Burnout among Postgraduate Healthcare Trainees at a Tertiary Healthcare Center in Saudi Arabia

Abstract

Objectives:

The aim of this study was to investigate the level of burnout among postgraduate healthcare trainees at a tertiary care center in Riyadh, Saudi Arabia, and assess the need to establish a well-being program.

Methods:

This cross-sectional study was conducted between December 2021 and January 2022 and used two validated questionnaires: the Copenhagen Burnout Inventory (CBI) for assessing burnout among postgraduate healthcare trainees, and a questionnaire for assessing program directors’ opinion on the need for a well-being program.

Results:

A total of 386 trainees and 85 program directors completed the questionnaire. In both groups, the majority of the respondents were male (trainees: 53.9%; program directors: 61.2%). A total of 226 trainees (58.5%) scored above the CBI burnout cut-off score, with the median score being highest in the personal domain (62.5,IQR: 45.8–75). In the univariate analysis, the mean burnout score was higher among trainees who were married (P = 0.036), had children (P = <0.001), and were seniors (P = 0.028), whereas in the multivariate analysis, the only significant predictor of burnout was having 1–2 children (P = 0.023) or 3–4 children (P = 0.013). In the program directors survey, 90.6% agreed that improving physicians’ well-being would directly rectify patients’ overall well-being, but only 28.2% stated that it is currently incorporated in the curriculum.

Conclusion:

This study found that a large proportion of postgraduate healthcare trainees experience burnout, particularly in the personal domain. Although program directors supported the concept of trainees’ well-being, its incorporation into the curriculum was lacking, suggesting the necessity of establishing a well-being program.

INTRODUCTION

Burnout is defined by the World Health Organization as energy exhaustion, depersonalization, or negativism to one’s job, and reduced professional efficacy resulting from chronic work-related stress.[1] Burnout can differ according to occupation. In general, studies have found that those studying and working in the medical field have a higher level of burnout than the general population.[2] A large-scale study from the United States found that while the level of burnout remained steady in the general population between 2011 and 2014, it increased by about 10% among physicians.[3] Similarly, Del Carmen et al. found a 5% increase in burnout over a 3-year period among physicians.[4]

Burnout among physicians not only affects them individually,[5] but can also have a substantial effect on the healthcare system, as it has been reported to result in breakdown in patient–doctor relationship, increased medical errors/malpractice claims, patient dissatisfaction, longer patient recovery times, and physician attrition.[2,6,7,8,9,10,11]

Early-career physicians have been found to be at a higher risk of burnout.[4] A systematic review found that the prevalence of burnout syndrome was 35.7% among medical residents worldwide.[12] In Saudi Arabia, a study by Aldrees et al. at a tertiary hospital found that residents reported a higher rate of burnout than consultants (56% vs. 44%, respectively).[13] The present study was conducted with the aim of investigating the level of burnout among postgraduate healthcare trainees in a tertiary care center and assess the need to establish a well-being program.

METHODS

Study design, setting, and participants

This cross-sectional study included medical residents and fellowship trainees from all programs at King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh, Saudi Arabia, and data collection was conducted between December 29, 2021, and January 18, 2022. The study was approved by the Institutional Review Board of KFSHRC.

KFSHRC is one of the largest referral centers in Saudi Arabia, with specialized medical treatment within an educational, research, and integrated environment. The hospital has a 1549-bed capacity, 857 trainees (508 residents and 349 fellows in 40 and 76 programs, respectively), and a total staff strength of 14,650, including medical, research, nursing, administrative, and technical staff.[14]

Data collection

Data were collected using a self-administered questionnaire that was shared as a Google Forms link. The questionnaire distribution was directed at two cohorts: postgraduate healthcare trainees (to assess burnout) and program directors (to assess the need for establishing a well-being program). Three email reminders were sent to all trainees and program directors (1 week apart). All participants provided a digital consent before undertaking the survey. The first page of the questionnaire provided the participants with the objectives of the study, and assured them of data confidentiality and anonymity, with no identifying information collected. It also informed that participation was voluntary (with no incentives).

Burnout among trainees

The questionnaire for assessing burnout was composed of two sections, wherein the first part elicited data regarding demographics and professional characteristics, including gender, age, living status, marital status, number of children, level of experience, and training program. The second section was the 19-item Copenhagen Burnout Inventory (CBI) questionnaire that has three subcategories: personal burnout (6 items), work-related burnout (7 items), and client-related burnout (6 items).[15] Responses are through a five-point Likert scale: ranging from 100 (always) to 0 (never/almost never) or 100 (to very high degree) to 0 (to a very low degree), with some items having reverse coding. If a respondent answered fewer than three questions in the personal or the client-related burnout sections or fewer than four questions in the work-related burnout section, those responses were not considered for the final analysis. The mean score of each domain was calculated and then the average overall score was obtained. A score of ≥50 (of 100) indicated “burnout.”

The residents and fellows were classified as “junior” and “senior.” Junior residents were those in the first 2 years of a 4-year program or first 3 years of a 5-year program. Junior fellows were defined as being in the first year for a 2-year program or in the first 2 years for a 3-year program.

Program directors’ survey

A two-part questionnaire was distributed to all program directors in the hospital. The first section elicited information regarding demographics (gender and age), program management, number of trainees, and years of experience as a program director. The second section comprised a previously developed resident wellness program survey.[16] The original questionnaire had 13 closed-ended questions divided into the following three parts: Attitudes toward resident health and wellness (5 items), current wellness initiatives (5 items), and wellness modular curriculum (3 items); however, the last 3 questions from section 2 were deleted for the current study considering the applicability.

Validity and reliability

For the CBI, the Cronbach’s alpha test was done to check the internal reliability. The test revealed a high internal consistency in all domains (α ≥0.8): personal burnout α = 0.892, work-related α = 0.864, and patient-related α = 0.841. In addition, the overall reliability score of the questionnaire was excellent (α = 0.926). No tests were done for the directors’ survey, as it has already been validated.[16]

Data analysis

Data were analyzed using STATA 17 (StataCorp LLC, College Station, TX, USA). Categorical data were presented as frequency, percentage, and bar graphs. The Kolmogorov–Smirnov test assessed normality; continuous data were described as mean and standard deviation (SD) if normally distributed; if not, the median and interquartile range were used.

For the trainees’ questionnaire, relationships between demographic data and the total burnout score were examined using Student’s t-test for two-group comparisons or one-way analysis of variance for comparisons involving more than two groups. Subsequently, if the results were statistically significant, adjustments were made using multivariable linear regression. A P value <0.05 was considered statistically significant. For the program directors’ questionnaire, only descriptive analysis was conducted, aligning with the methodology of the original study.[16]

RESULTS

Burnout among trainees

The questionnaire was sent to 857 trainees, of which 469 responses were received (response rate: 54.7%); however, 83 responses were incomplete and excluded, and thus 386 complete responses (completion rate: 82.3%) were included in the final analysis. Figure 1 shows the responses across programs, with the highest response being from the internal medicine program trainees (23.6%), followed by pediatrics (12.9%), anesthesiology (8.8%), emergency medicine (8.3%), and family medicine (7.0%).

Figure 1.

Responses according to department

Table 1 illustrates the demographic information of the study participants. The majority of the participants were males (53.9%), aged 24–30 years (70.7%), living with family/parents (57.5%), and unmarried (62.4%). In terms of training program, 67.4% were residents and 32.6% were fellows. Regarding experience level, 54.4% were juniors.

Table 1.

Characteristics of the study participants (N=368)

Characteristics	Total, n (%)	CBI-score categories			Overall CBI score	P by CBI score
		Personal	Work-related	Patient-related
Gender
Male	208 (53.9)	58.0±19.4	59.0±18.1	40.3±17.9	52.5±15.8	0.161
Female	178 (46.1)	62.9±19.1	61.9±19.3	39.4±18.6	54.7±16.0
Age group (years)
24–30	273 (70.7)	60.5±19.4	60.7±18.5	39.0±17.6	53.4±15.5	0.843
31–35	97 (25.1)	59.6±19.9	59.1±18.8	41.5±20.0	53.4±17.0
>35	16 (4.2)	61.1±17.5	61.1±22.3	45.1±16.4	55.8±17.3
Living status
Alone	82 (21.2)	61.9±19.6	59.4±19.6	40.5±18.7	53.9±15.7	0.388
With a roommate(s)	3 (0.8)	58.3±20.8	45.2±5.4	33.3±11.0	45.6±11.1
With family/parents	222 (57.5)	58.7±18.8	59.4±18.3	39.9±17.3	52.7±15.7
With spouse, children	79 (20.5)	63.1±20.8	64.6±18.5	39.6±20.6	55.8±16.9
Marital status
Unmarried	241 (62.4)	59.4±18.9	59.0±18.3	38.2±17.2	52.2±15.3	0.036
Married	145 (37.6)	61.8±20.2	62.7±19.1	42.7±19.5	55.7±16.7
Number of children
1–2	76 (19.7)	56.5±21.4	57.0±19.6	40.3±17.6	51.3±16.7	<0.001
3–4	17 (4.4)	74.0±13.1	76.4±15.7	56.5±17.5	68.9±13.6
No children	293 (75.9)	60.5±18.8	60.3±18.2	38.8±18.0	53.2±15.4
Experience level
Junior	210 (54.4)	59.0±20.1	58.3±18.4	38.4±17.7	51.9±15.8	0.028
Senior	176 (45.6)	38.4±17.7	62.8±18.8	41.7±18.7	55.5±15.8
Training program
Fellowship	126 (32.6)	60.2±19.9	59.1±20.1	40.6±17.8	53.3±16.9	0.849
Residency	260 (67.4)	60.3±19.2	61.0±18.0	39.6±18.4	53.6±15.4

A total of 226 (58.5%) of the respondents experienced burnout, with a median CBI score of 53.2 (IQR: 41.6–63.6) [Table 2 and Figure 2]. The mean burnout score was highest in the personal domain (72%; 278) (median score: 62.5, IQR: 45.8–75), followed by work-related (70.7%; 273) (median score: 60.7, IQR: 46.4–75), and patient-related (30.8%; 119) (median score: 37.5, IQR: 25-50) domains.

Table 2.

Mean and median overall and domain-wise scores of the Copenhagen Burnout-19 Questionnaire (N=386)

Domain	Mean±SD	Median (IQR)
Personal burnout	60.3±19.4	62.5 (45.8–75)
Work-related	60.3±18.7	60.7 (46.4–75)
Patient-related	39.9±18.2	37.5 (25–50)
Overall score	53.5±15.9	53.1 (41.6–63.6)

SD – Standard deviation; IQR – Interquartile range

Figure 2.

Burnout according to the Copenhagen Burnout Inventory domains

Figure 3 shows the overall mean burnout score across training programs, with the highest mean score being observed among trainees in ophthalmology (72.2), followed by adult oncology (66.4), medical genetics (64.4), and critical care medicine (64.4). The mean burnout score was higher among trainees who were married (P = 0.036), had children (P = <0.001), and were seniors (P = 0.028) [Table 2]. In the multivariate analysis, the only significant predictor of burnout was having 1–2 children (P = 0.023) or 3–4 children (P = 0.013) [Table 3].

Figure 3.

Mean burnout score by department

Table 3.

Multiple regression analysis of factors influencing the total Copenhagen burnout inventory-score

Variables	β	95% CI	P
Marital status
Unmarried	Reference	-	-
Married	4.5	−0.0–9.1	0.051
Number of children
No children	Reference	-	-
1–2	−6.1	−11.4–−0.8	0.023
3–4	10.7	2.2–19.3	0.013
Experience level
Junior	Reference	-	-
Senior	2.0	−1.2–5.4	0.220
R2	51.6	49.3–53.8	<0.001

R² – Constant of regression; β – Regression coefficient; CI – Confidence interval

Program directors’ survey

The questionnaire was distributed to 116 program directors, of which 85 (73.3%) provided complete responses. The median age of the participants was 42 years (IQR: 37–48), with most being male 61.2%. In terms of program management, 51.8% manage the fellowship program and 48.2% manage the residency program. Directors had a median of 8 (IQR: 4–14) trainees and a median experience of 2 (IQR: 1–4) years [Table 4].

Table 4.

Demographic information of the program directors (N=85)

Variables	n (%)
Gender
Male	52 (61.2)
Female	33 (38.8)
Age (years), median (IQR)	42 (37–48)
Program management
Fellowship	44 (51.8)
Residency	41 (48.2)
Number of trainees, median (IQR)	8 (4–14)
Years of experience in their position as program director, median (IQR)	2 (1–4)

IQR – Interquartile range

Most directors agreed that the trainee physicians’ wellness can have a positive direct impact on patients’ health and well-being (90.6%) and that educating the trainees about physicians’ well-being is an integral part of a postgraduate training program (94.1%). Similarly, most agreed that the trainees’ well-being is valued by the department and faculty/staff (81.2%), encouraged in the department (83.5%), and that their program supports the trainees’ work–life balance (82.4%) [Table 5].

Table 5.

Perception of program directors toward the health and wellness of postgraduate healthcare trainees

Questions	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
1. Resident/physician wellness directly affects patient’s health and well-being	5 (5.9)	0	3 (3.5)	28 (32.9)	49 (57.7)
2. Educating residents about physician’s well-being is an important part of a postgraduate training program	3 (3.5)	0	2 (2.4)	37 (43.5)	43 (50.6)
3. In my department, the faculty/staff value resident’s well-being	4 (4.7)	0	12 (14.1)	46 (54.1)	23 (27.1)
4. In my department, resident’s wellness is encouraged	4 (4.7)	1 (1.2)	9 (10.6)	46 (54.1)	25 (29.4)
5. My program supports resident work/life balance	3 (3.5)	4 (4.7)	8 (9.4)	42 (49.4)	28 (32.9)
Data are presented as frequency (%)

Only about one-fourth (28.2%) of the directors stated that the trainees’ wellness is a well-defined part of the formal academic curriculum. Of those who agreed, the most common mode of incorporating residents’ wellness into the formal curriculum was stated to be the core program (54.2%), followed by grand rounds (50.0%), and simulator sessions (29.2%) [Table 6]. In terms of wellness themes ranked by the directors, the highest was for physical health (nutrition and activity)(n = 36), followed by recognizing/reaching out (n = 34), and promoting healthy behavior (n = 33) [Figure 4].

Table 6.

Residents’ wellness consideration in the curriculum according to the program directors

Variables	Responses	Total, n (%)
1. Is resident’s wellness a well-defined part of your formal academic curriculum?	Yes	24 (28.2)
	No	61 (71.8)
2. If yes, please indicate how you incorporate resident’s wellness into your formal curriculum. Please check all that apply	Core program	13 (54.2)
	Grand rounds	12 (50.0)
	Simulator sessions	7 (29.2)
	Visiting professors or lecture series on physician health topics	5 (20.8)
	Research	3 (12.5)
	Other	3 (12.5)

Figure 4.

Top five wellness themes according to the program directors

DISCUSSION

This study found that 58.5% of the postgraduate healthcare trainees at KFSHRC, Riyadh, Saudi Arabia, experienced burnout, which is almost identical to that reported among residents in the United States (58.2%)[17] and similar to that reported among healthcare providers from the Middle East (50%).[18] Of note, all these studies were conducted in tertiary care hospitals, which may explain similarities in burnout rates because such types of hospitals have high admission rates, compounded by heavy workloads, demanding working environments, and schedules.

The median burnout score was highest in the personal domain, followed by the work- and patient-related domains. A study from Jordan among residents reported similar results, wherein the personal-related burnout was scored the highest followed by the work-related burnout.[19] This might be because many trainees may not have adequate social support, take more than they can handle at work or at home, and resultantly, have poor self-care. In addition, the study reported that trainees who have children reported significantly higher burnout scores than other trainees; this can be because they tend to take on much strain to adapt to the new lifestyle with inadequate financial support, eventually leading to burnout.[19,20]

In terms of burnout based on specialty, while the highest mean score was observed in ophthalmology (72.2), it should be noted that the number of respondents in this group was very low, and thus the statistics is not adequately powered and should be considered accordingly. The second highest mean burnout score was among trainees in adult oncology (66.4). This finding is in coherence with that of a meta-analysis, which found that the pooled prevalence of burnout among oncologists is high (32%).[21] However, a systematic review that assessed physician burnout in 24 different specialties in the United States found that burnout was highest among emergency medicine physicians and lowest among preventive medicine/occupational medicine physicians.[20] To provide more robust findings, there is need for a multi-center, large-scale study from Saudi Arabia that assesses and compares the burnout across different specialties, as this finding would be of immense use for policymakers.

Physicians’ well-being not only affect them but also have an impact on patient care.[7,11] Therefore, it is important to ensure that efforts are made to improve physicians’ well-being, which was agreed upon by the majority of program directors. To do so, the program directors rated physical health (nutrition and activity) and recognition and outreach as the two highest wellness themes. Further studies can be conducted on the implementation of these themes and the consequent effect on burnout levels. In Saudi Arabia, a 6-month interventional study that used fitness warm-up, holistic nutrition, breathing/meditation, yoga, vegan diet, and mental health found a significant improvement in employees’ wellness.[22]

Because the cause of burnout is multifactorial, personal and organizational strategies have been widely used to prevent burnout. A systematic review found that cognitive and behavioral interventions had the highest efficacy in managing burnout.[23] Similarly, stress reduction programs have been found to yield beneficial and cost-effective results, especially in groups rather than individuals.[24]

Preventing burnout is more beneficial than management, as it limits the consequent effects of burnout and is more cost-effective.[2] Preventing burnout relies on modifying physicians’ work–life balance and executing structural and functional changes. Especially in the residency phase, changes must enhance the training experience, psychological and financial satisfaction, and career development plans. Physicians at that phase of their careers experience high workloads, sleep deprivation, and unsatisfactory salaries, which are more pronounced in specialties with high burnout.[25]

It is essential to establish a well-being program for employees that could include counseling and support, as needed. Studies including both interventions and preventive measures are essential for inquiry, as reports have suggested that they need several levels of interference and must address the complex nature of the variables that lead to burnout.[26]

Limitations

A limitation of this study is generalizability, as it provides data from a single tertiary hospital, and the lack of probability sampling method. Therefore, there is a need for conducting multi-center studies across Saudi Arabia to provide a more representative sample. In addition, because data were collected using a self-administered questionnaire, the possibility of response and recall biases cannot be eliminated. The likeliness of acquiescence bias is especially high among the program directors because of the way the original questionnaire was framed.

CONCLUSION

This study found that more than 50% of the participants in the sample had scores above the CBI burnout cut-off score, with the median score being highest in the personal domain. This finding, along with the finding of most program directors supporting the idea of trainees’ well-being but it not currently being incorporated in their curriculum, suggests the need for establishing a well-being program to support trainees in Saudi Arabia. Future studies that can more accurately determine the training specialties where trainees experience burnout could help tailor such programs.

Ethical considerations

The study was approved by the Institutional Review Board of KFSHRC (Ref. no.: RAC#2211264; date: December 29, 2021), Riyadh, Saudi Arabia. All study participants provided a digital consent before inclusion in the study. The study adhered to the principles of the Declaration of Helsinki, 2013.

Peer review

This article was peer-reviewed by two independent and anonymous reviewers.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author contributions

Conceptualization: F.A., A.A., and S.A; Methodology: R.A, M.G., N.A. and M.Ghaith; Data analysis: R.A, S.A., and F.Alanzi; Writing–original draft preparation: F.A, A.A, M.G, N.A., and M.Ghaith; Writing – review and editing: R.A., S.A., and F.Alanzi; Supervision: F.A.

All authors have read and agreed to the published version of the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.