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Personal resilience in psychiatrists: systematic review

Published online by Cambridge University Press:  11 March 2019

Ranjita Howard ,
Catherine Kirkley  and
Nicola Baylis
Ranjita Howard*
Affiliation:
Northumbria NHS Foundation Trust
Catherine Kirkley
Affiliation:
Gateshead Health NHS Foundation Trust
Nicola Baylis
Affiliation:
Tees, Esk and Wear Valleys NHS Foundation Trust
*
Correspondence to Ranjita Howard ([email protected])
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Abstract

Aims and method

The concept of personal resilience is relevant to physician well-being, recruitment and retention, and to delivering compassionate patient care. This systematic review aims to explore factors affecting personal resilience among psychiatrists, in particular, those that may impair well-being and those that facilitate resilience practice. A literature search was performed of the Ovid®, Embase®, CINAHL and PsycINFO databases, using keywords to identify empirical studies involving psychiatrists that examined resilience, stress and burnout from the past 15 years.

Results

Thirty-three international English language studies were included, showing that a combination of workplace, personal and non-workplace factors negatively and positively influenced well-being and resilience.

Clinical implications

Given that workplace factors were the most commonly cited, it would appear that any resilience package that predominantly targets interventions at the workplace level would be particularly fruitful. Future research, however, needs to address the absence of a universal measurement of well-being and its moderators so that any potential interventions are better evaluated.

Keywords

Psychiatristsresiliencewell-beingburnoutstress
Type
Original Papers
Information
BJPsych Bulletin , Volume 43 , Issue 5 , October 2019 , pp. 209 - 215
Creative Commons
Creative Common License - CCCreative Common License - BYCreative Common License - NCCreative Common License - ND
This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.
Copyright
Copyright © The Authors 2019

Physician well-being is considered as one of the cornerstones of professional effectiveness, health and happiness.Reference Eley, Cloninger, Walters, Laurence, Synnott and Wilkinson1 Psychiatrists, however, have been found to suffer from high levels of poor well-being, being more prone to burnout (characterised by emotional exhaustion, depersonalisation, and diminished personal accomplishment among those who work with peopleReference Maslach and Jacson2), psychiatric morbidity and suicidal ideation.Reference Martini, Arfken, Churchill and Balon3–Reference Fothergill, Edwards and Burnard5 Contributing factors reported to account for such poor well-being include working with patients perceived as aggressive and demanding, resource deficits, staff conflicts, lack of administrative support, responsibility without due authority, lack of experience, female gender, low self-esteem and working longer shifts.Reference Fothergill, Edwards and Burnard5 Recruitment and retention difficulties are also cited as exacerbating factors of poor well-being among existing staff.Reference Kumar, Bhagat, Liu and Ng6

Resilience, defined as ‘a dynamic process encompassing adaptation within the context of significant adversity’,Reference Jackson, Firtko and Edenborough7 is often considered an antidote to poor well-being, offsetting workplace stressors,Reference McAllister and McKinnon8 setbacks and trauma,Reference Herrman, Stewart, Diaz-Granados, Berger, Jackson and Yuen9 and buffering against adverse events.Reference Tugade and Fredrickson10 Four aspects of physician resilience have been identified, relating to attitudes and perspectives (e.g. valuing role), balance and prioritisation (e.g. scheduling time off) practice management (e.g. efficient organisation) and supportive relationships.Reference Jensen, Trollope-Kumar, Waters and Everson11 Moreover, several personality traits have been associated with resilience, including being mature, responsible, optimistic, persevering and cooperative.Reference Eley, Cloninger, Walters, Laurence, Synnott and Wilkinson1 Physicians also seem to benefit from certain facilitative practices, including mindfulness,Reference Shapiro, Astin, Bishop and Cordova12, Reference Zimmermann13 peer-care,Reference Vogel14 coaching and mentoring,Reference Schneider, Kingsolver and Rosdahl15–Reference Wald17 Balint group participation,Reference Benson and Magraith18 part-time employment,Reference Stevenson, Phillips and Anderson16 viewing medicine intellectuallyReference Stevenson, Phillips and Anderson16 and viewing medicine as a ‘calling’.Reference Yoon, Daley and Curlin19 A strong group identity,Reference Mavor, McNeil, Anderson, Kerr, O'Reilly and Platow20 peer-caringReference Zhao, Guo, Suhonen and Leino-Kilpi21 and mindfulnessReference Outram and Kelly22 also appear to increase resilience among medical students. In fact, the General Medical Council calls for UK medical schools to offer a resilience package to equip students with the skills to deal with current and future challenges.Reference Horsfall23

Method

Aim

The aim of this systematic review was to explore factors affecting personal resilience among psychiatrists, in particular, those that may impair well-being and those that facilitate resilience practice.

Search methodology

The Ovid®, Embase®, CINAHL and PsycINFO databases were searched in June 2017 using keywords ‘resilience’, ‘burnout’, ‘stress’, ‘strategies’ and ‘intervention’, all of which were combined with ‘psychiatry trainees’, ‘psychiatrist’ and ‘mental health professional’. Papers were included if they were empirical studies, available in English, and published within the past 15 years. Reference lists of previously published articles were also examined.

Study suitability

The first and last authors independently reviewed the titles and abstracts and appraised each article for inclusion before confirmation by an independent researcher (Rachel Steele, Librarian, Tees, Esk and Wear Valleys NHS Foundation Trust). Data collected included study aims, sample and sample size, study design, response rate, measures or scales used, and outcomes. Discussions between the authors helped to identify common themes as a basis for analysis and synthesis of the findings.

Search outcome

A total of 127 papers were initially identified by the electronic search, and a further 13 by examination of published references. Seventy-two articles were subsequently screened in more detail, of which 33 articles met all the inclusion criteria and were included for qualitative synthesis (Fig. 1). Article summaries are presented in Supplementary Table 1 (available at https://doi.org/10.1192/bjb.2019.12).

Fig. 1 Flow diagram illustrating search strategy for the review.

Results

Countries of origin

Studies originated from Australia,Reference Devilly, Wright and Varker29, Reference Littlewood40, Reference Rey, Walter and Giuffrida48, Reference Walter, Rey and Giuffrida55 New Zealand,Reference Cunningham and Cookson28, Reference Fischer, Kumar and Hatcher31, Reference Kumar, Sinha and Dutu38, Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39 the UK,Reference Falchi, Brown and Burnett30, Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34, Reference Murdoch43, Reference Rathod, Mistry, Ibbotson and Kingdon47 the USA,Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24, Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26, Reference Strasburger, Miller, Commons, Gutheil and LaLlave52 Canada,Reference Kealey, Halli, Ogrodniczuk and Hadjipavlou35, Reference Ruskin, Sakinofsky, Bagby, Dickens and Sousa50 Italy,Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 Finland,Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33, Reference Korkeila, Toyry, Kumpulainen, Toivola, Rasanen and Kalimo36 PortugalReference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44 and Romania.Reference Chiorean, Mihai, Stoica, Marculescu and Papava27 Several studies involved a combination of countriesReference Littlewood40, Reference Olarte45, Reference Priebe, Fakhoury, Hoffman and Powell46, Reference Rotstein and Jenkins49 and six studies did not specify location.Reference Harrison, Cook, Robertson and Willey32, Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37, Reference Mache, Bernburg, Baresi and Groneberg41, Reference Sprang, Clark and Whitt-Woosley51, Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53, Reference Yanchus, Periard and Osatuke56

Populations

Twenty studies involved psychiatry doctors only, comprising psychiatrists,Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25, Reference Chiorean, Mihai, Stoica, Marculescu and Papava27, Reference Fischer, Kumar and Hatcher31, Reference Harrison, Cook, Robertson and Willey32, Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37–Reference Mache, Bernburg, Baresi and Groneberg41, Reference Murdoch43–Reference Olarte45, Reference Rathod, Mistry, Ibbotson and Kingdon47, Reference Rey, Walter and Giuffrida48, Reference Strasburger, Miller, Commons, Gutheil and LaLlave52 psychiatry traineesReference Kealey, Halli, Ogrodniczuk and Hadjipavlou35, Reference McKensey and Sullivan42, Reference Walter, Rey and Giuffrida55 or a combination of both.Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24, Reference Rotstein and Jenkins49 Only three studies provided an indication of subspecialty, including child and adolescent,Reference Korkeila, Toyry, Kumpulainen, Toivola, Rasanen and Kalimo36, Reference Littlewood40 adultReference Korkeila, Toyry, Kumpulainen, Toivola, Rasanen and Kalimo36 and forensic psychiatry.Reference Strasburger, Miller, Commons, Gutheil and LaLlave52 Thirteen studies involved psychiatry doctors combined with other populations, including mental health practitioners,Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26, Reference Devilly, Wright and Varker29, Reference Falchi, Brown and Burnett30, Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34, Reference Priebe, Fakhoury, Hoffman and Powell46, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54, Reference Yanchus, Periard and Osatuke56 general practitioners,Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53 behavioural health providers,Reference Sprang, Clark and Whitt-Woosley51 medical school graduates,Reference Ruskin, Sakinofsky, Bagby, Dickens and Sousa50 other physiciansReference Cunningham and Cookson28, Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33, Reference Korkeila, Toyry, Kumpulainen, Toivola, Rasanen and Kalimo36 and psychologists.Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26

Study aims

The main aims of the included studies were factors relating to burnout,Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24–Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26, Reference Devilly, Wright and Varker29–Reference Fischer, Kumar and Hatcher31, Reference Kealey, Halli, Ogrodniczuk and Hadjipavlou35–Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37, Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39, Reference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44, Reference Sprang, Clark and Whitt-Woosley51, Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 factors associated with work stressReference Chiorean, Mihai, Stoica, Marculescu and Papava27, Reference Cunningham and Cookson28, Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33, Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37, Reference Murdoch43, Reference Olarte45, Reference Rey, Walter and Giuffrida48, Reference Rotstein and Jenkins49, Reference Strasburger, Miller, Commons, Gutheil and LaLlave52, Reference Walter, Rey and Giuffrida55 (including how to overcome it)Reference Harrison, Cook, Robertson and Willey32 and factors associated with job satisfaction.Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25, Reference Falchi, Brown and Burnett30, Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33, Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34, Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39, Reference Littlewood40, Reference Olarte45, Reference Rey, Walter and Giuffrida48, Reference Rotstein and Jenkins49, Reference Walter, Rey and Giuffrida55 Additional areas of focus included the efficacy of counselling,Reference Cunningham and Cookson28 trauma,Reference Devilly, Wright and Varker29 job resources,Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33 well-being,Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34 whether the Job Diagnostic Survey predicts scores on the Maslach Burnout Inventory (MBI),Reference Kumar, Sinha and Dutu38 recruitment and retention,Reference Littlewood40 use of a self-care training package,Reference Mache, Bernburg, Baresi and Groneberg41 the evaluation of a Balint group,Reference McKensey and Sullivan42 the evaluation of a stress-busting group,Reference Murdoch43 morale,Reference Priebe, Fakhoury, Hoffman and Powell46 the effects of recent National Health Service (NHS) changes,Reference Rathod, Mistry, Ibbotson and Kingdon47 patient suicide and support networks,Reference Ruskin, Sakinofsky, Bagby, Dickens and Sousa50 compassion fatigue and compassion satisfaction,Reference Sprang, Clark and Whitt-Woosley51 and the investigation of turnover intention.Reference Yanchus, Periard and Osatuke56

Measures

The predominant measures were burnout, work-related stress, job satisfaction and well-being. Thirteen studies measured burnout using the MBI,Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24–Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26, Reference Falchi, Brown and Burnett30, Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34, Reference Korkeila, Toyry, Kumpulainen, Toivola, Rasanen and Kalimo36, Reference Kumar, Sinha and Dutu38–Reference Littlewood40, Reference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44, Reference Priebe, Fakhoury, Hoffman and Powell46, Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 while others used the Copenhagen Burnout Inventory,Reference Devilly, Wright and Varker29 a tailored burnout questionnaire,Reference Kealey, Halli, Ogrodniczuk and Hadjipavlou35 and another measuring emotional exhaustion.Reference Yanchus, Periard and Osatuke56

Work stress was measured by nine of our included studies, utilising several pre-existing scalesReference Kumar, Hatcher, Dutu, Fischer and Ma'u37, Reference Littlewood40, Reference Mache, Bernburg, Baresi and Groneberg41, Reference Murdoch43, Reference Rathod, Mistry, Ibbotson and Kingdon47 such as the Sources of Stress Questionnaire and the Perceived Stress Questionnaire. Other studies applied more tailored measures, citing a work stress index,Reference Devilly, Wright and Varker29 a rating scale to evaluate a ‘stress-busting’ group,Reference Murdoch43 a rating scale to measure work-related stress,Reference Walter, Rey and Giuffrida55 a postal questionnaire,Reference Rey, Walter and Giuffrida48 an online surveyReference Rotstein and Jenkins49 and a 90-item stress-related scale.Reference Strasburger, Miller, Commons, Gutheil and LaLlave52

Job satisfaction was measured in 12 studies, ranging from pre-existing scalesReference Falchi, Brown and Burnett30, Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34, Reference Kumar, Sinha and Dutu38, Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39, Reference Mache, Bernburg, Baresi and Groneberg41, Reference Priebe, Fakhoury, Hoffman and Powell46 such as the Minnesota Job Satisfaction ScaleReference Priebe, Fakhoury, Hoffman and Powell46 to combined elements of other scalesReference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33, Reference Littlewood40 such as the General Health Questionnaire (GHQ-28).Reference Littlewood40 More bespoke assessment tools were also employed.Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25, Reference Rey, Walter and Giuffrida48, Reference Rotstein and Jenkins49, Reference Yanchus, Periard and Osatuke56

Well-being was measured by six of our included studies, using a number of pre-existing scalesReference Johnson, Osborn, Araya, Wearn, Paul and Stafford34, Reference Priebe, Fakhoury, Hoffman and Powell46, Reference Sprang, Clark and Whitt-Woosley51 including the GHQ,Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25, Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34, Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53 and one study used a scale which adopted items from the GHQ.Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33

A range of other variables were also measured, including resilience,Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33, Reference Mache, Bernburg, Baresi and Groneberg41 the efficacy of counselling,Reference Cunningham and Cookson28 team functioning,Reference Falchi, Brown and Burnett30, Reference Priebe, Fakhoury, Hoffman and Powell46 mental health,Reference Devilly, Wright and Varker29, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 trauma,Reference Devilly, Wright and Varker29, Reference Ruskin, Sakinofsky, Bagby, Dickens and Sousa50 a supportive environment,Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26, Reference Devilly, Wright and Varker29 supervisory support, civility and psychological safety measures,Reference Yanchus, Periard and Osatuke56 relationships and interpersonal skills,Reference Devilly, Wright and Varker29, Reference Mache, Bernburg, Baresi and Groneberg41 emotions,Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53 job resources,Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33 victimisation,Reference Devilly, Wright and Varker29 ward atmosphere,Reference Harrison, Cook, Robertson and Willey32 beliefs,Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24, Reference Devilly, Wright and Varker29 suicide,Reference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44 and reasons for career choice.Reference Olarte45, Reference Walter, Rey and Giuffrida55

Some studies also reported a number of demographic details, including career and military experience, working pattern, parental and family factors, and leisure activities.Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24, Reference Olarte45, Reference Walter, Rey and Giuffrida55

Synthesis of results

Factors that may impair well-being

Increasing burnout

Adult and child psychiatrists were found to experience higher levels of burnout versus other physician groups,Reference Korkeila, Toyry, Kumpulainen, Toivola, Rasanen and Kalimo36 reporting high levels of emotional exhaustion,Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24, Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39, Reference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 depersonalisationReference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44 and low levels of personal accomplishment.Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 Female psychiatrists,Reference Sprang, Clark and Whitt-Woosley51, Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53 psychiatry trainees,Reference Kealey, Halli, Ogrodniczuk and Hadjipavlou35 those working in rural settings,Reference Sprang, Clark and Whitt-Woosley51 and those working in the community and on acute general wardsReference Littlewood40 were found to be particularly vulnerable to high burnout levels.

Causes of burnout were excessive workload and/or working long hours,Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24, Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25, Reference Fischer, Kumar and Hatcher31, Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37, Reference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44 inadequate facilities and funding,Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25 working with patients perceived as aggressive and demanding,Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25 an aggressive administrative working environment,Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37 job demands,Reference Johnson, Osborn, Araya, Wearn, Paul and Stafford34 and the absence of support from either a colleagueReference Littlewood40 or management.Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37 Such causes of burnout also appeared to manifest in job turnover,Reference Yanchus, Periard and Osatuke56 unhealthy coping mechanisms (i.e. alcohol use, excessive shopping or unhealthy eating)Reference Kealey, Halli, Ogrodniczuk and Hadjipavlou35 and a lack of empathy for patients.Reference Kealey, Halli, Ogrodniczuk and Hadjipavlou35

Increasing stress

Psychiatrists reported higher levels of patient-related stress compared with other physicians,Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33 with most psychiatrists rating their stress levels as moderate or severe.Reference Murdoch43 Those most vulnerable to stress were new starters,Reference Devilly, Wright and Varker29 those without children and with academic affiliations/responsibilities,Reference Olarte45 those working with high-risk and difficult patients,Reference Murdoch43 and those who expressed job dissatisfaction.Reference Rey, Walter and Giuffrida48

Causes of stress were excessive workload,Reference Littlewood40, Reference Rotstein and Jenkins49 job and training demands,Reference Littlewood40 career prospects (notably Modernising Medical Careers),Reference Rathod, Mistry, Ibbotson and Kingdon47 concerns over personal safety,Reference Devilly, Wright and Varker29 illness,Reference Strasburger, Miller, Commons, Gutheil and LaLlave52 inadequate resourcesReference Chiorean, Mihai, Stoica, Marculescu and Papava27, Reference Littlewood40 and litigation.Reference Rey, Walter and Giuffrida48, Reference Strasburger, Miller, Commons, Gutheil and LaLlave52

Psychological illness and other factors

Psychiatrists reported higher levels of depression, psychotropic drug usage and mental illness compared with other physicians.Reference Korkeila, Toyry, Kumpulainen, Toivola, Rasanen and Kalimo36 Moreover, some trainees reported almost clinical levels of emotional disturbance in response to experiencing patient suicide.Reference Ruskin, Sakinofsky, Bagby, Dickens and Sousa50 Psychiatrists were also prone to compassion fatigue,Reference Sprang, Clark and Whitt-Woosley51 pessimismReference Rey, Walter and Giuffrida48 and the adoption of negative coping strategies, such as excessive worrying, denial and overworking.Reference Rathod, Mistry, Ibbotson and Kingdon47 Perceived status, inadequate decision-making capacities, and poor supervision and feedback also contributed to dissatisfaction.Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39, Reference Walter, Rey and Giuffrida55 Those without a supportive colleague also tended to take more time off and even regretted their career choice.Reference Littlewood40

Factors that may facilitate resilience

Reducing burnout

Factors that made psychiatrists more resilient to burnout included spending less time on the wards by engaging in more discrete work activities (i.e. clinical rounds, consultations) before departing to their offices,Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26 the extension of staffing roles and distribution of responsibilities,Reference Falchi, Brown and Burnett30, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 and having more clinical experience and supportive colleagues.Reference Ballenger-Browning, Schmitz, Rothacker, Hammer, Webb-Murphy and Johnson24 Interestingly, forensic psychiatrists suffered less burnout than other subspecialties, possibly because of being adept at maintaining professional boundaries, self-awareness and being better at reflective practice, owing to the moral and ethical challenges they regularly face.Reference Caldwell, Gill, Fitzgerald, Sclafani and Grandison26

To assist those more vulnerable to burnout, such as female psychiatrists and trainees, several studies proposed interventions that may facilitate resilience,Reference Neves, Vieira, Madeira, Santos, Garrido and Craveiro44, Reference Sprang, Clark and Whitt-Woosley51, Reference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 including psychological supportReference Volpe, Luciano, Palumbo, Sampogna, Del Vecchio and Fiorillo54 and assessment and treatment skills trainng.Reference Sprang, Clark and Whitt-Woosley51 Non-workplace factors such as holidays, hobbies and partner support may also improve resilience to burnout.Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37

Reducing stress

In addition to the benefits of a counselling service which encouraged stressed psychiatrists to remain in or return to work,Reference Cunningham and Cookson28 a self-care programme – comprising skills training, cognitive–behavioural therapy (CBT) and counselling – was also reported to reduce job stress.Reference Mache, Bernburg, Baresi and Groneberg41 Moreover, increasing stress awareness also allowed trainees and psychiatrists to be better prepared for the difficult aspects of their work, resulting in reduced stress levels.Reference Harrison, Cook, Robertson and Willey32, Reference Strasburger, Miller, Commons, Gutheil and LaLlave52 Reporting on the first author's personal experience, for example, one study highlighted the importance of being mindful of how work-related stress arises, how to recognise its symptoms and how to seek help.Reference Harrison, Cook, Robertson and Willey32 Actively seeking support, confiding in supportive colleagues and socialising were also recognised as a positive coping strategies.Reference Murdoch43, Reference Rathod, Mistry, Ibbotson and Kingdon47

Changes to the workplace environment through better management of economical and administrative measures,Reference Chiorean, Mihai, Stoica, Marculescu and Papava27 as well as the creation of functional teams, having crisis teams as gatekeepers, working in multidisciplinary teams, introducing generic/nurse-led services, and separating in-patient and community roles were also found to reduce stress levels among psychiatrists.Reference Rathod, Mistry, Ibbotson and Kingdon47

Job satisfaction and well-being

Some studies showed that the majority of psychiatrists were actually more satisfied with their job – finding the role interesting, intellectually challenging, providing good career prospects, and constituting a role that provided a better quality of life – than other physicians such as general practitioners.Reference Rotstein and Jenkins49, Reference Vicentic, Gasic, Milovanovic, Tosevski, Nenadovic and Damjanovic53, Reference Walter, Rey and Giuffrida55 Those able to combine children, intimate relationships and academic involvement were found to be the most satisfied,Reference Olarte45 while helping patients get better and thus boosting personal accomplishment also accounted for increased job satisfactionReference Rey, Walter and Giuffrida48 and the offsetting of emotional exhaustion.Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39

Self-care training was also found to improve job satisfaction among psychiatry doctors, with one study showing that a combination of skills training, CBT and counselling resulted in improvements in overall job satisfaction, as well as in self-efficacy and physician–patient relations.Reference Mache, Bernburg, Baresi and Groneberg41 More targeted practices that introduced job variety (i.e. combining teaching, administration and clinical work) were also deemed as factors that raise the job satisfaction of those experiencing high emotional exhaustion.Reference Kumar, Sinha and Dutu38

Changes to the workplace environment involving the extension of staffing roles and distribution of responsibilities,Reference Falchi, Brown and Burnett30 improved job control and better work organisation,Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33 and provision of a more civil workplace that provided autonomy and a supportive supervisory environment were also perceived positively and thus increased job satisfaction levels.Reference Yanchus, Periard and Osatuke56

Other factors

Although resilience among psychiatrists may to some degree be facilitated by a good team climate with a strong team identity,Reference Heponiemi, Aalto, Puttonen, Vanska and Elovainio33, Reference Priebe, Fakhoury, Hoffman and Powell46 it is also reported that the field may benefit from a number of other practices, including prioritising workload,Reference Littlewood40 obtaining multi-source feedback on performance,Reference Kumar, Fisher, Robinson, Hatcher and Bhagat39 maintaining good supportive relationships with superiors and colleagues,Reference Bressi, Porcellana, Gambini, Madia, Muffatti and Peirone25, Reference Kumar, Hatcher, Dutu, Fischer and Ma'u37 Balint and ‘stress-busting’ group participation,Reference McKensey and Sullivan42, Reference Murdoch43 involvement in leadership activities,Reference Rathod, Mistry, Ibbotson and Kingdon47 and training in communication and time management.Reference Priebe, Fakhoury, Hoffman and Powell46 A more energetic recruitment drive during undergraduate and postgraduate training may also encourage more to enter the profession and thus help with dealing with the recruitment problems the profession faces and relieve the pressure on existing staff.Reference Littlewood40

Discussion

The purpose of this review was to examine those factors that affect psychiatrists' well-being and to identify the practices that promote resilience within this population. Our findings are consistent with previous research showing that psychiatrists tend to suffer from higher levels of burnout, stress and psychological distress/illness relative to other physician groups,Reference Martini, Arfken, Churchill and Balon3–Reference Fothergill, Edwards and Burnard5 with female psychiatrists and trainee psychiatrists being particularly vulnerable.Reference Peckham4, Reference Fothergill, Edwards and Burnard5 Of particular concern is the rate of depression reported by this review, as well as the psychotropic drug usage, the almost-clinical-level emotional disturbance caused by patient suicide, and the consequential implications of poor well-being overall, such as a lack of empathy for patients and compassion fatigue.

In terms of the causal factors that affect psychiatrists' well-being, this review also corroborated previous research showing that workplace factorsReference Fothergill, Edwards and Burnard5, Reference Kumar, Bhagat, Liu and Ng6 and personality traitsReference Eley, Cloninger, Walters, Laurence, Synnott and Wilkinson1, Reference Fothergill, Edwards and Burnard5 are particularly influential. In an attempt to better frame an explanation of these findings, however, it might be useful to draw upon a theory of well-being such as Seligman's PERMA model,Reference Seligman57 which considers five elements (positive emotions, engagement, relationships, meaning and accomplishments) that can help people flourish and live a more fulfilled, happy and meaningful life.

Given that psychiatrists were reported to exhibit more pessimism, more anxiety and more indecisiveness, as well as a tendency to adopt repressive and avoidant coping strategies, it would seem that they struggle to maintain positive emotions, which may be a contributory factor towards the reported high levels of poor well-being. One possible explanation as to why psychiatrists find it difficult to maintain positive emotions is the complex psychodynamic processes that they are personally affected by as a result of their regular interactions with patients in negative emotional states or those who have experienced significant trauma.

Several reported workplace factors such as inadequate facilities and funding, working with patients perceived as aggressive and demanding, and working in an aggressive administrative environment may also fragment the attention of psychiatrists and thus compromise their capacity to fully engage in their workplace activities. This lack of complete engagement could be further exacerbated by the difficulty of defining goals and measuring progress within psychiatry, compared with the more acute specialties such as surgery and emergency medicine.

Cultivating positive peer relationships may also be difficult for psychiatrists, particularly those who are working in the more isolated settings of geographically disparate community clinics, who were indeed reported to suffer from higher levels of burnout within this review. In addition, the reported lack of administrative support and the high turnover of staff may further contribute to the problem of building positive and supportive relationships that can potentially offset the negative outcomes of poor well-being. It is quite possible that this combination of being unable to maintain a positive emotional approach, being unable to engage fully in a work role, and finding it difficult to cultivate positive peer relations manifests in significant negative outcomes such as compassion fatigue.

However, it is not all doom and gloom. Consistent with previous research,Reference Fothergill, Edwards and Burnard5, Reference Kumar, Bhagat, Liu and Ng6 this review also reports that psychiatrists do tend to find considerable purpose and meaning in what they do, as well as high levels of job satisfaction and personal accomplishment. There are a number of factors that may account for this, including the role offering intellectual satisfaction, favourable job prospects, strong team identity (at least for forensic psychiatrists), greater job control and a good work–life balance. In terms of the design of any intervention exercises, whether they be resilience workshops or recruitment initiatives, it is imperative therefore that these latter elements are emphasised. Moreover, given that certain psychiatry subspecialties (i.e. forensic) seem to be protected against poor well-being, the basis of this (i.e. strong group unity, maintenance of boundaries) needs to be considered when designing future resilience interventions.

However, again reflective of the broader medical literature,Reference Schneider, Kingsolver and Rosdahl15–Reference Benson and Magraith18 this review indicates that the basis of any thorough resilience intervention would have to be the implementation of certain practices at the workplace level. Indeed, organisations that offer the opportunity for psychiatrists to engage in more discrete work activities that incorporate multi-source feedback, maintain a supportive and collaborative working environment, and offer psychological support in the form of Balint group participation, stress-busting workshops and counselling appear to foster higher levels of well-being. Notably, the more vulnerable groups may benefit from specific strategies, for example, female psychiatrists may benefit from more psychological support to boost their ability to deal with particularly difficult patients, and trainees from more skills-based programmes may benefit from help to boost their experience and decision-making skills. On a more personal level, encouraging psychiatrists to be more aware of how work-related stresses arise and how to deal with them accordingly through self-awareness and self-care interventions may also prove protective, as may engagement in numerous non-workplace activities such as taking holidays and spending more time with family or friends.

Strengths and limitations

This review represents one of the very few systematic reviews that have explored the factors involved in the well-being of psychiatrists. It presents evidence from a range of countries, and provides data from a good number of studies. Data collection adhered to the Cochrane level of scrutiny, based on independent extraction by the first and last authors and subsequent review by an independent researcher. Limitations of the review included the restriction of studies to the English language and the limited number of psychiatrists used as the study group. Moreover, there was only one study comparing an intervention with a control group, suggesting a lack of high-quality research in this area. Given that the data taken from the vast majority of studies were based on self-reported questionnaires, there was also the problem of self-report bias. The heterogeneity of instruments used to assess well-being made it difficult to compare across studies, thus jeopardising generalisable conclusions.

BOX 1 Resilience interventions

  • • Workplace level

    • • Discrete working activities

    • • Extending staff roles

    • • Distributing responsibilities

    • • Multi-source feedback

    • • Facilitating a supportive environment

    • • Championing appeal of psychiatry

  • • Personal level

    • • Counselling

    • • Self-awareness/reflection

    • • Self-care training

    • • Skills training

  • • Non-workplace level

    • • Taking holidays

    • • Partaking in hobbies

    • • Family/social life

    • • Receiving support from partner

Implications

Understanding how resilience relates specifically to psychiatrists may lead to the implementation of more effective and potentially targeted interventions to help psychiatrists improve their resilience. Reducing the incidence of poor mental health and coping strategies may help doctors to thrive in the face of adversity and lead satisfying careers that consequently have positive effects on the care of their patients and working relationships with colleagues. While targeting the individual is important, this review shows that it is imperative for resilience or well-being packages to address a number of workplace factors. However, this review also highlights the lack of high-quality research within this area, underpinned by the absence of a universal measure of well-being; this needs to be addressed in order to better evaluate the efficacy of potential interventions. Only then will we be able to thoroughly address the fundamental causes of poor well-being among psychiatry doctors and implement the strategies necessary to move towards a more effective, healthier and happier psychiatric workforce.

Supplementary material

Supplementary material is available online at https://doi.org/10.1192/bjb.2019.12.

About the authors

Ranjita Howard is a Specialist Registrar (Child and Adolescent Mental Health Services) at the Albion Road Clinic, North Shields, Northumbria NHS Foundation Trust, UK. Catherine Kirkley is a Consultant Psychiatrist (Old Age Liaison) at Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, UK. Nicola Baylis is a Consultant Psychiatrist (Learning Disabilities) at the Adult Learning Disabilities Service, Darlington, Tees, Esk and Wear Valleys NHS Foundation Trust, UK.

Footnotes

Declaration of interest: None.

References

1Eley, DS, Cloninger, R, Walters, L, Laurence, C, Synnott, R, Wilkinson, D. The relationship between resilience and personality traits in doctors: implications for enhancing well being. PeerJ 2013; 1: e216.Google Scholar
2Maslach, C, Jacson, SE. Burnout: The Cost of Caring. Prentice Hall, 1982.Google Scholar
3Martini, S, Arfken, CL, Churchill, A, Balon, R. Burnout comparison among residents in different medical specialties. Acad Psychiatry 2004; 28: 240–2.Google Scholar
4Peckham, C. Physician Lifestyle – Linking to Burnout: A Medscape Survey. Medscape, 2013 (https://www.medscape.com/features/slideshow/lifestyle/2013/public).Google Scholar
5Fothergill, A, Edwards, D, Burnard, P. Stress, burnout, coping and stress management in psychiatrists: findings from a systematic review. Int J Soc Psychiatry 2004; 50: 54–65.Google Scholar
6Kumar, S, Bhagat, RN, Liu, T, Ng, B. Psychiatrists in New Zealand: are they burning out, satisfied at work and, in any case, who cares? Australas Psychiatry 2006; 14(1): 20–3.Google Scholar
7Jackson, D, Firtko, A, Edenborough, M. Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review. J Adv Nurs 2007; 60(1): 1–9.Google Scholar
8McAllister, M, McKinnon, J. The importance of teaching and learning resilience in the health disciplines: a critical review of the literature. Nurse Educ Today 2009; 29: 371–9.Google Scholar
9Herrman, H, Stewart, DE, Diaz-Granados, N, Berger, EL, Jackson, B, Yuen, T. What is resilience? Can J Psychiatry 2011; 56: 258–65.Google Scholar
10Tugade, M, Fredrickson, B. Resilient individuals use emotions to bounce back from negative emotional experiences. J Pers Soc Psychol 2004; 86: 320–33.Google Scholar
11Jensen, PM, Trollope-Kumar, K, Waters, H, Everson, J. Building physician resilience. Can Fam Physician 2008; 54(5): 722–9.Google Scholar
12Shapiro, SL, Astin, JA, Bishop, SR, Cordova, M. Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. Int J Stress Manag 2005; 12: 164–76.Google Scholar
13Zimmermann, F. Mindfulness-based practices as a resource for health and well-being. Med Acupunct 2015; 27(5): 349–59.Google Scholar
14Vogel, L. Physician suicide still shrouded in secrecy. CMAJ 2016; 188(17–18): 1213.Google Scholar
15Schneider, S, Kingsolver, K, Rosdahl, J. Physician coaching to enhance well-being: a qualitative analysis of a pilot intervention. Explore 2014; 10(6): 372–9.Google Scholar
16Stevenson, AD, Phillips, CB, Anderson, KJ. Resilience among doctors who work in challenging areas: a qualitative study. Br J Gen Pract 2011; 61(588): e404–10.Google Scholar
17Wald, HS. Professional identity (trans)formation in medical education: reflection, relationship, resilience. Acad Med 2015; 90(6): 701–6.Google Scholar
18Benson, J, Magraith, K. Compassion fatigue and burnout: the role of Balint groups. Aust Fam Physician 2005; 34(6): 497–8.Google Scholar
19Yoon, J, Daley, BM, Curlin, FA. The association between a sense of calling and physician well-being: a national study of primary care physicians and psychiatrists. Acad Psychiatry 2017; 41(2): 167–73.Google Scholar
20Mavor, KI, McNeil, KG, Anderson, K, Kerr, A, O'Reilly, E, Platow, MJ. Beyond prevalence to process: the role of self and identity in medical student well-being. Med Educ 2014; 48(4): 351–60.Google Scholar
21Zhao, F, Guo, Y, Suhonen, R, Leino-Kilpi, H. Subjective well-being and its association with peer caring and resilience among nursing vs medical students: a questionnaire study. Nurse Educ Today 2016; 37: 108–13.Google Scholar
22Outram, S, Kelly, B. You teach us to listen,… but you don't teach us about suffering: self-care and resilience strategies in medical school curricula. Perspect Med Educ 2014; 3(5): 371–8.Google Scholar
23Horsfall, S. Doctors Who Commit Suicide While Under GMC Fitness to Practice Investigation: Internal Review. GMC, 2014 (http://www.gmc-uk.org/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf).Google Scholar
24Ballenger-Browning, KK, Schmitz, KJ, Rothacker, JA, Hammer, PS, Webb-Murphy, JA, Johnson, DC. Predictors of burnout among military mental health providers. Mil Med 2011; 176(3): 253–60.Google Scholar
25Bressi, C, Porcellana, M, Gambini, O, Madia, L, Muffatti, R, Peirone, A, et al. Burnout among psychiatrists in Milan: a multicentre survey. Psychiatr Serv 2009; 60(7): 985–8.Google Scholar
26Caldwell, BA, Gill, KJ, Fitzgerald, E, Sclafani, M, Grandison, P. The association of ward atmosphere with burnout and attitudes of treatment team members in a state psychiatric hospital. Am J Psychiatr Rehabil 2006; 9(2): 111–29.Google Scholar
27Chiorean, A, Mihai, A, Stoica, M, Marculescu, I, Papava, I. Psychiatrists and occupational stress. Eur Psychiatry 2007; 22(2): S270-S.Google Scholar
28Cunningham, W, Cookson, T. Addressing stress-related impairment in doctors. A survey of providers and doctors experience of a funded counselling service in New Zealand. N Z Med J 2009; 122(1300): 19–28.Google Scholar
29Devilly, GJ, Wright, R, Varker, T. Vicarious trauma, secondary traumatic stress or simply burnout? Effect of trauma therapy on mental health professionals. Aust N Z J Psychiatry 2009; 43(4): 373–85.Google Scholar
30Falchi, V, Brown, H, Burnett, F. Community mental health team staff: burnout and satisfaction before and after the introduction of New Ways of Working for Psychiatrists. Ment Health Nurs 2009; 29(6): 12–15.Google Scholar
31Fischer, J, Kumar, S, Hatcher, S. What makes psychiatry such a stressful profession? A qualitative study. Australas Psychiatry 2007; 15(5): 417–21.Google Scholar
32Harrison, T, Cook, C, Robertson, M, Willey, J. Work-related stress and the psychiatrist: a case study. Psychiatr Bull 2006; 30(10): 385–7.Google Scholar
33Heponiemi, T, Aalto, AM, Puttonen, S, Vanska, J, Elovainio, M. Work-related stress, job resources, and well-being among psychiatrists and other medical specialists in Finland. Psychiatr Serv 2014; 66(2): 796–801.Google Scholar
34Johnson, S, Osborn, DP, Araya, R, Wearn, E, Paul, M, Stafford, M, et al. Morale in the English mental health workforce. Br J Psychiatry 2012; 201: 239–46.Google Scholar
35Kealey, D, Halli, P, Ogrodniczuk, JS, Hadjipavlou, G. Burnout among Canadian psychiatry residents: a national survey. Can Psychiatr Assoc 2016; 61(11): 732–6.Google Scholar
36Korkeila, JA, Toyry, S, Kumpulainen, K, Toivola, JM, Rasanen, K, Kalimo, R. Burnout and self-perceived health among Finnish psychiatrists and child psychiatrists: a national survey. Scand J Public Health 2003; 31(2): 85–91.Google Scholar
37Kumar, S, Hatcher, S, Dutu, G, Fischer, J, Ma'u, E. Stresses experienced By psychiatrists and their role in burnout: a national follow-up study. Int J Soc Psychiatry 2011; 57(2): 166–79.Google Scholar
38Kumar, S, Sinha, P, Dutu, G. Being satisfied at work does affect burnout among psychiatrists: a national follow-up study from New Zealand. Int J Soc Psychiatry 2013; 59(5): 460–7.Google Scholar
39Kumar, S, Fisher, J, Robinson, E, Hatcher, S, Bhagat, RN. Burnout and job satisfaction in New Zealand psychiatrists: a national study. Int J Soc Psychiatry 2007; 53(4): 306–16.Google Scholar
40Littlewood, S. Recruitment, retention, satisfaction and stress in child and adolescent psychiatrists. Psychiatr Bull 2003; 27(2): 61–7.Google Scholar
41Mache, S, Bernburg, M, Baresi, L, Groneberg, DA. Evaluation of self-care skills training and solution-focused counselling for health professionals in psychiatric medicine: a pilot study. Int J Psychiatry Clin Pract 2016; 20(4): 239–44.Google Scholar
42McKensey, A, Sullivan, L. Balint groups – helping trainee psychiatrists make even better use of themselves. Australas Psychiatry 2016; 24(1): 84–7.Google Scholar
43Murdoch, JM. ‘Stress-busting’ groups for consultant psychiatrists. Psychiatr Bull 2007; 31(4): 128–31.Google Scholar
44Neves, S, Vieira, F, Madeira, N, Santos, J, Garrido, P, Craveiro, A, et al. Psychiatrist's mental health: a look at burnout in a psychiatry department in Portugal. Eur Psychiatry 2016; 33(1,1): S483–4.Google Scholar
45Olarte, S. Women psychiatrists: personal and professional choices—a survey. Acad Psychiatry 2004; 28(4): 321–4.Google Scholar
46Priebe, S, Fakhoury, WK, Hoffman, K, Powell, RA. Morale and job perception of community mental health professionals in Berlin and London. Soc Psychiatry Psychiatr Epidemiol 2005; 40(3): 223–32.Google Scholar
47Rathod, S, Mistry, M, Ibbotson, B, Kingdon, D. Stress in psychiatrists: coping with a decade of rapid change. Psychiatrist 2011; 35(4): 130–4.Google Scholar
48Rey, JM, Walter, G, Giuffrida, M. Australian psychiatrists today: proud of their profession but stressed and apprehensive about the future. Aust N Z J Psychiatry 2004; 38(3): 105–10.Google Scholar
49Rotstein, S, Jenkins, K. Career satisfaction and work stressors in psychiatrists and psychiatry trainees in Australia and New Zealand. Australas Psychiatry 2017; 25(2): 172–4.Google Scholar
50Ruskin, R, Sakinofsky, I, Bagby, R, Dickens, S, Sousa, G. Impact of patient suicide on psychiatrists and psychiatric trainees. Acad Psychiatry 2004; 28(2): 104–10.Google Scholar
51Sprang, G, Clark, JJ, Whitt-Woosley, A. Compassion fatigue, compassion satisfaction, and burnout: factors impacting a professional's quality of life. J Loss Trauma 2007; 12(3): 259–80.Google Scholar
52Strasburger, LH, Miller, PM, Commons, ML, Gutheil, TG, LaLlave, J. Stress and the forensic psychiatrist: a pilot study. J Am Acad Psychiatry Law 2003; 31(1): 18–26.Google Scholar
53Vicentic, S, Gasic, MJ, Milovanovic, A, Tosevski, DL, Nenadovic, A, Damjanovic, A, et al. Burnout, quality of life and emotional profile in general practitioners and psychiatrists. Work 2013; 45(1): 129–38.Google Scholar
54Volpe, U, Luciano, M, Palumbo, C, Sampogna, G, Del Vecchio, V, Fiorillo, A. Risk of burnout among early career mental health professionals. J Psychiatr Ment Health Nurs 2014; 21(9): 774–81.Google Scholar
55Walter, G, Rey, JM, Giuffrida, M. What is it currently like being a trainee psychiatrist in Australia? Australas Psychiatry 2003; 11(4): 429–34.Google Scholar
56Yanchus, NJ, Periard, D, Osatuke, K. Further examination of predictors of turnover intention among mental health professionals. J Psychiatr Ment Health Nurs 2017; 24(1): 41–56.Google Scholar
57Seligman, M. PERMA and the building blocks of well-being. J Posit Psychol 2018; 13(4): 333.Google Scholar
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