|Year : 2019 | Volume
| Issue : 4 | Page : 181-186
Burnout syndrome among dermatologists and assessment of prevalence and risk factors: A nationwide survey
Ezgi Ozkur1, Ilknur Kivanc Altunay1, Emel Calikoglu2, Meltem Onder3
1 Department of Dermatology, University of Health Sciences, Şişli Etfal Training and Research Hospital, Istanbul, Turkey
2 Department of Dermatology, Aksaray University Medical Faculty, Aksaray, Turkey
3 Department of Dermatology, Emeritus Gazi University Medical Faculty, Ankara, Turkey
|Date of Submission||02-Jul-2018|
|Date of Decision||02-Dec-2018|
|Date of Acceptance||25-Dec-2018|
|Date of Web Publication||23-May-2019|
Dr. Ezgi Ozkur
Department of Dermatology, Sisli Etfal Training and Research Hospital, University of Health Sciences, Istanbul
Source of Support: None, Conflict of Interest: None
Background: Burnout is a syndrome of emotional exhaustion, depersonalization, and a sense of low personal accomplishment. Increasing patient volumes and rising health-care systems' productivity targets also pose a risk of burnout in all specialties including dermatology. Objectives: The aim of the present study was to study burnout syndrome in dermatologists and determine related factors. Methods: Dermatologists who were actively working (n = 2005) were E-mailed a questionnaire via the Turkish Dermatology Society, and 422 (21%) completed it anonymously. The first part of the questionnaire comprised demographic and work-related characteristics, and the second part was formed by the Turkish version of the Maslach Burnout Inventory (MBI). The MBI is a 22-item questionnaire for the assessment of burnout in the following three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment. Results: Emotional exhaustion and depersonalization scores of residents were significantly higher (P < 0.001), and personal accomplishment scores were significantly lower (P < 0.001) than that of the other groups. Dermatologists in the private sector had significantly lower scores for emotional exhaustion (P < 0.001) and depersonalization (P < 0.001) and significantly higher scores for personal accomplishment (P < 0.001) than those working in the public sector. Emotional exhaustion and depersonalization scores were significantly higher in participants who worked on weekends, those intended to change workplace, and had at least one chronic illness (P < 0.05 for all comparisons). A positive correlation was found between emotional exhaustion and depersonalization (r = 0.691,P < 0.001), number of patients (r = 0.355,P < 0.001), and number of shifts (r = 0.344,P < 0.001), and there was a negative correlation between personal accomplishment (r = −0.485,P < 0.001), age (r= −0.301,P < 0.001), number of vacation days (r = −0.149, P= 0.002), and years in the profession (r = −0.288,P < 0.001). Conclusion: Our study sheds light on factors that influence burnout and also indicates a need for health-care reforms for dermatologists' satisfaction and burnout, as well as patient satisfaction and quality of care.
Keywords: Burnout, general dermatology, psychology
|How to cite this article:|
Ozkur E, Altunay IK, Calikoglu E, Onder M. Burnout syndrome among dermatologists and assessment of prevalence and risk factors: A nationwide survey. Dermatol Sin 2019;37:181-6
|How to cite this URL:|
Ozkur E, Altunay IK, Calikoglu E, Onder M. Burnout syndrome among dermatologists and assessment of prevalence and risk factors: A nationwide survey. Dermatol Sin [serial online] 2019 [cited 2020 Jan 29];37:181-6. Available from: http://www.dermsinica.org/text.asp?2019/37/4/181/258942
| Introduction|| |
Burnout is a term of mental and physical exhaustion related to work, which was first described by Freudenberger in 1974. Later, Maslach defined burnout syndrome as consisting of the following three subscales: emotional exhaustion, depersonalization, and low personal accomplishment. The term depersonalization refers to taking care of patients in an unfeeling, negative way and having cynical thoughts toward them or colleagues. Burnout syndrome in healthcare professionals has significant importance because it may decrease the productivity of the physician both academically and practically and may lead to inadequate treatment of patients. Compared with other jobs, taking responsibility for critical decisions, facing potentially serious consequences of these decisions, and feeling pressure to avoid mistakes make physicians more stressed and prone to burnout. In a survey of more than 31,000 physicians in the USA, dermatologists emerged as the specialists who were the happiest, with 70% saying that they were very to extremely happy at home. In addition, they had the highest career satisfaction rating compared with other specialists., Two different studies aimed to evaluate the prevalence of burnout and satisfaction with work–life balance among physicians in the USA in 2011 and 2014. The first investigation revealed that dermatologists had the lowest rates of burnout compared with other specialties, general medicine, and preventive medicine and also the highest rates in satisfaction with work–life balance. The next survey found that the prevalence of burnout among dermatologists increased from 31.8% to 54.5%, which was a significant increase. Despite all the structural and procedural reforms in the health-care system in Turkey, the process and structure of primary care is not as strong as in most countries in Europe. In particular, the absence of a referral chain reveals a dysfunctional primary care service, which leads to high numbers of patients per specialist. Furthermore, the physicians' performance system in public hospitals has created extra pressure and workload.
On the other hand, the world of dermatology is divided into two separate camps, namely cosmetic and medical dermatology. More dermatologists have started to choose the cosmetic side because of the demand for cosmetics and higher salaries, thus leading to decreasing numbers of dermatologists in public or quasi-public hospitals and increasing number of patients per dermatologist. Moreover, most dermatologists feel pressure to learn new cosmetic techniques in their own time. Therefore, it is a subject of interest as to whether dermatologists are happy and satisfied with their profession.
This study was conducted to determine burnout and associated factors and work-related stressors among dermatologists.
| Materials and Methods|| |
A list of current active dermatologists, including residents, was provided by the Turkish Dermatology Society. All 2005 dermatologists registered as “active working” were E-mailed a questionnaire via the Turkish Dermatology Society. Four hundred and twenty-two questionnaires were completed, and due to the respondents' anonymity, it was impossible to send another request via mail.
The questionnaires were divided into two parts. The first part was regarding age, sex, marital status, number of children, affiliation, position held, weekly working hours, number of patients seen, number of cosmetic procedures (i.e., botox, fillers, laser) and interventional procedures (i.e., cryotherapy, excision, biopsy) performed weekly, number of vacation days per year, work experience, number of shifts per month, salary, active participation in academic life, desire to change workplace, and presence of chronic illness. Participants' affiliations were divided and compared as university hospitals (public, quasi-public, and private university hospitals), private hospitals, private practice, training and research hospitals, and public hospitals.
The second part was the Turkish version of the Maslach Burnout Inventory (MBI). The MBI is a 22-item questionnaire and is considered the gold standard for the assessment of burnout., It was validated by Ergin in 1993 and shown to be reliable and valid. The MBI evaluates the following three subscales of burnout: emotional exhaustion, which consists of nine items that assess feelings of being emotionally overextended and exhausted by the job and cognitive distancing from the job; depersonalization, comprising five items that assess cynicism and feelings of treating patients as inanimate, unfeeling objects; and personal accomplishment, consisting of eight items that assess feelings of success and achievement in one's work. Each item has a 5-point rating scale ranging from 0 (never) to 4 (every day). Independent subscale scores are calculated for each burnout subscale. A high degree of burnout is represented by high scores in emotional exhaustion and depersonalization subscales and low scores in personal accomplishment subscales.
Reliability analysis of the MBI in our study group indicated that it was a reliable instrument with high coefficients of internal consistency (Cronbach's α = 0.912 for emotional exhaustion, α = 0.842 for depersonalization, and α = 0.793 for personal accomplishment subscales).
Descriptive statistics were given as number and percentage for categorical variables and average and standard deviation for numeric variables. Comparisons between two independent groups were made using the Mann–Whitney U-test because they were not normally distributed. Categorical variables were compared using the Chi-square test. Spearman's correlation coefficient was used to analyze the association between numerical variables. Multivariate linear regression analysis was used to determine the responsible factors. The statistical alpha (level of significance) level was accepted as P < 0.05.
| Results|| |
Four hundred and twenty-two (21%) dermatologists completed and returned their questionnaires. The demographic characteristics and working conditions are described in [Table 1]. The majority were female (n = 317, 75%) and married (n = 323, 76.5%). The number of participants from each workplace was close to each other. Only over 40% (n = 174, 41%) reported working on weekends, taking part in academic life (n = 197, 46%), and having a chronic illness (n = 309, 49.5%).
|Table 1: Demographic and work-related characteristics of the participants|
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[Table 2] summarizes the mean MBI subscale scores of participants. The mean value of emotional exhaustion was 19.8 ± 8.7, depersonalization was 7.1 ± 5.0, and personal accomplishment was 22.8 ± 5.5 for the study group. There were no statistically differences between all subscales regarding sex (P > 0.05). Although participants who were single had higher scores regarding emotional exhaustion than married ones, it was not statistically significant (P = 0.113). In the subgroup comparison of married females and married/unmarried males, there was no statistically significant difference between all subscales. Only single females showed higher burnout scores regarding emotional exhaustion and depersonalization than widowed/divorced/separated females, which was statistically significant (P = 0.009 and P = 0.006). Emotional exhaustion and depersonalization scores were significantly higher in participants who worked in training and research hospitals, residents, those who wanted to change their workplace, and those with a chronic illness. The mean personal accomplishment scores of dermatologists who were single, worked in training and research hospitals, worked as residents, and those who wanted to change workplace were also significantly lower (P < 0.05 for all comparisons). In the subgroup analysis, emotional exhaustion and depersonalization scores of residents were significantly higher than those of professors, associated professors, assistant professors, senior residents, and specialists (P < 0.001 for all), whereas personal accomplishment scores were significantly lower (P < 0.001). The mean score of emotional exhaustion was 14.6 ± 8.9 in residents and 24.0 ± 7.0 in professors. In addition, emotional exhaustion and depersonalization scores of specialists were statistically lower than those of professors and associated professors (P = 0.001 and P < 0.001, respectively). Participants who were working in private hospitals had the least burnout scores among all subscales with significantly lower scores for emotional exhaustion (17.4 ± 8.7) and depersonalization (5.3 ± 4.3) and significantly higher scores for personal accomplishment (24.3 ± 4.2).
|Table 2: Mean Maslach Burnout Inventory subscale scores by demographic and work-related characteristics|
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Statistically significant correlations are shown in [Table 3]. There was a modest correlation between depersonalization and personal accomplishment and weak correlations between emotional exhaustion and depersonalization, number of patients (per week), number of shifts (per month), and also weak correlations between personal accomplishment, age, number of children, vacation days (per year), and years in the profession (P < 0.001 for all). Multivariate linear regression analysis results are presented in [Table 4]. Dermatologists who wished to change their workplace had higher numbers of shifts (per month), higher numbers of patients (per week), less vacation days (per year), at least one chronic illness, lower salary, and were more likely to report emotional exhaustion after controlling for the other variables.
|Table 3: Correlation of Maslach Burnout Inventory subscales with other factors using Spearman's correlation analysis|
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|Table 4: Multivariate linear regression analysis of emotional exhaustion subscale after controlling for the other variables (with forward selection)|
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| Discussion|| |
The psychosocial stress and burnout of dermatologists among other physicians had previously been evaluated; however, to our knowledge, there are no data for the presence and prevalence of burnout and contributing factors between dermatologists themselves in our country and other countries. Our return rate of 21% (n = 422) was lower than expected, but our study provides valuable information about the burnout status of dermatologists dependent on work-related characteristics and also represents the whole country. A meta-analysis on survey response rates showed that web-based survey response rates were 11% lower than the response rates of other survey methods. Furthermore, we cannot know the respondents' levels of computer usage. In addition, it is possible that some emails remained in spam folders or E-mail addresses of participants who did not respond might be inactive. Due to confidentiality and anonymity reasons, we could not resend the questionnaire to nonresponders.
In 2006, Ozyurt et al. randomly selected a sample group of 598 physicians from different health-care institutions in Istanbul and reported mean MBI subscale scores of emotional exhaustion (15.23 ± 5.80), depersonalization (4.47 ± 3.31), and personal accomplishment (23.38 ± 4.29) in general practitioners. In our study, personal accomplishment scores of dermatologists were higher than that in general practitioners as we expected, but surprisingly, emotional exhaustion and depersonalization scores were also higher. These may result from the heavy workload of specialists because of the absence of a referral chain and dysfunctional primary care service. On the other hand, Ozyurt et al.'s survey was conducted 12 years ago, but our health-care system has undergone tremendous changes since that time. Accordingly, we believe that our study may also show the results of structural changes in the Turkish health-care system.
Renzi et al. studied dermatologists and nurses working with dermatologic patients and compared them with physicians and nurses of other specialties. Sixty-seven dermatologists were enrolled in their study, and they found that the probability of emotional exhaustion was similar for dermatologists and other specialists. They found that the mean value of emotional exhaustion was 17.7 ± 12.3, depersonalization was 4.8 ± 5.1, and personal accomplishment was 40.5 ± 6.1. The present study showed higher burnout scores in all subscales. In addition, it is possible that responders who were unsatisfied with their working conditions and wanted to change their workplace (n = 286, 67.8%) were more likely to indicate higher scores in questionnaire and burnout might have been overestimated.
In one study in which MBI scores of 128 urologists were reported in Germany, there was a considerably higher rate of burnout among urologists working in public hospitals versus those in private practice. Our results were similar; dermatologists who work in private sector seem to experience less burnout. Dermatologists in the private sector see fewer patients per week and have higher monthly income. In addition, office-based dermatologists in particular have more work autonomy and thus control mechanisms for their work regarding flexible working hours and leisure time. In our opinion, these points may account for the lower burnout scores among private sector physicians. Ratnakaran et al. investigated burnout among 558 residents using the Copenhagen Burnout Inventory and reported that more than half of the residents (51.85%) had high scores of personal burnout. Consistent with their study, we found statistically significantly higher scores among residents for emotional exhaustion and depersonalization and low scores for personal accomplishment (P < 0.001 for all). Martini et al. reported that 50% of residents met the criteria for burnout among 321 residents across eight different specialisms, ten of whom were from dermatology. The higher number of shifts, lower monthly salary, lack of autonomy, longer working hours, high patient volume, clerical burden, and stressful relationships with supervisors might be the cause of high burnout scores in residents. In contrast, professors had the least burnout among all the subgroups in all subscales. This may be explained by seeing fewer patients per week, participation in decision-making, having an active role in academic life, higher monthly salary, and greater job satisfaction. Not surprisingly, dermatologists who worked on weekends, wanted to change their workplace, and had a chronic illness showed statistically higher burnout scores (P < 0.05).
McMurray et al. studied 5700 physicians and found that female physicians were more likely to report burnout than male physicians. Maslach stated that burnout syndrome increased along with the number of years in the profession. In our study, we could not confirm these results because there was no statistical difference between the sexes, also dermatologists at younger ages, and those in their early years of the profession showed higher burnout scores. Frank et al. conducted a survey with 4500 female physicians and found that older age and having more children were associated factors with higher levels of career satisfaction; however, they did not investigate burnout. We found that single participants had higher burnout scores than married or separated ones. Furthermore, in the correlation analysis, we found that participants who had more children had lower degrees of burnout. In a large-scale survey of oncologists, most participants indicated the need for more vacation time. In another study of surgeons, less leisure time per month was one of the strongest predictors of burnout in the emotional exhaustion subscale. Grantcharov et al. found that surgery residents were more prone to having double the rate of technical errors after overnight work. Keeton et al. reported that higher income was associated with a greater sense of personal accomplishment. Our findings had similarities with these findings; those with more children, more vacation time, fewer shifts, and higher salary had lower burnout scores. The similarity between our results and that of others suggests that our findings may have international value.
According to the multivariate analysis, dissatisfaction with workplace, higher number of shifts and patients, fewer vacation days, chronic illnesses, and low income were significant predictors for burnout. In one study with infectious diseases' physicians, 58.9% of the respondents who intended to change their job reported having high emotional exhaustion scores. In another systematic review in 2017, the authors implied that physicians with symptoms of burnout were more likely to report having made a major medical mistake in the past 3 months and to have lower patient satisfaction scores., In addition, Swensen et al. claimed that approximately one physician committed suicide each day in the USA. In this context, excessive workload appears to be a critical influence on burnout in dermatologists in our study.
There are some limitations to our study. It is possible that dermatologists who felt burned out were more or less likely to respond to the questionnaires. This is a preliminary study, so we cannot assume that we covered all factors influencing burnout among dermatologists. No major life events in recent months or psychiatric comorbidities were investigated. Doctor–patient relationship and communication with superiors and colleagues were not questioned either.
| Conclusion|| |
Our study sheds light on factors that influence burnout and also indicates a need for health-care reforms. To decrease burnout among dermatologists, realistic solutions are required that promote physicians' well-being. Focusing on relevant factors for burnout in dermatologists with health-care reforms may reduce burnout and improve the quality of patient care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4]