Brief Review of Burnout Syndrome in Emergency Department Physicians

Prevalence

The prevalence of burnout in the medical literature varies from 77.8% in a study of American Emergency trainees [9] to 25% in pediatric emergencies [10]. Many causes can be determined to explain the difference in burnout prevalence, such as different countries, health systems, and populations, where most of the studies were performed by EM physicians, without determining the ratio of residents to specialists.

In a systematic review study, Boutou, et al. from 27 studies found that differences in the availability of emergency physicians, limitation of health resources, accessibility of emergency departments, dissimilarities in the number, available subspecialties, and level of experience of the rest of the emergency department personnel, which could be seen between countries, are some factors that could produce significant differences in the overall working environment of emergency departments. Consequently, there is less or more psychological burden on the medical staff [11].

The incidence of burnout ranged from 53.4% to 77.8% in six studies on EM emergency medicine residents and trainees [9, 12, 13, 14, 15, 16]. In another study by Soltanifar, et al. [17] the prevalence of EE among female physicians working in EM in Iran was up to 84.5%. On the other hand, Patterson et al reported a low level of 25% burnout among physicians working in an emergency pediatric department [1]. Thus, when evaluating the prevalence of burnout, the characteristics of the studied population and the definitions used for diagnosis have to be considered.

Some studies have reported the prevalence of each subscale of the MBI [17, 18, 19, 20, 21, 22], thus, burnout prevalence was calculated as medium-high EE or medium-high DEP [10, 22, 23].

A systematic review of 182 studies involving 109 628 participants in 45 countries from 1991 to 2018. They found that 85.7% (156/182) of the studies used the MBI to assess burnout. Either overall burnout (0% to 80.5%) or burnout subcomponents, (0% to 86.2%) on EE, (0% to 89.9%) on DEP, or (0% to 87.1%) on PA. The differences return to inconsistencies in definitions and assessment methods.

In a study of 139 Pediatric Emergency fellows, where (65%) female, the  burnout  prevalence was 30.9% (95% CI, 24%–39%), men (13%), women (39.8%), single (50%), divorced (66.7%), and married (27%). In addition, the major risk factors of burnout  were work environment (52.5%), fellowship academic responsibilities (36%), schedule (35.3%), work-life balance (33.8%), and career/occupational stress (33.1%) [24].

Another study included 16 666 physicians (1584 emergency physicians, 12 103 surgeons and 2979 radiologists/ pathologists) between 1997 and 2010. They found that emergency physicians have a higher range of specialties than surgeons and radiologists/pathologists due to the high stress of emergency medicine [25].

Risk Factors

Work environment related burnout: Several risk factors associated with the occurrence of work-related burnout have been reported. In a large study of 1272 EM physicians in the USA [22], the predictors of burnout were increased number of shifts per month, lack of job involvement, dissatisfaction with career, low self-assessment of productivity and effectiveness, dissatisfaction with specialty services, and intent to leave practice within 10 years. Similarly, in another study of 160 EM physicians, Jalili et al. found that shortage of equipment, problems with the work’s physical environment, relationship with other services, work overload, and feeling of insecurity for future careers were risk factors for burnout [19]. Other study by Golberg, et al., in a 4-year study among 1272 EM physicians, found that job involvement, workload (number of shifts per month), and career satisfaction are risk factors [22]. Several studies found that the problematic coworker’s relationship was the most frequent risk factor of burnout in the literature [19, 22, 26, 27]. Emergency staff in different departments have to present facilitated teamwork with other hospital services, despite the difficulty in being fulfilled.

In a Turkey study of 167 EM residents, they found that the presence of a consultant and his appreciation for the EM resident was a good predictor of DEP and EE scores [28]. However, the presence of violence (physical and verbal) in the emergency department is increases both EE and DEP [21, 26].

Balancing work and private life: The difficulty in balancing work and private life due to high job demands is another factor that has been associated with burnout. In a study by Jalili et al, among 160 EM physicians, difficulties in balancing professional and family life were the strongest predictors of EE [19]. In addition, Estryn-Bahar, et al. reported that the clash between work and family, which is more dominant among emergency physicians than other specialties, is strongly associated with burnout [27]. Work–life balance decreases burnout in the study of Ben-Itzhak et al. on 70 EM physicians. Consequently, the presence of a supportive family and sufficient time with family are two factors that can reduce the severity of burnout [20].

The number of years in the job: The association between the number of years in the job and the risk of burnout has also been studied. In a study of 263 physicians in Romania, more years in the job was associated with higher burnout scores; the percentage of physicians who reported high EE changed from 11% in the 4th year of work to 17% in the 7th year [29]. In addition, Toker et al. indicated that physicians who stayed >10 years in the job had significantly lower DEP scores than those during their first year [26].

Other Risk Factors have also been mentioned. In a study of 193 EM physicians, Kuhn et al. reported that the single strongest predictor of burnout was anxiety due to concern for a bad future [30]. In several studies on EM physicians, depression-related with Number of Years in the Job was found to be a predictor of burnout [13, 20, 31].

Demographic risk factors: The association between sex and burnout was also studied. In a study by AL Qahtani, et al. on EM physicians in Saudi Arabia, the development of burnout in male physicians was three times higher than in females [32]. In contrast, in a Canadian study, Patterson et al. reported an association between female sex and burnout among physicians [10]. Additionally, Jalili, et al. reported that younger physicians are associated with the development of high DEP scores [19]. In addition, Toker, et al. reported that younger EM physicians had higher DEP and EE scores [26].

Lifestyle: The effects of lifestyle on the development of burnout were assessed. AL Qahtani, et al. found that smokers were at a higher risk of burnout than non-smokers [32]. Goldberg, et al. reported that alcohol consumption is associated with burnout in 1272 EM physicians in the USA [22]. Furthermore, several studies have reported that sleep disorders and taking medications are associated with a high risk of burnout [22, 32]. In contrast, frequent and regular exercise is associated with a low risk of burnout [22, 27].

War environment related burnout: Professor Helal, et al. noticed a steady association between the development of burnout and war environment. Physicians who come from war countries suffer from bullying, persecution, racial discrimination, psychological and social stress, and employers’ domination over them in some countries; therefore, they must work in unsuitable environments.

As an example, what happened in Syria, where thousands of physicians were forced to flee from the scourge of war, spread worldwide: Turkey, Arab Gulf countries, and Europe. Where they faced difficulties in obtaining visas and jobs, they were also forced to work in jobs that were not suitable psychologically or physically, exposure to extra hours of work without pay, exposure to unsuitable working conditions and location, and the lack of work essentials such as an office table or a chair to sit on. Most of Syrian doctors cannot return to their country, they are forced to work, in any circumstances. Furthermore, their families are not allowed to visit them, which increases their psychological and physical stress.

Dealing with Burnout

The participants faced burnout using various methods. Keller et al. studied the methods of facing stress on 77 emergency physicians in the USA, and found that physicians used short- and long-term coping methods to deal with stress, such as talking with others, crying, making alternate plans, daydreaming, preparing for the worst, using food or coffee, and sleeping more than usual [28]. In another study on all staff in the emergency department, Howlett et al. reported that action responses were associated with decreased burnout, whereas emotional responses were associated with increased burnout [33].