Critical decision making in a limited time and stressful situations is common in anesthesia practice. Moderate amounts of stress provide a driving force for optimal function; however, there is a delicate balance between positive effects and inability to cope with constant stressful situations. Burnout may follow persistent stress and is a state of fatigue or frustration motivated by a relationship that does not meet expectations.1 There is evidence that physicians with high burnout levels make more medical errors.2 Therefore, job stresses need to be minimized for optimal working conditions and retention of professionals in the field. There is limited literature available on the topic, especially from low- and middle-income countries where the nature of job stress for anesthesiologists may be different from that of colleagues working in high-income countries.3 Pakistan is a country of 200 million people and is categorized among the low middle income countries.4 The objective of our study was to find the level of burnout in a cohort of anesthesiologists working in academic institutions in 2 large cities in Pakistan and to identify factors that were associated with it.
The study design was a cross-sectional survey. An anonymous questionnaire was designed in 2 parts (Supplemental Digital Content, Appendix 1, http://links.lww.com/AA/C722). The first part included the demographic details including gender, age group, marital status, number of children, practicing hospital, years of experience, working hours per week, on-call hours per week, number of hours spent in the operating room, voluntary choice of anesthesiology as a career, and satisfaction with work–life balance. The second part was based on the Maslach Burnout Inventory scale, which had 3 components: emotional exhaustion; depersonalization; and personal achievement.5 Exhaustion and depersonalization were assessed with a set of 7 questions each, and personal achievement was assessed with 8 questions. All were answered on a 7-point Likert scale ranging from 0 to 6.
Both trainees and consultants were asked to take part in the survey. Anesthesiologists who had retired or who were not in active practice and those in full-time administrative jobs were excluded.
A waiver was requested and obtained from the ethical review committees of institutions involved in this noninterventional survey.
The questionnaire was sent by email or by post. Each questionnaire was accompanied by a cover letter explaining the purpose of the survey and a separate consent form to be signed by the individual anesthesiologist. Emails were followed by 2 reminders after 15 and 30 days of the initial send-out.
The following cut-off points were used:
- Emotional exhaustion: A total score ≤17 was considered a low level of burnout; 18-29 was taken as a moderate level; and >30 was considered a high level of burnout.
- Depersonalization: A total score ≤5 was taken as a low level of burnout; 6–11 was considered moderate burnout; and >12 was considered a high level of burnout.
- Personal achievement: A total score ≤33 was taken as a high level of burnout; 34–39 was considered moderate; and >40 was considered a low level of burnout.
This scoring is given in Table 1.
Statistical analyses were performed by using SPSS Version 19 (SPSS Inc, Chicago, IL). Continuous variables were reported by using mean and SD, and categorical variables were reported in terms of frequency and percentages. After checking assumption of normality by Kolmogorov–Smirnov test, continuous data were analyzed by independent sample t test. Categorical data were analyzed by χ2 test or Fisher exact test. According to the Maslach Burnout Inventory score, burnout was classified into 3 different aspects: emotional exhaustion, depersonalization, and personal achievement. Emotional exhaustion scores were categorized into 2 levels: low-level burnout score (Maslach Burnout Inventory score ≤17) and moderate- to high-level burnout score (Maslach Burnout Inventory score >18). Similarly, depersonalization score was also categorized as low-level burnout (Maslach Burnout Inventory ≤5) and moderate-level to high-level (Maslach Burnout Inventory >5) burnout. Personal achievement was also categorized as low-level burnout (Maslach Burnout Inventory >40) and moderate- to high-level burnout (Maslach Burnout Inventory ≤40). These categories were treated as the binary-dependent outcome for each subscale, and binary logistic regression analysis was performed to assess factors associated with the outcome. Multivariable analysis of factors significantly associated with outcomes at a level of significance <0.20 was performed using a forward stepwise approach with the significance level for removal of variable set at .05. Odds ratio and 95% CI were calculated for the variables in the final model. For personal achievement, city (site) was included in the final model irrespective of its statistical significance to adjust for differences. Multicollinearity was evaluated using variance inflation factors. Hosmer–Lemeshow test was used to evaluate goodness of fit.
Our sample size calculation was based on a previous survey6 in which burnout rate had been estimated as 50%, a margin of error of 5% on a 95% CI. Based on this, 600 forms were distributed to anesthesiologists working in academic institution in 2 major cities of Pakistan, Karachi and Lahore, during 2017. We aimed for a response rate of ≥70%. The questionnaire was anonymous.
A total of 447 questionnaires out of 600 were retrieved representing a return rate of 74.5%. This was a sufficient response rate.
Table 2 shows the sociodemographic variables, experience, and the work status of the complete group. A total of 221 forms were returned from Lahore (73.6%) and 226 from Karachi (75.3%). The gender balance was 66.9% males versus 33.1% females. Seventy-seven percent of the responders were trainees. Regarding satisfaction with work/life balance, 37.9% (95% CI, 33.295%–42.48%) reported being not satisfied, and 62.1% (95% CI, 57.52%–66.71%) were partially or completely satisfied.
Table 3 shows the frequency and percentages related to various factors that were observed in relation to moderate- to high-level stress. A total of 176 anesthesiologists (39.4%; 95% CI, 34.8%–44.1%) experienced moderate- to high-level emotional exhaustion, 306 (68.4%; 95% CI, 63.9%–72.7%) showed a moderate to high level of depersonalization, and 225 (50.3%; 95% CI, 45.6%–55.07%) experienced a moderate to high level of burnout in personal achievements.
Measure of strength of factors associated with moderate- to high-level stress and burnout on univariate analysis is shown in Table 4. A moderate to high level of burnout was observed in all 3-dimensional scales if anesthesiology was not the first specialty career choice. Association of depersonalization and personal achievement burnout was observed more among trainees compared with consultants and >2 on-call commitments per week. Emotional exhaustion and depersonalization burnout were higher in those working in Lahore and working >40 h/wk inside the operating room. Personal achievement burnout was higher in the younger age group, those with lesser experience, and working >40 h/wk in the operating room.
The P value, adjusted odds ratio, and 95% CI of factors associated with a higher level of burnout on multivariable analysis are shown in Table 5. Anesthesia not being the first choice in choosing a profession was a significant independent factor for burnout in all 3-dimensional scales. Other significantly associated factors for emotional exhaustion burnout were working in Lahore, working >2 nights on call per week, and working >40 h/wk in the operating room. Depersonalization was again associated with Lahore as city of work and >40 h/wk in operating room. Greater than 2 nights on call per week was a significant factor for personal achievement.
With regard to age, those between 31 and 45 years of age showed a significantly lower association with emotional exhaustion compared with the older age group. A higher association with personal achievement burnout was observed in those between 20 and 30 years of age.
This study suggests that the frequency of moderate- to high-level emotional exhaustion in anesthesiologists working in academic institutions of 2 major cities in Pakistan was 39% for emotional exhaustion, 68% for depersonalization, and 50% for personal achievement. We identified the following factors associated with a higher degree of burnout: (1) anesthesiology was not the first preferred career choice; (2) Lahore was the city of work; (3) work hours were >40 per week in the operating room; (4) and >2 night on-call commitments per week.
Burnout was first described in 1974.7 In the 1990s, Maslach defined burnout as “a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that is experienced in response to chronic job stressors that can occur in any occupation but mostly among human service professionals.” She described its 3 components as emotional exhaustion, depersonalization, and personal achievement.8 In contrast to depression, burnout is specific to a work-related context.5 Occupational stress can lead to effects on cognitive function, anxiety, depression, detachment, and lack of compassion for patients.9,10 Perioperative clinicians are noted to be at an increased risk of burnout.11
Physician burnout can also differ between regions and specialties, and hence, it is important to study it in different regions.12 Studies on risk of burnout in anesthesia have been done in high-income countries such as Finland, Sweden, and Belgium13–15 which document the frequency of burnout between 25% and 40%; however, data differ from country to country. There is a paucity of literature from lower- and middle-income countries, where the sociodemographic factors and work-related stressors are different. For example, there is a supply–demand gap that leads to overwork, longer working hours, economic uncertainties, insufficient resources, employment in more than 1 hospital, and limited career opportunities.
To the best of our knowledge, no previous survey related to anesthesiology has been reported from our country. We found some surveys from other lower- and middle-income countries such as India,16 Poland,17 and Egypt.18 The results of the Indian and Polish surveys are not directly comparable to our results because they used different questionnaire tools. The study from an Egyptian university did use the Maslach Burnout Inventory-Human Services Survey scale, but this was a single-center study, whereas our study was multicenter. In the Egyptian study, 62% of participants experienced emotional exhaustion; 56% experienced depression; and 58% reduced personal capacity. In comparison, our results were 39%, 68%, and 50%, respectively. Contrary to our results, burnout in staff from the Egyptian university was related to male gender, marriage, and having children. We did not observe any association between gender, marital status, or having children. Other researchers have also reported that marriage and family can act as a social support rather than having negative effects.19,20 Higher professional satisfaction, with lower scores in emotional exhaustion and depersonalization, was seen in anesthesiologists with >2 children.19 On the other hand, being single predisposed them to burnout.20 We used the English language version of the Maslach Burnout Inventory-Human Services Survey tool to measure burnout.21 It is a standard tool that has been widely used and recognized as a valid means for measuring burnout.21 English is the second language in our country, but our participants were well versed with the language. We choose to study anesthesiologists working in academic institutions because anesthesia has been shown to be more stressful in academics,6,22 with additional stressors being present in university staff.
Some authors have observed a higher incidence of stress among trainees.11,20 Additional stressors that have been identified among trainees are nature of work, stress of examinations, and being front-line patient attendees. Our cohort had 77% trainees. We did not observe an association of burnout with academic level or years of experience. Other authors have observed that experienced anesthesiologists manage stressful situations by converting them to challenges because they may have more sense of control over work.23,24 In our results, age had an effect. Those between 20 and 30 years of age showed a higher association with personal achievement burnout, and emotional exhaustion was less likely in the age group 31–45 years compared with the older age group. This effect of age could be due to the fact that by the early 30s, most trainees have completed their training and taken up consultant appointments. There is still a need to introduce trainees to coping strategies earlier in their careers, an aspect that is neglected in training programs in our country.
In our survey, a higher association of burnout was also seen with more on-call commitments and higher working hours per week. The reason for this may be that there are no national policies or directives in place regarding the maximum time spent inside the operating room or on call, and these vary from institution to institution. In the majority of institutions, working hours exceed the norms recommended in US or European countries. The national anesthesia society and the national colleges responsible for training need to play a more active role in taking this cause further.
Anesthesia as a career choice also influenced the percentage of all 3 components of burnout. The stress was higher if anesthesia was not the first preference for career choice. In our country, there are no national or state matching programs for specialty training. Therefore, the choice of specialty by the residency applicant frequently depends on multiple factors. Health service in Pakistan is provided by state-owned as well as private enterprises. The recognition of training posts in both sectors is done by the relevant faculty in the College of Physicians and Surgeons of Pakistan. In state-owned hospitals, trainee applicants apply to a provincial-based body known as Public Service Commission and take an examination of general competency. They are then posted by the health department as a general medical officer to any district hospital, depending on the provincial health needs, availability of training posts, and rural/urban quotas. Hence, they may be posted in a specialty that was not their first choice. In privately owned institutions, there is no uniform induction policy for training programs, and the training job availability varies. Trainees interested in anesthesiology may change their choice of specialty if they want a job in a particular geographical area. This issue calls for a change in recruitment policies of the national health system into postgraduate training programs.
It is difficult to explain the difference in burnout seen between the 2 cities. Burnout was higher among those working in Lahore. A possible explanation could be more opportunity for better training for residents and more opportunities for institutional practice of consultants in Karachi compared with Lahore. Unfortunately, we do not have exact trainee-to-consultant ratios available for the 2 cities; therefore, only assumptions can be made.
Our survey has some limitations. It is self-reported data at one point in time. Second, the results are not generalizable because the survey was limited to 2 major cities and to academic institutions only; however the 2 selected cities represent nearly 20% of the population of the country. We did not measure stress per se, only burnout. In addition, there is controversy regarding the optimal model building and covariate selection process to identify a set of exploratory variables. Therefore, our analysis is more exploratory in nature and more useful for generating a hypothesis about relationships and may not provide conclusive evidence.
Our strengths were that we used a standardized tool for measuring burnout, we had an adequate number of participants respond, our sample size was larger than previously reported surveys from lower- and middle-income countries, and ours was a multicenter design. We also analyzed different domains of burnout.
Further work needs to be done to address the issues identified in this survey. In addition, standards relating to work hours and on-call commitments need to be agreed on nationally. The role of physician burnout in medical errors and the effect on quality of care has not been adequately investigated, perhaps because of the complexity of the factors involved.11 There is a need to look at this in the future.
In conclusion, our findings suggest a high rate of moderate to severe burnout in anesthesiologists working in academic institutions in our country in 2 major cities. Several factors have been identified, some of which are common to high-income countries. In addition, some new associated factors, such as choice of a specialty and city of work, have been identified. Based on these findings, mitigation strategies need to be introduced at both the institutional and national level.
We thank Amir Raza, Department of Anaesthesiology, Aga Khan University, Karachi, for statistical support in this study.
Name: Fauzia A. Khan, FRCA.
Contribution: This author helped generate the idea, coordinate the survey, author the first draft, coordinate and conduct the revisions, and publish the final approval of versions.
Name: Mubashir H. Shamim, MBBS.
Contribution: This author helped write the protocol, conduct the survey in Karachi, and contribute to the revisions.
Name: Liaqat Ali, FCPS.
Contribution: This author helped review and critique the protocol, conduct the survey in Lahore, and revise the drafts.
Name: Arshad Taqi, FCPS.
Contribution: This author helped review and critique the protocol, conduct the survey in Lahore, and revise the drafts.
This manuscript was handled by: Angela Enright, MB, FRCPC.
1. Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Burnout in intensive care units - a consideration of the possible prevalence and frequency of new risk factors: a descriptive correlational multicentre study. BMC Anesthesiol. 2013;13:38.
2. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302:1294–1300.
3. Khan FA, Merry AF. Improving anesthesia safety in low-resource settings. Anesth Analg. 2018;126:1312–1320.
4. The World Bank. Low & Middle Income. Available at: https://data.worldbank.org/?locations=XN-PK
. Accessed May 30, 2018.
5. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397–422.
6. Shams T, El-Masry R. Job stress and burnout among academic career anaesthesiologists at an Egyptian University Hospital. Sultan Qaboos Univ Med J. 2013;13:287–295.
7. Fruedenberger HJ. The staff burnout syndrome in alternative institutions. Psychother Theor Res Pract. 1975;12:72–82.
8. Maslach C, Leiter MP. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. 1997.San Francisco, CA: John Wiley & Sons/Jossey-Bass.
9. Weber K, Miller GA, Schupp HT, et al. Early life stress and psychiatric disorder modulate cortical responses to affective stimuli. Psychophysiology. 2009;46:1234–1243.
10. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347:1249–1255.
11. Hyman SA, Michaels DR, Berry JM, Schildcrout JS, Mercaldo ND, Weinger MB. Risk of burnout in perioperative clinicians: a survey study and literature review. Anesthesiology. 2011;114:194–204.
12. Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout across regions and specialties: a meta-analysis. Hum Resour Health. 2013;11:48.
13. Lindfors PM, Nurmi KE, Meretoja OA, et al. On-call stress among Finnish anaesthetists. Anaesthesia. 2006;61:856–866.
14. Larsson J, Rosenqvist U, Holmström I. Enjoying work or burdened by it? How anaesthetists experience and handle difficulties at work: a qualitative study. Br J Anaesth. 2007;99:493–499.
15. Nyssen AS, Hansez I, Baele P, Lamy M, De Keyser V. Occupational stress and burnout in anaesthesia. Br J Anaesth. 2003;90:333–337.
16. Shidhaye R, Divekar D, Dhulkhed V, Goel G, Gupta A, Shidhaye R. Evaluation of stressors and coping strategies for stress in Indian anaesthesiologists. Indian J Anaesth. 2011;55:193–198.
17. Mansour A, Riad W, Moussa A. The occupational fatigue in anesthesiologists: illusion or real? Middle East J Anaesthesiol. 2010;20:529–534.
18. Gaszynska E, Stankiewicz-Rudnicki M, Szatko F, Wieczorek A, Gaszynski T. Life satisfaction and work-related satisfaction among anesthesiologists in Poland. Sci World J. 2014;2014:601865.
19. Abut YC, Kitapcioglu D, Erkalp K, et al. Job burnout in 159 anesthesiology trainees. Saudi J Anaesth. 2012;6:46–51.
20. Castello-branco C, Figueras F, Eixarch E, Quereda F, Concello MJ, Gonzalez S, et al. Symtoms and burnout in obstetrics and gynaecology residents. Br J Gynecol. 2007;45:63–84.
21. Hwang CE, Scherer RF, Amma MF. Utilizing the Maslach burnout inventory in cross cultural research. Int J of Management. 2003;20:3–10.
22. Tijdink JK, Vergouwen AC, Smulders YM. Emotional exhaustion and burnout among medical professors; a nationwide survey. BMC Med Educ. 2014;14:183.
23. Larsson J, Sanner M. Doing a good job and getting something good out of it: on stress and well-being in anaesthesia. Br J Anaesth. 2010;105:34–37.
24. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol. 2007;109:949–955.