Burnout among physicians; a significant issue in Sri Lanka?

Burnout is a psychological condition of emotional exhaustion, depersonalization and reduced personal accomplishment in people persistently exposed to emotional and interpersonal stressors at work. According to the International Classification of Diseases (ICD 11) of World Health Organization, burnout is defined as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”1. Burnout is well recognized among medical doctors. Identifying and, where possible, treating burnout is critical, as it has a major impact on the quality of life of physicians, patient safety and health outcomes2,3. United States and European countries have imposed guidelines to restrict duty hours of doctors, however no such restrictions are implemented in Sri Lanka.


Introduction
Burnout is a psychological condition of emotional exhaustion, depersonalization and reduced personal accomplishment in people persistently exposed to emotional and interpersonal stressors at work. According to the International Classification of Diseases (ICD 11) of World Health Organization, burnout is defined as "a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed" 1 . Burnout is well recognized among medical doctors. Identifying and, where possible, treating burnout is critical, as it has a major impact on the quality of life of physicians, patient safety and health outcomes 2,3 . United States and European countries have imposed guidelines to restrict duty hours of doctors, however no such restrictions are implemented in Sri Lanka.

Reasons for physician burnout
There are many factors that can lead to physician burnout with increasing levels of dissatisfaction, disillusion, frustration, anger and stress. They include both internal and external factors. Internal factors such as age and generational values, gender differences, culture, ethnic, and religious beliefs, geographic contributions, and life experiences all lead to a person's "personality" which affects attitudes, values, and behaviors. External factors include new environmental pressures and thwarted expectations 2, 3 .
There are several sources of stressors affecting physicians. They include lack of leisure time, excessive workload, lack of sleep, emotional drain and work responsibilities coinciding with major events of life. Heavy workload, lack of resources to provide effective patient care, associated legal implications, adverse reactions of seniors in pressure situations, and deficiencies in the administrative system can be the main causes of stress experienced by Sri Lankan doctors during practice. Furthermore, deprivation of Burnout among physicians; a significant issue in Sri Lanka?

Indika Karunathilake 1
Journal of the Ceylon College of Physicians, 2019, 50, 1-3 Editorial personal time due to continued patient commitments, individual responsibility towards patient care, guilt due to management errors and interpersonal conflicts among healthcare workers appeared to be contributors 3 .
Symptoms in burnout can be categorized into three domains: emotional exhaustion, feeling isolated, and low work satisfaction. Postgraduate trainees are at higher risk due to the combination of academic and in-training clinical care responsibilities 4, 5, 6 .

How burnout can manifest
Burnout can manifest in different ways, including, physical and emotional exhaustion, dysfunctional coping mechanism such as keeping the patients at a distance, cynicism, sarcasm, fatigue and feeling lack of efficacy such as work has no purpose. Severe symptoms of burnout include distress, anxiety, worry and depression. If not managed appropriately, burnout can result in a lowered quality of life, negative impact on patient care, and in extreme cases, substance abuse, and even suicidality. Major impacts from physician burnout include lower job satisfaction, desire to work fewer hours, and desire to retire early or to leave the practice for another career 3, 4, 5 .

How serious is the problem?
Physician burnout of multifactorial origin is real, currently under diagnosed and the impact on the healthcare workforce and systems is underappreciated. Manifestations such as diminished compassion, irritability, reduced ability to listen to the patients will have a serious impact on patient care. Stress or psychological difficulties faced by doctors in the work place may result in reduced productivity and negative effects on personal wellbeing among doctors. Unfortunately, it seems to be relegated to low priority status. This issue of JCCP will carry two articles which highlight the gravity of this problem in Sri Lanka 7, 8 .
Burnout is an issue identified during all the stages of a physician's career: period as a medical student, intern, postgraduate trainee, overseas training and as a specialist.

Indika Karunathilake
Medical students undergo many stressors during their long course of studying. Moreover, their final year is probably more stressful with more clinical work and stringent assessments 2, 3 .
Intern medical officers (IMOs) are at a very high risk for burnout due to work and lifestyle-related causes (ie heavy and monotonous work-load, lack of control over work-load, chaotic work environment, inadequate rest and sleep, lack of help, and absence of a supportive relationship). IMOs are expected to work long duration shifts with frequent on-calls. Lack of adequate sleep due to prolonged duty hours leads to increase in medical errors. Several studies conducted in Sri Lankan teaching hospitals found that IMOs were over worked, fatigued and were sleepy at work. Self reported medical errors during internship were found to be high. One third of doctors reported medical errors due to fatigue and sleepiness, which was significantly high in medicine rotations 7,8,9,10,11 .
Postgraduate doctors who simultaneously engage in patient management, knowledge gathering, skill development and exam preparation, are prone to burnout, resulting from chronic stress at work. Fernando and Samaranayake (2019) found that 41.6% Postgraduate doctors in Colombo have high personal and work-related burnout prevalence while client-related burnout prevalence was low. Several personal, family, work and training factors are associated with burnout among PG trainees. Post-MD trainees who proceed for overseas training face burnout due to issues of adaptation to different working environments and cultures. In a study conducted among trainees undergoing overseas training in the UK, 38 (58.5%) felt that there was discrimination between them and UK trainees and the majority of trainees felt burnt out, worn out and physically exhausted during their training 6,11 .
A study on prevalence of "burnout" among doctors in the National Hospital of Sri Lanka identified age between 30-40 years, being single, not having children, being an intern or a postgraduate trainee and not involving in the private medical practice as factors associated with high burnout 12 . However, another study identified private practice as a factor associated with burnout 10 . Therefore, the association between private practice and physician burnout needs further study. Other specific areas that need further study include the impact of annual transfer system, lack of logistical facilities and resources in hospitals.

Conclusion
Burnout is a significant problem among Sri Lankan doctors. This could have serious impacts on quality of patient care. Main causes of stress among doctors were work and patient related, and it was aggravated by both personal and interpersonal factors. Stress adversely influences the performance of doctors thereby compromising both patient care and individual well-being.
Stress management is an important aspect for trainees who face challenging clinical and educational demands. A system to detect and treat burnout, particularly among IMOs, is an urgent necessity. Among PG trainees, improving awareness and preventive actions from beginning and throughout training is recommended by incorporating a training module on personal development with emphasis on burnout prevention. Establishment of recreational centers for doctors within the hospital premises can enhance the physical and psychological wellbeing and reduce the burnout.
Physicians and the institutions where they work should be knowledgeable about key symptoms of burnout, but also have programmes and services that quickly and effectively address the issues. Preventive programmes should aim at capacity building in stress management that would help to buffer burnout and stress related disorders.