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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 91-103

Burnout in medical professionals working in a tertiary care hospital: A re-analysis of the data


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication22-Jul-2020

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_63_19

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  Abstract 


Background: Burnout is highly prevalent among medical professionals. The three dimensions of burnout, i.e., emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA) often co-exist and have been found to negatively affecting professionalism. Objectives: To evaluate the prevalence of burnout in terms of three dimensions of Maslach burnout inventory (MBI) and to explore the correlates of the same among the doctors. Methodology: An online survey questionnaire was circulated among the medical professionals (residents and senior consultants/faculty) of a tertiary care hospital of North India to evaluate burnout, depression, stress, and internet addiction (IA). Results: The survey included data of 445 responders, of whom 376 (84.5%) were resident doctors and 69 (15.5%) were faculty members in the institute. Based on the suggested cutoffs, 79.1% of the participants (n = 352) reported moderate-to-high level of EE, 59.55% of the participants reported experiencing moderate-to-high level of DP, and 7.0% of the participants (n = 31) reported of having low PA. Burnout in any one dimension of MBI was seen in 30.6% (n = 136), in two dimensions in 50.6% (n = 225), and in all the three dimensions in 10.8% (n = 48). Highest level of EE and DP and low PA were reported by participants from the specialty of pediatrics, and this was followed by internal medicine. Participants with high EE and high DP were significantly younger, were more often females, and had significantly higher average number of working hours per week. All the three domains of burnout were associated with the presence of depression and perceived stress and significantly higher scores on Young IA scale. Linear regression analysis suggested that for all the three dimensions of burnout, perceived stress score was the variable, which explained the maximum variance. Conclusions: Burnout is highly prevalent among medical professionals, especially in the domain of EE, and this is followed by DP. Younger age, female gender, and longer working hours/week are significantly associated with EE and DP and with low PA. Perceived stress is one of the important predictors of burnout in medical professionals.

Keywords: Burnout, depression, medical professionals


How to cite this article:
Grover S, Sahoo S, Bhalla A, Avasthi A. Burnout in medical professionals working in a tertiary care hospital: A re-analysis of the data. J Mental Health Hum Behav 2019;24:91-103

How to cite this URL:
Grover S, Sahoo S, Bhalla A, Avasthi A. Burnout in medical professionals working in a tertiary care hospital: A re-analysis of the data. J Mental Health Hum Behav [serial online] 2019 [cited 2020 Aug 10];24:91-103. Available from: http://www.jmhhb.org/text.asp?2019/24/2/91/290522




  Introduction Top


The concept of burnout came into existence to understand the job-related stress or occupational stress and includes three main dimensions, i.e., emotional exhaustion (EE) (in which overwhelming work demands overpower over one's energy/efficiency to work), depersonalization (DP) (in which the individual feels detached from his/her job), and diminished personal accomplishment (PA) (in which the individual develops feelings of inefficacy/feelings of personal in achievement).[1],[2] It has been well studied across the different parts of the world among professionals involved in different occupations, and it is suggested that these three dimensions often co-exist in different degrees and negatively affect professionalism and work output.[3] It has now been identified as an alarming issue by the World Health Organization and has been labeled as an “occupational phenomenon” and is included in the upcoming International Classification of Diseases-11th Revision in the chapter “Factors influencing health status or contact with health services (QD85) – which includes reasons for which people contact health services but that are not classified as illnesses or health conditions.”[4],[5]

Burnout among medical/health professionals has been investigated since the inception of the concept of burnout, and there has been an upsurge in literature related to burnout among physicians,[6],[7] residents,[8] intensive care/emergency doctors,[9] and nursing staff.[10],[11]

Different meta-analysis has evaluated the prevalence of burnout among medical students, those pursuing residency, and qualified professionals.[8],[12],[13],[14],[15] Available data suggest the prevalence of burnout among medical students ranges from 35% to 57%,[8],[15],[16] among those pursuing residency ranges from 40% to 60%,[16],[17],[18] and among the qualified doctors ranges from 49% to 67%.[13],[19] Available data suggest differential prevalence of burnout across different specialties; however, there is lack of consensus with respect to the specialty reported across different meta-analyses which have included participants from different countries, have focused on doctors at different levels of their career, and have used different inclusion and exclusion criteria.[8],[14] A meta-analysis reported higher prevalence of burnout (42.5%) among residents in general surgery, anesthesiology, obstetrics and gynecology; moderate prevalence (29.4%) among residents from internal medicine, plastic surgery, and pediatrics; and low prevalence (23.5%) of burnout in residents of otolaryngology and neurology.[8] In terms of various dimensions of burnout, higher rates of DP have been reported in cardiology residents followed by those in otolaryngology and obstetrics and gynecology. Higher rates of EE have been found among residents from general surgery, otolaryngology, and radiation oncology while lowest PA had been found in residents of internal medicine, plastic surgery, and emergency medicine.[8]

A recent meta-analysis (37 studies, 15,183 French physicians) reported more severe burnout in emergency physicians compared to other physicians,[13] whereas another recent meta-analysis suggests that the lowest prevalence of burnout in specialties of psychiatry, oncology, and family medicine in another meta-analysis (47 studies, n = 22,778).[15]

Burnout among medical professionals has now been regarded as a global crisis[6] and has been found to be strongly associated with patient safety, medical errors, low professionalism, and reduced patient satisfaction.[20],[21],[22] It has also been shown to impact the physician/doctor's productivity in the form of greater number of sick leaves/absenteeism, reduced work ability, intent to either continue practicing or change jobs/setups,[23] and even development of psychological problems in the form of depression, anxiety, chronic fatigue, insomnia, and substance dependence.[24],[25]

Various factors have been implicated for burnout among medical professionals, such as high workload, long working hours, unsatisfactory salaries, and taking on multiple responsibilities at their workplaces.[26],[27],[28] Trainees have been found to have higher rates of DP and monthly number of night shifts have been found to be associated with lower PA among medical residents/physicians.[13] Another meta-analysis (65 studies, n = 28,882) which focused on the correlates of physician burnout found EE to be strongly associated with work–life/home conflict and contributes to poor mental health and ineffective coping strategies.[14] DP was found to be strongly associated with quality of work, safety culture at workplace and work attitudes, and poor mental health (though less than EE).[14] Further, studies had revealed higher DP among physicians to be associated with diminished patient satisfaction and longer postdischarge recovery time.[29]

There is ample amount of literature on burnout among doctors from the United States, European countries, and Latin America, yet very few studies on this issue have been reported from India.[30],[31],[32],[33],[34],[35] While one study reported that 45% of medical practitioners reported high EE, 65% reported high DP, and 87% scored low on the dimension of PA,[32] other studies reported 30% of the residents to be experiencing burnout in the dimensions of EE and DP.[34] The study from a tertiary medical center in Kerala, India, which assessed burnout using Copenhagen burnout inventory among 558 interns and residents, showed the highest burnout among the interns in the domains of personal burnout (64%) and patient-related work (68%), with the least prevalence of burnout among super-specialty senior residents and in nonmedical/nonsurgical residents.[33]

We evaluated the psychological problems and burnout among medical professionals (residents and senior faculty doctors) and reported that more than 90% of the surveyed participants had some degree of burnout.[31] However, further details specifically related to burnout and its various dimensions were not analyzed. Therefore, the aim of the present paper is to evaluate the prevalence of burnout in terms of three dimensions of Maslach burnout inventory (MBI) and to explore the correlates of the same among the doctors.


  Methodology Top


This survey was carried out in a tertiary care postgraduate institute (Postgraduate Institute of Medical Education and Research, Chandigarh) in North India. The institute has most of the departments of various medical and surgical specialties as well as various super-specialty departments. The institute has postgraduate training in almost all the specialties and also has super-specialty courses. Trainees can also continue as senior resident for 3 years after completion of the postgraduation courses. The details of the methodology and the online survey had been mentioned in the previous paper pertaining to the perceived stress, depression, and burnout,[31] while another paper from the same survey focused on the internet addiction (IA)/problematic internet use.[36] The interested readers can go through the same to understand the methodology.

The specific instruments, which were included in the survey to assess various psychological problems, were physical health questionnaire-9 (PHQ-9),[37] perceived stress scale (PSS),[37] IA test[38] and MBI (Maslach and Jackson, 1981). In addition, self-designed questions were used to assess variables such as substance abuse, frequency of involvement in any recreational activities, medical errors, and patient-related violence.

Confidentiality of the information was maintained, and no personal information of participants was disclosed to anyone.

MBI is a well-validated 22-item questionnaire for measuring burnout. It evaluates EE, DP, and low PA due to burnout. Authors have used various cutoffs to define the presence or absence of burnout across different studies. For this paper, we followed the cutoffs given in the manual of the scale. There are established cutoff score for each dimension (EE: ≤17 – low level, 18–29 – moderate level, and ≥30 – high level; DP: ≤5 – low level, 6–11 – moderate level, and ≥12 – high level; PA: ≤33 – high level, 34–39 – moderate level, and ≥ 40 – low level).[1],[2] EE and DP are considered to be present if one scores in the moderate or high level range, and PA was considered to be low if one scores ≥40 in PA items.

The data obtained were analyzed using SPSS-20. Initial descriptive analysis involved calculation of frequency and percentages for the categorical variables. Similarly, continuous variables were computed in terms of mean and standard deviation. Comparison statistics involved use of Chi-square test with Yate's correction (wherever applicable) and t-test. Associations between different dimensions of burnout and other variables (depression, perceived stress, and average working hours) were studied using Pearson's correlation coefficient or Spearman's rank correlation. In view of multiple comparisons, Benforroni's correction was applied and P ≤ 0.001 was considered statistically significant. We had used Benforroni's correction in [Table 1] in view of multiple comparisons of 5 × 2 table. We had considered that P ≤ 0.001 was considered statistically significant (0.05/21 = 0.0023). Multiple regression analysis and binary regression analyses were carried out to evaluate the predictors of burnout.
Table 1: Responses to patient care and professional interactions in participants with and without emotional exhaustion

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  Results Top


The survey included data of 445 responders, of whom 376 (84.5%) were resident doctors and 69 (15.5%) were faculty members in the institute. The majority of the responders were males (n = 308; 69.2%), and the mean age of the sample was 31.63 (standard deviation [SD] – 7.45) years. The mean age of the residents was 28.93 years (SD – 3.00; range – 24–39) and that of faculty was 46.36 years (SD – 7.27; range – 33–64). Majority of the responders were from medical stream (65.2%), followed by surgical stream (26.7%) and paramedical stream (8.1%).

Prevalence of burnout

Based on the suggested cutoffs, 79.1% of the participants (n = 352) reported moderate-to-high level of EE, 59.55% of the participants reported experiencing moderate-to-high level of DP, and 7.0% of participants (n = 31) reported of having low PA [Figure 1].
Figure 1:Prevalence of burnout in different dimensions with regard to specific presence and absence of different burnout dimensions

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When the number of affected dimensions was evaluated, burnout in any one dimension of MBI was seen in 30.6% (n = 136), two dimensions in 50.6% (n = 225), and in all the three dimensions in 10.8% (n = 48). Only 8% of the participants had no burnout in any of the three domains [Figure 2].
Figure 2: Prevalence of burnout in different dimensions

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Prevalence of burnout in different specialties of medicine/surgery

Maximum numbers of responses were from pediatrics (n = 68), and this was followed by internal medicine (n = 56) and psychiatry (n = 39). Highest levels of EE and DP were reported by participants from the specialty of pediatrics, and this was followed by internal medicine [Figure 3] and [Figure 4]. Highest level of low PA dimension was reported by participants from the specialty of pediatrics, followed by internal medicine [Figure 5].
Figure 3: Prevalence of presence of emotional exhaustion in different specialties

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Figure 4: Prevalence of presence of depersonalization in different specialties

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Figure 5: Prevalence of presence of low personal accomplishment in different specialties

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Factors associated with various dimensions of burnout

Participants with high EE were significantly younger, were more often females, and had significantly higher average number of working hours per week. Similarly, those with DP were more often females and had significantly higher average number of working hours per week. Low PA was not associated with age, gender, broad medical, surgical, or paramedical specialties, and place of origin but was associated with greater number of average working hours per week [Table 2].
Table 2: Comparison of burnout dimensions across different socio.demographic variables

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All the three domains of burnout were associated with the presence of depression, perceived stress and significantly higher scores on Young IA scale. However, there was no association with severity of IA with the any of the burnout dimensions [Table 3].
Table 3: Comparison of participants with different burnout dimensions on depression, perceived stress and internet addiction scales

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Patient care and professional interactions and its relation to different burnout dimensions

More often experience of verbal abuse by patient/caregiver, having ever shouted at the patient or caregiver, having feeling of seeing more than the desired number of patients, more often feeling that seniors do not show empathy toward them and their colleagues, feeling that seniors/faculty have positive or negative biases toward particular residents, and feeling that your seniors or faculty colleagues have negative biases toward them were associated with EE [Table 1]. DP was not associated with any of these variables.

Those with low PA reported of having felt of seeing more than the desired number of patients, feeling that seniors do not show empathy toward you or your colleagues, feeling that your seniors or faculty colleagues have negative biases toward them [Table 1].

Relationship of different burnout dimensions with perceived stress, depression, internet addiction, and working hours

When the correlation analysis was carried out, higher EE score was strongly associated with higher perceived stress, higher depressive scores, higher IA scores (Young's IA Test [YAT]), higher DP score, but low PA score. Similarly, higher DP score was significantly associated with higher perceived stress, higher level of depressive scores, and greater EE scores of burnout. Lower PA was found to be associated with higher perceived stress, higher depression, and higher EE. Only the EE dimension of burnout was found to have significant positive association with average number of working hours [Table 4].
Table 4: Relationship between perceived stress, depression and burnout domains with average number of work hours

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Predictors of burnout

Linear regression analysis was used to determine the predictors of burnout. For all the three dimensions of burnout, perceived stress score was the variable, which explained the maximum variance. Highest variance of EE (42.0%) was explained by PSS score, and this was followed by PA (6.2%) and DP (4.2%). For EE, other variables which explained some variance were number of working hours (1.3%) and age (0.4%). Details are mentioned in [Table 5].
Table 5: Predictors of emotional exhaustion, depersonalization, and personal accomplishment

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  Discussion Top


The present study was a re-analysis of the burnout data from survey done among medical professionals in a tertiary health care center from North India.[31] The previous paper gave a rough estimate that about 90% of the participants had burnout.[31] In this article, the details of different dimensions of burnout were evaluated and it was found that about four-fifth of the participants reported high level of EE (79.1%, n = 352), three-fifth of the participants (59.55%, n = 265) of the participants reported experiencing moderate to high level of DP, and less than one-tenth (7.0%, n = 31) of the participants reported of having low PA. This is in line with the existing literature from the Western countries as evident from the meta-analysis of studies evaluating burnout among residents and physicians.[13],[15] However, in the present study, the prevalence of EE was slightly higher and the prevalence of low PA was lower when compared to some of the previous studies from India, which had reported prevalence of EE, i.e., range of 30%–45%,[32],[34] and higher prevalence of low PA (i.e., 87%).[32] These differences can be attributed to different working environment, work cultures, settings (emergency vs. nonemergency), and duration of average working hours which varies across the different institutions in the country. In addition, the degree of PA also depends on many subjective factors, such as work/career satisfaction,[39] relationship with staff and fellow colleagues, environmental characteristics, family life satisfaction, salary structure/pay scale, and work–life balance.[40]

With regard to burnout in one or more dimensions, the present study reported that about 10% of the participants have burnout in all the three dimensions and majority had burnout in at least two dimensions. These studies are in concordance with the existing studies, which also suggest that burnout among medical residents and health professionals is seen mostly in the dimensions of EE and DP.[14] It has also been conceptualized that usually in the initial years, exhaustion develops in response to high demands and work overload, which in turn precipitates detachment and negative reactions to people and to the job, and if both of these are continued, it leads to a sense of inadequacy and personal failure.[24] Therefore, it can said that in the present study, many of the participants were possibly in the mid-phase of development of burnout and were more likely develop more negative consequences, if burnout is not addressed.

Studies from the West suggest higher level of burnout among surgeons/residents from surgical branches (53%–64%)[8],[15] as compared with medical residents/physicians (25%–51%).[8],[15] However, the present study did not find any statistical significant difference in the prevalence of burnout in the three streams of medicine.

However, when evaluated on the different burnout dimensions across the different specialties, it was seen that higher proportion of participants from pediatrics and internal medicine had reported the presence of EE, DP, and low PA. These findings are not supported by the data from the developed countries which suggest higher proportion of EE among residents from general surgery, otolaryngology, and radiation oncology, whereas higher proportion of residents from cardiology report DP.[8] Possible reasons could be difference in workload and working standards in the Indian scenario, when compared to the Western countries. It is also possible that the present study included a small proportion of participants from surgical specialties, and due to the same, the differences could not have been apparent. Low degree of PA among residents of internal medicine and pediatrics has been reported by previous studies and same has been reflected in the present study too.[8]

In the various factors associated with burnout, the present study revealed younger age and female gender to be significantly associated with the presence of EE and DP. This finding is supported by the existing literature, which also suggests that younger age is one of the strongest predictors of EE.[41] Previous studies also suggest higher prevalence of burnout among female residents.[41],[42],[43] The higher prevalence of burnout among female residents is attributed to experiencing more work–home conflicts when compared with male residents.[44]

The present study also revealed more average number of working hours per week to be significantly associated with the presence of burnout in the dimensions EE and DP. This finding is supported by the existing literature.[25] Studies have shown that surgeons working for more than 60 h per week and having at least two nights on-call per week have a higher risk of burnout with younger colleagues reporting more burnout than older colleagues.[45] Further, it has also been well documented that extended duty shifts (>80 h/week) result in reduced sleep, which is considered to be one of the most potential precursors for burnout among physicians.[46],[47] Longer working hours has also been linked with serious medical errors and adverse events.[48],[49] Therefore, it can be recommended that every effort should be made at organizational level to reduce the working hours/week of the medical professionals to reduce burnout.

The present study also found that higher level of EE and DP to be associated with higher level of depressive symptom (PHQ-9), higher perceived stress, and higher IA score (YAT score). Higher number of participants with higher EE and higher DP had major depression (as per PHQ-9 score cutoffs) and reported moderate-to-high perceived stress (PSS cutoff scores). Similarly, those with low PA had higher depressive scores and perceived more stress. Further, all the three dimensions of burnout had significant association with perceived stress and depressive symptom scores. Perceived stress was also found to be one of the important predictors of EE, DP, and PA (although variance explained for DP and PA was very low). The link between stress and burnout is bidirectional, while some studies report that physician burnout might contribute to increased incidence of stress, disruptive behavior, mood disorders, and depression,[50],[51],[52],[53] and others suggest that stress partially mediates the development of burnout.[54] Further, it has been suggested that EE is more predictive of stress related health outcomes than the other two dimensions and had been typically correlated with stress symptoms (headaches, chronic fatigue, hypertension, cold/flu, gastrointestinal symptoms, sleep disturbances, etc.).[24] Findings of the present study also suggest the same.

Available data suggest that there is high level of overlap between burnout and depression and the distinction between the two entities is conceptually fragile.[51],[55] A large number of studies have reported strong correlation between severity of depression and the EE component of burnout.[51],[56] The findings of the present study too echo the same.

With regard to the association of various dimensions of burnout with patient-care interactions, the present study suggests that more often experience of verbal abuse by patient/caregiver, history of ever committing a lapse in patient care which was either life-threatening or nonlife-threatening for the patient, and more often feeling of seeing more than the desired number of patients are associated with EE. Previous studies had also reported similar associations of EE with medical errors,[57] workload and violence, and low patient–physician satisfaction score.[57],[58] These findings suggest that there is an urgent need to address the issue of violence against the physicians and rationalization of patient load. In most of the developed countries, there is focus on provided quality care to a limited number of patients attending the routine services and there is long waiting list for various procedures, at times running into years.[59] In contrast to this, at our set-up, patient can walk-in any time to seek medical care and there is no upper cap on number of patients seen by a doctor. These factors possibly lead to a feeling among physicians of seeing more than desired number of cases and not able to provide quality services. Accordingly, there is an urgent need to change the orientation of the services, with priority given to providing quality services, rather than catering to all the patients.

In the present study, EE was also found to be associated with professional interactions such as having more often feeling that seniors do not show empathy toward them and their colleagues, feeling that seniors/faculty have positive or negative biases toward particular residents, and feeling that seniors or faculty colleagues have negative biases toward them. As previous studies have not looked into these aspects, it is difficult to compare the findings of the present study with the existing literature. Available data suggest that burnout mediates the relationship between being bullied in workplace and intention to quit the job, and this results in high physician turnover and associated financial burden.[60],[61] Those who stay on job, despite experiencing burnout contribute to lower productivity and reduced quality of work, ultimately lead to poor job satisfaction and reduced commitment to the job/organization.[24] Therefore, it is suggested that burnout interventions should address building healthy professional relationships in addition to developing strategies to improve organizational-related issues. Accordingly, it can be recommended that there is a need to focus on the interaction patterns and improving the empathy in various interactions to reduce the risk of burnout. Further, there should be mechanism for address the relationship issues emerging among people working at different level to improve the working conditions.

The present study had some limitations. It was a cross-sectional study, which was based on an online survey questionnaire and self-rated scales. Therefore, there is every possibility of subjective bias while reporting the responses. The sample size was nonhomogenous i.e., unequal distribution of responses from different specialties. Various other personal and organizational-related factors, which are known to influence burnout, were not assessed. In addition, some factors such as working environments of different departments and respective workloads are likely to be different which can affect burnout. Further, issues related to burnout may be different during different stages of resident-ship, and these may be totally different for the faculties/senior residents. The generalizability of the study is also limited as the expectations and workloads and working environment of other medical institutes may be significantly different from the study institute of the paper. Future studies with a multicenter study design with inclusion of a larger sample size from a national representative sample can be helpful for better understanding of burnout.

To conclude, the present study suggests that burnout is highly prevalent among medical professionals, especially in the domain of EE, and this is followed by DP. Younger age, female gender, and longer working hours/week are significantly associated with EE, DP, and with low PA. Burnout dimensions are strongly associated with perceived stress and depressive symptoms. Perceived stress is one of the important predictors of burnout in medical professionals. Accordingly, it can be said that reduction in the stress levels, by reducing the workload and improving the coping and resilience, can help in reducing burnout among the medical professionals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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