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Burnout in Physicians: Global and Bangladesh Perspective

Introduction

Medical practice is stressful as because, medical personnel have to respond to the needs of patients as well as families very quickly with limitations and uncertainties and medical errors or mistakes may be costly, harmful to a patient’s   life and sometimes irreversible.  Physicians pass busy life with long work hours, shift work, night work and often ignore their own health. Burnout is a common syndrome seen in healthcare workers, particularly physicians who are exposed to a high level of stress at work and has become a leading challenge within health care in the twenty-first century. It is a comprehensive concept first introduced in 1974 by Freudenberger; then by Christina Maslach and described as a “negative consequence of human service work, characterized by emotional exhaustion, loss of energy, and withdrawal from work”. Burnout is a state of mental and physical exhaustion related to work and myriad of researches have indicated that long-term exposure to job-related stress can lead to burnout.

Defining Burnout

Burnout can be defined as a psychological syndrome that may emerge when employees are exposed to a stressful working environment with high job demands and low resources, although Freudenberger defined ‘burnout’ to describe the gradual emotional depletion, loss of motivation and reduced commitment among volunteers who worked for a drug misuse.  Burnout is also defined as a prolonged physical, emotional, and psychological exhaustion experienced as disengagement, blunting of emotions, feelings of helplessness/hopelessness, and loss of motivation.  Maslach et al., described burnout as a 3-dimensional syndrome including emotional exhaustion (EE): the depletion of emotional energy by continued work-related demands, depersonalization (DP): a sense of emotional distance from one’s patients or job, and reduced personal accomplishment (PA). Emotional exhaustion refers to feelings of being emotionally over-extended and exhausted; depersonalization is characterized by an unfeeling and impersonal response toward recipients of one’s care, treatment, or to one’s institution; personal accomplishment refers to one’s feelings of competence and achievement. Perlman and Hartman defined it, as emotional and physical weariness, depersonalization and reduced productivity as a result of chronic emotional stress at work whereas Pines and Aronson, defined it, as a state of emotional, mental and physical exhaustion due to chronic exposure to situations of emotional overload.

Prevalence of burnout in physicians

Burnout in physicians is a common syndrome, and studies show a prevalence of 30% to 78%  and Dewa et al., found that about one-third to one-half of physicians experience burnout. In another study, it was found as 50% and ranged from 27% to 75% among different specialties particularly with vulnerabilities in early career physicians. Most burnout was found, 75% in obstetrics-gynecology followed by 63% in internal Medicine & Neurology, 60% in ophthalmology, 50% in dermatology, 40% in general surgery, 40% in psychiatry, and 27% in family medicine; though the differences were not statistically significant. In another study, Haukes et al., found that about 20% of the GPs is clinically burned out but still working.  Lamothe et al., found the prevalence as ranging from 30 to 70%; McCray et al found it as ranged between 43%–45% of US residents and between 22%–60% of practicing specialists and general practitioners. Prevalence was found in range between 40%–76% among internal medicine and pediatric residents, 47%–70% among surgery residents, and a high prevalence (56%–80%) of burnout among family physicians. Lee et al., found the prevalence rate was 55%; Maslach & Leiter found that Australian  Medical  Association (AMA) in 2009  reported a  69%  incidence of burnout among junior doctors, at metropolitan tertiary hospitals in Australia,  with  55.9% of study sample experiencing burnout at some point during. Another study found physicians’ burnout rates range between 30 and 65% across medical specialties with particular reference to those working at the front line of clinical care, in general, internal medicine and emergency medicine.

Responsible Factors

The potential sources of physician burnout are time pressure, limited control and a loss of autonomy, conflict between career and family, feelings of isolation, as well as research and teaching activities. Long working hours, working for ≥8 h/shift, serving ≥51 patients per shift, being on call ≥41 times per week, having medical malpractice experience, not being satisfied with one’s specialty, the number of medical error, mental depression, personality, the evaluation assessment system, hospital culture, patient-physician relationships, keeping up with changing technology, and the environment can be the important sources of burnout. Younger healthcare professionals having children in addition to working more than 60 hours per week, heavy workload, resource limitation, sleep deprivation, and having compensation determined entirely based on billing can also be an important source of burnou. Maslach & Leiter identified six domains those can be responsible for burnout as workload, control, reward, community, fairness, and values.

Effects

Burnout endangers the health and well-being of physicians, as well as also is associated with absenteeism, low job satisfaction, higher medical errors and suboptimal quality of care. For medical professionals, the negative implications of burnout are wide ranging and include decreased quality of patient care, anxiety, depression, divorce, increased anxiolytic use, medical illness, and increased suicidality. Burnout may be associated with decreased productivity, decreased job satisfaction, cardiovascular disease, increased inflammation biomarkers, physical symptoms may take many different forms, including insomnia, appetite changes, fatigue, colds or flu, headaches, and gastrointestinal distress; psychological symptoms such as low or irritable mood, cynicism, and decreased concentration can negatively affect productivity and rapport, and substance abuse.

Bangladesh Perspective

Bangladesh is a densely populated country having population density 1063 per square kilometer and the total population is about 160 million;  achieved health related  Millennium Development Goals (MDGs)  significantly with a shortage of healthcare providers as well as an inequitable distribution of  human resource for health. The number of total registered physician is about 82,500 for this huge population and most of the physicians are related with the primary health care in different ways with poor referral system between the care levels enabling the patients to visit physician as per their choice.  As a result there is huge workload both in the institution as well as in the private chambers and Physicians face difficulties during the community level service provision as well as sometimes doctors and health services providers have to face the harassment even physical assault by the patient party. Physician patient relationship is still poorly addressed and only one scale validated to search the matter adequate (PDRQ-9 Bangla). Author’s best knowledge revealed, any systematic research on physician burnout is yet to be started, though previous publications mentioned the situation as physicians are being deprived according to their intellectual contribution.

Conclusion

As burnout affects both the physician and patients health and health service delivery; health service providers, physicians, the country, society and other stakeholder should consider the issue seriously and appropriately. Maslach stated effective working through burnout by stating:  ‘‘If all of the knowledge and  advice about how to beat burnout could be summed  up in 1 word, that  word  would  be balance—balance between  giving and getting,  balance between  stress and  calm,  balance between work  and  home.’’

MBBS, MBA, MPH, & MD Phase B Resident, Department of Psychiatry, Bangabandhu Sheikh Mujib Medical University. Adjunct Faculty, Department of Public Health, ASA University, Bangladesh. Contact: arafatdmc62@gmail.com