Participants were invited from medical specialists dedicated to LT, including surgery, hepatology, anesthesiology, intensive care, pediatrics, and pediatric surgery. The survey was sent to all members of Spanish Society of Liver Transplantation (SETH), and to achieve wider dissemination, the directors of transplant teams were contacted and asked to send the survey to specialists in their transplant units who were not members of SETH.

The survey was also sent to medical residents from the same specialty as the other staff doctors. They were residents in the specialties of general and digestive surgery, gastroenterology and hepatology, anaesthesiology and intensive care medicine.

The Scientific committee of SETH designed a survey based on the questions of the Maslach model [18], adapted to the socio-labor structure of our environment, with 39 questions evaluating emotional exhaustion with a loss of interest in work, depersonalization or lack of empathy for patients and colleagues, and professional dissatisfaction. Questions were included about the impact of stress on professional life, personal life, and team support, as well as the approach to burnout and the attitude toward its therapeutic options. Personality refers to the subjective perception of personal character. The item “felt recognized” was referred to subjective feel of recognition of your own work by colleagues related and no related to LT.

Once designed and agreed upon by the working group, the survey was created using SurveyMonkey ¹ . Personal or specific workplace data were not requested to ensure anonymity. An email was sent to eligible participants that included a cover letter explaining the purpose of the study, encouragement to participate, and a web link to the survey.

Descriptive statistics were estimated using frequencies (n) and percentages (%) for categorical data and means and standard deviations (SD) for continuous data. Differences between groups were analyzed using the non-parametric Mann–Whitney U test for quantitative variables, and differences between percentages or frequencies were assessed using Pearson’s chi-square test or Fisher’s exact probability test. A p-value <0.05 was considered significant. The IBM SPSS statistical software (version 22.0; IBM Corp., Armonk, NY) was used for calculations.

The survey was distributed to 496 physicians and had a 43% response rate (n = 212 responses). Of these, 78% (n = 165) were SETH members, with an even distribution between males and females (50.9% females), and a mean age of 45.17 ± 11.6 years (range 26–70 years). The mean age was significantly higher for males (48.6 ± 12.4 vs. 42.3 ± 10 years old (p = 0.00008). Of note, 30% of participants had been working in the same unit for >20 years and 44% had been in the same unit for <10 years. Nearly half of the respondents were surgeons (49%), followed by hepatologists (27.8%), anesthesiologists (16%), intensivists (3.8%), and others from various specialties (3.3%). Anesthesiologists (67.6%), intensivists (62.5%), and hepatologists (54.2%) were more often women, while only 42.3% were female surgeons (p = 0.101). Regarding the positions of respondents, 69.3% (n = 147) were attending physicians, 9.9% (n = 21) were residents, and 20.75% (n = 44) were department or unit heads. Only 20.5% of the heads were women. Overall 59%, 31%, and 6% of respondents worked in centers performing 21–50, 51–100, and >100 LTs annually.

On a scale of 1–100, mean overall satisfaction with activities within the transplant unit was 68.86 (SD 24.3), while satisfaction with economic remuneration was the worst-rated aspect at 48.9 (SD 27.7) points. Department or unit heads were generally more satisfied and had a lower perceived burnout (Figure 1). Significant differences were observed in overall satisfaction, satisfaction with remuneration, perception of burnout, the consequences of burnout on life, and overall job satisfaction when analyzing data by specialty; notably, anesthesiologists and surgeons were most dissatisfied and had the highest reported burnout. These differences remained after excluding medical residents from the analysis (Table 1). Women also reported higher perceived burnout (55 ± 29.6 vs. 44 ± 32.9; p = 0.01) and impact on personal life (44.3 ± 26.9 vs. 35.6 ± 29.3; p = 0.02) (Table 2). Among respondents, 78% (n = 165) believed they suffered from some degree of burnout, all agreeing that it affected their work in some way. Regarding the impact on personal life, 27.4% (n = 58) reported that this was affected to a moderate-to-severe degree, with this especially common among women (33.6% vs 21%; p = 0.02) and surgeons (Table 3).

Factors related to burnout that affected the personal life of respondents are shown in Table 4. Among the reported symptoms, tiredness was the most frequent (n = 74), followed by irritability (n = 47) and lack of motivation (n = 37). Depression was present in 24 (11.3%) participants, with 9 (4.2%) acknowledging a need for treatment. There were no differences between males and females in the rate of depression (12.4% vs. 10.3%; p = 0.6) or in acknowledging the need for treatment (2.9% vs 5.6%; p = 0.3). However, although there were no differences among specialties in the rate of depression, there were differences in acknowledging the need for treatment (Table 3).

Regarding burnout management, 26.9% of participants (n = 57) sought support from family or friends, 34.9% (n = 74) turned to physical exercise, and only 4.2% (n = 9) reported needing the support of mental health services or pharmacological treatment. Although 78.8% (n = 167) reported that they would find it interesting if their institution offered support for stress or burnout, only 44% (n = 74) acknowledged they would use such a service, with no differences in response by gender or specialty (Table 3). Regarding the influence of personality on the onset of burnout, 10.9% (n = 23) were unsure if it affected them, 71.2% (n = 151) attributed their burnout to external factors, and 17.9% (n = 38) believed their personality played a role, with differences noted across specialties (Table 3). There were no differences between men and women (17.1% vs. 18.7%; p = 0.6). Factors recognized as affecting burnout were excessive working hours, excessive bureaucratic tasks, and lack of respect from the institution, bosses, and colleagues (Figure 2).

Univariate and multivariate analyses were conducted to assess variables associated with burnout. The results indicated that being younger than 60 years old (OR 2.89; 95% CI 1.09–7.61; p = 0.032), not being head of service or transplant unit (OR 4.14 95% CI 1.83–9.38; p = 0.001) and being an intensivist (OR 0.98 95% CI 0.021–0.448; p = 0.003) were significantly correlated with the risk of experiencing burnout (Table 5).

Regarding to satisfaction with the work performed in the transplant unit (scale 0–100 points) we performed a multiple linear regression analysis and found that the independent factors related to this were: being a surgeon (correlation coefficient −0.257; p < 0.001), being an anesthesiologist (correlation coefficient −0.238; p = 0.001) and not being the head of the transplant unit (correlation coefficient −0.203; p = 0.002).

When respondents were asked to rank issues within their transplant unit from least to most important on a scale of 1–5, three critical issues were identified: lack of personnel, lack of economic compensation, and lack of organization and leadership (Figure 3). Lack of the appropriate technological tools was the only factor perceived to be a more significant problem by men compared to women, with average scores of 2.77 ± 1.5 and 3.36 ± 1.5, respectively (p = 0.005). The other problems were rated similarly by both sexes. Differences were observed by specialty in the importance attributed to lack of economic reward, technological tools, and personnel (Table 6) (Figure 3). Additionally, compared with other physicians, department or unit heads considered the lack of technological tools more important (4.09 ± 1.36 vs. 2.86 ± 1.5; p < 0.001) and the lack of organization and leadership less important (2.68 ± 1.57 vs. 3.66 ± 1.86; p < 0.002). There was no significant differences whether they were women or men. Another noteworthy aspect is that heads respond that they can make their own decisions almost always or always more often than physicians who are not heads (80% vs. 45.8%; p < 0.001).

Assessment of time constraints revealed high levels of clinical pressure among 25.5% of participants (n = 54), who felt they almost never had enough time to perform their tasks well; another 43.9% (n = 93) felt this way sometimes. Of the 212 respondents, 33% (n = 70) felt their opinions were not considered within the team, though they were allowed to express them, and 30.7% (n = 65) believed their achievements were never or almost never recognized. Despite 4.25% (n = 9) feeling undervalued compared to other physicians not involved in LT, most (66%) felt recognized or highly recognized, although this sentiment varied by specialty (Table 6). None of the department or unit heads felt undervalued, as compared with 5.1% of other professionals. Likewise, 94.3% of department or unit heads felt recognized or very recognized compared with 60.5% of other professionals (p = 0.02). No statistically significant differences were found by gender. Colleague support was present always or almost always for 65% of respondents.

Regarding decision-making in professional performance, 51.4% (n = 109) had the ability to make decisions and only 45.8% (n = 98) believed their work was well organized almost always or always. Concerning opportunities for professional development, 29.7% (n = 63) were dissatisfied or very dissatisfied. Up to 43.4% (n = 92) were dissatisfied or very dissatisfied with work flexibility and family life balance. This parameter showed the highest dissatisfaction levels among anesthesiologists (70.6%) and the lowest levels among hepatologists (15.3%; p < 0.001) (Table 6). By gender, women reported higher rates of being dissatisfied or very dissatisfied with work flexibility and family life balance (48.6% vs. 38.1%; p = 0.014). We carried out a multivariate analysis to study which variables influence dissatisfaction with work-life balance, we found that gender was not a statistically significant variable, however, the following variables had a greater influence on dissatisfaction: Not being head of service or head of a department (OR 4.119 CI 95% 1.624–10.45; p = 0.003), being anesthesiologist (OR 10.663 CI 95% 4.073–27.917; p < 0.001) or surgeon (OR 5.948 CI 95% 2.862–12.362; p < 0.001).

Continued education was seen as always or almost always accessible for 42% of respondents (n = 89), while 19.8% (n = 42) admitted they never or almost never had access. No gender differences were detected (Table 2), but variations were observed by specialty, with anesthesiologists reporting the least access (Table 6). A similar pattern emerged for participation in research and innovation, with 24.1% (n = 51) stating they never or almost never had the opportunity to participate. Differences were observed among specialties, with anesthesiologists again reporting the least access (Table 6). Additionally, twice as many women as men reported that access to research and innovation was never or almost never possible (16.2% vs. 31.8%; p = 0.008) (Table 2).

Overall, 147 respondents (69.3%) reported that going to work was satisfying or very satisfying, and 104 (49%) considered their working conditions good or very good. Despite the challenges faces, 91% of transplant physicians felt committed or very committed to their work.

Regarding their futures within transplant teams, 54.3% of physicians (n = 115) saw themselves as part of the team in 5 years, while 21.2% (n = 45) would either not be or prefer not to be in the team. Importantly, 24.5% (n = 52) expressed a desire to stay, but they were unsure if they could withstand the pressure. To refine the analysis of how many physicians did not wish to remain in the transplant unit within 5 years, we excluded residents and those over 65 years of age. Among the remaining 132 respondents, 27 (17%) indicated they would not want to be part of the team. This percentage was higher among men than women (26% vs. 9.3%; p = 0.005); among the different specialties, it was highest among anesthesiologists (34.5%; p = 0.001) (Table 6). Among the surgery residents, it was notable that 27.8% thought they would not work or would not like to work in a LT unit.