Burnout Among Otolaryngology Residents in Saudi Arabia: A Multicenter Study

ORIGINAL REPORTS

Burnout Among Otolaryngology Residents in Saudi Arabia: A Multicenter Study Turki Aldrees, MBBS, MBA,* Motasim Badri, MScMed, PhD,† Tahera Islam, MD,‡ and Khalid Alqahtani, MD, MSs, FRCSc§ *

Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Prince Sattam Bin Abdulaziz University, Alkharj, Riyadh, Saudi Arabia; †College of Sciences and Health Professions, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; ‡College of Medicine and Research Center, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; and §Department of Otolaryngology-Head and Neck Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia OBJECTIVE: Determine the prevalence of, and associated

CONCLUSION: Burnout prevalence was found to be high

risk factors for, burnout among otolaryngologist residents in Saudi Arabia.

among otolaryngologist residents in Saudi Arabia. The associated variables examined in this study should be addressed to decrease this level of burnout and provide residents with a less stressful work environment. ( J Surg C 2015 Association of Program Directors in ]:]]]-]]]. J Surgery. Published by Elsevier Inc. All rights reserved.)

DESIGN AND SETTING: A cross-section study of multi-

center hospitals in Saudi Arabia conducted in March 2013. PARTICIPANTS: Registered residents in Saudi Otolaryngology Board Program. MAIN OUTCOMES MEASURES: The Maslach Burnout

Inventory was used to measure burnout status. Questions supplementary to the Maslach Burnout Inventory were also included to identify associated potential risk factors such as demographic data, resident satisfaction, and work conditions. RESULTS: Of the initial 123 questionnaires that were

distributed, 85 yielded responses, a rate of 69%. The mean age (standard deviation [SD]) of respondents was 29 (2.3) years. Of those, 67% (57/85) were men and 66% (55/85) were married. Resident levels were delineated: level 2, 19%; level 3, 33%; level 4, 29%; and level 5, 19%. The mean number of on-call days/month (SD) was 7 (2), clinics/week (SD) was 3 (1), sleep hours/day (SD) was 6 (1), and operations/week (SD) was 2 (1). The mean emotional exhaustion (EE) and depersonalization scores were high at 29.5 (SD ¼ 9.6) and 10.7 (SD ¼ 6), respectively. The mean personal accomplishment was low at 32.33 (SD ¼ 6). The mean of all subscales did not differ by sex (EE p ¼ 0.5; depersonalization p ¼ 0.09; personal accomplishment p ¼ 0.4). Mean EE differed by marital status, which was 31.2, 31.3, and 25.6 for married, divorced, and single, respectively, analysis of variance test p ¼ 0.045.

Correspondence: Inquiries to Turki Aldrees, MBBS, MBA, Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Prince Sattam Bin Abdulaziz University, Alkharj, Riyadh, Saudi Arabia; e-mail: [email protected]

KEY WORDS: burnout, physicians, residents, otolaryngology COMPETENCIES: Medical Knowledge, Systems-Based

Practice

INTRODUCTION Researchers have been compelled to investigate the complex issue of burnout owing to the serious physical and emotional effect it has been shown to have on health care workers, resulting in inferior patient care. Burnout has been recognized as an occupational hazard and has been frequently studied across different medical specialties and in different countries.1-4 In recent years, a number of studies have investigated the various dimensions of burnout syndrome and factors associated with it among otolaryngology residents, academic chairs, and academic faculties of otolaryngology. Each of these studies reported the prevalence of high levels of burnout, ranging from 3% to 16%. The studies also identified several different work- and homerelated stressors that correlated with burnout levels, such as the number of work hours per week, age, and marital status.5-8 The term “burnout” was first introduced in the 19th century by psychologist Herbert Freudenberger.9 Christina Maslach would later define burnout as a syndrome characterized by emotional exhaustion (EE), depersonalization (DP), and a sense of low personal accomplishment

Journal of Surgical Education  & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.02.006

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(PA).10,11 EE refers to feelings of emotional drain and fatigue when interacting with others. DP denotes negative feelings or cynical attitudes or both one harbors toward the recipients of their service or care. Finally, there is the selfevaluation or PA dimension of burnout, which is characterized by the tendency to negatively evaluate one’s own work. Christina Maslach and Susan Jackson developed Maslach Burnout Inventory Scale (MBI) to quantify burnout status using these 3 dimensions. In this scale, EE is measured using 9 questions, DP with 5 questions, and PA with 8 questions. Answers to these questions are given on a scale of frequency of occurrence, ranging from 0 (none) to 6 (every day).10,11 Although several studies had investigated burnout among otolaryngology residents worldwide, this is the first such study to specifically address the prevalence of burnout and its associated risk factors in otolaryngology residents in Saudi Arabia.

MATERIALS AND METHODS

worthwhile things in this job.” Finally, the PA section included 8 conditions such as “I feel like I treat some of my patients as if they were impersonal objects.” Participants responded to the 22 conditions using a 7-point scale, ranging from “never” (0) to “every day” (6). The results were then stratified into the 3 levels of relative burnout: mild, moderate, and severe. The cutoff points for each level were selected based on the suggestions of previous literature on the subject, (low EE r18, high EE Z27; low DP r 5, high DP Z10; and high PA Z40, low PA r33).5-8,10,11 Demographic data collected from the residents consisted of sex, age, marital status, residency year level, and number of children. Career satisfaction, balance between personal and professional life satisfaction, and monthly job income satisfaction were measured using a 5-point Likert scale, ranging from “very satisfied” (1) to “very dissatisfied” (5). Work schedules and stressors were reported as an average value based on certain criteria such as on-calls per month and hours of sleep per day. Lastly, spousal support was also measured using a 5-point Likert Scale, ranging from “very supported” (1) to “very unsupported” (5).

Study Design and Participants The study used a cross-sectional questionnaire, which was sent to all otolaryngology residents registered for Saudi board training in March 2013. We included all residents attaining level 2(postgraduate year 2 [PGY2]) through level 5 (PGY5) training in Riyadh City, Western Region, Eastern Region, and Abha City. We excluded level 1 (PGY1) residents as they rotate through other surgical specialties such as plastic surgery, and as they had not yet begun otolaryngology training, a mandatory part of the first year of the Saudi Otolaryngology Board Training Program. Each questionnaire included a cover letter detailing the purposes of the study and instructions on how to complete the form. To maintain confidentiality, no questions regarding the identity of the resident were included in the questionnaire. To increase the response rate, the questionnaires were distributed and collected by a senior resident during weekly resident education academic activities. The questionnaires collected from Western Region, Eastern Region, and Abha City were sent to the principal investigator via FedEx. The study was conducted between March and May 2013 after obtaining approval from the research committee at the King Saud University Research Center.

Statistical Analysis Data were summarized as means or proportions. The nonparametric Spearman correlation coefficient was calculated to determine the association between continuous variables, and the analysis of variance test was used to compare means for continuous outcomes and discrete categories. Categorical variables were compared using the chi-square test. All tests were 2 sided, and p o 0.05 was considered significant in all tests. The statistical analysis was performed using IBM SPSS software, version 21 (IBM SPSS Inc., NY).

RESULTS

We used the English version of the MBI-Human Services Study to assess the prevalence of burnout. The MBI questionnaire consists of 22 questions meant to assess the 3 components of burnout, EE, PA, and DP. The section examining EE involved 9 resident conditions such as “I feel emotionally drained from my work.” The DP section included 5 conditions, such as “I have accomplished many

Questionnaires were distributed to 123 resident, and 85 questionnaires were collected, a response rate of 69% (85/ 123). The mean age (standard deviation [SD]) of the residents was 29 (2.3) years. Overall, 67% (57/85) of respondents were men, and 66% (55/85) were married. Level 2, level 3, level 4, and level 5 residents represented 19%, 33%, 29%, and 19% of the sample, respectively. The mean of number of on-calls/month (SD) was 7 days (2), number of clinics/ week (SD) was 3 (1), number of sleep hours/day (SD) was 6 (1), and number of operations/week (SD) was 2 (1) (Table 1). The mean EE score was high at 29.5 (SD ¼ 9.6), as was the mean DP score at 10.7 (SD ¼ 6). The mean PA was low at 32.33 (SD ¼ 6). The mean of all subscales was not statistically significant by sex (EE P ¼ 0.5; DP p ¼ 0.09; PA p ¼ 0.4.). Mean EE differed by marital status— 31.2,

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Questionnaire Content

TABLE 1. Demographic Characteristic of Participants (n ¼ 85)

TABLE 3. Number of Participants Meeting Criteria for Burnout

Characteristic

Burnout Group

Age (y) Call (d/mo) Sleep (h/night) Number of children Number of clinics/wk Number of operated days/wk

Male Female Married PGY2 PGY3 PGY4 PGY5

Mean

Range

29 7 6 1 3 2

25-40 2-10 4-12 0-4 1-9 1-5

No.

%

57 28 55 16 28 25 16

67 33 64 19 33 29 19

31.3, and 25.6 for married, divorced, and single, respectively, analysis of variance test p ¼ 0.045. The stratification of burnout subscales into mild, moderate, and high is shown in Table 2. Of all respondents, 53 (62%) were found to be in high EE status, 47 (55%) in high depersonalized status, and 48 (56%) in low PA status. The number of respondents meeting the criteria for highburnout status, characterized by high EE, high DP, and low PA, are 28 (33%) (Table 3). The level of EE, DP, and PA was not statistically significant across the residency training years (EE p ¼ 0.96; DP p ¼ 0.3; PA p ¼ 0.6) The literature shows the EE subscale to be the best predicator measurement of burnout. Therefore, we performed a Spearman correlation to determine the important associative factors for burnout based on the EE subscale (Table 4). Satisfaction with the balance between personal and professional life and satisfaction with monthly job income both showed an inverse correlation with EE ([r ¼ 0.55, p o 0.001] and [r ¼ 0.29, p o 0.006], respectively). Likewise, satisfaction with otolaryngology specialty and spousal support both showed an inverse correlation with EE ([r ¼ 0.42, p o 0.001] and [r ¼ 0.25, p ¼ 0.04], respectively). Overall, 82% (70/85) of the residents were satisfied with their choice of specialty and 80% (68/85) answered that were they given the choice to reselect their specialty, they would still choose otolaryngology. TABLE 2. Burnout Subscales Stratification Residents in Each Stratum, n (%) Burnout Subscale Emotional exhaustion Depersonalization Personal accomplishment

Low

Moderate

High

12 (14) 18 (21) 48 (56)

20 (24) 20 (24) 23 (27)

53 (62) 47 (55) 14 (17)

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No. (%)

High EE/DP High EE/DP þ low PA

38/85 (45) 28/85 (33)

DISCUSSION It is a generally accepted fact in the medical field that taking preventive measures to deter an illness is preferable to treating the illness after it has occurred. This rule is equally applicable in the case of burnout syndrome. However, to implement preventive measures, one must have an understanding of the fundamental problem and its causes. Unfortunately, there are only a limited number of studies that explore the effect and causes of burnout among otolaryngology residents worldwide. This dilemma is only amplified when we specify our criteria for the Middle East. This study seeks to resolve this situation by enhancing otolaryngology literature with greater knowledge and depth regarding burnout syndrome in otolaryngology residents in the Middle East. A recent report, published in Saudi Arabia, from 1 tertiary hospital, showed a high prevalence of EE and DP, reaching 54% and 35% respectively, among residents/ consultants in different medical and surgical specialties.12 The study served as a wake-up call, alerting the medical field to the need to conduct more studies to determine prevalence and understand the effect of burnout syndrome among practicing physicians in Saudi Arabia. Sadat-Ali et al.13 found that 50.7% of orthopedic consultants in the Western region have high levels of EE. Another study, conducted among residents in different specialties in Riyadh city, showed equally high percentages of EE, 54%, and DP, 24%.14 However, these studies were conducted in either a single center or single city. Our study was conducted in multiple centers located in different cities across Saudi Arabia and achieved a good response rate. In TABLE 4. Spearman Correlation of Emotional Exhaustion Subscale Covariate Age Number of children Number of operated day/wk Number of on-calls/mo Number of clinics/wk Number of sleep hours/d Satisfaction with balance between personal and professional life Satisfaction with monthly job income Satisfaction with otolaryngology specialty Spousal support

Spearman r

p

0.12 0.19 0.14 0.34 0.18 0.71 0.55

0.2 0.07 0.18 0.34 0.09 0.52 o0.001

0.29

o0.006

0.42

o0.001

0.25

0.04 3

addition, we used the MBI inventory, which is widely used internationally. This study shows that this inventory can be successfully used in our setting as well. Therefore, more accurate generalizations may be drawn from our results. Moreover, our study also underscores the importance of routine assessment of the perceptions of health care workers to identify factors negatively affecting their work environment and the prevalence of such factors. Interestingly, the prevalence of EE and DP in our study came out to be 62% and 55%, respectively, both higher than the results reported by the previous studies. In addition, our reported EE and DP percentages are higher than those of many other Western countries. Golub et al.5 reported high EE among US otolaryngology residents at 33%, with DP at 53%. Fletcher et al.6 reported high EE and high DP among practicing otolaryngologists at 19% and 21%, respectively. Johns and Ossoff7reported rates of EE and DP among academic chairs of otolaryngology to be 26% and 13%, respectively. Another study found that 23% of academic faculties of otolaryngology reported high levels of EE.8 In other surgical specialties, Businger et al.15 reported high rates of EE and DP at 29.9% and 12.6%, respectively, among surgeons and surgical residents. Burnout was remarkably prevalent in our study, with 45% of sample residents showing both high levels of EE and DP, with 33% also having high EE/DP and low PA. This is in contrast to the studies on US otolaryngology residents, which reported only 10% as having high levels of EE, DP, and low PA.5 Based on current otolaryngology literature, residents show the highest levels of burnout, followed by academic chairs, academic faculties, and, lastly, practicing otolaryngologists. Interestingly, despite these high levels of burnout in all subscales among residents, a high percentage of them are nonetheless satisfied and happy having otolaryngology as their specialty. Residents’ satisfaction with the choice of an otolaryngology specialty may be explained by the uniqueness of the otolaryngology specialty, which combines both medical and surgical skills. Moreover, this trend may reflect their satisfaction with the availability of surgical cases, the amount of active participation in surgeries, the teaching from attending staff, or the regular academic education activities. Nonetheless, all these factors should be investigated in future studies. Furthermore, our findings are consistent with findings from a study conducted among Canadian residents that showed a high satisfaction level across different domains despite 30% of residents reporting burnout. More interestingly, 91% of surveyed residents would still choose the otolaryngology field as their career.16 Our study agrees with the existent evidence regarding the association between burnout and consequences for the personal and professional lives of residents, including effects on resident satisfaction with the otolaryngology specialty, spousal support, and satisfaction with job income.5,12

Golub et al. reported a statistically significant negative association between residents’ satisfaction with balance between personal and professional life, satisfaction with the otolaryngology specialty, and spousal support (r ¼ 50, 48, 44, respectively). This study does have a number of limitations. The crosssectional study design cannot establish a cause and effect relationship between the dependent and independent variables. In addition, we cannot firmly establish long-term association. The study also does not account for nonresponse bias, which may have a consequential effect on the burnout levels as nonparticipants may, for instance, have high levels of burnout which precluded them from participating in the survey. Nevertheless, our respond rate of 69% is better than that of many similar studies.5,6 In conclusion, our study found that otolaryngology residents in the Saudi Board Training Program experience higher levels of burnout compared with those enrolled in other board training programs. The association variables accounting for these levels should be addressed to decrease the levels of burnout and to provide less stressful work environments to prevent burnout reoccurrence and to attract new graduate physicians to the field of surgery.

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ACKNOWLEDGMENTS This study was supported by College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Kingdom of Saudi Arabia.

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