To the Editor:
For many in the healthcare industry, feelings of exhaustion and low satisfaction with work are commonplace. Thirty years ago, the term “burnout” was coined to describe this state of frustration and fatigue among health and service workers, which arose from excessive demands on their resources.1 Burnout syndrome has primarily been described as a multidimensional process with three central constructs: Emotional Exhaustion or “EE” (feeling emotionally drained and exhausted by one's work), Depersonalization or “DP” (negative or very detached feelings toward clients or patients), and Reduced Personal Accomplishment or “PA” (evaluating oneself negatively and feeling dissatisfied with positive job performance and achievements).2 Burnout is different from stress in that while stress is acute, burnout tends to be chronic and is exacerbated by an accumulation of emotional and interpersonal stressors on the job.2
Burnout is relevant for both healthcare personnel as well as for the patients they serve as it has been associated with negative consequences for both groups.3,4 Burnout can result in decreased morale and increased physician turnover, as well as poor judgment in patient care decision making, increased medical errors, diminished dedication, decreased quality of care, and reduced patient safety all of which can have consequences. It is important for the culture of medicine, for healthcare workers, and for patients, that burnout be identified in practice and its symptoms alleviated. Physicians and healthcare workers are able to provide a higher standard of care when their work satisfaction is high.4
The burden of burnout in healthcare providers is significant. In fact, in the United States, burnout is more common among physicians than any other type of US worker.5 The prevalence of burnout in US physicians was reported at 45.8% in 2011 where physicians reported at least one symptom of burnout and rose to 54% in 2014.5 Its prevalence has been found to range from 17% to 52% in UK physicians6 and 9% to 82% in Middle-Eastern physicians. In all three groups the burnout symptom most commonly reported was EE. While mental well-being has been investigated among Caribbean physicians, burnout has not been studied in this group. Burnout has also been found to affect medical students and residents.7,8
Healthcare personnel (HCP) in the Bahamas were queried to assess the burden of burnout in this group. A convenience sample of HCPs who attended a Scientific Conference at the University of the West Indies (UWI) in the Bahamas was surveyed. In this cross-sectional survey the study population consisted of attending/private practice physicians, resident physicians, and medical students, all of whom practice and train in the Bahamas. The study tool used was the Abbreviated Maslach Inventory Human Services Survey for Medical Personnel,8 which participants completed prior to entering the conference. The Abbreviated Maslach Inventory Human Services Survey for Medical Personnel measures the three dimensions of burnout—Emotional Exhaustion, Depersonalization, and Low Personal Accomplishment. For each item, participants were asked to respond, “Every day,” “A few times a week,” “Once a week,” “A few times a month,” “Once a month or less,” “A few times a year,” or “Never.” Each item was scored with a number ranging from 0 to 6; 6 being “Every Day” and 0 being “Never.” It consists of an abbreviated 9 items taken from the original 22, the latter being a gold standard, validated, survey.
Sixty-six surveys were returned, some of which had incomplete sections of either PA, DP, or EE. Fifty four respondents answered all of the Personal Accomplishment items, 51 respondents answered all of the Depersonalization items, and 58 respondents answered all of the Emotional Exhaustion items. Most of the respondents were women (49/66; 75%), 41% were attending/private practice physicians and the remainder were resident physicians (16/66; 24%) and medical students (35%; 23/66). Of the three dimensions of burnout, emotional exhaustion was the only one reported as being experienced and it was only reported among resident physicians and medical students. Medical students and residents were significantly more likely to report this dimension. No symptoms of burnout were reported by attending/private practice physicians. In addition, healthcare workers aged 20 to 29 and 30 to 39 reported feelings of burnout in this dimension (emotional exhaustion), while those over the age of 40 did not report burnout in any dimension. Women were also significantly less likely than men to report burnout in the dimension of depersonalization. Neither attending/private practice physicians, resident physicians, nor medical students reported feelings of burnout in the dimensions of depersonalization or personal accomplishment.
In summary, Bahamian medical students and resident physicians report burnout symptoms in the dimension of emotional exhaustion, to a significant degree, while practicing physicians did not report experiencing burnout in any dimension. This finding that burnout in the dimension of emotional exhaustion decreases with increased age may be partially explained by the fact that older physicians who are either attendings or private physicians, are able to set their own hours, while resident physicians and medical students are studying and working under unrestricted hours. It could also suggest that Bahamian medical professionals tend to learn how best to cope with their work environment over time through increased feelings of self-efficacy and increased resilience. Those who struggled more and did not experience this change over time may have exited the medical field entirely. A study conducted by Ey et al9 in 2013 found that 87% of residents who were aware of a Resident Wellness Program addressing burdens like burnout would be willing to seek help through the program. In order to promote physician well-being, leaders within organizations, including medical schools, residency programs, hospitals, and healthcare systems have to play a large role.10 Residents and fellows are looking to physician leaders for counseling regarding how to avoid as well as cope with distress in training.8 If burnout is identified and counseling made available, as well as provision of an environment that “cultivates well-being,”10 residents and medical students will benefit in the short term, and will also likely acquire some of the necessary tools to combat burnout throughout their careers.
This convenience sample sheds some light on the burden of burnout in this setting. A more rigorous study design using the validated 22-item Maslach survey and securing a larger sample size may allow an improved understanding of burnout in this setting. However, it may be prudent to consider strategies to alleviate burnout and build resilience among medical students and resident physicians in the Bahamas. Importantly, burnout prevention methods must be explored, trialed, and implemented as well.
The authors would like to acknowledge Dr Fran Shofer for her help with the statistical analysis.
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