Why ignore Cochrane systematic reviews? Our response to a systematic review published in the Lancet

We read with great interest but also with disappointment the systematic review by West et al. (1). According to the authors: “previous reviews of physician distress have been limited in their ability to inform these issues by … an absence of focus on physicians and burnout and inconsistent adherence to modern methodological systematic review standards.” This includes our Cochrane review of preventing occupational stress in health care workers, which uses the same outcome measures (2). The protocol of our review was published in 2000, the first version of the review in 2006 and the latest updated version in 2015. This was hard work.

We included 58 studies on all healthcare workers, i.e. not just physicians but also nurses, as we found no reason to assume that stress levels would be different or that a stress management interventions would work differently in these subpopulations of healthcare workers. Our subgroup analyses supported this assumption. Conversely, West et al. provide no justification for their narrower focus.

Our review adheres to all Cochrane standards (3) that have been proven to make Cochrane reviews higher quality than other systematic reviews (4). West et al. on the other hand did not adhere to at least the following Cochrane standards: publishing a protocol, not combining RCTS and case studies (referred to as cohort studies by West et al.), not combining widely different interventions, and using GRADE.

West et al. claim that their results represent “clinically meaningful reductions”. However, for the Maslach Burnout Inventory a minimal clinically important difference has never been established. We believe that physicians are put on the wrong foot with the conclusion of moderate quality evidence of clinically meaningful reductions in burnout. In spite of the more recent studies included by West et al., we still believe that there is at most low quality evidence for all interventions except for relaxation for which there is moderate quality evidence of an effect.

Given the rate at which the number of studies is increasing and the low quality of evidence, we invite West et al. to join us in updating our Cochrane review according to the highest methodological standards for systematic reviews. This way we would reach the most relevant, the most reliable and the most up-to-date evidence to advise all healthcare workers on how to manage their stress and avoid burnout, which is Cochrane’s mission and which has been praised by the Lancet (5).

Contributions of authors
Both authors contributed equally to writing this manuscript.

Declaration of interests
We are the Managing Editor and the Coordinating Editor of Cochrane Work, the review group responsible for supporting and publishing Cochrane systematic reviews about the effectiveness of occupational safety and health interventions.

Role of the funding source
No funding received for this work.



1. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Lancet. 2016 Nov 5;388(10057):2272-2281. doi: 10.1016/S0140-6736(16)31279-X.

2. Ruotsalainen JH, Verbeek JH, Mariné A, Serra C. Preventing occupational stress in healthcare workers. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD002892. DOI: 10.1002/14651858.CD002892.pub5.

3. Higgins JPT, Lasserson T, Chandler J, Tovey D, Churchill R. Methodological Expectations of Cochrane Intervention Reviews (MECIR). Standards for the conduct and reporting of new Cochrane intervention reviews, reporting of protocols and the planning, conduct and reporting of updates. Cochrane: London, 2016

4. Page MJ, Shamseer L, Altman DG, Tetzlaff J, Sampson M, Tricco AC, Catalá-López F, Li L, Reid EK, Sarkis-Onofre R, Moher D. Epidemiology and Reporting Characteristics of Systematic Reviews of Biomedical Research: A Cross-Sectional Study. PLoS Med. 2016 May 24;13(5):e1002028. doi: 10.1371/journal.pmed.1002028

5. Clarke M, Horton R. Bringing it all together: Lancet-Cochrane collaborate on systematic reviews. Lancet. 2001 Jun 2;357(9270):1728.