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Burn‐out and employability rates are impacted by the level of job autonomy and workload among Dutch gastroenterologists

Abstract Background Increasing burn‐out rates among gastroenterologists make it necessary to find ways to prevent burn‐out and to stimulate their ability and willingness to continue working (i.e., their employability). Understanding their antecedents might help organizations to prevent burn‐out and to enhance employability among this occupational group. Objective The purpose of this study is to provide insight in the relationship between job characteristics and job crafting behavior on the one hand and job outcomes (burn‐out symptoms and employability) on the other hand. Methods Data from two surveys in 2020 and 2021 were collected in a longitudinal study among 238 Dutch gastroenterologists. The data were analyzed with multiple linear regression analyses and paired‐samples t‐tests. Results Job characteristics, specifically job aspects that require sustained physical and/or psychological effort or skills (i.e., job demands), are important predictors of burn‐out symptoms among gastroenterologists. Specifically, high quantitative and emotional workload are significantly related to more burn‐out symptoms. No strong relationship was found between job crafting and burn‐out symptoms. Furthermore, job aspects that reduce the negative impact of these demanding aspects and that help to achieve work goals (i.e., job resources), and job demands to some extent, significantly predict employability. In particular, high job autonomy is related to higher employability, and high quantitative workload is associated with lower employability. Job crafting does not significantly affect employability. Furthermore, levels of burn‐out symptoms and employability differed only little across time. Conclusion In gastroenterologists, a high quantitative workload and emotional workload are associated with a higher burn‐out risk, while low job autonomy and high quantitative workload are associated with more negative perceptions of employability. To prevent burn‐out and to create positive perceptions of employability, it is important to take these aspects into account.


INTRODUCTION
"As a member of the medical profession: (1) I solemnly pledge to dedicate my life to the service of humanity, and (2) The health and well-being of my patient will be my first consideration." This part of the Hippocratic oath (art 1 and 2) shows physicians' strong focus on the well-being of others. Combined with a strong work ethic, this results in some physicians to "submerse themselves in their work and devote themselves to it until they have nothing left to give"-that is, they burn out. 1 In a work environment that is centered around the well-being of patients, the well-being of physicians tends to be neglected. This may cause physicians to routinely self-sacrifice when serving their patients. 2 Scholars argue that there is a "culture of silence and stigma around mental issues" for physicians. 3 Only limited attention is paid to physicians' well-being in the short run and to their performance in the long run, for instance, to their ability and willingness to continue working in their profession (which is here referred to as their employability). 4 Unfortunately, this "culture of silence and stigma" translates in increasing burn-out rates among physicians 5 and especially among gastroenterologists. A study by the American Medical Association with more than 7000 participants concluded that 37% of gastroenterologists reported burn-out. 6,7 This, together with lower employability rates in health care than in other sectors, 8 has raised awareness of topics related to physicians' well-being and employability. Where some years ago burn-out was still described as an "underrecognized threat to safe and high-quality care," 5 high physician burn-out rates are now referred to as having reached "epidemic proportions" 9 and as an "occupational problem" which should be prevented rather than neglected. 6 Burn-out might result in turnover, 7 as physicians may be no longer employable. Given the pivotal position of physicians in the health care system, burn-out is thus not only an individual but also an organizational as well as societal problem, due to the organizational challenges and high costs associated with possible drop-out and turn-over in this occupational group.
This makes it necessary to find ways to prevent burn-out and to stimulate employability of physicians. Understanding the antecedents of these phenomena provides insights in the aspects organizations must invest in to prevent burn-out and to enhance employability.
Studies in work psychology have shown that job characteristics are important antecedents of burn-out and employability. Job characteristics can be divided into job demands, which are job aspects that require sustained physical and/or psychological effort or skills, and job resources, referring to job aspects that reduce the negative impact of these demanding aspects and help to achieve work goals. 10,11 According to Job Demands-Resources theory, 11,12 high job demands have negative consequences for health, such as burn-out. In contrast, high job resources result in positive outcomes, such as high levels of engagement and job satisfaction. 12,13 In addition, studies have examined the relationship between job characteristics and employability. These studies suggest that job demands, like physical and emotional demands, negatively affect employability. 4,14 Note that the relationships between job characteristics on the one hand and job outcomes such as burn-out and employability on the other hand, vary for different occupations. 15 This emphasizes the need to study the relationships between job characteristics and job outcomes for gastroenterologists as well.
Further, studies have suggested that job crafting is an important antecedent of job outcomes such as well-being 16,17 and may also affect employability. Job crafting refers to the "self-initiated behaviors that employees take to shape and change their jobs." 18(p. 126) Physicians can proactively lower the job demands that they perceive as hindering, or they could increase their social job resources. This, in turn, can enhance their well-being (e.g., lower burn-out symptoms) and may boost their employability.

Key summary
Summarize the established knowledge on this subject � Increasing burn-out rates are seen in gastroenterologists � There is a lack of understanding of the causes of burnout in gastroenterologists What are the significant and/or new findings of this study?
� Burn-out risk in gastroenterologists is associated with high quantitative and emotional workload � Ability and willingness to continue working (i.e., employability) are associated with strong job autonomy and low quantitative workload � Job crafting does not play a major role in developing burn-out symptoms and employability � Organizations, professional associations and teams of physicians should take the aforementioned job characteristics into account to prevent burn-out and to stimulate employability VAN The present study addresses the research question: What are the effects of job characteristics (job demands and job resources) and job crafting on job outcomes (burn-out symptoms and employability)?
In answering this question, this study responds to a recent call for more research on burn-out among gastroenterologists. 19 Studying employability next to burn-out will enhance insights on the possible impact of job characteristics on physicians in the near future. Insights from work psychology are used to interpret the findings, which helps in understanding the well-being of gastroenterologists.

Sample and descriptives
Two hundred and thirty-eight physicians completed the first survey (response rate: 29%). 77% of these physicians were medical specialists (n = 183) and 23% were residents (n = 55).
Fifty-two percentage was male (n = 124) and 48% female (n = 114). The average age of respondents was 44.6 (SD = 10.9). 55% was self-employed (n = 101) and 45% was contracted by their hospital (n = 82). Seventy-five physicians completed both surveys. This group consisted of 85% medical specialists (n = 60) and 15% residents (n = 11). Their average age was 45.6 (SD = 10.6). Fifty-seven percentage was self-employed (n = 34) and 43% was contracted by their hospital (n = 26). Further demographics of the study population are shown in Table 1. Table 2 shows the means, standard deviations and correlations of the main study variables.

Measures
Job characteristics were measured using validated scales. [20][21][22] Job autonomy was measured with three items (e.g., "The job allows me to decide on my own how to go about doing my work"; 1 = totally disagree-5 = totally agree; α = 0.652). 21 Quantitative workload was measured with three items (e.g., "Do you have too much work to do?", 1 = never-5 = very often; α = 0.871). 22 Emotional workload was measured with five items (e.g., "Is your job emotionally demanding?", 1 = never-5 = very often; α = 0.672). 22 Physical workload was measured with one item ("My job is physically demanding"; 1 = totally disagree-5 = totally agree). 20 These job characteristics were selected because research has shown that workload and autonomy are central job characteristics in many professions. 23 Moreover, these job characteristics are also relevant in the work situation of physicians, who have much professional autonomy 24 and a high workload. 25 Job crafting was measured using two validated scales. 26 -299 less intense"; α = 0.703). 27 Job crafting to increase social job resources was measured with four items (e.g., "I ask colleagues for advice"; α = 0.686). 27 Answers for all job crafting dimensions were given on a 5-point Likert scale (1 = never, 5 = very often).
Burn-out symptoms were measured with five items of the Utrecht Burnout Scale that measured exhaustion as a core dimension of burn-out (e.g., "I feel emotionally drained from my work"; 1 = never-7 = daily; α T1 = 0.903; α T2 = 0.905). 28

Burn-out and job characteristics
All job demands correlate significantly positively with burn-out symptoms. The correlations are especially strong for quantitative workload and emotional workload, and slightly weaker for physical workload (Table 2). Thus, physicians who report a higher quantitative workload, emotional workload, and to some extent physical workload, are also more likely to experience burn-out symptoms. Job autonomy correlates significant negatively with burn-out symptoms (Table 2). Thus, if physicians perceive more job autonomy, they are less likely to report burn-out symptoms.

Burn-out and job crafting
Job crafting behavior does not significantly correlate with burn-out symptoms. Only job crafting to decrease hindering job demands correlates significantly positively with burn-out symptoms in the cross-sectional data, but this effect is not found longitudinally (Table 2).

Multiple linear regression analyses of the cross-sectional data
show that job crafting significantly predicts burn-out symptoms and accounts for 11% of the change in burn-out symptoms (F (11,54) = 4.026, p < 0.001**, Table 3). Unexpectedly, high levels of job crafting to decrease hindering job demands is associated with higher levels of burn-out symptoms. However, the corresponding longitudinal effect is not significant. A paired-samples t-test further shows that at T1 the level of burn-out symptoms do not differ significantly from T2 (Table 7). Multiple linear regression analyses show that job characteristics significantly predict employability, both cross-sectionally (F (7,57) = 2.424, p = 0.030*; Table 5) and longitudinally (F (7,53) = 2.931, p = 0.011*; Table 6). Job characteristics account for 16% of the variance in employability in the cross-sectional data, and for 20% of the

Employability and job crafting
There are no strong correlations between job crafting behavior and employability perceptions ( Table 2). This is in line with multiple linear regression analyses showing that job crafting does not significantly predict employability at T1 and at T2 (model 3), neither in the cross-sectional (Table 5) nor in the longitudinal data analyses (Table 6). Finally, a paired-samples t-test further shows that employability at T1 and employability at T2 do not differ significantly (Table 7).

DISCUSSION AND CONCLUSIONS
This study aimed to provide insight in the relationships between job characteristics (specifically job demands and job resources), job crafting, and job outcomes (burn-out symptoms and employability). A two-wave longitudinal research design was used to collect survey data from Dutch gastroenterologists.
The high prevalence of burn-out among physicians underlines the need for understanding how this can be prevented and how their employability can be stimulated. [5][6][7] As there is no standard list of specific job demands and job resources that are important to address when aiming to lower the risk of burn-out and to create an employable workforce, it is essential to examine which job demands and job resources are important in the work context of gastroenterologists.
This study shows that especially job demands are important predictors of burn-out symptoms. Specifically, gastroenterologists are more likely to experience burn-out symptoms when they experience a high quantitative workload and emotional workload. Results

T A B L E 3
Outcomes multiple linear regression analyses of control variables, job demands, job resources and job crafting (independent variables) at T1 on burn-out symptoms (dependent variable) at T1 (n = 238)  This study further examined the effect of job crafting on burn-out and employability. The present study among gastroenterologists could not replicate previous findings on job crafting as an effective strategy to prevent burn-out and increase positive perceptions on employability. 17,29 Perhaps professionals in this study were not familiar with how they can effectively craft their jobs. If so, training them how to do so might enhance their job crafting behavior, as was found in previous intervention studies. 16,30 In turn, this could positively affect their well-being, in line with previous job crafting intervention studies. 16,31 Future research could further explore if job crafting is an effective strategy to better deal with a highly demanding work environment by training physicians in how to engage in job crafting

Demographics
behaviors. The present study shows that these job crafting initiatives are more likely to be effective if they focus on handling a high quantitative workload, emotional workload and enhancing job autonomy.

Practical implications
This study provides information on the elements within the work environment of gastroenterologists that should be addressed if one aims to reduce the chances of occurrence of burn-out and to create an employable workforce. Two types of interventions can be distinguished: organization-directed interventions or person/physiciandirected interventions. 32 This study shows that interventions will be most effective when they focus on quantitative workload, emotional workload and job autonomy.
Organization-directed interventions can focus on structural changes made to the work environment. These changes can entail finding strategies to lower quantitative workload, for instance by reducing administrative requirements. In addition, changes in the work environment can focus on ways to enhance or maintain the job autonomy of physicians. This may be particularly relevant for residents, who might perceive less autonomy in their work than senior physicians.

T A B L E 4
Outcomes multiple linear regression analyses of control variables, job demands, job resources, job crafting and burn-out symptoms (independent variables) at T1 on burn-out symptoms (dependent variable) at T2 (n = 75) -303 data analyses. In the present study, the disadvantages of crosssectional data analyses are limited as they are complemented with longitudinal data analyses.

ACKNOWLEDGMENTS
The authors thank all the participating gastroenterologists and trainees of the Dutch Society for Gastroenterology (NVMDL) for their time and effort in completing the surveys for this study. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

CONFLICT OF INTEREST
The authors have no conflicts of interest to declare.

ETHICS APPROVAL
The Ethical Committee of the University Medical Center Utrecht confirmed that this study fell outside the scope of the Dutch Law on Medical Research (WMO). Formal ethical approval was therefore not required.

PATIENT CONSENT STATEMENT
Not required, as no patients were involved in this study.

DATA AVAILABILITY STATEMENT
Raw data are available upon reasonable request. Ethical restrictions related to participant confidentiality prohibit the authors from making the dataset publicly available.
T A B L E 6 Outcomes multiple linear regression analyses of control variables, job demands, job resources, job crafting and employability (independent variables) at T1 on employability (dependent variable) at T2 (n = 75)