Letter to the Editor Regarding "Burnout Among Neurosurgeons and Residents in Neurosurgery: A Systematic Review and Meta-Analysis of the Literature".

Letter:

We read with great interest the article by Zaed et al about factors that affect the burnout syndrome of neurosurgeons and residents. The authors performed a meta-analysis that incorporated the data from 6 articles in their final analysis. They aimed at mitigating excessive stress and burnout in neurosurgeons. We commend the authors for their timely summary and analysis of the topic. However, we came across what we believed were flaws in the study methodology as we progressed. Therefore we would like to discuss them with the authors.

First, general clinical meta-analysis needs to be registered on the Cochrane website. After consulting, we found that the author of this paper did not register, which needs to be further improved in similar studies in the future.

Second, we found repetitive data in the 2 articles of Shakir, , and their research purposes were the same to determine and compare the prevalence of burnout among U.S. neurosurgery residents with published rates for residents/fellows and practicing physicians from other specialties. Their research population was same and had the same inclusion criteria. Their research times were 2017 and 2019, respectively. Considering that the training cycle of resident doctors in the United States is 7 years, many residents had been recruited twice, which had an impact on the conclusion. Although the authors noticed this, they did not deal with it. We think the authors should exclude an experiment for research or look for the original data and remove the part of repeated recruitment. They should try their best to reduce repeat data.

Third, a randomized controlled trial is the best analysis in meta. All the experiments included in this study are retrospective studies, and this conclusion was not convincing. In addition, retrospective studies need Newcastle-Ottawa-Scale evaluation. Although the Newcastle-Ottawa-Scale is mentioned in this paper, it is not listed in the article. We hope to see the details of this scale to better illustrate the reliability of the study.

Fourth, the main research objects of this article were neurosurgeons and residents. Their inclusion criteria were different. From the authors’ table, it can be seen that there are differences in burnout between the 2 different types of people. Usually, subgroup analysis should be carried out. In addition, in Yu et al's study, residents of neurosurgery and neurosurgeons were included. This led to great heterogeneity. Stata or Review Manager is more commonly used in meta-analysis. This paper uses SPSS to analyze data, but meta-analysis uses Stata or Review Manager more. We think it is better to use Review Manager to make tables in this case.

Fifth, in this paper, American studies were conducted through e-mail, which caused the risk of bias. Although the authors mentioned this bias, this bias was too large.

We respectfully appreciate that Zaed et al provided us with an important meta-analysis. However, more accurate databases should be selected and screened, and subgroup analysis should be carried out for better analysis.