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Prevalence of burnout among intensive care physicians: a systematic review

Abstract

Objective:

We performed a systematic review to summarize the knowledge regarding the prevalence of burnout among intensive care unit physicians.

Methods:

We conducted a systematic review of the MEDLINE and PubMed® databases (last update 04.02.2019) with the goal of summarizing the evidence on burnout among intensive care unit physicians. We included all studies reporting burnout in intensive care unit personnel according to the Maslach Burnout Inventory questionnaire and then screened studies for data on burnout among intensive care unit physician specifically.

Results:

We found 31 studies describing burnout in intensive care unit staff and including different healthcare profiles. Among these, 5 studies focused on physicians only, and 12 others investigated burnout in mixed intensive care unit personnel but provided separate data on physicians. The prevalence of burnout varied greatly across studies (range 18% - 49%), but several methodological discrepancies, among them cut-off criteria for defining burnout and variability in the Likert scale, precluded a meaningful pooled analysis.

Conclusion:

The prevalence of burnout syndrome among intensive care unit physicians is relatively high, but significant methodological heterogeneities warrant caution being used in interpreting our results. The lower reported levels of burnout seem higher than those found in studies investigating mixed intensive care unit personnel. There is an urgent need for consensus recommending a consistent use of the Maslach Burnout Inventory test to screen burnout, in order to provide precise figures on burnout in intensive care unit physicians.

Keywords:
Burnout, professional/epidemiology; Working conditions; Physicians/psychology; Occupational diseases/epidemiology; Depression; Prevalence; Intensive care units

RESUMO

Objetivo:

Realizar uma revisão sistemática para sumarizar o conhecimento relativo à prevalência de burnout entre médicos atuantes na unidade de terapia intensiva.

Métodos:

Conduzimos uma revisão sistemática nas bases de dados MEDLINE e PubMed® (última atualização em 4 de fevereiro de 2019), com o objetivo de resumir a evidência a respeito de burnout entre médicos atuantes em unidades de terapia intensiva. Incluímos todos os estudos que relatavam burnout em trabalhadores na unidade de terapia intensiva, segundo o Inventário de Burnout de Maslach e, a seguir, triamos os estudos quanto a dados relativos a burnout especificamente em médicos atuantes na unidade de terapia intensiva.

Resultados:

Encontramos 31 estudos que descreviam burnout em membros da equipe da unidade de terapia intensiva e incluíam diferentes perfis de profissionais de saúde. Dentre estes, cinco estudos se focalizavam apenas em médicos, e 12 outros investigavam burnout em uma mescla de profissionais atuantes na unidade de terapia intensiva, mas forneciam dados à parte relativos aos médicos. A prevalência de burnout teve grande variação entre os estudos (variando entre 18% e 49%), porém diversas discrepâncias metodológicas, dentre elas os critérios de corte para definição de burnout e variabilidade da escala de Likert, impediram uma análise agrupada significativa.

Conclusão:

A prevalência da síndrome de burnout entre médicos atuantes na unidade de terapia intensiva é relativamente alta, porém heterogeneidades metodológicas significantes exigem precauções na interpretação de nossos resultados. Os níveis mais baixos de burnout relatados parecem mais elevados do que os identificados em estudos que investigaram uma mescla de profissionais da unidade de terapia intensiva. Há uma necessidade urgente de consenso que recomende o uso consistente do Inventário de Burnout de Maslach para triar a presença de burnout a fim de fornecer dados precisos a respeito de burnout entre médicos atuantes na unidade de terapia intensiva.

Descritores:
Esgotamento profissional/epidemiologia; Condições de trabalho; Médicos/psicologia; Doenças ocupacionais/epidemiologia; Depressão; Prevalência; Unidades de terapia intensiva

INTRODUCTION

Psychological stress among medical disciplines is a “hot-topic”, and several specialties are deemed at high risk.(11 Cordes CL, Dougherty TW. A Review and an Integration of Research on Job Burnout. Acad Manage Rev. 1993;18(4):621-56.) When faced properly with an adequate cognitive approach and coping strategies, stress can exert beneficial effects.(22 Jackson SH. The role of stress in anaesthetists' health and well-being. Acta Anaesthesiol Scand. 1999;43(6):583-602.) Indeed, the ability to tackle challenging scenarios may build self-confidence and enhance the sense of well-being and of being helpful.(33 Rama-Maceiras P, Jokinen J, Kranke P. Stress and burnout in anaesthesia: a real world problem? Curr Opin Anaesthesiol. 2015;28(2):151-8.) However, an exaggerated degree of stress and/or a suboptimal approach to stressful situations may lead to decreased satisfaction, undermining a physician’s mental and physical health,(44 Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334-41.

5 Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-71.

6 Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-85.
-77 Faragher EB, Cass M, Cooper CL. The relationship between job satisfaction and health: a meta-analysis. Occup Environ Med. 2005;62(2):105-12.) ultimately increasing the risk of developing a psychological syndrome known as burnout.(88 Grau A, Suñer R, García MM. [Burnout syndrome in health workers and relationship with personal and environmental factors]. Gac Sanit. 2005;19(6):463-70. Spanish.)

In the 11th Revision of the International Classification of Diseases, burnout is classified as an occupational phenomenon but not a medical condition.(99 World Health Organization (WHO). Burn-out and "occupational phenomenon": International Classification of Diseases. [cited 2020 May 17]. Available from: https://www.who.int/mental_health/evidence/burn-out/en/
https://www.who.int/mental_health/eviden...
) Burnout is described as a syndrome resulting from chronic workplace stress that has not been successfully managed, and it is characterized by three dimensions (main components): high emotional exhaustion (EE), high depersonalization (DP) and low personal accomplishment (PA).(1010 Maslach C, Jackson SE, Leiter MP. Maslach burnout inventory. In: Zalaquett CP, Wood RJ, editors. Evaluating stress: A book of resources. 3a ed. Lanham, MD, US: Scarecrow Education; 1997. p. 191-218.) In brief, EE is a subjective work-related sense of fatigue (feelings of energy depletion or exhaustion), DP is a defense mechanism in the attempt to separate oneself from work (feelings of negativism or cynicism work-related), and low PA represents a feeling of frustration with work-related achievements (reduced professional efficiency). Burnout differs from depression because it is related to the work environment. It develops in response to chronic interpersonal stressors,(1111 Rössler W. Stress, burnout, and job dissatisfaction in mental health workers. Eur Arch Psychiatry Clin Neurosci. 2012;262 Suppl 2:S65-9.) and it is more likely to occur in the absence of appropriate support from healthcare organizations.(1212 Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-6.

13 Sikka R, Morath JM, Leape L. The Quadruple Aim: care, health, cost and meaning in work. BMJ Qual Saf. 2015;24(10):608-10.
-1414 Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374(9702):1714-21.) Its presence negatively affects patients’ care(1515 Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642):488-91.

16 Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000.
-1717 West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302(12):1294-300.) and physicians’ professionalism;(1818 Dyrbye LN, Massie FS Jr, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA. 2010;304(11):1173-80.

19 Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44(3):234-42.

20 Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146(1):54-62.
-2121 West CP, Shanafelt TD. Physician well-being and professionalism. Minn Med. 2007;90(8):44-6.) moreover, it has been associated with relationship impairment among team members,(2222 Devi S. Doctors in distress. Lancet. 2011;377(9764):454-5.) decreased work activity,(2323 Cassella CW. Burnout and the relative value of dopamine. Anesthesiology. 2011;114(1):213-7.) worsened quality of care delivered,(1919 Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44(3):234-42.,2424 Williams ES, Konrad TR, Scheckler WE, Pathman DE, Linzer M, McMurray JE, et al. Understanding physicians' intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. 2001. Health Care Manage Rev. 2010;35(2):105-15.,2525 Kluger MT, Townend K, Laidlaw T. Job satisfaction, stress and burnout in Australian specialist anaesthetists. Anaesthesia. 2003;58(4):339-45.) and higher healthcare costs.(2626 Williams ES, Skinner AC. Outcomes of physician job satisfaction: a narrative review, implications, and directions for future research. Health Care Manage Rev. 2003;28(2):119-39.) Although work-related, burnout seems to play a role in the development of major depression or substance abuse.(2727 Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203(1):96-105.) Therefore, it is easy to understand why physician burnout seriously affects healthcare professionals’ performances and well-being, and the implementation of strategies to reduce its impact is under scrutiny.(2828 West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet. 2016;388(10057):2272-81.)

Burnout is reaching epidemic levels among physicians, with prevalences in several disciplines reported to be over 50%, and those working in the intensive care unit (ICU) have been reported to have the highest prevalence of burnout.(2929 Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al. Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. 2015;90(12):1600-13.) This finding is not entirely surprising since the ICU is certainly one of the most stressful environments, continuously exposing physicians to great responsibilities and stressful situations, such as the management of life-threatening scenarios, decisions to withdraw life-supporting strategies, and dealing with multiple and difficult tasks simultaneously. Moreover, the work pattern is certainly more stressful than that of other medical disciplines, including overnight duties and shifts during weekends and festivities.

Several studies and surveys have studied the prevalence of burnout in the ICU setting. One study reported that the prevalence of burnout in the ICU varies from 0% to 70%,(3030 van Mol MM, Kompanje EJ, Benoit DD, Bakker J, Nijkamp MD. The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PLoS One. 2015;10(8):e0136955.) while another found a narrower (though still large) range (6% - 47%).(3131 Chuang CH, Tseng PC, Lin CY, Lin KH, Chen YY. Burnout in the intensive care unit professionals: A systematic review. Medicine (Baltimore). 2016;95(50):e5629.) Nonetheless, there was gross heterogeneity in their design: different ICU healthcare professionals were included (physicians, residents, nurses, physiotherapists), and different countries and regions and different ICU settings (general, neuro, cardiac) were examined. In consideration of such heterogeneity and considering that a systematic assessment of physicians only has not yet been conducted, we performed a systematic review to summarize the knowledge regarding the prevalence of burnout in ICU physicians.

METHODS

We undertook a systematic, web-based, advanced literature search, using the National Health Service (NHS) Library Evidence tool, on the prevalence of burnout in ICUs. We followed the approach suggested by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting systematic reviews.(3232 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-34.) However, since the search was already performed, registration on PROSPERO was not possible.

Systematic search

To identify relevant articles, an initial computerized search of MEDLINE and PubMed® was conducted from inception until 2 October 2018; with the findings from this search, we started the data extraction. The search was then updated on 4 February 2019, limiting the search to the end of 2018. The manuscript was amended with the new findings.

Our core search was structured on the combination of two groups of terms. The first group included only the term “burnout,” while the second group included the following words: “intensive care” and “critical care”. Comparable search strategies have been adopted by similar studies.(3030 van Mol MM, Kompanje EJ, Benoit DD, Bakker J, Nijkamp MD. The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PLoS One. 2015;10(8):e0136955.,3131 Chuang CH, Tseng PC, Lin CY, Lin KH, Chen YY. Burnout in the intensive care unit professionals: A systematic review. Medicine (Baltimore). 2016;95(50):e5629.,3333 Sanfilippo F, Noto A, Palumbo GJ, Ippolito M, Gagliardone M, Scarlata M, et al. Burnout in cardiac anesthesiologists: results from a national survey in Italy. J Cardiothorac Vasc Anesth. 2018;32(6):2459-66.)

Study eligibility, data extraction and outcomes

Inclusion criteria were pre-specified according to the PICOS approach (Table 1). Study selection and determination of eligibility for inclusion in the systematic review and subsequent data extraction were performed independently by five reviewers with cross-checking (two assessors for each article). The included articles and extracted data were subsequently reviewed by the other two authors. Each discrepancy was discussed with the initial assessors. Discordances were resolved by involving the senior author.

Table 1
PICOS approach for selecting studies in the systematic search

Language and timing restrictions were applied: we read the full manuscript only for articles published in English or Italian, and we limited our search to the period of 1999-2018 (i.e., the last 20 years). A manual search was conducted independently by three authors and included exploration of the lists of references from the studies found in the systematic search. We excluded book chapters, reviews, editorials and letters to the editor for the qualitative synthesis. We expected high heterogeneity for data concerning burnout, partly because of the different tools used for assessing burnout. Since the most commonly used burnout assessment tool is the Maslach Burnout Inventory (MBI), in order to facilitate the aggregation and comparison of data, we decided to include only studies assessing burnout using a version of the MBI. The aim of this systematic search was to summarize knowledge and provide broader insight into the topic.

RESULTS

The literature web-based search yielded a total of 754 citations on PubMed® and 425 on MEDLINE. The manual search identified two other articles. After the exclusion of 362 duplicates, 819 records were screened, but only 195 assessed the topic of burnout in intensive care. Of these, we excluded 178 articles after assessment for eligibility; therefore, we included in our literature summary a total of 17 articles (Figure 1). Of these, we found that five studies directly assessed burnout in ICU physicians only (n = 5/17, 29%), while the other twelve studies (n = 12/17, 71%) included physicians as well as other professionals. In particular, during our screening of full texts, 26 studies were potentially eligible for inclusion in the qualitative synthesis as they involved surveys on burnout in mixed ICU personnel (nurses and/or physiotherapists and/or auxiliary staff). However, from the full texts of these mixed studies, we were able to retrieve separate data on physician burnout in almost half (n = 12/26, 46%), which allowed us to increase the pool of studies for our qualitative synthesis by over three times. We attempted to further increase the amount of data by emailing the corresponding authors of the remaining 14 studies, but unfortunately, we did not get any responses in two attempts (the second email sent two weeks after the first).

Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the conducted screening.

MBI - Maslach Burnout Inventory. Adapted from: Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.


Table 2 summarizes the results of the included studies along with the response rate (for physicians, if provided, or overall, if not, in case of mixed studies), ICU setting and country/region, the type of MBI questionnaire used, the finding on burnout and/or on its domains (EE, DP, PA), and the criteria used for burnout diagnosis. The reported response rate varied greatly (range: 30% to 90%), and the data on physician participation in the study were not always available. Similarly, the presence of severe (or high degree) burnout varied and was reported in the range of 18% to 49%. The vast majority of studies (n = 15/17) investigated burnout by means of the full version of the MBI questionnaire (22 questions; EE = 9, DP = 5, PA = 8); one used an abbreviated MBI (9 questions),(3434 Colville GA, Smith JG, Brierley J, Citron K, Nguru NM, Shaunak PD, et al. Coping with staff burnout and work-related posttraumatic stress in intensive care. Pediatr Crit Care Med. 2017;18(7):e267-e273.) and another used an almost full version (21 questions) coupled with four questions on “consternation”.(3535 Lederer W, Kinzl JF, Traweger C, Dosch J, Sumann G. Fully developed burnout and burnout risk in intensive care personnel at a university hospital. Anaesth Intensive Care. 2008;36(2):208-13.) The cutoffs for diagnosis of burnout varied greatly, with EE ranging from 24 to 31, DP from 9 to 13 and PA from 29 to 33. Moreover, the interpretation of these cutoffs was even more cumbersome because the Likert scale used for the MBI varied (scales ranging from 4 to 7 points), there was an unclear range in 3 studies (18%), and the cutoff was not specified at all in 7/17 (41%) studies.

Table 2
Included studies reporting data on physician burnout in the intensive care unit

From a geographical perspective, the largest (and more recent) study found in our search was a continental Asian survey containing data on 992 physicians with a high response rate (above 75%).(3636 See KC, Zhao MY, Nakataki E, Chittawatanarat K, Fang WF, Faruq MO, Wahjuprajitno B, Arabi YM, Wong WT, Divatia JV, Palo JE, Shrestha BR, Nafees KMK, Binh NG, Al Rahma HN, Detleuxay K, Ong V, Phua J; SABA Study Investigators and the Asian Critical Care Clinical Trials Group. Professional burnout among physicians and nurses in Asian intensive care units: a multinational survey. Intensive Care Med. 2018;44(12):2079-90.) Brazil and France had the greatest number of studies investigating burnout in ICU physicians (four(3737 Barbosa FT, Leao BA, Tavares GM, Santos JG. Burnout syndrome and weekly workload of on-call physicians: cross-sectional study. Sao Paulo Med J. 2012;130(5):282-8.

38 Fumis RR, Junqueira Amarante GA, de Fatima Nascimento A, Vieira Junior JM. Moral distress and its contribution to the development of burnout syndrome among critical care providers. Ann Intensive Care. 2017;7(1):71.

39 Garcia TT, Garcia PC, Molon ME, Piva JP, Tasker RC, Branco RG, et al. Prevalence of burnout in pediatric intensivists: an observational comparison with general pediatricians. Pediatr Crit Care Med. 2014;15(8):e347-53.
-4040 Tironi MO, Teles JM, Barros DS, Vieira DF, Silva Filho CM, Martins Júnior DF, et al. Prevalence of burnout syndrome in intensivist doctors in five Brazilian capitals. Rev Bras Ter Intensiva. 2016;28(3):270-7.) and three(4141 Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175(7):686-92.

42 Garrouste-Orgeas M, Perrin M, Soufir L, Vesin A, Blot F, Maxime V, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015;41(2):273-84.
-4343 Malaquin S, Mahjoub Y, Musi A, Zogheib E, Salomon A, Guilbart M, et al. Burnout syndrome in critical care team members: A monocentric cross sectional survey. Anaesth Crit Care Pain Med. 2017;36(4):223-8.) publications, respectively), followed by Italy with two studies.(4444 Giannini A, Miccinesi G, Prandi E, Buzzoni C, Borreani C; ODIN Study Group. Partial liberalization of visiting policies and ICU staff: a before-and-after study. Intensive Care Med. 2013;39(12):2180-7.,4545 Raggio B, Malacarne P. Burnout in intensive care unit. Minerva Anestesiol. 2007;73(4):195-200.) The other seven studies included ICU physicians working in the United States,(4646 Shenoi AN, Kalyanaraman M, Pillai A, Raghava PS, Day S. Burnout and psychological distress among pediatric critical care physicians in the United States. Crit Care Med. 2018;46(1):116-22.) Austria,(3535 Lederer W, Kinzl JF, Traweger C, Dosch J, Sumann G. Fully developed burnout and burnout risk in intensive care personnel at a university hospital. Anaesth Intensive Care. 2008;36(2):208-13.) Greece,(4747 Ntantana A, Matamis D, Savvidou S, Giannakou M, Gouva M, Nakos G, et al. Burnout and job satisfaction of intensive care personnel and the relationship with personality and religious traits: An observational, multicenter, cross-sectional study. Intensive Crit Care Nurs. 2017;41:11-7.) Portugal,(4848 Teixeira C, Ribeiro O, Fonseca AM, Carvalho AS. Burnout in intensive care units - a consideration of the possible prevalence and frequency of new risk factors: a descriptive correlational multicentre study. BMC Anesthesiol. 2013;13(1):38.) United Kingdom,(3434 Colville GA, Smith JG, Brierley J, Citron K, Nguru NM, Shaunak PD, et al. Coping with staff burnout and work-related posttraumatic stress in intensive care. Pediatr Crit Care Med. 2017;18(7):e267-e273.) Switzerland(4949 Merlani P, Verdon M, Businger A, Domenighetti G, Pargger H, Ricou B; STRESI+ Group. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184(10):1140-6.) and Argentina.(5050 Galván ME, Vassallo JC, Rodríguez SP, Otero P, Montonati MM, Cardigni G, Buamscha DG, Rufach D, Santos S, Moreno RP, Sarli M; Members of Clinical and Epidemiological Research Group in Pediatric Intensive Care Units - Sociedad Argentina de Pediatría. Professional burnout in pediatric intensive care units in Argentina. Arch Argent Pediatr. 2012;110(6):466-73.)

Table 3 summarizes further findings retrieved from the included studies that were deemed of interest by the authors, with a focus on factors associated or correlated with burnout.

Table 3
Findings retrieved from the included studies and deemed of interest, with particular focus on factors associated or correlated with burnout

DISCUSSION

Burnout is particularly common in health-care professionals working in the emergency/critical care field, as shown by the Medscape physician lifestyle report in 2016,(5151 Peckham C. Medscape Lifestyle Report 2016: Bias and burnout. [cited 2016 Jan 13]. Available from: https://www.medscape.com/slideshow/lifestyle-2016-overview-6007335
https://www.medscape.com/slideshow/lifes...
) where the highest percentage of burnout occurred in critical care and emergency medicine physicians (55%), closely followed by anesthesiologists (50%).

Our systematic review aimed to summarize the findings on ICU physician burnout, since pooled data are currently available for all ICU personnel,(3030 van Mol MM, Kompanje EJ, Benoit DD, Bakker J, Nijkamp MD. The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review. PLoS One. 2015;10(8):e0136955.,3131 Chuang CH, Tseng PC, Lin CY, Lin KH, Chen YY. Burnout in the intensive care unit professionals: A systematic review. Medicine (Baltimore). 2016;95(50):e5629.) but a summary on studies including data on burnout among ICU physicians only has not yet been conducted. During abstract screening, we noted that burnout in ICU staff was investigated more frequently in non-physician populations, with 85 studies being excluded because physicians were not involved. In our study, we undertook a significant effort to extrapolate data on physician burnout from studies including heterogeneous populations of critical care staff (i.e., including ICU nurses, nurse assistants, physiotherapists). Indeed, of the 17 included studies, only 5 focused on ICU physicians only, while the other 12 investigated physician burnout together with that of other critical care staff populations. Despite our efforts to enlarge the amount of data available by deep screening full texts, we were able to extract subgroup data regarding isolated physician burnout in almost half of the studies in mixed ICU populations (12 of the 26 selected initially). We also emailed the corresponding authors of the 14 mixed studies in order to expand the available data, but no one responded to our request. Nonetheless, the high heterogeneity already noted in the included studies suggests that the addition of further data would not have changed the main underlying message of our research: there is high methodological variability in studies investigating burnout in ICU physicians, and hazardous and meaningless conclusions from these studies should be avoided.

A previous systematic review on burnout in anesthesiologists found that different versions of the MBI questionnaire were used,(5252 Sanfilippo F, Noto A, Foresta G, Santonocito C, Palumbo GJ, Arcadipane A, et al. Incidence and factors associated with burnout in anesthesiology: a systematic review. Biomed Res Int. 2017;2017:8648925.) thus hampering the interpretation of the results. For such reasons, we limited our appraisal regarding burnout among ICU physicians to studies using the MBI questionnaire, and we found that the vast majority used its full version. Despite this consistency, we found similar issues already brought up by the abovementioned systematic review on anesthesiologists:(5252 Sanfilippo F, Noto A, Foresta G, Santonocito C, Palumbo GJ, Arcadipane A, et al. Incidence and factors associated with burnout in anesthesiology: a systematic review. Biomed Res Int. 2017;2017:8648925.) the included studies used very different cutoffs for EE, DP and PA. Moreover, we added an analysis on the Likert scale used for the MBI, and we found that this range varied greatly. Unfortunately, the cutoffs adopted for the diagnosis of burnout did not seem to correlate directly with such variability in the Likert-scale range (i.e., lower EE scores with a smaller Likert scale). Thus, any statistical or mathematical approach attempting to correct values or synthesize the reported levels of burnout in ICU physicians is meaningless. Of note, the included studies also gave different importance to the three domains. Some studies gave the same value to them, while others considered mainly EE and DP(3434 Colville GA, Smith JG, Brierley J, Citron K, Nguru NM, Shaunak PD, et al. Coping with staff burnout and work-related posttraumatic stress in intensive care. Pediatr Crit Care Med. 2017;18(7):e267-e273.,3636 See KC, Zhao MY, Nakataki E, Chittawatanarat K, Fang WF, Faruq MO, Wahjuprajitno B, Arabi YM, Wong WT, Divatia JV, Palo JE, Shrestha BR, Nafees KMK, Binh NG, Al Rahma HN, Detleuxay K, Ong V, Phua J; SABA Study Investigators and the Asian Critical Care Clinical Trials Group. Professional burnout among physicians and nurses in Asian intensive care units: a multinational survey. Intensive Care Med. 2018;44(12):2079-90.) or EE only(4646 Shenoi AN, Kalyanaraman M, Pillai A, Raghava PS, Day S. Burnout and psychological distress among pediatric critical care physicians in the United States. Crit Care Med. 2018;46(1):116-22.) as pivotal domains in classifying high risk of burnout. In truth, a practical approach to easier interpretation of the MBI would be to get an overall result balancing the findings in the three domains, but such attempts to summarize the overall burnout levels were made only by a minority of studies (n = 4);(4141 Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175(7):686-92.,4242 Garrouste-Orgeas M, Perrin M, Soufir L, Vesin A, Blot F, Maxime V, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015;41(2):273-84.,4444 Giannini A, Miccinesi G, Prandi E, Buzzoni C, Borreani C; ODIN Study Group. Partial liberalization of visiting policies and ICU staff: a before-and-after study. Intensive Care Med. 2013;39(12):2180-7.,4949 Merlani P, Verdon M, Businger A, Domenighetti G, Pargger H, Ricou B; STRESI+ Group. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med. 2011;184(10):1140-6.) even in these studies, the authors did not provide a clear explanation of the formula used to obtain the overall result, and different cutoffs were reported.

Some studies attempted to stratify the risk into low, moderate and high risk, while others defined only a high risk of burnout. We found the findings of a French survey very interesting; Garrouste-Orgeas et al.(4242 Garrouste-Orgeas M, Perrin M, Soufir L, Vesin A, Blot F, Maxime V, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture. Intensive Care Med. 2015;41(2):273-84.) investigated burnout levels according to two different definitions, the first considering burnout as the presence of an alteration in all domains and the second evaluating the overall burnout score. The findings of the authors are striking in the sense that the first definition identified only 2.5% of physicians at high risk of burnout, while the second identified over 40%. In our belief, this finding again supports the idea that averaging literature findings provides biased conclusions; moreover, despite the attempt to reduce data heterogeneity by including only studies using the MBI questionnaire, our findings on the heterogeneous methodology of the included studies highlight the urgency for a consensus on burnout cutoffs when using the MBI questionnaire, together with clear reporting.

Apart from the difficulty of drawing conclusions, we found a variable response rate (from 30% to 90%). The response rate is a very important - and possibly underestimated - concept in the conduction of surveys because it may shift results on both sides. In the case of burnout, opposite interpretations are plausible. Indeed, it is possible that people at risk of burnout may not be keen on answering due to their disengagement in work-related issues and initiatives (such as a survey). Alternatively, it is possible that ICU physicians at risk of burnout show greater appreciation towards initiatives devoted to the support of workers, perceiving the importance of evaluating and addressing their work-related fatigue and sense of frustration.

Limitations

Our systematic review has strengths and limitations. We performed a highly specific systematic review focusing on physician burnout in the ICU and included only studies using the MBI questionnaire, which is by far the most commonly used questionnaire to screen burnout. This decision was intentionally planned in order to - theoretically - obtain more comparable results. Although such an a priori decision was reasonable, the presence of several other weaknesses in reporting and methodological heterogeneities identified in our appraisal indicated that a numerical synthesis of the retrieved data was not warranted.

Importantly, we excluded studies in which the ICU personnel surveyed was not purely from the ICU but also consisted of surgeons and pediatricians working in the ICU. This approach permitted us to conduct a sectorial appraisal, but we still found high heterogeneity in the population of ICU physicians included. Indeed, several studies included ICU physicians at different stages of their careers (specialists and/or residents and/or interns) and variable ICU settings, ranging from any type of ICU to very specific ICU subtypes (in this regard, conducted mainly in the setting of pediatric and/or neonatal ICUs).(3939 Garcia TT, Garcia PC, Molon ME, Piva JP, Tasker RC, Branco RG, et al. Prevalence of burnout in pediatric intensivists: an observational comparison with general pediatricians. Pediatr Crit Care Med. 2014;15(8):e347-53.,4646 Shenoi AN, Kalyanaraman M, Pillai A, Raghava PS, Day S. Burnout and psychological distress among pediatric critical care physicians in the United States. Crit Care Med. 2018;46(1):116-22.,5050 Galván ME, Vassallo JC, Rodríguez SP, Otero P, Montonati MM, Cardigni G, Buamscha DG, Rufach D, Santos S, Moreno RP, Sarli M; Members of Clinical and Epidemiological Research Group in Pediatric Intensive Care Units - Sociedad Argentina de Pediatría. Professional burnout in pediatric intensive care units in Argentina. Arch Argent Pediatr. 2012;110(6):466-73.) We also identified single center studies as well as surveys conducted on regional to national (and one continental) scales. Another source of heterogeneity was related to the variability in response rate. To the best of our knowledge, there is no established cut-off for response rate to decide whether to include a study.

CONCLUSION

This survey aimed to summarize data on the prevalence of burnout in intensive care unit physicians over the past 20 years. The appraisal of the published literature showed great heterogeneity in the methodological designs, including different scales for the evaluation and different cutoffs for burnout diagnosis. We believe it is urgent to achieve a consensus on methodological approaches for burnout evaluation.

Take-home message: Our systematic review on the prevalence of burnout in intensive care unit physicians, as evaluated by the Maslach Burnout Inventory questionnaire, found huge variability in the setting of the studies as well as in their methodologies, with variable definitions of burnout, different ranges used in the Maslach Burnout Inventory scale and mutable cut-offs. While it is impossible to draw conclusions on the true prevalence of physician burnout in the intensive care unit, it is urgent to establish a consensus on the methodology for conducting and reporting studies investigating burnout.

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  • Erratum

    In the article Prevalence of burnout among intensive care physicians: a systematic review, with DOI number: 10.5935/0103-507X.20200076, published in the journal Revista Brasileira de Terapia Intensiva, 32(3):458-467, on page 458:
    Where it read:
    Mirko Minieri
    Read:
    Mirko Mineri

Edited by

Responsible editor: Felipe Dal-Pizzol

Publication Dates

  • Publication in this collection
    12 Oct 2020
  • Date of issue
    Jul-Sep 2020

History

  • Received
    26 Feb 2020
  • Accepted
    25 May 2020
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