Physician burnout and associated factors during the COVID-19 pandemic: a cross-sectional studyABSTRACT
Introduction Burnout Syndrome is a set of psychological symptoms arising from chronic workplace stress, with increased prevalence during the COVID-19 pandemic. This study aimed to assess burnout prevalence and associated factors among physicians in Porto Velho, RO, Brazil, during the pandemic.
Methods This cross-sectional study utilized the Maslach Burnout Inventory (MBI), completed by physicians who provided informed consent between August 2021 and May 2022. Recruitment occurred via messages and direct outreach in hospitals and clinics. Variables were classified as quantitative or qualitative. Fisher’s exact test (one-tailed) was applied to qualitative variables (p < 0.05), while the Mann-Whitney U (one-tailed, 95% significance) and Kruskal-Wallis tests were used for quantitative data. Mean values’ confidence intervals were based on the Z test.
Results Among 138 participants, 63% were female, with a mean age of 30 years, and 69.56% had under 10 years of medical experience. Burnout prevalence was 77.5% (107/138), with 43.48% (60/138) showing emotional exhaustion and depersonalization. Factors associated with burnout included being female, under 30 years, single, and working on the frontline. Marriage and having children appeared as potential protective factors.
Conclusions High levels of burnout syndrome were observed among participants, with findings highlighting associated factors consistent with the literature. This study underscores the mental health challenges faced by physicians during the COVID-19 pandemic.
Burnout Syndrome; Physicians; COVID-19 Pandemic; Mental health; Brazil
RESUMO
Introdução A síndrome de burnout é um conjunto de sintomas psicológicos decorrentes do estresse crônico no trabalho, com aumento de prevalência durante a pandemia de COVID-19. Este estudo teve como objetivo avaliar a prevalência de burnout e fatores associados entre médicos em Porto Velho, RO, Brasil, durante a pandemia.
Métodos Este estudo transversal utilizou o Maslach Burnout Inventory (MBI), respondido por médicos que forneceram consentimento informado entre agosto de 2021 e maio de 2022. O recrutamento foi feito por mensagens e abordagem direta em hospitais e clínicas. As variáveis foram classificadas como quantitativas ou qualitativas. O teste exato de Fisher (unicaudal) foi aplicado às variáveis qualitativas (p < 0,05), enquanto os testes Mann-Whitney U (unicaudal, significância de 95%) e Kruskal-Wallis foram usados para variáveis quantitativas. Os intervalos de confiança dos valores médios foram baseados no teste Z.
Resultados Entre os 138 participantes, 63% eram mulheres, com idade média de 30 anos, e 69,56% tinham menos de 10 anos de experiência médica. A prevalência de burnout foi de 77,5% (107/138), com 43,48% (60/138) apresentando exaustão emocional e despersonalização. Fatores associados ao burnout incluíram ser mulher, ter menos de 30 anos, ser solteiro e atuar na linha de frente. Ser casado e ter filhos apareceram como possíveis fatores de proteção.
Conclusões Níveis elevados de síndrome de burnout foram observados entre os participantes, com fatores associados consistentes com a literatura. Este estudo ressalta os desafios de saúde mental enfrentados por médicos durante a pandemia de COVID-19.
Síndrome de Burnout; Médicos; Pandemia da COVID-19; Saúde mental; Brasil
INTRODUCTION
Burnout Syndrome (BS) consists of a group of psychological symptoms resulting from chronic exposure to emotional and interpersonal stressors in the workplace. This set of signs and symptoms can be defined by three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment. Each of these dimensions characterizes a group of symptoms. The emotionally exhausted physician loses enthusiasm for work and feels helpless, trapped, and defeated. The depersonalized professional treats patients in an indifferent and objectified way, developing a negative attitude toward colleagues and the profession. Similarly, low personal accomplishment is characterized by the individual’s withdrawal from responsibilities and detachment from work. Therefore, physicians with burnout are at greater risk of causing iatrogenic harm. 1,2
Even under normal conditions, healthcare professionals experience stress; however, the pandemic caused by SARS-CoV-2 (COVID-19) has drastically exacerbated this situation, adding greater pressure on doctors due to the overwhelming of the healthcare system, along with other stress factors, such as the risk of infection, the shortage of personal protective equipment, and the need for social distancing. 3 As an example of a similar scenario, during the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003, 18% to 57% of healthcare professionals faced serious emotional and psychiatric problems during and after this period. Likewise, during the Middle East Respiratory Syndrome (MERS) outbreak in 2015, professionals experienced dysphoria and stress, conditions that predisposed them to misconduct, treatment delays due to poor communication, and absenteeism. 4
Similar studies have investigated the impact of the COVID-19 pandemic on healthcare professionals. For example, in Canada, Singh et al (2022) reported burnout in 73% of participants, while in Argentina, Appiani et al. (2021) found an even higher prevalence, affecting 73,5%. 5,6 In Spain, depersonalization levels among physicians reached 38.9%, and approximately 85.4% reported that the lack of PPE led to increased stress and anxiety. 7 Additionally, a systematic review involving 117 studies identified a prevalence of 28% (26% to 31%) of burnout syndrome in the context of the COVID-19 pandemic. 8
Given these findings, this study aimed to identify the prevalence of burnout syndrome among doctors working in Porto Velho, Rondônia, Brazil, during the COVID-19 pandemic, as well as to explore possible associated factors and the epidemiological characteristics of this population.
METHODS
Data collection
This research is a cross-sectional study conducted via a virtual questionnaire using Google Forms®, filled out by doctors working in health units located in Porto Velho, Rondônia, Brazil. Data were collected between August 2021 and May 2022.
The Maslach Burnout Inventory (MBI) model, considered the gold standard in medical research literature to identify BS, was used as the basis for the questionnaire, in the format adapted for health workers (MBI-HSS) and further tailored for this study. It includes 22 items to measure all three dimensions of BS (emotional exhaustion, personal accomplishment, and depersonalization). In addition, personal data deemed important for the research were collected, as follows: sex, age, children (yes or no), living with family, religion (yes or no), psychological or psychiatric care, marital status, time since graduation, medical specialty, weekly working hours, type of work (whether on the COVID-19 frontline or not), with no distinction between the public or private healthcare system.
To recruit participants for the research, we contacted the medical staff coordinators of the hospitals in the city to obtain the contact information of active doctors, regardless of their specialty or position in the hospital. Subsequently, participants were contacted by message or approached in person at an opportune time. Physicians who expressed interest in participating were provided with an explanation of the research terms by one of the data collection team members, either remotely or in person.
Data collection was then conducted remotely via Google Forms®, after the informed consent form was signed. Data such as the participant’s name and workplace were not collected in the questionnaire, which was answered anonymously. The time and date of data collection were kept confidential by the researchers throughout the study and were deleted after completion.
Data analysis
The scoring system of the MBI-HSS scale was used as a basis: never (0 points), a few times a month (3 points), a few times a week (5 points), and every day (6 points). A score was assigned to each dimension evaluated in this questionnaire. BS was defined as a score greater than or equal to 27 for the emotional exhaustion dimension or greater than or equal to 10 for depersonalization, while the presence of low personal accomplishment was evaluated separately from BS and was defined when the score of this dimension was less than or equal to 33. 9
Study variables were classified as quantitative or qualitative, quantitative variables were represented as averages, and qualitative variables were represented as percentage. For the statistical tests, the Fisher test (one-tailed) was used for qualitative variables (with p < 0.05%) and the Mann-Whitney U test (one-tailed, with a significance of 95%) and the Kruskal-Wallis test were used for quantitative variables. The confidence index of the mean values was based on the Z test. Cases where there were participants with missing data were excluded from the statistical tests.
Inclusion/Exclusion criteria
The inclusion criteria for participants were: physicians working in emergency care units, hospitals, and other health facilities in the city of Porto Velho, Rondônia, Brazil, who agreed to participate and signed the informed consent form. Physicians not meeting these requirements were excluded from the study.
Ethical and legal aspects
This research was approved by the Research Ethics Committee of Centro Universitário São Lucas on May 31, 2021, the voucher number is 035296/2021, CAAE: 45510721.1.0000.0013.
RESULTS
Of the 263 physicians invited to participate in the survey, only 138 participated, representing 52.47% of the guests, of which 63% (87/138) were female. The age of the participants ranged from 23 to 70 years, with a mean of 30 years (95% CI: 28.32 - 31.67) and a mode of 26 years (Table 1).
According to the National Medical Council (Conselho Federal de Medicina - CFM) demographic study (2024), Porto Velho has 2,238 physicians authorized to work in the state. Thus, this research has a margin of error of 8.08%, considering a confidence level of 95%. Approximately 52.1% of these physicians are under 40 years old, with 17.3% aged 29 or younger, 16.5% aged 30-34, and 18.3% aged 35-39. Women represent around 46.3% of the total physician workforce. Notably, women already make up the majority in the younger age groups, indicating a trend toward gender balance—or even a shift to female predominance—in the medical workforce in the state, reflecting broader demographic changes within the field of medicine. 10
Regarding work experience, according to the CFM demographic study, doctors in Porto Velho have an average of 13.99 years since graduation, with a standard deviation of 13.13. 10 In our research, the results ranged from 5 months to 44 years, with 69.56% of the sample having less than 10 years of experience. Among physicians with 10 or more years since graduation, 17.39% had graduated between 10 and 20 years ago, 7.25% between 20 and 30 years ago, 3.62% between 30 and 40 years ago, and 2.17% over 40 years ago.
Concerning the MBI-HSS scale results based on the total Likert range score separately for each of the three dimensions evaluated, the following results were obtained: 77.54% (107/138) of the participating physicians had some type of burnout. Of these, 43.48% (60/138) had both emotional exhaustion and depersonalization, 28.99% (40/138) had only emotional exhaustion, and 5.07% (7/138) had only depersonalization. A total of 17.39% (24/138) had low personal accomplishment, and 95.83% (23/24) of these were associated with some type of burnout.
Among 107 cases of burnout, 73 were women (68.22%). The prevalence of BS in women was 83.91% (95% CI: 74.66-90.29), while in men it was 66.67% (95% CI: 52.92-78.08), with a prevalence ratio of 1.259 (95% CI: 1.015-1.56) and p = 0.01746. Thus, being female represented a higher possible risk of burnout syndrome.
The mean age among men who did not have any type of burnout syndrome was 43 years (95% CI: 37.68-48.31), while the mean age among men with BS was 30.5 years (95% CI: 27.09-33.90) (p = 0.0139). For women, the mean ages were 40.5 years (95% CI: 33.87-47.12) and 28 years (95% CI: 26.38 -29.61), respectively, with a p of 0.00001. This indicates that the greater the age, lower the possible risk of burnout for both males and females.
Furthermore, in this study, the prevalence of burnout was higher among those aged up to 30 years of age (94.20%), decreasing according to the age group as shown in Table 2 (p=0.000000165).
Similarly, work experience was related to the occurrence of burnout, and it was more prevalent among those with up to 5 years of experience, decreasing as the number of years of experience increased (Table 3), p-value of 0.001884. Furthermore, physicians with less experience also showed more emotional exhaustion (p=0.002067) and depersonalization (p=0.001058). There was no relationship between years of work experience and personal accomplishment (p=0.2944).
The average weekly workload for these above-mentioned three groups had no significance (p=0.07835).
Moreover, men and women had the same average weekly workload (60 hours for both). In addition, there was no relationship between the number of hours worked and the occurrence of BS (p=0.6781), as shown in Table 4.
When comparing doctors who have worked on the frontline, either currently or in the past, with those who have never been exposed to this scenario, a significantly higher likelihood of developing burnout syndrome was observed among the first group.
The risk of burnout among frontline doctors was 80.95% (95% CI: 73.16% - 86.91%), while among those who had no exposure, the risk was 41.67% (95% CI: 19.26% - 68.11%), with a prevalence ratio of 1.943 (95% CI: 0.9895 - 3.815). This indicates that frontline doctors have nearly double the likelihood of developing burnout syndrome compared to their non-exposed colleagues (p=0.00533).
In addition, when comparing doctors who are still on the frontline with those who no longer work in that position, the risk of burnout was found to be 87.65% (95% CI: 78.56% - 93.34%) for the former and 68.89% (95% CI: 54.26% - 80.55%) for the latter. This suggests that even among those who no longer work on the frontline, the risk of burnout remains significantly high. The prevalence ratio was 1.272 (95% CI: 1.029 - 1.574) for this comparison. Therefore, working on the frontline, currently or in the past, represents a substantial associated factor for burnout syndrome (p=0.01078).
As indicated in Table 5, those who have never worked on the frontline were older (p = 0.00015) and had more years of experience (p = 0.00218) compared to the other groups. Additionally, doctors who are still working on the frontline have less experience (p = 0.0268) compared to those who are no longer on the frontline, but the age difference was not statistically significant (p = 0.07215).
Among male participants with children, the risk of developing burnout syndrome was 53.85%, increasing to 80% among those without children (p=0.04531). For female participants, these percentages were 72.97% with children and 92% without children, respectively (p=0.01838). This translates to prevalence ratios of 0.67 (95% CI: 0.4484-1.01) for men and 0.79 (95% CI: 0.6414-0.9809) for women, indicating that doctors with children had a lower chances of developing burnout syndrome.
The research participants were predominantly single (47.1%) and married (44.2%), with 8.7% classified as having other marital statuses. When comparing the risk of burnout between these two groups, a prevalence ratio of 0.7224 (95% CI: 0.5929 - 0.8803) was obtained. Among single doctors, the risk was 90.77% (95% CI: 80.96% - 96.03%), compared to 65.57% (95% CI: 53.02% - 76.29%) among married individuals (p = 0.0005213). These results indicate a significant reduction among married doctors.
Moreover, when assessing the association between having a religious affiliation and the risk of burnout, no statistically significant correlation was observed (p = 0.2925).
Among participants without burnout syndrome, only three doctors reported receiving treatment from a psychologist or psychiatrist. In contrast, among those experiencing burnout syndrome, 32.71% (35/107) were under the care of a psychologist or psychiatrist.
DISCUSSION
This study aimed to determine the prevalence of burnout syndrome among physicians working in Porto Velho, RO, Brazil, during the COVID-19 pandemic. The main findings revealed a significant presence of burnout syndrome among these doctors. Identified factors contributing to the development of burnout included female gender, younger age, and frontline exposure to COVID-19 patients. In contrast, protective factors such as being married, having children, and possessing greater professional experience appeared to reduce the risk of experiencing burnout.
In this study, the response rate was 52.47%, similar to other burnout studies, such as Castro et al. (2020) in which the response rate was 63.4%; 38% for Khan et al. (2021); 23.28% for Civantos et al. (2020); 44% for Singh et al. (2022); and 68.63% for Appiani et al. (2021). With the exception of Civantos et al. (2020), which used the Mini-Z burnout assessment model, all the other studies used the MBI model - the same used in the present study - which is considered the gold standard in the medical research literature for identifying BS. 5,6,9,11,12
Regarding the prevalence of burnout syndrome among physicians in this study, 77.54% of professionals had BS. The prevalence of depersonalization was 48.55% (67/138), and emotional exhaustion was 72.46% (100/138). These results are comparable to those of Khan et al. (2021), conducted in Vancouver, Canada, where 68% of the sample had burnout, with 39% (99/251) prevalence of depersonalization and of 63% (157/250) prevalence of emotional exhaustion. 9 Similarly, Singh et al. (2022) found a burnout prevalence of 73% in Ontario, Canada. 5 Additionally, a study conducted in Buenos Aires, Argentina, by Appiani et al. (2021) reported a burnout prevalence of 73.5% among physicians working during the COVID-19 pandemic, with higher rates observed particularly among residents and emergency physicians working 24-hour shifts.6
Concerning the characteristics of the population evaluated, in the present study, 63% of the participants were female. Similar results were found by other studies. 9,11,13 In our study, being female was identified as a possible risk factor for the development of BS, as demonstrated by Civantos et al. (2020), conducted in Brazil, where women were more likely to have a positive burnout screening (p = 0.036) and higher mean scores (p = 0.002). Furthermore, Baptista et al. (2021), conducted in Portugal, showed that being a woman was significantly associated with higher rates of patient-related burnout (OR = 2.57; 95%; CI = 1.17-5.65; p = 0.019). The results from Khan et al. (2021) also indicated that women were more prone to emotional exhaustion (p = 0.03). However, the study conducted by Appiani et al. (2021) reported no statistically significant difference between genders in burnout prevalence, highlighting a contrasting perspective on the role of gender in BS. 6,9,11,13
In this research, professionals up to 30 years of age were more likely to have Burnout syndrome (p=0.000000165), with the prevalence decreasing as aging. Similarly, in the study by Khan et al. (2021), the prevalence of BS was higher among those aged 36-50 years (74%), decreasing to 32% for those over 66 years. The same pattern was observed in Ma et al. (2020), where occupational burnout levels decreased as age increased, and emotional exhaustion and low personal accomplishment were significantly lower in individuals over 45 years old. This was corroborated by studies like Baptista et al. (2021) and Ferry et al. (2021). Singh et al. (2022) noted that those aged 56 years or older had a lower probability of burnout (OR = 0.16; 95% CI: 0.1 - 0.4; P < .001). Notably, while most of these studies used the MBI model, Baptista et al. (2021) and Ferry et al. (2021) employed the Copenhagen Burnout Inventory. 5,9,13,16,17
Moreover, no statistically significant difference was found between the average weekly workload for physicians with or without burnout. Similarly, there was no relationship between years of experience and hours worked. In contrast, Khan et al. (2021) found a significant relationship between increased working hours and the probability of burnout. 9 Furthermore, Lin et al. (2021) also observed an association between weekly workload and burnout using the Copenhagen Burnout Inventory scale, showing a nonlinear dose-dependent relationship. However, burnout among physicians was less sensitive to workload changes compared to other healthcare professionals. 18
Working (currently or previously) on the frontline almost doubled the risk of developing burnout compared to doctors who were not exposed. Cahill et al. (2022) observed that the number of hours spent on aerosol-generating procedures for COVID-19 patients was positively correlated with burnout, anxiety, and depression. 19 Greene et al., 2021 also demonstrated that frontline workers were more likely to suffer from anxiety, depression, or PTSD if they: lacked reliable access to personal protective equipment (PPE), contracted COVID-19, felt stigmatized due to their job, were concerned about infecting others, or were unable to communicate with their managers about their struggles. 20
In this study, having children appeared to be a potential protective factor for burnout, especially among women. According to C. Buehrsch et al., 2012, using the MBI, both men and women with children exhibited lower depersonalization levels, while lower levels of emotional exhaustion were noted only among men. 21
Regarding marital status, being married was a potential protective factor against burnout (prevalence ratio of 0.7224 [95% CI: 0.5929 – 0.8803]; p = 0.0005213). Likewise, Zheng et al. (2022) also showed that single physicians were more likely to experience depersonalization than their married counterparts. Similarly, Ma et al. (2020) found that single individuals experienced occupational burnout more severely than married people, especially concerning depersonalization and low personal accomplishment. 16,22
On the topic of religiosity, our study did not find a statistically significant association between being religious and a lower risk of burnout (p=0.2925). Similar results were obtained by Giusti, et al. (2020) and Castro, et al. (2020). 12,23
Of the total sample (n = 138), 77.54% (107/138) of participants experienced burnout. However, only 27.53% (n = 38) were seeking psychological or psychiatric help, and of these, 92.1% (n = 35) had burnout. This aligns with findings from a systematic review where doctors cited concerns about confidentiality and career impact as barriers to seeking mental health support. 24 Moreover, doctors are culturally expected to be infallible, which perpetuates stigma around mental health struggles and makes it challenging for them to identify symptoms and vulnerabilities in themselves. As a result, they may turn to self-diagnosis and self-medication, leading to unrecognized issues with substance abuse, especially involving prescription drugs. 24
This study had some limitations. Although the MBI is considered the most widely used method in the medical research literature for identifying BS, there is still no consensus on the appropriate clinical features that should be included in the clinical assessment of BS; the minimum duration and frequency of symptoms; the expected impact on patients’ lives or workplaces; or the appropriate differential diagnosis procedures. 25 Furthermore, as the MBI is a self-administered questionnaire and was modified from the original, there is the possibility that some participants may have minimized or exaggerated their responses, or even felt insecure despite the guarantee of anonymity. Given the cross-sectional design of this study, our ability to establish direct causal relationships is limited, allowing us only to estimate prevalence ratios and possible risk factors. It is also important to acknowledge that factors such as the sample size and the response rate to the questionnaire may have influenced the results. Another limitation is that the study was conducted in just one city, which should be considered in future research. Moreover, the data collection was conducted remotely via Google Forms®, and it is possible that in-person distribution might have resulted in higher participation rates. Despite these challenges, the relevance of the findings remains strong within the context of this research. Therefore, it is imperative to employ additional approaches, such as multivariate analyses, to obtain a more comprehensive understanding of the complex interactions underlying the identified possible risk factors.
CONCLUSION
In conclusion, this study highlights the significant prevalence of burnout syndrome among physicians, particularly during the COVID-19 pandemic. Our findings not only corroborate previous research but also identify key associated factors, such as female gender, young age, and frontline exposure, alongside potential protective factors, such as marriage, children, and professional experience. These results underscore the pressing need for immediate actions to address this occupational health issue. The implementation of comprehensive interventions, including psychological support and the promotion of work-life balance, is essential to preserve the mental health of doctors, ensure the quality of patient care, and strengthen our healthcare system during challenging times. Furthermore, future research should focus on assessing the effectiveness of these interventions and developing long-term strategies for combating physician burnout in a continuous and effective manner.
ACKNOWLEDGMENTS
The authors thank Doctor Luís Marcelo Aranha Camargo and Doctor Robinson Cardoso Machado Yaluzan for their contribution and assistance throughout the development of this manuscript. Raissa Santos Reimann received a research scholarship from the National Council for Scientific and Technological Development (CNPq). We are grateful for their support and incentive. The authors would like to acknowledge Zaira Cristina Barbosa Assis, Sabrina Alexandre Gonçalves, Josiel Neves da Silva, Camila dos Santos Guimarães Riquelme, Antônio Cézar Batista Filho, and Ana Maria Bezerra Ramos for their help collecting data.
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