Burnout in Primary Care Pediatrics and the Additional Burden from the COVID-19 Pandemic

The term burnout describes a condition of work-related stress that leads individuals to exhaust their mental and physical resources.¹ Burnout is a manifestation of negative psychological symptoms, including apathy, nervousness, restlessness, and demoralization, which may also be associated with physical problems, including headaches, sleep disturbances, and gastrointestinal disorders.² This condition can affect any worker performing any task, in any work environment. However, the most severe consequences of a stressful working condition are generally observed in the helping professions,3, 4, 5 including physicians, nurses, pharmacists, social workers, and staff members of private and public health organizations who are dedicated to others.⁴ Concern about the problem of burnout in health care workers goes back many years.⁶ However, the COVID-19 pandemic, which introduced new and unexpected stressors in almost all areas of life, has significantly increased the workload of health care workers in a short period of time. The level of physical and emotional stress has increased to the point that, because of the threat posed by this condition to the nation's health, several countries in Europe and the United States have declared the health-worker burnout crisis and the protection of their well-being a national priority.^{2 ,} 7, 8, 9 Several studies have highlighted the role of COVID-19 in causing increased burnout in various categories of health care professionals working in different settings and roles, and in other fields including finance, administration, academics, and the military.10, 11, 12 However, limited attention has been paid to the phenomenon of burnout in primary care pediatrics which was exacerbated by the COVID-19 pandemic, with negative effects on public health. Alarming recent data show that the COVID-19 pandemic has significantly increased the pressure on the workforce of general pediatricians and significantly worsened from 10%-30% to 40%-70% of the burnout levels generally observed prior to the pandemic.^{13 , 14}

This commentary, compiled by the EPA-UNEPSA social pediatrics working group in collaboration with the European Confederation of Primary Care Pediatricians (ECPCP) and the Italian Federation of Primary Care Pediatricians (FIMP), briefly discusses the growing frequency of burnout in primary care and in primary care pediatrics, and debates how to reduce the risk of burnout and mitigate stress caused by this condition.

Definition of Burnout

Burnout was first described in 1974 by psychoanalyst Freudenberger,⁶ who analyzed the stressful dedication to work, which can cause workers to experience physical signs and behavioral symptoms considered indicators of extreme pressure.⁶ Initially, the debate focused on the positive and negative aspects that dedication and commitment to caring for people can entail for health care workers and the consequences caused by an overload of energy leading to a strong feeling of failure.^{6 , 15 , 16} However, its meaning and use have gradually expanded to include any type of professional, whose occupation has caused exhaustion, apathy, and inability to cope.

Over the past 4 decades, the concept of burnout has become increasingly popular and the condition described by this term has gradually permeated various fields of civil society. The term burnout has evolved to become an indicator of individual distress with important repercussions in various organizational contexts, often far removed from the health care area, including the manufacturing sector, military personnel, and economic, administrative, and academic institutions.^{17 , 18} That is, academic burnout commonly describes students' feelings of debilitation, pessimism, and low self-efficacy, symptoms experienced by students pressured and stressed by demanding school schedules. Academic burnout can also refer to feelings of fatigue and disengagement experienced by teachers due to the need to complete large programs.¹⁹ In military personnel, burnout is currently a commonly used term to describe the level of stress associated with the duties and challenges of professional life for combatants and their families.²⁰

In 2019, the World Health Organization (WHO) noted that job burnout has become an important indicator of mental health.²¹ Therefore, it proposed its inclusion in the 11th edition of the International Classification of Diseases ^{21 , 22} (ICD-11). However, there is still no unanimous consensus for the definition of the condition of burnout and currently several definitions are used to refer to the same concept, including “occupational exhaustion syndrome,” “psychological exhaustion,” “fatigue syndrome,” and “burned out syndrome”.³ Several studies have been conducted over the years exploring the relationships between persistent fatigue among employees, burnout, and chronic fatigue syndrome, 3 fatigue conditions that share several conceptual similarities and characteristics.¹⁸ However, results have been indecisive and currently a consensus definition of occupational burnout is still lacking, despite evidence of its impact on society.^{5 , 23} This may explain the large variability in the prevalence of burnout among physicians (from 0% to 80.5%) reported in a recent review of data from 45 countries.^{15 , 24}

The Issue of Burnout in Primary Care

Burnout has been extensively studied in various types of health care workers in public and private health care organizations. The Physician Health and Wellness guideline published in November 2022 by the American Academy of Pediatrics reports that from 2011 to 2014, the prevalence of burnout in general pediatricians increased by 10%, from 35.3% to 46.3%.²⁵ The National Physician Burnout & Depression Report 2022, which surveyed more than 15 000 physicians from 29 specialties working in the United States, shows high rates of burnout in many medical specialties, including pediatrics (49%), after 3 years of COVID-19 pandemic management. The report also revealed that a significant increase in burnout was reported by physicians of all specialties in 2021 (47%) compared with 2020 (42%). Not surprisingly, a marked increase in burnout, from 43% to 60%, was also described in emergency medicine physicians during the same period. However, 54% of survey participants reported that burnout had a strong-to-severe impact on most aspects of their lives.²⁶ However, data on pediatricians working in primary care settings were not included in these reports. Similar studies conducted in Europe show that especially after the pandemic, sleep disorders, stress, and anxiety have affected a large group of health care workers with an impact on their physical, emotional, and psychological well-being. Over the past decade, a considerable number of health care workers have left or are considering leaving their jobs due to physical and mental factors causing chronic exhaustion and unhappiness at work,^{13 , 27} which are characteristic symptoms of burnout.^{28 , 29} In the United Kingdom, the 2015 Commonwealth Fund survey revealed that 30% of general practitioners intended to leave the profession within 5 years, and later in 2019, a study reported a 3-fold increase in their early retirement compared with the previous decade.¹³ This social phenomenon has caused a significant workforce shortage in primary care, which was further exacerbated by the COVID-19 pandemic. Primary care physicians have faced significant levels of stress since the onset of the pandemic, with more than half of physicians under 55 years of age experiencing emotional distress and burnout.³⁰ A survey conducted by the Federation of Italian Medical Boards reports that after the pandemic, 24% of community physicians experience sleep disturbances, stress, and fear, while depression and anxiety are reported in 20.5% and 25.8% of cases, respectively.³¹ However, in studies devoted to burnout and its manifestations in health care workers, the working condition of primary care pediatricians has received relative attention,³² and studies assessing their state of work-associated emotional, mental, and physical exhaustion are scarce.

Prevention and Reduction of Stress

Early identification of the many physical, emotional, and behavioral factors that are recognized as warning signs of burnout in health care workers^{33 , 34} (Table I ) can help develop useful strategies to prevent or mitigate this condition and introduce stress-reducing practices into the lifestyle that can safeguard their well-being35, 36, 37 (Table II ).

Table I.

Burnout in health care workers: revealing signes

Warning signs of burnout in health care workers
Physical
Migraine or dizziness
Muscle strain or pain
Cramps, persistent nausea, or vomiting episodes
Colitis
Chest sprain or strain or a tachycardia
Changes in sexual activity
Sense of fatigue
Worsened health conditions
Shortness of breath
Loss of appetite
Eating disorders
Sleeping disorders
Mental and emotional
Attention disorders
impaired decision-making ability
Overwhelming thoughts
Negative thinking and constant worrying
Absent-mindedness
Forgetfulness
Loss of self-confidence
Sense of failure
Feelings of hopeless and helpless
Detachment and loneliness
Low motivation and frustration.
Development of suspiciousness and negative outlook.
Feeling of missing accomplishment
Feeling of work overload and excessive job demand
Feeling of pressure
Inability to manage conflicting situations
Feeling poorly rewarded for the work performed
Feeling isolated and emarginated.
Inability to start new relations at work and in the personal life
Perceiving the work to be unfair or inequitable or meaningless
Behavioral
Avoiding responsibilities.
Social isolation.
Slower performance at work
Introducing drugs or alcohol to cope.
Overeating
Oversleeping
Insomnia
Sense of frustration
Irregular attendance at work
Absenteeism
Hyperactivity disorders, irritability
Increased smoking
Loss of personal goals and commitments
Difficulty in keeping relationships active
Breaking friendships
Making careless mistakes
Obstructive and uncooperative behavior
Careless spending

Table II.

Burnout stress reducing practices

Stress reducing practices recommended to safeguard the well-being of health care workers with burnout
• Making changes in the personal lifestyle
• Making changes in the work environment
• Reorganizing working hours
• Taking breaks during the working days or taking days off during the weeks or months.
• Knowing the list of signs typical of burnout to perform self-examinations.
• Introducing physical exercising in the daily schedule
• Keeping control of the diet and avoid eating disorders
• Keeping control of the daily schedule
• Keeping control of the sleeping schedule
• Avoiding routine activities perceived as stressing factors.
• Avoiding relaxing behaviors that can cause boredom.
• Considering the practice of meditation and yoga
• Socializing with colleagues
• Connecting with a friend or family members and dedicate time to catch up
• Checking in with a therapists.
• Seeking professional help
• Taking advantage of support or advocacy groups

Preventive strategies include identifying, removing or reducing stress-causing factors, developing a supportive social network, taking care of personal health, reorganizing work life and setting clear expectations, increasing understanding of self-identity and acquiring a stable and consistent perception of it through careful reorganization of personal values, thinking, and actions.33, 34, 35, 36

Conclusions

Numerous studies show that health care workers are particularly exposed to burnout.^{6 , 33} Since the COVID-19 pandemic, higher rates of burnout have been reported in all medical specialties, including pediatrics. Burnout can now be considered a COVID-19 pandemic-related health condition affecting an increasing number of primary care physicians. However, only occasional data on the effects of burnout in primary care pediatricians are reported. EPA-UNEPSA, in collaboration with the FIMP and ECPCP, has established a working group to study the condition of burnout in primary care pediatrics in Europe. The goal is to develop a guide for early identification and mitigation of this condition in pediatricians working in primary care settings.³⁸

Declaration of competing interest

The authors declare no conflicts of interest.