Abstract
Background: Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment. The aim of this study was to identify burnout incidence in pediatric residents and evaluate possible risk factors for burnout.
Methods: Using a cross-sectional study design, we approached all pediatric residents in the Saudi Pediatrics Residency Program in Riyadh, Saudi Arabia (n=457) between January and March 2019. The Maslach Burnout Inventory-Human Services Survey was used to assess burnout incidence. In addition, demographic factors, schedule burden, career choice satisfaction, and work-life balance were assessed.
Results: The response rate was 57.8% (264/457). Males represented 46.6%. Only 14% of the residents in the study were satisfied with their work-life balance, and 62% were satisfied with their career choice of pediatrics. The overall high burnout incidence was 15.9%, the high emotional exhaustion incidence was 63.6%, the high depersonalization incidence was 27.7%, and the low sense of personal accomplishment incidence was 48.5%. In the multivariate analysis, an increase in the average number of on-calls per month (odds ratio [OR]=1.66, 95% CI 1.12-2.46; P=0.012) and satisfaction with salary (OR=0.47, 95% CI 0.33-0.66; P<0.001) showed significant associations with high overall burnout.
Conclusion: We found a high level of emotional exhaustion and a low sense of personal accomplishment among respondents. However, less than one-third of residents had feelings of depersonalization or overall high burnout. Residency program directors may need to make modifications in their programs to ensure a good work-life balance for residents that will help ensure that these physicians provide safe and sustained patient care.
INTRODUCTION
Practicing medicine while studying can be challenging, and studies have shown that the incidence of burnout among pediatric residents ranges from 17% to 67.8%.1 Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and a low sense of personal accomplishment.2 Symptoms include anger, blame, helplessness, hopelessness, treating patients as impersonal objects, loneliness, and frustration with patients and with the health care system.3 Overburdened schedules, increased on-call scheduling, lack of mentorship, an unsupportive family or partner, dissatisfaction with work-life balance, and a lack of self-care are all risk factors that can precipitate burnout.4-6
Physicians with burnout are in danger of making medical errors and have lower patient satisfaction rates than non–burned-out physicians.7,8 While burnout has been investigated in many specialties, burnout among pediatric residents in Saudi Arabia has been recognized only recently (2018).9 A single-center study of 32 pediatric residents in Jeddah, Saudi Arabia, showed high emotional exhaustion in 43% of participants.9 Understanding burnout incidence and the risk factors among residents can help residency program directors control the working environment to create a support system that can reduce burnout incidence.6
Residency is a stressful phase in a physician's career and an ideal time to implement personal and organizational plans to decrease burnout incidence.10 We investigated burnout among pediatric residents in Saudi Arabia using a validated measure. We also evaluated possible risk factors, including demographic factors, schedule burden, lack of career choice satisfaction, and work-life balance.
METHODS
Institutional review board approval was obtained from the College of Medicine, Imam Mohammad ibn Saud Islamic University, for this quantitative cross-sectional study. We distributed a survey to all pediatric residents in the city of Riyadh (n=457) between January and March 2019. The survey was distributed to residents during their academic activities at each center and was collected at the end of the activities. The first page of the survey included a description of the study and a consent form. We did not ask for the name of the resident or any detail that could reveal the resident's identity. Participation was totally voluntary.
The first part of the survey collected demographic information (age, sex, marital status, and residency level/postgraduate year), health-related factors (smoking status, hours of sleep/day, exercise days/week), and work-related factors (average on-calls/month, average working hours/day, number of clinics/week, and average number of patients under daily care). Satisfaction with work-life balance, choice of pediatrics as a career, and salary was measured using a 5-point Likert-type scale ranging from 1 (“very satisfied”) to 5 (“very unsatisfied”). Prior to the analysis, scores were recoded so that 5 corresponded to very satisfied and 1 corresponded to very unsatisfied. The second part of the survey was the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), a validated measure of burnout.11
The MBI-HSS includes 22 questions that evaluate 3 domains of burnout: emotional exhaustion (9 questions), depersonalization (5 questions), and sense of personal accomplishment (8 questions). The severity of each item is assessed on a 7-point Likert scale, ranging from 0 (“never”) to 6 (“always”). Higher emotional exhaustion and depersonalization scores are associated with higher levels of burnout, whereas higher personal accomplishment scores are associated with lower levels of burnout. High emotional exhaustion was defined as a score >26, and high depersonalization was defined as a score >12. Low sense of personal accomplishment was defined as a score <32. A high risk of burnout was defined as coexisting high emotional exhaustion, high depersonalization, and low sense of personal accomplishment.
Statistical analysis was performed using SPSS, version 24.0 (IBM Corp). Counts and percentages were used to summarize participant demographics. Mean ± SD was used to summarize continuous variables. Burnout dimensions and overall burnout were analyzed as continuous and categorical (dichotomous) variables based on the previously mentioned cutoff criteria. Likert-scale items—satisfaction with work-life balance, career choice, and salary—were summarized using counts and percentages. Binary logistic regression was used to assess the predictors of the burnout dimensions as well as overall burnout. Univariate binary logistic regression was used to assess the associations of demographics and residency-related factors with burnout. Four models were constructed, 1 for each of the 3 dimensions of burnout and 1 for overall burnout. In addition, a chi-square test of independence was used to assess whether the distribution of each dependent variable across the various demographics was significantly different from what was expected under the null hypothesis. Multivariate binary logistic regression was used to assess the independent predictors of high risk of burnout. All independent variables were initially included in the model. A backward approach (using the P value for the Wald chi-square statistic) was used for variable selection. Variables were kept in the model if the P value for the multivariate Wald chi-square statistic in the final model was <0.1. Two-tailed hypothesis testing was performed at α≤0.05. Odds ratios (ORs) and 95% CIs were calculated for the independent variables included in the analysis. Exercise, age, and residency level were dichotomized prior to the analysis. The dichotomized versions of the burnout dimensions were handled as dependent variables. Satisfaction levels with work-related aspects were treated as continuous variables. Model performance was assessed by using R2 (the proportion of variance explained by the independent variables).
RESULTS
Of the 457 surveys distributed, 264 surveys were returned for a response rate of 57.8%. Demographic characteristics of the respondents are shown in Table 1. Satisfaction with work-life balance, career, and salary is shown in the Figure.
Respondents’ satisfaction with work-life balance, career choice of pediatrics, and salary.
Demographic Characteristics of the Pediatric Resident Respondents (n=264)
High emotional exhaustion was reported by 63.6% of residents (n=168), while a low sense of personal accomplishment was expressed by 48.5% (n=128). High depersonalization was the least prevalent of all burnout dimensions 27.7% (n=73). High risk of overall burnout was present in 15.9% (n=42) of the pediatric residents in this study (Table 2).
Mean Scores for Burnout Domains, Prevalence of Negative Scores, and Prevalence of Overall High Burnout Among Pediatric Residents (n=264)
Univariate logistic regression analysis (data not shown) showed that having more on-calls/month (OR=1.58, 95% CI 1.17-2.12; P=0.003) and more patients under daily care (OR=1.09, 95% CI 1.01-1.19; P=0.035) were both significantly associated with high emotional exhaustion. The probability of high emotional exhaustion increased by 58% for each additional on-call in the month. Similarly, the probability of high emotional exhaustion increased by 9% for each additional patient under the daily care of a pediatric resident in this study. None of the remaining work-related variables showed a statistically significant association with emotional exhaustion.
High depersonalization was associated significantly only with the average number of on-calls/month (OR=1.57, 95% CI 1.14-2.15; P=0.005) (data not shown). None of the remaining work-related variables showed a statistically significant association with depersonalization. None of the work-related variables showed a statistically significant association with low sense of personal accomplishment.
Table 3 shows the association of demographic and work-related variables with high overall burnout. More on-calls/month was significantly associated with the risk of high burnout (OR=1.88, 95% CI 1.27-2.77; P=0.001). The probability of burnout increased by 88% for each increase in on-calls/month. None of the remaining variables was significantly associated with high risk of burnout.
Association of Demographic and Work-Related Factors With High Burnout
As shown in Table 4, high satisfaction with job salary was associated with lower odds of high emotional exhaustion (OR=0.50, 95% CI 0.38-0.67; P<0.001). For each 1-unit increase in satisfaction with job salary, the odds of high emotional exhaustion decreased by 50%. Similarly, for each 1-unit increase in satisfaction with job salary, the odds of high depersonalization also decreased by approximately 50% (OR=0.52, 95% CI 0.39-0.68; P<0.001). A 1-unit increase in job satisfaction score was associated with a 32% decrease in the odds of low sense of personal accomplishment (OR=0.68, 95% CI 0.53-0.87; P=0.002). Overall, the odds of high burnout decreased by 56% for each 1-unit increase in satisfaction with job salary (OR=0.44, 95% CI 0.32-0.62; P<0.001).
Univariate Logistic Regression Analysis of Career Variable Satisfaction and Burnout Domains and High Burnout
Each 1-unit increase in satisfaction with the choice of pediatrics as a career was associated with a 53% decrease in the odds of high emotional exhaustion (OR=0.47, 95% CI 0.35-0.64; P<0.001), a 29% decrease in the odds of high depersonalization (OR=0.71, 95% CI 0.55-0.92; P=0.008), a 45% decrease in the odds of low sense of personal accomplishment (OR=0.55, 95% CI 0.43-0.71; P<0.001), and an overall 41% decrease in the odds of high burnout (OR=0.59, 95% CI 0.44-0.79; P=0.001).
Each 1-unit increase in satisfaction with work-life balance was significantly associated with lower likelihood of high emotional exhaustion (P<0.001), high depersonalization (P<0.001), low sense of personal accomplishment (P=0.006), and high burnout (P<0.001).
As displayed in Table 5, male respondents were at lower risk of high emotional exhaustion than females (OR=0.51, 95% CI 0.29-0.99; P=0.025), and the risk of high emotional exhaustion was 2.5 times higher in smokers compared to nonsmokers (OR=2.49, 95% CI, 1.12-5.53; P=0.046). Each 1-call increase in the average number of on-calls/month was associated with a 59% increase in the odds of high emotional exhaustion (OR=1.59; 95% CI, 1.09-2.31, P=0.015). Each 1-unit increase in satisfaction with salary was associated with a 38% decrease in the odds of high emotional exhaustion (OR=0.62, 95% CI 0.44-0.88; P=0.007). Each 1-unit increase in satisfaction with work-life balance was associated with a 66% decrease in the odds of high emotional exhaustion (OR=0.34, 95% CI 0.23-0.49; P<0.001).
Multivariate Logistic Regression Analysis Results
Year 3 and 4 residents were at lower risk of high depersonalization than year 1 and 2 residents (OR=0.49, 95% CI 0.25-0.97; P=0.04). Each 1-unit increase in satisfaction with job salary was associated with a 39% decrease in the odds of high depersonalization (OR=0.61, 95% CI 0.45-0.82; P=0.001). Similarly, each 1-unit increase in satisfaction with work-life balance was associated with a 43% decrease in the odds of high depersonalization (OR=0.57, 95% CI 0.41-0.80; P=0.001).
Each 1-unit increase in satisfaction with career choice of pediatrics was associated with a 45% reduction in the odds of low sense of personal accomplishment (OR=0.55, 95% CI 0.43-0.71; P<0.001).
Each 1-call increase in the average number of on-calls/month was associated with a 66% increase in the odds of high burnout (OR=1.66, 95% CI 1.12-2.46; P=0.012), and each 1-unit increase in satisfaction with salary was associated with a 53% reduction in the odds of high burnout (OR=0.47, 95% CI 0.33-0.66; P<0.001).
DISCUSSION
Burnout—a constellation of emotional exhaustion, a state of depersonalization, and a diminished feeling of achievement—is caused by interactions between environmental stressors and genetic tendencies.5 Burnout can lead to physical and psychological symptoms, as well as substance abuse. All of these factors can negatively affect the life quality of residents and impact their ability to provide competent and safe patient care while meeting their responsibilities to study and learn.5 The Accreditation Council for Graduate Medical Education has stated that general practice residents, a group that includes pediatric residents, are among the medical education learners most affected by burnout.12
The prevalence of emotional exhaustion and low sense of personal accomplishment among the residents sampled for our study was 63.6% and 48.5%, respectively. These findings are similar to those of previous studies.13-15 Depersonalization was the least prevalent of the 3 dimensions of burnout. The incidence of high burnout was 15.9% among the respondents. In a large review, McKinley et al showed that the prevalence of burnout varies between 17% and 67.8% among pediatric residents.1 Pantaleoni et al found that burnout increases from 17% to 46% between the start of residency and the mid-intern level.16 However, in our multivariate regression analyses (Table 5), we found no significant differences between the year 1 and 2 residents and year 3 and 4 residents in prevalence of high burnout. The number of on-calls showed a significant association with high burnout. In a study of medical and surgical residents at 3 hospitals in Saudi Arabia, Hameed et al found that increased working hours/week was significantly associated with burnout.17 Kassam et al studied resident physicians at the University of Calgary in Canada to assess predictors of well-being and demonstrated that personal burnout and work dissatisfaction were the only significant indicators of overall well-being.18 However, on-calls affected residents’ sleep quality and minimized their leisure and family time.
Study limitations include the use of a survey that creates a dependence on self-reported data at risk for bias. Moreover, data were collected from one city only. An additional limitation of this study is the high proportion of first- and second-year residents relative to the higher levels. The Saudi Commission for Health Specialties (SCFHS)—which is responsible for all residency programs in Saudi Arabia—significantly increased the number of residents accepted in 2017 and 2018, and that increase may be the reason for the higher number of year 1 and 2 residents vs year 3 and 4 residents included in this study. Another limitation is that residents who experienced preexisting anxiety, depression, or other mood-related disorders were not excluded from participation. Also, as with all cross-sectional studies, this study offers relationships but is unable to posit causation. Thus, prospective cohort studies should be conducted to verify the outcomes reported.
An advantage of this study is its sample size that reflects a representative cross-section of pediatric residents in the capital city of Saudi Arabia. Although survey respondents were residents from different pediatric residency programs in Riyadh, Saudi Arabia, we did not intend to compare the results from each residency program. This study illustrates the incidence of burnout in pediatric residents overall, and SCFHS can potentially use this understanding of burnout among pediatric residents to create standardized organizational plans for all residency programs to improve residents’ well-being.
CONCLUSION
Saudi pediatric residents reported high levels of emotional exhaustion and a low sense of personal accomplishment, although less than one-third of residents had feelings of depersonalization or overall high burnout. These findings suggest that residency program directors need to make adjustments to ensure a better work-life balance for residents, which would promote safe and sustained patient care. Prospective studies involving a large cohort of residents from different medical and surgical specialties and from a variety of regions are needed to reproduce these outcomes and to identify other factors that drive burnout.
This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Medical Knowledge, Professionalism, and Systems-Based Practice.
ACKNOWLEDGMENTS
The authors wish to express their admiration to all the pediatric residents who participated in this study. The authors have no financial or proprietary interest in the subject matter of this article.
- ©2021 by the author(s); Creative Commons Attribution License (CC BY)
©2021 by the author(s); licensee Ochsner Journal, Ochsner Clinic Foundation, New Orleans, LA. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (creativecommons.org/licenses/by/4.0/legalcode) that permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
