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Comparison of stress in anaesthetic trainees between Hong Kong and Victoria, Australia.

Psychological stress can be defined as a perceived imbalance between the demands being made on an individual and the ability to meet such demands. A moderate amount of stress motivates and helps one to function better. However, excess stress is untenable and may, in extreme situations, result in mental or physical morbidity (1-3). This may in turn impair clinical judgement and compromise patient care. Burnout represents a psychological syndrome resulting from extreme work-related stress. Anaesthetists do suffer from stress-related problems and this is reflected in increased rates of early retirement (4) and suicide (5). Trainee anaesthetists seem to be particularly vulnerable. A recent editorial commented that stress-related sick leave among anaesthetic trainees in the United Kingdom was rising at an alarming rate (6).

In a survey conducted in 2001, anaesthetic trainees in Hong Kong reported having insufficient time to undertake research in addition to clinical duties and studying for examinations (7). For Hong Kong trainees, it is mandatory to be registered with the Hong Kong College of Anaesthesiologists but it is optional to be registered with the Australian and New Zealand College of Anaesthetists (ANZCA). Seventy percent of Hong Kong trainees choose to do complete training with both Colleges to help facilitate professional advancement throughout Australasia. This means that they need to fulfil the requirements of both Colleges (8,9). With the implementation of a three-year contract system for new trainees, passing examinations has become the basis for renewal of contracts and this may be an additional stressor to Hong Kong trainees.

This study was designed to explore similarities /and differences in occupational stress levels between trainees in Hong Kong and in Victoria, Australia, where the training requirements are simpler (i.e. ANZCA alone). The study also aimed to investigate what factors contribute to stress levels and what might be done to alleviate it. Victoria was chosen as an example for Australian trainees, as this state has a similar number of ANZCA trainees as Hong Kong. Despite the geographical distance between the two regions, there are similarities in the operation of their busy metropolitan hospitals.



All ANZCA trainees in Hong Kong and Victoria, Australia were eligible for inclusion.

Study design

epidemiological survey.

Data collection

This study was approved by the Hong Kong Hospital Authority (Kowloon West Cluster, Hong Kong) Clinical Research ethics Committee and ANZCA Clinical Trials Group. A mailing list database for both Victoria and Hong Kong was released by ANZCA to obtain representative samples from these two groups. Subsequently, a cover sheet and postage-paid return envelope was distributed with the questionnaire by post in late 2005. The cover sheet emphasised voluntary participation in this survey and confidentiality of collected information. Reminders were sent out after four weeks. Failing to reply after eight weeks was regarded as being non-respondent.


The self-administered questionnaire contained 64 items, divided into four parts (see Appendix on the online version). Part 1 consisted of demographic data including age, gender, marital status and mortgage home loan, year of anaesthetic training, examination record and formal project status.

Part 2 assessed different sources of stress. Although these ordinarily differ from one occupation to another, the anaesthetist-specific stressors incorporate a previously validated model developed by interviewing anaesthetists (10). The scale consists of 22 questions with a 6-point Likert scale format, from 1 being "very definitely not a source of stress" to 6 being "very definitely a source of stress".

In part 3, the Maslach Burnout Inventory (MBI) was used to quantify levels of stress and the prevalence of burnout (11). This psychological instrument involves 22 statements which are graded on frequency by respondents. Three subsets are derived from these responses, namely emotional exhaustion, depersonalisation and personal accomplishment. These were used and compared with published data by Kluger et al which measured burnout in Australian specialists in 2003 (12) and Hong Kong nurses (13) in 2007. Using identical criteria for burnout, comparisons were also made with United States internal medicine residents (14) and Spanish obstetric and gynaecology residents (15).

In part 4, the Olson and Stewart Global Job Satisfaction Score (GJSS) was included (16). It consists of seven questions regarding attitudes to work, answered with a 5-point Likert scale format from 1 "very dissatisfied" to 5 "very satisfied".

Statistical analysis

The statistical software used was SPSS for Windows, Release 15.0.1 (SPSS Inc., Chicago, IL, USA).

Demographic data were analysed by chi-square test. Anaesthetist-specific stressors, MBI and global job satisfaction scores were analysed by Mann-Whitney U test. The independent t-test was used to detect differences in MBI scores between trainees, specialists and other health professionals. Correlation analysis was subsequently used to determine association between stress (MBI) and job satisfaction (GJSS).


Response rates

Sixty-four out of 133 Hong Kong trainees (48.1%) and 108 out of 196 Victorian trainees (55.1%) responded.

Demographic characteristics

Demographics from the two samples showed differences in age, gender and relationship status (Table 1). The majority of Hong Kong respondents were single. Furthermore, a significantly larger proportion of the Victorian respondents had children or a mortgage. Figure 1 depicts age distribution, with 56.5% of the Victorian respondents aged in the 30 to 34 year range, versus 65.6% of those from Hong Kong aged 25 to 29 years.



Level of anaesthetic training

Although there were trainees in each of the five year levels, Figure 2 shows that there was no statistically significant difference in the proportion of respondents undertaking their Basic Training years 1 (BTY1) and 2 (BTY2), between Hong Kong and Victoria (49.2% vs. 42.6%, P=0.408).

Figure 3 shows collectively the progress of respondents through the ANZCA training program. Most have passed their Primary examination (87% in Victoria vs. 62.5% in Hong Kong, P <0.001). Despite there not being a significantly greater proportion of Victorian respondents in Advanced Training years 1 (ATY1), 2 (ATY2) and Provisional Fellowship year/Advanced Training year 3 (PFY/ATY3) as noted previously, there were more Victorian respondents who had also completed their Final examination (33.3% vs. 17.2%, P=0.022) and research project (28% vs. 12.5%, P=0.018).



Figures 4 and 5 demonstrate the level of training at which completion of the Primary and Final examinations occurred, respectively. Respondents from Victoria have completed their Primary examination at an earlier stage (P <0.001), in some cases during pre-vocational training. This difference is less marked for the Final examination (P=0.321), given the structured nature of the ANZCA training.

Employment and training institution

Regarding employment, Hong Kong trainees are mostly awarded three-year contracts (89.1%) while Victorian trainees are given yearly contracts (84.2%). However, the latter group are generally retained within their respective training programs throughout the duration of the ANZCA training scheme. As mentioned earlier, Hong Kong trainees had to face the problem of contract renewal according to examination success.

Two Victorian trainees reported being in locum medical practice. The workplace environment in which respondents trained were markedly skewed towards teaching hospitals in Victoria (97%) compared with Hong Kong (31.3%). However, the designation of what is a teaching hospital may differ between the two areas. For example, Hong Kong has only two of 16 accredited hospitals which are affiliated with the two medical schools (University of Hong Kong or Chinese University of Hong Kong). In contrast, most hospitals accredited for ANZCA training in Victoria are directly or indirectly affiliated with medical schools (University of Melbourne or Monash University). In a non-teaching hospital in Hong Kong, junior doctors are still being trained and many of those centres are ANZCA accredited, while in Victoria the term "teaching hospital" generally refers to non-private hospitals which undertake training similarly as Hong Kong.

To generalise from this demographic data, Victorian respondents were older and more advanced in completing examinations and research. With few exceptions, all were based in teaching hospitals. Conversely, the Hong Kong respondents sampled were younger and at earlier stages of their ANZCA training. This age difference is also reflected in lower rates of marriage, child-rearing and home ownership.

Anaesthetist-specific stressors

Sources of stress as graded by respondents are shown in Table 2. Higher scores indicate that a given item is of greater stress amongst respondents. Common stressors include treating critically ill patients and attending to challenging clinical circumstances (Items 5 and 8). Medicolegal considerations, reflected in Items 4 and 7, also scored highly for both groups of respondents. Overall, there was good agreement between both groups when comparing sources of stress. However, significant differences (P <0.05) in numerical scores between the two regions were detected in 13 out of 22 items. Hong Kong respondents regarded Items 1, 9, 20 and 21 more highly than their Victorian counterparts, indicating a workplace emphasis on service provision and perceived lack of resources. except for four items, all scores from Hong Kong trainees were higher than those for Victorian trainees. However, for these (Items 3, 12, 13 and 15), no statistically significant difference was observed.

Maslach Burnout Inventory

High scores for emotional exhaustion and depersonalisation and low scores for personal accomplishment are indicative of burnout (9). Table 3 demonstrates that Hong Kong trainees have greater burnout-related symptoms than Victorian trainees in all three subsets.

Applying validated criteria of emotional exhaustion (above 26) and depersonalisation (above 9), the prevalence of burnout in Hong Kong respondents was 65.1% versus Victorian respondents 38.2% (P=0.001). (This compares with 76% for a study of burnout in United States internal medicine residents (14) and 58% for Spanish obstetric and gynaecology residents (15).)

Global Job Satisfaction Scores

The seven-item measure of job satisfaction developed by Olson and Stewart showed that higher scores correlate with greater satisfaction at work (16). each individual component and the cumulative total demonstrate higher scores for Victorian trainees than Hong Kong trainees (Table 4).

Using Pearson correlation analysis between burn- out and job satisfaction for both Hong Kong and Victorian trainees (Table 5), emotional exhaustion and depersonalisation similarly demonstrated a negative correlation with job satisfaction. Both associations achieved statistical significance. However, no positive correlation of personal accomplishment with job satisfaction was noted. These results show that the inverse association between emotional exhaustion and job satisfaction is greater than for either depersonalisation or personal accomplishment. This is consistent with a metaanalysis on the three dimensions of burnout, showing that emotional exhaustion is strongly predictive of job dissatisfaction (17).


Anaesthesia training is challenging, given the requirements to achieve fellowship status, superimposed on personal and work-related commitments. This is evident in results of the Maslach Burnout Inventory, which are at least comparable to published data and perhaps even favourable for Victorian trainees. Major work-related stressors as identified by both populations related to dealing with critically ill patients and medicolegal considerations. While the perception of stress is subjective, respondents from Hong Kong consistently rated more highly, and thus less positively, than those from Victoria. This was apparent from occupational stressors to stress levels and burnout, and in job dissatisfaction. Postulated reasons underlying this are multifactorial and from this cross-sectional study alone cannot be considered causal but merely associated.

First, the adverse working environment with an emphasis on productivity and service provision may explain the different results between Hong Kong and Victorian respondents in the anaesthetist-specific stressors. The former often work under 2:1 or 3:1 trainee:supervisor ratios, due to limited resources. This is particularly the case outside normal working hours (7). Altogether, Hong Kong trainees and fellows average 48 standard working hours per week not including a further 20 hours of on-call work (18). This compares to basic training hours of 43 per week in Victoria, including five hours of training time, and where overtime rostering tends to be limited by remuneration based upon the industrial award (19). Furthermore, in-hours supervision is generally conducted on a 1:1 basis, particularly during basic training years (20). Consequently, discontent with isolation and feelings of being unappreciated may be an issue for anaesthetic trainees in Hong Kong. The survey of Spanish obstetric and gynaecology residents also noted increased odds ratios for burnout with heavier workloads and less supervision (15). However, diminishing working hours, and thus caseload, is controversial as it compromises clinical exposure. For example, 28% of British respondents recently confirmed that off-shift (unrostered) working was occurring in their anaesthetic departments and most of this revolved around acquiring subspecialty experience (21).

Second, the demographic data indicates an older population of trainees in Victoria, with associated family (26% with children) and home ownership (71% with a mortgage) responsibilities. With similarities to medical training in the United Kingdom, specialist anaesthesia training in Hong Kong usually begins following internship (7). In contrast, few aspiring residents in Victoria are accepted directly into anaesthesia training programs following the prerequisite of 24 months of general hospital appointments. This may be reflected by a more mature postgraduate medical program which makes Victorian respondents more competitive.

Despite children and mortgage being potential stressors, stable relationships and marriage (64% in Victoria) represents a social support which balances the emotional burden of having multiple other commitments. Castelo-Branco et al similarly identified single marital status as a predisposing factor for the development of burnout (15). A narrative review also concluded younger age to be associated with burnout (22). An extension of this is seen in the Australian specialist anaesthetists, predominantly aged between 30 and 60 years, where stress levels compared favourably to younger trainees of all specialties (12). This may be due to psychological development or the presence of social support, but survival bias may also influence this. Survival bias refers to the apparent decrease in work-related stress levels with increasing age, due to earlier retirement or falling out of those who cannot tolerate or accept such stress.

Independent of this difference in age or level of training, Victorian respondents fulfil the requirements of ANZCA training sooner than trainees in Hong Kong. This earlier success may contribute to less stress and greater job satisfaction. Alternatively, this earlier success may, through motivation and interest, be the result of less stress and greater job satisfaction. In either case a negative association between stress, particularly emotional exhaustion and job satisfaction exists, as evident from the correlation analysis.

As Hong Kong subjects were dual college trainees one might speculate that this may require greater effort to fulfil training requirements and this may be a possible contributing factor to a higher burnout rate than their Victorian counterparts.

Social and cultural differences between the two regions may impact upon individual trainees (personality and coping strategies) and their work- place environments (resources and productivity), and in turn the results of this survey. Conducting this survey in two distinct populations undertaking a common training program does allow further conclusions to be drawn, compared to surveying a single-study population, regarding predisposing factors for stress and burnout. Reference has already been made to working hours and levels of supervision.

The similarities in MBI indices observed between Hong Kong medical trainees and Hong Kong nurses points to social or cultural factors being responsible for high stress levels and risk of burnout, compared to those practising in Victoria. It may reflect cultural differences between the mostly Chinese Hong Kong residents and mostly Caucasian Victorians. Unfortunately, no formal data on this was collected in the survey. Further data collection and subgroup analysis may allow future research to isolate and deduce the impact of cultural and ethnic background, rather than environmental factors on stress levels.

Limitations of this survey include a relatively low response rate, which may introduce a non-response bias into the study results. This compares with other surveys on stress in trainees undertaking varying specialties of 35% to 77% (7,14,15,23). It is possible that the populations of responders and non-responders differ in their psychological well-being. For example, perhaps non-respondents endure greater stress and are less inclined to participate in this survey. The higher non-response rate from Hong Kong would support this hypothesis. Unfortunately, maintaining anonymity of all subjects precludes further characterisation of non-responders. Strategies used to improve participation have been suggested by Jones et al (24). While attempts were made to optimise the response rate by posting reminder notices and avoiding unnecessary questioning, making preliminary contact with subjects or providing incentives were not undertaken.

By focusing on stress and burnout, this study did not consider stressors beyond the workplace environment, such as interpersonal relationships or personality traits or balance between work and leisure. Recent studies showed that trainees do not have much work-hour related stress. Their morning salivary amylase level, which was used to reflect stress levels, varies significantly with their lifestyle (25). Because the questionnaire utilised closed responses rather than free text, no opportunity was given for respondents to mention other personal stressors. Although this simplified data collection and interpretation, stress is the product of many and varied external pressures.

Implications for anaesthesia practice include providing a supportive environment to staff and adopting various strategies for managing stress. excessive stress may adversely affect clinical judgement and patient care. Throughout this decade, the Australian Medical Association has audited working hours and promoted safer work patterns (26). This has resulted in a noticeable reduction in working hours, allowing trainees to better balance their lifestyles. ANZCA have also acknowledged the importance of patient safety by preventing fatigue (27). Mentorship schemes have been developed within several anaesthetic departments in Victoria. For those who encounter difficulties, the Victorian Doctors Health Program is a resource independent of the Medical Practitioners' Board of Victoria and specialist medical colleges (28). This organisation services doctors and medical students who require assessment or case management of mental health concerns and substance abuse. Thus, support at department and regional levels may help to reduce the stress of anaesthetic training and beyond. This may be a factor in the lower stress indices from Victorian trainees as shown in this survey.

Equivalent initiatives are yet to be established in Hong Kong. It may be related to the relative lack of concerns towards mental wellbeing of trainees in Hong Kong. With the relatively low response rate, it is difficult to generalise the findings from respondents to all Hong Kong trainees. However, our results indicate that Hong Kong respondents, despite studying for the same ANZCA fellowship as their Australian counterpart, seem to be consistently under higher indices of stress and are less satisfied with their job. Given their complex training system and busy working environment, there is an urgent need for more attention to trainees' mental health.


The authors are grateful to Ornella Clavisi of the ANZCA Clinical Trials Group for coordinating the distribution and processing of questionnaires in Victoria.


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(7.) Irwin MG, Soon NTC, Fung SKY. A profile of anaesthesia trainees in Hong Kong. Hong Kong Med J 2001; 7:227-235.

(8.) Hong Kong College of Anaesthesiologists. Vocational training guide for anaesthesiology (2004). From pdf Accessed September 2007.

(9.) Australian and New Zealand College of Anaesthetists. Regulation 15: Training and examinations in anaesthesia (2007). From Accessed September 2007.

(10.) Rowbottom AM. Stress and job satisfaction in anaesthetists. MSc Dissertation, University of Manchester Institute of Science and Technology, 1996.

(11.) Maslach C, Jackson SE. Maslach Burnout Inventory--Human Services Survey (MBI-HSS). In: Maslach C, Jackson Se, Leiter MP, eds. MBI Manual, 3rd ed. Palo Alto, California: Consult Psych Press 1996.

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A. C. L. CHIA *, M. G. IRWIN [[dagger]], P. W. H. Lee [[double dagger]], T. H. W. Lee [[section]], S. F. MAN **

Department of Anaesthesia, Kwong Wah Hospital, Hong Kong and Department of Anaesthesia and Pain Management, Royal Melbourne Hospital and Department of Anaesthesia, St Vincent's Hospital, Melbourne, Victoria, Australia

* M.B., B.S., F.A.N.Z.C.A., Pain Fellow, Department of Anaesthesia and Pain Management, Royal Melbourne Hospital.

[[dagger]] M.B., Ch.B., M.D., F.R.C.A., F.H.K.A.M., Head of Department, Department of Anaesthesiology, Queen Mary Hospital, University of Hong Kong.

[[double dagger]] B.Soc.Sc., M.Soc.Sc. (Clin.Psy.), Ph.D., C.Psychologist (B.P.S.), A.F.B.Ps.S., J.P., Professor in Clinical and Health Psychology, Department of Psychiatry, Queen Mary Hospital, University of Hong Kong.

[[section]] M.B., B.S., Consultant Anaesthetist, Department of Anaesthesia, St Vincent's Hospital.

** B.A., M.Stat., Statistician, Department of Anaesthesiology, Queen Mary Hospital, University of Hong Kong.

Address for reprints: Dr T. H. W. Lee, Consultant Anaesthetist, Department of Anaesthesia, St Vincent's Hospital, PO Box 2900, Fitzroy, Vic 3065.

Accepted for publication on June 25, 2008.
Demographic data of respondents

 Hong Kong Victoria P value
 (n=64) (n=108)

Age See Figure 1 See Figure 1 <0.001
Gender F 49.2% F 33.6% 0.045
 M 50.8% M 66.4%
Marital status Single 76.6% Single 35.5% <0.001
Have children 4.70% 26.90% <0.001
Have mortgage 34.90% 73.10% <0.001

Anaesthetist-specific stressors. Data are mean [+ or -] SD.

 Hong Kong (n=64) Victoria (n=108) P value

1 4.0 [+ or -] 1.1 3.3 [+ or -] 1.3 0.005
2 3.8 [+ or -] 1.0 3.2 [+ or -] 1.2 0.001
3 3.9 [+ or -] 0.9 4.0 [+ or -] 1.2 0.488
4 4.5 [+ or -] 1.0 3.7 [+ or -] 1.1 <0.001
5 4.9 [+ or -] 1.0 4.3 [+ or -] 1.2 0.004
6 3.9 [+ or -] 1.2 3.8 [+ or -] 1.2 0.715
7 4.0 [+ or -] 0.9 4.0 [+ or -] 1.0 0.554
8 4.9 [+ or -] 1.0 4.4 [+ or -] 1.1 0.053
9 4.0 [+ or -] 1.0 3.3 [+ or -] 1.2 0.003
10 3.6 [+ or -] 0.9 3.5 [+ or -] 1.2 0.845
11 3.6 [+ or -] 1.0 3.1 [+ or -] 1.2 0.024
12 3.6 [+ or -] 1.1 3.9 [+ or -] 1.1 0.271
13 3.6 [+ or -] 0.9 3.8 [+ or -] 1.2 0.147
14 4.1 [+ or -] 1.1 3.4 [+ or -] 1.2 <0.001
15 3.7 [+ or -] 0.9 3.9 [+ or -] 1.2 0.325
16 4.4 [+ or -] 1.1 3.8 [+ or -] 1.1 0.001
17 3.5 [+ or -] 1.0 3.2 [+ or -] 1.2 0.051
18 3.4 [+ or -] 1.0 2.9 [+ or -] 1.0 0.001
19 4.0 [+ or -] 1.0 3.3 [+ or -] 1.0 <0.001
20 4.3 [+ or -] 1.0 3.7 [+ or -] 1.2 0.006
21 3.6 [+ or -] 1.0 3.1 [+ or -] 1.2 0.001
22 3.6 [+ or -] 0.8 3.1 [+ or -] 0.9 0.027


1 Lack of available human resources
2 Conflict patients and standards
3 Lack of control over work pattern
4 Risk to patients
5 Extremely ill patients
6 Recent changes in training
7 Legal side of anaesthetics
8 Unexpected difficult situations
9 Lack of appreciation by others
10 Relationships with surgeons
11 Being in a service specialty
12 Not know what to expect on call
13 Lack of communication
14 Acute nature of anaesthetics
15 Time pressure (day case surgery)
16 Need to act quickly
17 Counselling relatives
18 Patient's charter
19 Level of concentration required
20 Level of responsibility
21 Isolation from other anaesthetists
22 Dealing with other specialties

Elements of burnout from anaesthesia trainees in Hong Kong and

MBI subset Hong Kong (n=64) Victoria (n=108) P value

EE 27.2[+ or -]8.1 20.1[+ or -]8.9 <0.001
DP 10.2[+ or -]4.5 7.5[+ or -]5.1 <0.001
PA 27.7[+ or -]5.9 34.5[+ or -]5.3 <0.001

EE = emotional exhaustion, DP = depersonalisation, PA = personal
accomplishment. Data are mean [+ or - ] SD.

Global Job Satisfaction Scores

 Hong Kong Victorian P value
 trainees trainees

1 Interesting 3.67 [+ or -] 0.57 4.44 [+ or -] 0.57 <0.001
2 Possibility 3.85 [+ or -] 0.55 4.05 [+ or -] 0.74 0.036
 to contribute
3 Pay for work 2.50 [+ or -] 1.05 3.22 [+ or -] 0.90 <0.001
4 Prospects for 2.15 [+ or -] 0.88 3.73 [+ or -] 0.77 <0.001
5 Relationship 3.30 [+ or -] 0.87 3.88 [+ or -] 0.93 <0.001
 with superior
6 Time 2.95 [+ or -] 0.79 3.58 [+ or -] 0.80 <0.001
7 Consideration 2.92 [+ or -] 0.77 3.55 [+ or -] 0.82 <0.001
 of ideas

Total 21.21 [+ or -] 3.24 26.30 [+ or -] 3.83 <0.001

Data are mean [+ or -] SD.

Correlation between MBI subsets and GJSS

Correlation Hong Kong trainees Victorian trainees

r (EE) -0.525 -0.469
 (P <0.001) (P <0.001)

r (DP) -0.361 -0.243
 (P = 0.004) (P = 0.014)

r (PA) +0.054 +0.002
 (P = 0.672) (P = 0.986)

r = Pearson correlation coefficient, EE = emotional exhaustion,
DP = depersonalisation, PA = personal accomplishment.
GJSS = global job satisfaction scores
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Article Details
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Title Annotation:Survey
Author:Chia, A.C.L.; Irwin, M.G.; Lee, P.W.H.; Lee, T.H.W.; Man, S.F.
Publication:Anaesthesia and Intensive Care
Article Type:Survey
Geographic Code:8AUST
Date:Nov 1, 2008
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