violence was one factor cited among others for physicians seeking to leave their jobs.
One key factor that seems to stand out in China is the prevalence of workplace violence, with some 77.5% of doctors in a recent study reporting experiencing physical or emotional violence at work. Workplace violence was associated with an increased the level of depressive symptoms and burn-out.
Our Chinese physician colleagues reported that a number of cultural challenges made it more difficult for doctors in China to address their epidemic of physician burnout. These include cultural norms, the enduring stigma of mental illness, and a strong work ethic and desire not to let patients and colleagues down by taking time off.
Cultural norms for doctors have been explored in a study by Lo and colleagues (2018).
The Chinese attitude to working or fulfilling one’s duty is to stand all the hardship without complaining of fatigue until the end of his or her life. This is regarded as compliance to rites (Li) with moral respect. This inherited traditional working attitude may result in a self-expectation of maintaining a higher moral standard than the social norm, to stand all the hardships of working in medicine without complaining. Lo says: “Although Chinese doctors can sense that they are overloaded or burnout, the Chinese culture of standing all the hardship without complaint may account for the high elasticity of this high burnout population and the sustainability of the medical service despite the adverse conditions.”
Under-recognition of provider health needs and overwhelming demand were described as a toxic mix leading to such startling burnout rates.
The Chinese culture of standing all the hardship without complaint may account for the high elasticity of this high burnout population and the sustainability of the medical service despite the adverse conditions.
Chinese physicians told us that the idea of a safe space for them to meet and share their experiences in anonymity and with colleagues from China and around the world was very appealing. Many of them speak good English, although some would prefer Chinese-speaking groups.
We hope that we can support our colleagues around the world by providing a safe online platform for them to address their burnout, improve their wellbeing, and ultimately offer better care for their patients.
