Keywords:
Burnout, professional - neurology - occupational stress - job satisfaction
Palavras-chave:
Esgotamento profissional - neurologia - estresse ocupacional - satisfação no emprego
Burnout syndrome was initially described as a psychological illness secondary to professional
stress, especially in work conditions involving significant interpersonal relationships[1],[2]. Although the practice of medicine can be important and individually rewarding,
the demand for responsibility and stress levels are considered high. In general, medical
doctors are more likely than other professions to have to deal with situations of
suffering, pain and death. It has also been observed that physicians have a heavier
workload than other professionals, and it is more difficult to integrate work life
with other areas[3].
Results from several studies suggest that many physicians experience burnout syndrome,
which is characterized by loss of interest and enthusiasm for the practice (emotional
exhaustion), feelings of cynicism and detachment from patients (depersonalization)
and a feeling of career dissatisfaction, with a decrease in self-esteem and reduction
of professional accomplishments (professional accomplishment)[1]. Findings from recent studies suggest that burnout syndrome can impair professionalism
and influence the quality of care, increasing the risk of medical errors, and even
resulting in career withdrawal[4]. Some adverse professional consequences may also be related to relationship breakdown,
problematic alcohol and drug abuse and suicidal ideation[5].
The prevalence of burnout syndrome can vary according to the different medical specialties,
as well as the career stage (length of time in the activity) of an individual[3]. Neurology is one of the few specialties with both high rates of burnout syndrome
and low satisfaction with work-life balance, according to Busis et al[6]. Newly-trained physicians have lower professional accomplishment and higher levels
of depersonalization, as the limited amount of experience results in difficulties
in dealing with stress[7],[8]. Physicians who are in the challenging mid-career stage are generally more satisfied
and have lower stress levels. Differences among specialties have been evidenced in
several studies[7],[9],[10]. An American nationwide survey of 7,288 physicians found that 45.8% of respondents
exhibited at least one burnout symptom, with neurology ranking third among several
specialties, after emergency medicine and general internal medicine[6]. Over 50% of neurologists exhibited at least one burnout symptom[3],[11]. We found only one study with Brazilian neurologists conducted in the State of Rio
de Janeiro that showed a high prevalence in 60.6% of the participants[12].
Recently, neurology has developed a new area of action due to advances in thrombolytic/thrombectomy
treatment of acute stroke, that resulted in a change of neurologist behaviour, including
full-time intrahospital performance for emergency care for stroke, according to the
guidelines of the Brazilian Society of Cerebrovascular Diseases[13]. We aimed to study whether being a stroke neurologist carried a higher burnout risk
in comparison with those who only worked with outpatients in the same specialty.
METHODS
We performed a cross-sectional observational study with a quantitative approach to
neurologists in the State of Paraná, Brazil, approved by the Human Research Ethics
Committee of HC-UFPR.
The inclusion criteria for responders was: being active in neurology at the time of
completion of the questionnaire; having a medical record associated with the Regional
Council of Medicine - Paraná chapter; and having signed the informed consent form.
Burnout was measured by using the Maslach Burnout Inventory - Human Services Survey,
a self-administered validated questionnaire, which is considered the standard criterion
tool for measuring burnout[14],[15]. It contains 22 items that evaluate aspects of burnout syndrome: nine questions
address emotional exhaustion, five are related to depersonalization and eight to professional
accomplishment. Scores can indicate a burnout syndrome diagnosis in each of the three
independent variables, not the sum of them[11]. The scores obtained in these dimensions allow the classification of the intensity/degree
by which the individual is affected: severely, moderately or minimally affected. Scores
between 19 and 26 for emotional exhaustion, 6 and 9 for depersonalization, and 34
and 39 for professional accomplishment reflect an average degree of burnout syndrome.
High scores in emotional exhaustion (greater than 26) or depersonalization (greater
than 9) reflect a high degree of burnout syndrome[16].
The Maslach Burnout Inventory - Human Services Survey is based on the use of the Likert
scale, a method commonly used in opinion polls, in which the questions specify in
7 points the agreement with a given statement: 0 = never; 1 = sometimes in the year
or less; 2 = once a month or less; 3 = sometimes in a month; 4 = once a week; 5 =
sometimes during the week; and 6 = every day. In the initial part of the questionnaire,
we added identification questions about gender, age, workplace (either Curitiba and
its metropolitan region, or in the country) and divided the current activity of the
participant according to the field of action - emergency (stroke neurologists) or
non-emergency (nonstroke neurologists).
The questionnaire was made available on the Regional Council of Medicine - Paraná
chapter website in a Google Form format and sent to the neurologists, members of the
Associação Paranaense de Ciências Neurológicas (Paraná's Association of Neurological Sciences) for four months, being resent every
two weeks. The neurologists were invited to participate anonymously in the study,
just answering some demographic and social/occupational data that was also included.
Responses could be sent from either a computer or other electronic devices such as
cell phones or tablets. Access to the link began with a brief description of the research
objective, followed by the explanation of voluntary participation and a field of consent
to participate. The responses were automatically stored on a database, with no possibility
of individual access to the reply by email. The resulting data were accessed only
by the researchers conducting statistical analysis.
Statistical software R (Core Team, 2017) version 3.4.0 was used for data analysis.
Initially, the information was analyzed descriptively. We applied the Mann-Whitney
test and Chi-squared test for comparison between the groups and Spearman's correlation
as a correlation coefficient between the variables[17]. For this study, p values lower than 0.05 were considered as significant.
RESULTS
Of the 271 neurologists who work in Paraná, 74 completed and returned the questionnaires,
a response rate of 27.3%. Of these, 56.8% worked with stroke emergency as their main
activity and were thus considered as stroke neurologists; and 43.2% did not work in
emergency services, therefore were dubbed non-stroke neurologists; 52.7% were male,
and 74.3% worked in Curitiba and its metropolitan region. The average age was 45.9
± 12.0 years, ranging between 27 and 71 years. Thirty-three neurologists (44.6%) fulfilled
criteria for severe burnout syndrome. Of these, 60.6% were female, 51.5% were stroke
neurologists, and 75.8% worked in Curitiba and its metropolitan region.
The average age of the stroke neurologists was 44.3 ± 11.6 years and of the non-stroke
neurologists was 47.9 ± 12.5 years. In the stroke neurologist group, 50% were female,
and 73.9% worked in Curitiba and its metropolitan region, whereas in the non-stroke
neurologist group 43.8% were female and 75% worked in Curitiba and its metropolitan
region.
The average score in the emotional exhaustion section was 23.0 (± 11.6), that is,
an average degree of emotional exhaustion; in the depersonalization section it was
6.2 (± 5.3), corresponding to a mean degree of depersonalization; and in the professional
accomplishment section it was 39.8 (± 5.9), indicating a high degree of professional
accomplishment. When analyzed in the two different groups, mean emotional exhaustion
scores were 21.4 (± 10.5) in the stroke neurologist group and 25.1 (± 12.7) in the
non-stroke neurologist group; depersonalization mean scores were 6.1 (± 5.2) in the
stroke neurologist group and 6.4 (± 5.5) in the non-stroke neurologist group; and
the mean professional accomplishment scores were 40.6 (± 5.0) in the stroke neurologist
group and 38.8 (± 6.8) in the non-stroke neurologist group.
High levels of depersonalization were observed in 28.6% of stroke neurologists, similar
to the rate in the non-stroke neurologist group, which was 28.1%. As for emotional
exhaustion, the difference was slightly higher, 26.2% of the stroke neurologists showed
a high degree of emotional exhaustion, whereas, in the non-stroke neurologist group,
28.1% showed this degree, with no statistical relevance. It was observed that 4.8%
of stroke neurologists showed a low level of professional accomplishment and 15.7%
of non-stroke neurologists had a low level of professional accomplishment, also not
statistically relevant.
Emotional exhaustion was observed at higher levels in female neurologists (25.8 ±
11.9) than in male neurologists (20.5 ± 10.9), although without statistical relevance.
An inverse correlation between age and emotional exhaustion levels (p < 0.001, [Figure 1]) was observed when the total sample was analyzed.
Figure 1 Relationship between emotional exhaustion levels and age in the total sample.
Median depersonalization levels did not show large discrepancies in gender, although
the mean number of females (7.5 ± 6.0) was slightly higher than that of males (5.1
± 4.4). Nevertheless, it was observed that male physicians had higher levels of professional
accomplishment (40.7 ± 6.8) than female physicians (38.7 ± 4.6, p < 0.03).
It was possible to observe that among the non-stroke neurologists, females had a mean
high degree of emotional exhaustion (29.1 ± 13.3), while their male counterparts had
an average degree (22.7 ± 11.7). Among the stroke neurologists, the difference between
genders was lower, with both genders showing an average degree (men had a mean of
19.1 ± 10.2 and women had a mean of 23.5 ± 10.5), although with no statistical relevance.
In both groups, there was a statistically significant inverse correlation between
emotional exhaustion and professional accomplishment (p <0.001), as well as a correlation
between emotional exhaustion and depersonalization (p < 0.001, [Figure 2]).
Figure 2 Relationship between emotional exhaustion levels and other indices: A - professional
accomplishment in the non-stroke neurologist group; B - professional accomplishment
in the stroke neurologist group; C - depersonalization in the non-stroke neurologist
group; D - depersonalization in the stroke neurologist group. Relationship between
professional accomplishment levels and depersonalization: E - non-stroke neurologist
group and F - stroke neurologist group.
Among the stroke neurologists, there was a difference in professional accomplishment
regarding gender, with females having medium levels (38.7 ± 4.1) and males with high
levels (42.5 ± 5.3, p < 0.05). Conversely, there was no statistical relevance in the
non-stroke neurologist group, with a medium level of professional accomplishment for
both genders (males had a mean score of 38.9 ± 5.5, females had a mean of 38.7 ± 7.9).
In both non-stroke neurologists and stroke neurologists, an inversely proportional
relationship was observed between the levels of professional accomplishment and depersonalization
(p < 0.001, [Figure 2]).
Regarding depersonalization, it was observed that in both groups females had a medium
score (stroke neurologists had a mean of 7.4 ± 5.7; non-stroke neurologists had a
mean of 7.6 ± 6.7), while males had low scores (stroke neurologists showed an average
of 4.9 ± 4.4, non-stroke neurologists showed an average of 5.4 ± 4.4), albeit without
statistical significance.
DISCUSSION
The results of this study demonstrated a high prevalence of burnout syndrome in neurologists
in Paraná, comparable with recent publications. Physicians in specialties at the front
line of health care access, such as emergency medicine and general internal medicine,
are at a greater risk of burnout syndrome, according to previous studies[3],[18]. With the new categorization of stroke neurologists, who are responsible for the
emergency care of stroke, particularly caring for hyperacute and acute strokes, which
started mainly in the 2000s[19], this could theoretically have led to a higher prevalence of burnout syndrome in
this specific new setting. We did not find any study in the literature that categorized
burned-out neurologists according to subspecialties, specifically stroke neurologists,
and so we chose to divide our sample into two groups: stroke neurologists and non-stroke
neurologists. The analyzed groups were homogeneous for epidemiological data - age,
gender and workplace.
Our findings did not corroborate the hypothesis that the stress related to the context
of emergency stroke care would be a significant factor for burnout syndrome in neurologists.
This finding contrasts with several studies that reported that emergency care in other
specialties led to greater burnout syndrome[1],[3],[20]. We hypothesize that standardized guidelines, restricted to a single neurological
emergency (namely stroke), reduces the variability of stress factors to which stroke
neurologists are exposed in a highly-controlled setting. Data in the literature corroborate
the idea that the frequency of burnout syndrome may not be related exclusively to
the workload or high-stress demand, but rather to the amount of control that the emergency
physician has in different situations[21],[22].
Professionals with higher levels of emotional exhaustion had a lower level of professional
accomplishment and greater depersonalization; conversely, those with a lower level
of emotional exhaustion had a higher level of professional accomplishment and lower
indexes of depersonalization. Likewise, neurologists with higher levels of professional
fulfillment had lower rates of depersonalization ([Figure 2]). This study demonstrated that the three burnout syndrome descriptors are closely
intertwined, corroborating previously-reported data[23],[24],[25]. However, each of these three variables has an impact on burnout syndrome incidence
independently[16].
Similar to other previously-published studies, female neurologists had significantly
lower levels of professional accomplishment than their male counterparts[20],[22], which could be explained by an excessive workload superimposed on a concomitant
family burden, as well as lower satisfaction concerning financial return[26],[27],[28].
Although the literature reports that younger neurologists are more likely to work
in an emergency setting, when we evaluated all neurologists split into groups of vascular
neurologists who either work with stroke emergencies and those who don't, we could
not find any differences of distribution between these two settings in different age
groups. Therefore, in spite of some predominance of younger age groups in emergency
rooms or intensive care units in general, or in other specialties, that is not the
case among neurologists. Furthermore, younger neurologists, regardless of whether
they were stroke neurologists or non-stroke neurologists, did not have a higher incidence
of burnout syndrome than older ones. However, when we analyzed all domains separately
in the different age groups, we found a significantly higher incidence of emotional
exhaustion in the younger group (p < 0.05), as shown in [Figure 1]. This finding is similar to those of other studies that considered that an emergency
environment leads to specifically higher levels of emotional exhaustion[1],[20],[29].
Pediatricians are known to have lower incomes and higher demands, but have a lower
incidence of burnout syndrome than neurologists[3], a specialty of low resolution and higher income, partly due to the lower number
of practising professionals. This finding suggests that the causes of burnout syndrome
are much more complex than a simple equation comparing financial income and workload.
Other factors such as perceived greater responsibilities, greater demands and job
insecurity[30] are likely to play a major role as underlying causes of burnout syndrome. Preventive
measures to relieve doctor-patient pressures include individual counseling, motivational
meetings, available leisure time, career planning, self-acceptance, among others and,
therefore, should be implemented.
One of the limitations of our study was the low number of respondents, which prevent
us from generalizing the idea that stroke neurologists are more prone to burnout syndrome
than other neurological subspecialties. This may be due to the extremely limited time
of the physician, as well as the great amount of information he/she receives. Currently,
the excess of electronic demand for online questionnaires, as an online methodology
is more feasible, may be a complicating factor. Also, we could not make any comparison
with other specialties that work either in an emergency setting or only within a medical
clinic for outpatients, such as cardiology. The similarities and differences between
vascular neurology and vascular cardiology may lead to a better understanding of burnout
syndrome in these two subgroups. The increase of all vascular emergencies, regardless
of specialty, might be a determining factor in the occurrence of burnout syndrome
in other specialties, like vascular surgery, radiology, angiology, etc.
Nevertheless, this study had numerous benefits. It was the first to investigate burnout
syndrome in neurologists in Brazil. Despite growing research in the area, studies
on burnout syndrome have not yet been consolidated in the literature, particularly
in Brazilian research. It was also a forerunner in comparing two areas of activity
of the same specialty, and observed how burnout syndrome could vary according to such
specificities.
In addition, with the recent acceptance of the neurohospitalist as a new area of activity,
this work was the first in Brazil to incorporate this in the research. Future studies
in this area are needed, as well as research comparing neurology with other vascular
emergency specialties, and their areas of practice, which will deepen our understanding
on the subject.
