J Aziz Fatm Med Den College JAN-JUNE 2020; VOL.2, NO 1 17 Original Article Burnout Syndrome and its Risk Factors among Gynecology Consultants Khadija Asim Khan, Sarah Ejaz, Noor-i-Kiran Naeem, Asim Khan ABSTRACT Objective: To assess the frequency of burnout among gynecologists and to determine the factors leading to burnout. Methodology: This was a cross-sectional study done at the Gynecology and Obstetrics department of King Edward Medical University; Lahore from January to June 2017. Fifty-five consultant gynecologists, working in public sector teaching hospitals of Lahore filled Maslach Burnout Inventory (MBI) proforma for assessment of burnout. The data analysis was performed by SPSS version 20. Results: Burnout was found in 13 of 55 (23.6%) consultants. Twenty-four participants (43.6%) were having high emotional exhaustion (EE), 41.8% had high depersonalization (DP) and 16.4% had low personal and professional achievement (PPA). Single doctors were found to be more burnout as compared to those who were married (p = 0.037). Additionally, having private practice was associated with high EE and high PPA. Those having higher monthly income were more burnout in EE domain. Conclusion: Burnout Syndrome is common among the consultant gynecologists of public sector healthcare. Risk factors for having burnout syndrome include dual practice as well as low monthly salary. KEYWORDS: Burnout, Gynecologist, Stress, Depersonalization, Emotional Exhaustion, Professional achievement. INTRODUCTION Burnout syndrome is a complex of conditions which may have severe and long-lasting effects on its sufferers. It is assumed to be more prevalent among healthcare workers than general workers because of their stressful nature of job. 1 Burnout may have some serious effects on mental as well physical health of the healthcare workers and may lead to fatigue, depression and even cardiovascular events. 2 It may also lead to decreased, poor performance and lower productivity. The quality of life is severely affected and generally overall health system may turn to negative roadmap. 3-5 Generally, doctors and particularly surgeons including gynecologists are facing more burnout than other specialties because of more stressful and demanding _____________________________________________________________________ Dr. Khadija Asim Khan, MBBS, FCPS Assis. Prof. Obstetrics and Gynecology, Kind Edward Medical University, Lhr Dr. Sarah Ejaz, MBBS, FCPS Prof. Obstetrics and Gynecology, Red Crescent Medical College, Lhr Dr. Noor-i-Kiran Naeem, MBBS, MMEd Assis. Prof. Medical Education, Aziz Fatimah Medical College, Fsd Dr. Asim Khan, MBBS Medical Officer, Dr. Rehmatullah Hospital Gojra Correspondence: Dr. Noor-i-Kiran Naeem Email: noorikiran@yahoo.com job nature. A study from Pakistan conducted on nurses, showed that nurses working in gynecology department were most commonly burnout than the other departments and their quality of life was poorest of all. 6 In another study conducted at gynecology and obstetrics department, which included all its staff members , found doctors most commonly facing burnout than nurses and ancillary staff. 7 Burnout can be assessed by various tools; however, the most commonly used tool is Maslach Burnout Inventory (MBI). It is a validated tool which has been extensively used in the literature for assessment of Burnout syndrome. 8,9 MBI is a 22-item scale with measuring burnout in three domains namely Emotional Exhaustion (EE), Depersonalization (DP) and Personal and Professional Achievement (PPA). 1 Many studies and meta-analysis have shown the superiority of MBI over other tools and its psychometric properties have been assessed in many languages and countries. 10,11 Limited data is available from Pakistan addressing consultants in the Gynecology and Obstetrics department in terms of Burnout. Therefore this study was planned with the objective to assess the frequency of burnout among gynecologists and to determine the factors which may lead to their burnout. Noor-i-Kiran Naeem et al. J Aziz Fatm Med Den College JAN-JUNE 2020; VOL.2, NO 1 18 METHODOLOGY This cross-sectional study was conducted at the Gynecology and Obstetrics department of King Edward Medical University, Lahore. It was conducted after permission from Ethical review board of the hospital (269/RC/KEMU) from January to March, 2017. All the consultant gynecologists, working in all teaching public sector hospitals of Lahore were included in this study via purposive sampling. They were contacted personally and proforma was sent to them either via email or was filled by them on paper. The proforma was anonymous and the doctors were informed that by filling the questionnaire they were consenting to participate in the study. Study proforma consisted of two parts. The First contained the demographic details of the participants. The second part contained Maslach Burnout Inventory (MBI) questionnaire. MBI has 22 items and all questions are answered on a 7-point Likert scale from 0-6. It is a fully validated tool so it was not validated again for index study. Formal permission for using MBI was sought and license for usage was purchased (http://www.mindgarden.com). MBI has shown high internal consistency with Cronbach’s α coefficient values of 0.837, 0.869, and 0.881 with high test-retest reliability. The MBI inventory assesses three domains; Emotional Exhaustion (EE), Depersonalization (DP) and Personal and Professional achievement (PPA). All the three domains are categorized as low, moderate and high. PPA is scored reversed and higher the score, lower is the burnout while for EE and DP, higher is the score, more is the burnout. The cut-off levels for all three domains are provided by the licensure. In this study, burnout was labeled if there is high EE along with high DP or low PPA. Statistical analysis: The data was analyzed using SPSS version 20. Quantitative variables were summarized as mean and standard deviation while qualitative variables were summarized as frequency and percentages. Risk factors were assessed for overall burnout and three domains of burnout using chi square test and taking P≤0.05 as significant value. RESULTS A total of 55 gynecologists were contacted and proforma was filled. The mean age of participants in this study was 42.47 ± 7.07 years with the age range being from 32-56 years. Fifty-one participants (92.7%) were female while 4 participants (7.3%) were male. The most common fellowship degree was FCPS (96.4%) and 92.7% were married. Additionally 53 participants (96.4%) felt satisfied with their specialty (Table 1). Table 1: Demographic Details of Participants Mean ±SD Age 44.89 ± 8.50 Gender Male Female 4 (7.3%) 51 (92.7%) Post-graduate Experience 0-5 years 6-10 years 11-20 years >20 years 19 (34.5%) 18 (32.7%) 13 (23.6%) 5 (9.1%) Fellowship degree FCPS MCPS 53 (96.4%) 2 (3.6%) Marital status Single Married 4 (7.3%) 51 (92.7%) Working hours/weak 50-60 hours 61-80 hours More than 80 hours 8 (14.5%) 16 (29.1%) 31 (56.4%) Private practice Yes No 37 (67.3%) 18 (32.7%) Income per month <60 thousand PKR 60-100 thousand PKR >100 thousand PKR 17 (30.9%) 25 (45.5%) 13 (23.6%) Are you satisfied after choosing this specialty? Yes No 53 (96.4%) 2 (3.6%) Participants were labeled burnout if they had high EE along with either high DP or low PPA. It was found that 23.6% consultants were facing burnout syndrome. Twenty-four participants (43.6%) were having high EE, 41.8% had high DP and 16.4% had low PPA (Figure 1).Also 70.9% of the respondents were having burnout in at least one domain of MBI. Additionally it was found that all the 13 participants who had burnout were those who felt satisfied, while the two participants who were unsatisfied, were not having burnout according to MBI. Factors leading to burnout were also assessed. Taking overall burnout, it was found that single doctors were more burnout than the married ones (p = 0.037). No impact of age on burnout levels was noticed (p value = 0.89). Burnout was assessed for all three domains with the findings that having private practice was associated with high gynecologists who are also doing private practice along with public sector job (p value = 0.01). Doctors having income between Burnout among gynecologist J Aziz Fatm Med Den College JAN-JUNE 2020; VOL.2, NO 1 19 Figure 1: Burnout Among Study Participants EE=Emotional Exhaustion, DP=Depersonalization PPA=Personal and Professional Achievement 60-100 thousand PKR have comparatively higher burnout PPA (Table 2). Higher levels of burnout were found in low paid than in high paid doctors (p value= 0.04) (Table 2). Table 2: Significant Risk Factors for Burnout Yes No P- Value Marital Status 0.03* Single ( n=4) 3( 75%) 1 (25%) Married (n=51) 10 (20%) 41(80.3%) Emotional Exhaustion Low Moderate High Private Practice 0.01* Yes (n=37) 6 (16.2%) 10 (n=27%) 21(56%) No (n=18) 8(44%) 7(n= 38.8%) 3 (16.6%) Income 0.04* <60,000 PKR(n=17) 8 (47) 5(29.4) 4(n=23.5) 60-100,000 PKR (n=25) 6 (24) 8(32) 11(44) >100,000 PKR(n=13) 0(0) 4(30.7) 9(69.2) Personal & Professional Achievement Private Practice 0.006* Yes (n=37) 4(10.8) 6(16.2) 27(72.9) No (n=18) 5(27.7) 8(44.4) 5 (27.7) p value < 0.05 is significant DISCUSSION The main objective of this study was to determine the frequency of burnout among gynecologists and to identify the leading risk factors. The burnout among gynecologists was found to be 23.6%. Martini et al conducted a study on eight different specialties residents and found gynecology residents showing the prevalence of burnout to be as high 75%. 12 Similar results shown by Castelo, Branco et al where 58 % gynecology residents fulfilled the criteria of burn out syndrome 13 . The reason for this difference may be due to that our study group were mainly comprised of consultant as compare to residents in above both studies. In a study conducted on medical professionals deployed in Afghanistan from US, showed that burnout was higher in those having less team member care and self-caring attitude. 14 In a large study on medical oncologists that had included oncologists from 51 countries, it was found that single marital status was significantly more commonly associated with burnout syndrome. Also they found having a younger age was a significant risk factor for burnout. 15 Our results are in line with above mentioned study, as was found burnout in unmarried doctors than married doctors. Burnout is called a syndrome because all of its aspects and outcomes have not yet been discovered and studied. A research on nursing students, authors identified 60 important factors which may lead to burnout and their experts panel admitted that many of them have not been studied yet 16 . Therefore lot of research has to be done on burnout in order to have better understanding of the issue. This study showed that gender had no relation with overall burnout nor its subscales. Similar findings were narrated by Lahana et al in a study on nurses. 17 However, Vassos et al have suggested that being a male does predispose to high EE and DP. 18 In current study, age of the participants and experience of work were also not associated with burnout. Again the literature shows contrary results over this risk factor. Kilfedder et al have shown that higher age is usually associated with less EE because of more experience and higher PPA 19 . However, our results are supported by Hastings et al study That reported no impact of age over burnout prevalence. 20 In contradiction to current results, recent study from Karachi has suggested moderate burnout was more prevalent in males and married as compared to single subjects. This aforementioned previous study also reported lesser burnout levels among participants with older age as compared to younger age. 21 Current results also revealed that doctors who are involved in private 0 5 10 15 20 25 30 35 EE DP PPA 14(25.4%) 23(41.8%) 9(16.3%) 17(30.9%) 19(34.5%) 14(25.4%) 24(43.6%) 23(41.8%) 32(58.1%) F e r q u e n c ie s Low Moderate High Noor-i-Kiran Naeem et al. J Aziz Fatm Med Den College JAN-JUNE 2020; VOL.2, NO 1 20 practice along with jobs in public sector have higher levels of burnout, might be because of overburden and hectic stressful job routine. Furthermore we also noticed higher burnout levels in doctors having pay between 60-100 thousand PKR as compared to doctors having pay greater than 100 thousand PKR. These finding are supported by Liaqat et al study conducted at Lahore. 1 Doctors should be paid more by government hiring agencies, so they can avoid to do private practice along with their public sector stressful jobs to reduce burnout among these front line soldiers. Limitations and Recommendation: The limitation of this research was that since it was a simple cross-sectional study without any intervention for treatment/prevention of the burnout syndrome, therefore its results cannot be generalized and spatial conclusion can be drawn. However, this study was unique, particularly in a developing country which has addressed gynecologists particularly. Conclusion: Burnout among gynecologists working in public sector is quiet frequent with high scores in one domain at least. Burnout was common in unmarried than married doctors. It is recommended to take preventive measures in order to save the gynecologists form this syndrome and to improve their quality of life. Conclusion: Burnout Syndrome is common among the consultant gynecologists of public sector healthcare. Risk factors for having burnout syndrome include dual practice, being married as well as low monthly salary. Funding Source: None. Conflicts of Interest: None. REFERENCES 1. Liaqat N, Dar SH, Waheed K. Burn out among the paediatric surgeons of Pakistan. J Pak Med Assoc. 2019 ;69(11):1730-1733. doi: 10.5455/JPMA.300916 2. Cohen R, Bavishi C, Haider S, Thankachen J, Rozanski A. Meta-analysis of relation of vital exhaustion to cardiovascular disease events. 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Dr. Noor-i-Kiran Naeem Data analysis, manuscript writing and accountable for material provided in manuscript. Dr. Asim Khan Data collection, manuscript writing and accountable for material provided in manuscript. Received: 11 April 2019, Revised received: 13 August 2019, Accepted: 23 September 2019