Khadija Waheed  ( Gynaecology and Obstetrics Department , King Edward Medical University, Lahore )
Naeem Liaqa  ( Paediatric Surgery Department, Holy Family Hospital, Rawalpindi )
Sara Ejaz  ( Gynaecology and Obstetrics Department, Sir Ganga Ram Hospital, Lahore )
Amna Khanum  ( Gynaecology and Obstetrics Department , King Edward Medical University, Lahore )
Shamila Ijaz  ( Gynaecology and Obstetrics Department , King Edward Medical University, Lahore )
Ambreen Butt  ( Medicine Department, King Edward Medical University, Lahore )
Fawad Ahmed Randhawa  ( Medicine Department, King Edward Medical University, Lahore )
Iffat Naheed  ( Gynaecology and Obstetrics Department , King Edward Medical University, Lahore )
Salman Javed  ( Medicine Department, Fatima Jinnah Medical University, Lahore, Pakistan )

Objective: To determine the prevalence of burnout among gynaecological residents and factors associated with it.
Methods: This cross-sectional study was conducted at King Edward Medical University, Lahore, Pakistan over a period of one month in June, 2016. Residents of gynaecology and obstetrics from 7 teaching hospitals of Lahore were included in the study. Along with demographic details, information regarding social life and job satisfaction was acquired. For burnout, Maslach Burnout Inventory-Human Services Survey was used which is a 22-question scale. Data was analysed using SPSS 20.
Results: Of the 102 participants, 57(55.9%) were satisfied after choosing gynaecology as career. It was found that emotional exhaustion and depersonalisation were significantly higher among residents working in government institutions than private institutions (p<0.05). Those having more than 2 years of post-graduate experience had significantly higher depersonalisation than those with lesser experience (p=0.016). Also, working for 50-60 hours/week and feeling dissatisfied with the specialty were associated with significantly higher emotional exhaustion and depersonalisation (p<0.05).
Conclusion: Burnout was highly prevalent among gynaecological residents.
Keywords: Burnout, Gynaecology, Residents, Maslach Burnout Inventory, Pakistan, Lahore. (JPMA 67: 1318; 2017)

Introduction

Burnout is a syndrome which is common in demanding jobs and among those people who care for others like  teachers, social workers and healthcare professionals, particularly gynaecologists, surgeons and paediatricians.1 Healthcare workers, especially gynaecologists and surgeons, are exposed to high levels of stress at workplace. Demanding jobs, hectic duty hours without break and persistent tension can lead to exhaustion, and physical and psychological distress. Moreover, burnout syndrome can increase the risk of medical errors and decrease job satisfaction and lack of interest at workplace which incites early retirement.^2-4
According to Maslach et al., burnout has three interrelated dimensions: depersonalisation, emotional exhaustion and low personal accomplishment and poor self esteem. Prolonged and intense quality of distress and exposure to stress is the most important cause of emotional exhaustion and it results in loss of enthusiasm for work, feeling trapped, defeated and helpless. Depersonalisation happens when physicians manage their patients differently, objectify them, and create a negative environment and attitude towards their co-workers and profession. Inefficiency and the lack of a sense of personal achievement and defeat are characterised by the individual unable to perform their duties and responsibilities and detachment and retirement from the job.^5,6
A few studies are available in the literature which address the factors for burnout among residents. The current study was planned to look for prevalence of burnout syndrome among gynaecologic residents, and also to identify the factors which contribute to high burnout. The study is expected to help us to address and take care of those issues in order to decrease stress and burnout and increase quality of life of gynaecological residents.

Subjects and Methods

This cross-sectional study was conducted at Department of Gynaecology and Obstetrics, King Edward Medical University, Lahore, Pakistan over a period of one month in June, 2016. There are about 10 institutions in Lahore which are training the residents in the field of obstetrics and gynaecology. However, due to some logistic issues and technical problems (not getting approval from ethical board), we included 7 teaching hospitals (4 public-sector and 3 private-sector hospitals) in this study. Approval from ethics committees of all the hospitals was obtained. A questionnaire was designed and all the residents in those hospitals were contacted in person and were asked to fill the proforma. The questionnaires were anonymous and written consent from all residents was obtained.
Our questionnaire consisted of 2 portions:1) demographic portion; and 2) Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Regarding demographic details, following details were asked from residents: age; gender; year of graduation; post-graduation experience; medical degree other than Bachelor of Medicine, Bachelor of Surgery (MBBS); religion; marital status; number of children; is your spouse a doctor?; time taken to reach workplace; job status (i.e. adhoc, contract, permanent); how many hours do you work/week? (50-60 hours, 60-80 hours, >80 hours); do you work at any other set-up also?; are you satisfied after choosing the specialty; and monthly income.
Second portion of the proforma was MBI-HSS.⁷ It is a validated and reliable tool for assessing burnout among healthcare professionals and residents and has been used in many studies.^8,9 It comprises 22 items, which assess burnout among health professionals in mainly 3 domains, namely emotional exhaustion (EE), depersonalisation (DEP) and personal and professional achievement (PPA). Each of these domains was assessed on a 7-point Likert scale. The following cut-offs were used to define low, average or high levels of each dimension of the MBI; EE: low, < 14; average,15-24; high, > 25; DEP: low, < 3; average, 4-9; high, > 10; PPA: low, > 40 ; average, 33-39; high, < 32 (inverse scale). The burnout was labelled if any resident had high score in EE and/or DEP. Initial analysis of our data sheets showed that only one participant was male. Also, only 2 participants had an additional post-graduate degree. We excluded the three pro-formas. 
In the statistical analysis, simple descriptive statistics were used for frequency and percentages. To ascertain risk factors associated with the existence of burnout, chi-square test was used. P>0.05 was considered significant.

Results

Of the 102 participants, 66(64.7%) were from public and 36(35.3%) from private hospitals. The overall mean age of the residents was 27.45±1.69 years. Moreover, 57(55.9%) were satisfied after choosing gynaecology as a career while 45(44.1%) were dissatisfied. Besides, 96(94.1%) participants were earning less than Rs60,000 per month while 6(5.9%) had a monthly income of Rs60,000-100,000. We found that 97(95.1%) residents were aged below 30 years and 86(81.9%) were between their 1st and 3rd year of their residency training


.



Professional burnout scores showed that EE levels were high in 73(71.6%) participants, whereas DEP and PPA levels were high in 54(52.9%) and 50(49%) participants, respectively.

.


Further analysis showed that EE and DEP were significantly higher in government institutions than private ones. Those having more than 2 years of post-graduate experience had significantly higher DEP than those with less experience (p=0.016). Those residents working for 50-60 hours/week had significantly higher EE and DEP than those working more than 80 hours/week (p>0.00). Also, those residents who were dissatisfied with their speciality had significantly higher EE and DEP than those feeling satisfied (p>0.00 and p=-0.025)

.

Discussion

Burnout is an important condition being encountered more frequently among all workers particularly physicians. Among physicians, residency is considered as the most exhaustive phase and is thought of promoting burnout among them. Burnout has been defined by many authors. Maslach had described it as a syndrome involving three aspects of one\\\'s life, including emotional exhaustion, feeling of depersonalisation and reduction of personal performance and efficiency.¹⁰
Campbell et al. conducted a prospective trial among internal medicine residents and found that 78% of the residents were burned out. Of them, 42% residents continued to burn out throughout their residency.¹¹ Among gynaecology residents, burnout prevalence varies from 11-83%, as suggested by many authors.¹² In our study, we found the prevalence of burnout in 76.9% participants, which is quite high. Govardhan et al. conducted a similar trial on gynaecology residents in the United States and found the prevalence of burnout in >50% of residents.¹³ Ghetti et al. reported the prevalence of burnout in gynaecological residents in United States as 70%.¹⁴ In a study from Pakistan, Muzaffar Y. and et al. found burnout in 30.6% of medical students.¹⁵
In another study by Zubairi et al., burnout was found in 74.6% of residents in a hospital from Pakistan.¹⁶ This shows that burnout is a universal thing and is highly prevalent among all residents, irrespective of state and race. It is almost equally and highly prevalent in both developing and developed countries. However, some authors have suggested some difference according to culture variation.¹⁷
As burnout is highly prevalent, it is important to identify the risk factors associated with it. In our study, we have identified that significant risk was present in those senior residents who had already completed their two years of residency. Similar findings were noted by Chaput et al. among plastic surgery residents.¹⁷ Other factors we identified that lead to higher burnout scores included more working hours, working in government set-up and dissatisfaction with the specialty. Another study found that higher burnout scores among gynaecology residents were related with more working hours and dissatisfaction with their jobs among.¹³ Moradi et al. conducted a meta-analysis on the topic and they emphasised that work-related stress and job satisfaction are important risk factors which need to be addressed in order to effectively deal with burnout.¹²
Working hours of the residents is a factor which is generally considered as severely influencing their personality and hence burnout. Gynaecology and obstetrics are generally demanding fields which keep residents on their toes in order to deal with any kind of emergency at any time. Therefore, it is important to address the working hours and working environment of residents, particularly in a resource-restricted country like Pakistan where doctors are already small in number than required. West et al. reported that higher burnout scores and working hours were associated with higher medical error rate and leads to decreased empathy and poor quality of life of residents.¹⁸ Landrigan reported a significant decrease in the medical errors by intensive care unit (ICU) residents when their working hours were adjusted.¹⁹ Martini et al. also concluded in their study that working  >80 hours/week were significantly associated with decreased efficiency by residents.²⁰ They also found that among all specialities, working hours were influencing gynaecological residents the most (75% burnout prevalence).
Our study had many limitations as well. Firstly, we included only gynaecological residents in our study, therefore, our results may not be generalised. Secondly, the sample size was limited as we included few hospitals of only one city due to limited resources. Also risk factors and outcomes were assessed at the same time, so temporality cannot be assessed in this study. 

Conclusion

High burnout scores were related to more working hours and dissatisfaction with job among gynaecology residents. We need to perform survey on national level to identify and address the risk factors. We also recommend regular counselling and motivational sessions for residents for better outcome.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.

References

1. Pereira-Lima K, Loureiro SR. Burnout, anxiety, depression, and social skills in medical residents. Psychol Health Med. 2015;20:353-62.
2. Aldrees T, Badri M, Islam T, Alqahtani K. Burnout Among Otolaryngology Residents in Saudi Arabia: A Multicenter Study. J Surg Educ. 2015;72:844-8.
3. Pantaleoni JL, Augustine EM, Sourkes BM, Bachrach LK. Burnout in pediatric residents over a 2-year period: a longitudinal study. Acad Pediatr. 2014;14:167-72.
4. Guido Lde A, Goulart CT, da Silva RM, Lopes LF, Ferreira EM. Stress and burnout among multidisciplinary residents. Rev Lat Am Enfermagem. 2012; 20:1064-71.
5. Maslach C. What have we learned about burnout and health? Psychol Health. 2001; 16:607-11.
6. Maslach C, Leiter MP. Early predictors of job burnout and engagement. J Appl Psychol. 2008;93:498-512.
7. Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory. In: CP Zalaquett & RJ Wood (Eds.). Evaluating stress: A book of resources. Lanhan, MD: The Scarecrow Press,1997; pp 191-218.
8. Malik AA, Bhatti S, Shafiq A, Khan RS, Butt UI, Bilal SM, et al. Burnout among Surgical Residents in a lo wer-middle income country-Are we any different? Ann Med Surg (Lond). 2016; 9:28-32.
9. Biaggi P, Peter S, Ulich E. Stressors, emotional exhaustion and aversion to patients in residents and chief residents-what can be done? SwissMed Wkly. 2003; 133:339-46.
10. Lorenz VR, Guirardello Ede B. The environment of professional practice and Burnout in nurses in primary healthcare. Rev Lat Am Enfermagem. 2014;22:926-33.
11. Campbell J, Prochazka AV, Yamashita T, Gopal R. Predictors of persistent burnout in internal medicine residents: a prospective cohort study. Acad Med. 2010;85:1630-4.
12. Moradi Y, Baradaran HR, Yazdandoost M, Atrak S, Kashanian M. Prevalence of Burnout in residents of obstetrics and gynecology: A systematic review and meta-analysis. Med J Islam Repub Iran. 2015; 29:235.
13. Govardhan LM, Pinelli V, Schnatz PF. Burnout, depression and job satisfaction in obstetrics and gynecology residents. Conn Med. 2012;76:389-95.
14. Ghetti C, Chang J, Gosman G. Burnout, psychological skills, and empathy: balint training in obstetrics and gynecology residents. J Grad Med Educ. 2009; 1:231-5.
15. Muzafar Y, Khan HH, Ashraf H, Hussain W, Sajid H, Tahir M, et al. Burnout and its Associated Factors in Medical Students of Lahore, Pakistan. Cureus. 2015; 7:e390.
16.  Zubairi AJ, Noordin S. Factors associated with burnout among residents in a developing country. Ann Med Surg (Lond). 2016; 6:60-3.
17.  Chaput B, Bertheuil N, Jacques J, Bekara F, Garrido I, Herlin, et al. Professional burnout among plastic surgery residents: can it be prevented? Outcomes of a national survey. Ann Plast Surg. 2016; 76:2.
18. West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA 2006;296:1071-8.
19. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns\\\' work hours on serious medical errors in intensive care units. N Engl J Med. 2004;351:1838-48.
20. Martini S, Arfken CL, Churchill MA, Balon R. Burnout comparison among residents in different medical specialties. Acad Psychiatry. 2004; 28:240-2.