key: cord-327809-9uhhqasl
authors: Dimitriu, Mihai C.T.; Pantea-Stoian, Anca; Smaranda, Alexandru C.; Nica, Anca A.; Carap, Alexandru C.; Constantin, Vlad D.; Davitoiu, Ana M.; Cirstoveanu, Catalin; Bacalbasa, Nicolae; Bratu, Ovidiu G.; Jacota-Alexe, Florentina; Badiu, Cristinel D.; Smarandache, Catalin G.; Socea, Bogdan
title: Burnout syndrome in Romanian medical residents in time of the COVID-19 pandemic
date: 2020-06-07
journal: Med Hypotheses
DOI: 10.1016/j.mehy.2020.109972
sha: 
doc_id: 327809
cord_uid: 9uhhqasl

Burnout is a state of physical or mental collapse caused by overwork or stress. Burnout during residency training has gained significant attention secondary to concerns regarding job performance and patient care. The new COVID-19 pandemic has raised public health problems around the world and required a reorganization of health services. In this context, burnout syndrome and physical exhaustion have become even more pronounced. Resident doctors, and especially those in certain specialties, seem even more exposed due to the higher workload, prolonged exposure and first contact with patients. This article is a short review of the literature and a presentation of some considerations regarding the activity of the medical residents in a non-Covid emergency hospital in Romania, based on the responses obtained via a questionnaire. Burnout prevalence is not equal in different specialties. We studied its impact and imagine the potential steps that can be taken in order to reduce the increasing rate of burnout syndrome in the pandemics.

The burnout syndrome in health care professionals has gained significant attention over the last several years. Given the intense emotional demands of the work environment, clinicians are particularly susceptible to developing this syndrome more than in other jobs. Residency can cause a significant degree of burnout, leading to individuals' ability to establish correct communication with the patient, solve diagnostic dilemmas, and have a good overview of the correct treatment. Burnout is associated with a variety of negative consequences including depression, risk of medical errors, and negative effects on patient safety. The goal of this review is to provide an overview of the prevalence in different specialties of the burnout syndrome, even more pronounced in Covid context, provide team leaders with options to minimize the risks and prevalence and recognize its potential hazards towards the medical act and its medical caregiver [1] . Although reported and discussed long before the pandemic, after its outbreak, burnout syndrome became even more pregnant [2] .

The coronavirus epidemic broke out in Wuhan, China, in a metropolis of 11 million people in December 2020 [3] . Free movement of people led to the spread of the virus in Europe (Italy), the United Kingdom and the United States in January-February 2020, becoming soon a pandemic that affected almost all countries [4] .

Resident physicians often represent the communication interface between the attending physician and the patient, so that the time spent with the patient is often longer. In the context of the pandemic, physical fatigue is added to the mental stress associated with a possible infection. Resident physicians have the most prolonged contact with patients, including in the time window from the testing moment to the arrival of the result for SARS-CoV-2, therefore the stress is even more pronounced.

Some physical factors are added to the equation. Prolonged wearing of personal protective equipment, excessive heat provided by them, lack of hydration, alimentation, sleep deprivation, all together accentuate fatigue and the burnout syndrome. From this point of view, the most affected doctors are from the emergency units, radiology, intensive care units, but also from the specialties that ensure surgical, obstetrical, orthopedic and neurosurgery emergencies.

The modification of the shifts and of the work schedule, of the type of the current activity, the time and the technique of dressing and undressing the protective equipment, all constitute the novelty that adds an additional stress factor.

Last, but not the least, wearing facial protection equipment leads to a depersonalization of the activity, both in contact with patients and medical staff. The impossibility of reading facial expressions, the lack of interpersonal interactions and facial expressions decreases the possibility of socialization and mutual encouragement. In this sense, the idea related to wearing a photo of the holder on the protective suit appeared.

There are studies that paradoxically indicate a higher level of stress in regular, non-Covid wards of hospitals, compared to front-line ones [5] . A possible explanation would be that better organization and a sense of control reduce the stress level of those in the front line, while the fear of being exposed when the protocols do not seem perfect is higher in non-Covid wards.

Here, however, there is a permanent threat of a positive patient, so no one seems to be safe.

Some studies in China and UK have also revealed depression and anxiety due to the COVID-19 outbreak that medical staff experienced [6, 7, 8] .

The pandemic has led to numerous cases of depression and anxiety, as well as worsening preexisting mental illnesses [9] .

The term "burnout" was described by psychologist Herbert Freudenberger [10] in 1974 in an article entitled "Staff Burnout" in which he discussed job dissatisfaction precipitated by workrelated stress. A broadly applicable description defines burnout as a state of mental and physical exhaustion related to work or care-giving activities. A long-standing conceptual and operational definition characterized burnout as a triad of emotional exhaustion (emotional overextension and exhaustion), depersonalization (negative, callous, and detached responses to others), and reduced personal accomplishment (feelings of competence and achievement in one's work) [11] .

The Maslach Burnout Inventory (MBI) [12] is the most used questionnaire to measure burnout in research studies. The MBI human services survey is a self-administered, 22 item questionnaire that was developed to measure burnout in human services workers and is the "gold standard" of measuring burnout [13] . The MBI items are rated on a Likert scale from 0 to 6 (0 = never, 1 = a few times per year, 2 = once a month, 3 = a few times per month, 4 = once a week, 5 = a few times per week, and 6 = every day) and score sample items such as: "I feel emotionally drained from my work.". It is designed to assess the 3 primary dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment. Burnout is detected using cutoff scores of high emotional exhaustion (≥27), high depersonalization (≥10), and low personal accomplishment (≤33), based on normative data from 1104 medical professionals [14] . A study in China, comparing burnout of front line workers with that of normal ward staff, in COVID context, used Maslach questionnaire for medical workers and the results were interesting and quite unexpected [3] .

In 2004, Martini et al [15] did a unique study that compared burnout rates among the different specialties using the MBI. The overall burnout rate was 50% and ranged from 27% to 75% among different specialties. This variation among specialties was not statistically significant; however, burnout rates were as follows: 75% in obstetrics-gynecology followed by 63% in internal medicine, 63% in neurology, 60% in ophthalmology, 50% in dermatology, 40% in general surgery, 40% in psychiatry, and 27% in family medicine. However, this variation among specialties was not statistically significant. Being in one's first year in residency, mood fluctuation, dissatisfaction with clinical faculty, recent family stress, and being unmarried were all associated with increased likelihood to meet burnout criteria [15] . Psychiatry residents were noted to have additional stressors including fear and exposure to patient violence and suicide [16] [17] [18] [19] [20] In a study by Fahrenkopf et al [21] , no actual correlation was found between burnout and the number of medical errors seen in collected data. One plausible explanation may be that residents reporting symptoms of burnout may be more likely to over-report their errors.

In this pandemics, there is a need for practical methods to assess medical stuff burnout. Some researchers have even proposed the continuous wearing of sensors to quantify fatigue [22] .

The aim of our study was to compare the frequency of burnout syndrome between medical residents considered to work on the front line (emergency unit, radiology and intensive care unit) and those working in normal hospital wards (surgery, obstetrics and gynecology, obstetrics). Our hypothesis that we wanted to prove is that there is higher prevalence of burnout syndrome in regular, non-Covid wards of hospitals, compared to front-line ones.

The study was conducted in a hospital with an emergency clinical profile, which is not in the frontline in the fight against coronavirus, ensuring non-covid emergencies or suspects until the result of the real time polymerase chain reaction test is obtained. During the pandemic, the teaching processes in the hospital were stopped, both for medical students and residents, opting for online teaching. Students' access to the hospital was stopped by a university decision to limit the spread of the infection. The medical residents continued to carry out medical activity, restricted to the activity in this only hospital where they have an employment contract.

We distributed a survey of 30 questions to 100 medical residents, 50 for resident doctors in the emergency department, radiology and intensive care unit (considered first-contact with 

The 50 questionnaires for first-line medical resident were distributed as follows: 30 for residents in emergency unit, 10 for residents in intensive care unit and 10 for residents in radiology department (lot A).

The other 50 questionnaires were distributed in that we considered normal wards. They were allocated for residents in general surgery (25 questionnaires), gynecology (15) and orthopedics (10) -lot B in our study.

All the invited participants anonymously completed the survey and the responses were valid to be analyzed.

Demographics characteristics can be found in table 1.

Demographic characteristics showed that the two groups were relatively homogeneous in terms of distribution by age and gender. The extreme ages were 24 and 35 years, respectively, given that the target was represented by resident doctors.

Burnout was defined as a high level of emotional exhaustion (≥27), and/or high level of depersonalization (≥10), and/or low personal accomplishment (≤33).

According to our results, we obtained an average burnout for medical residents of 76%, about two months after the outbreak of the pandemics in our country, which is superior to studies conducted in normal periods. The global prevalence of burnout syndrome among medical residents is high, proving that the threat posed by SARS-CoV-2 is a major stressor for medical staff. The results are all the more worrying as the target group was represented by resident doctors, of young age (maximum 35 years), who, at least theoretically, should have a better adaptability to the new condition represented by this pandemics, compared to senior doctors.

The burnout was significantly more frequent in normal wards workers (lot B) (prevalence 86%) compared to medical residents working in places that we considered front-line departments: emergency unit, radiology, including CT/MRI department and intensive care unit -lot A in our study, that showed a prevalence of burnout of only 66% (p<0.05, from chi-square statistic test) (table 2). We considered emergency unit, radiology, including CT/MRI department and intensive care unit as front-line departments as all the patients, at presentation time, are now considered potentially infected ones till invalidation by a negative real time polymerase chain reaction test that usually takes 24 hours in our hospital. The prolonged time is due to the fact that this test is analyzed in an external laboratory.

There can be an array of methods that can be used to fight against the burnout sydrome. In a sample of 200 professionals, Maslach [23] showed that venting, laughing, and discussing care with colleagues decreased personal anxiety. In conditions of social distancing, even between colleagues, all these mechanisms are annulled. The place of direct socialization is partially replaced by social media groups and net socialization.

There are no studies on suggested interventions for reducing the prevalence or how it works on each individual. Each person is different genetically, racially, different sex and culture, different family environment and so on. With these many factors comes the problem of pinpointing the trigger factor for each individual. That is why with these many stress factors comes a multitude of anti-stress factors which can be used: from physical activity to meditation. Mentoring programs in residency training can also be helpful in this regard [24, 25] .

The negative impact of burnout on patient care includes risk of medical errors, patient safety risks, and potential compromise of quality of care. Burnout and fatigue can affect the caution of medical staff, lead to negligence on self-protection measures and increase the risk of infection. Negative consequences of burnout on physicians in training include depression, suicidal tendencies, and medical illnesses. The problems of medical errors related to fatigue and burn-out syndrome seem to be more serious for the surgical specialties [26] . Effective interventions to address burnout should be developed at both the individual and institutional levels [1] .

In a previous study conducted in our hospital, in non-pandemic conditions, the conclusion was that surgeons' fatigue seems to be a more subjective self-perception of surgeons than an objective fact and that surgeons tend to attribute their mistakes to burn-out syndrome, this being more acceptable for their conscience. In normal times, the rates of complications were not statistically higher on call-days and the days immediately after, when exhaustion should be maximum [27] .

Maslach [28] summarized 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."

Pandemics of this magnitude have appeared in humanity about once every 100 years [29] . So you cannot talk about personal experience in managing a crisis like this. It is also difficult to assume that the competent centralized structures, such as governments, public health organizations, could fully manage the situation at individual level. In certain critical situations, it even turned out that local authorities, along with the population, had more competent organization and involvement (the example of hurricanes). In our opinion, the local organization at the hospital level is much more important for decreasing the stress level and the prevalence of the burnout syndrome. The existence of clear protocols for any possible situation, the practical trainings with the personnel regarding the protection measures, the adequate use of the protection equipment are all measures that ensure a state of confidence and control, which obviously decreases the stress level. This could explain the higher prevalence of burnout syndrome in staff in regular wards, compared to employees in the emergency department.

Medical residents in emergency unit had more training hours about the protective equipment and the wearing of the personal protection equipment was continuous, throughout the working time, that gave them the feeling of being safe, reducing the stress.

All the successes of medical teams must be promoted by all means, being a source of positive emotions. The shift program must be organized in such a way as to respect the epidemiological timing (incubation period or quarantine time). Periods of rest and relaxation are important and must be observed to prevent burnout, even if, often, they cannot take place in the privacy of families.

The burnout-syndrome is a real phenomenon and may manifest in many forms. Each resident and other higher level caregiver is susceptible to it. Being aware of this, the new physician generations are shown to have an attraction towards balancing activities. All in all medical leaders and mentors should be aware of their colleagues and residents, thus allowing themselves to partake in the well-being of the team and making the work environment less stressful. The research in individual stress-factors and its many ways in which to actively fight them it is a gateway to making a whole medical environment better by concentrating upon the individual and giving a successful education to the next generation of physicians.

In the context of COVID-19, the best way to combat burnout seems to be, in our opinion, the precise local organization within the hospital and practical training sessions on the use of personal protective equipment, source of a mental comfort feeling.

Mean age (standard deviation) 27 Low personal accomplishment 13 11 Total (Burnout frequency) 33 (66%) 43 (86%) P=0.019208 Table 2 . Characteristics of burnout syndrome elements of the two lots

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The mother of all pandemics Is 100 years old (and going strong)!

Maria Sklodowska Curie

Carol Davila

Sos. Pantelimon, 021659, bogdan.socea@umfcd.ro, +40788491091, kindly ask you to take in consideration our submission for your journal, having the title

All authors have been read and approved the final manuscript. The study was performed according to the World Medical Association Declaration of Helsinki and according to national legislation, using a protocol approved by the local Bioethics Committee. All subjects have previously signed an informed written consent about future publication of data

All authors have significant scientific contribution to the manuscript. All authors have been read and approved the final manuscript. The study had no funding. There are no conflicts of interest.
