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Occupational Medicine Advance Access published online on September 16, 2008
Occupational Medicine, doi:10.1093/occmed/kqn122
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Burnout and patient care in junior doctors in Mexico City

Rodrigo Toral-Villanueva1, Guadalupe Aguilar-Madrid2 and Cuauhtémoc Arturo Juárez-Pérez2

1 Coordinación de Salud en el Trabajo, Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, D. F., México
2 Unidad de Investigación en Salud en el Trabajo, IMSS, Ciudad de México, D. F., México

Correspondence to: Rodrigo Toral-Villanueva, Coordinación de Salud en el Trabajo, IMSS, Av. Cuauhtémoc 330, Edif. C, 4° Piso, Col. Doctores, Del. Cuauhtémoc, C. P. 06725, Ciudad de México, D. F., México. Tel: +52 (55) 56 27 69 00 x 21838; fax: +52 (55) 55 19 50 52; e-mail: rodrigo.toral{at}imss.gob.mx


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Funding
 Conflict of interests
 References
 
Background Burnout is known to occur in public service workers leading to a reduction in effectiveness at work.

Aim To estimate the prevalence of burnout in junior doctors and its impact on patient care.

Methods A cross-sectional study of junior doctors at three hospitals in Mexico City was conducted. Measures used included the Maslach Burnout Inventory (MBI), measuring depersonalization (DP), emotional exhaustion (EE) and personal achievement (PA), a questionnaire about patient care practices and attitudes and one on sociodemographic characteristics. Logistic regression analysis was used to assess the association between burnout and suspected risk factors.

Results A total of 312 junior doctors participated (response rate 65%). In total, 57% were male and the average age was 28. Average scores in MBI subscales were EE: 18.2, DP: 6.9 and PA: 37.6. Burnout prevalence was 40% (126). Junior doctors with burnout were more likely to report suboptimal patient care practices occurring monthly (OR 5.5; 95% CI 2.7–11.2) and weekly (OR 5.2; 95% CI 1.6–16.3). The logistic regression model for burnout included shifts lasting >12 h, current depression, former major depression, first- or second-year junior doctors, male gender and single status.

Conclusions Burnout was most strongly associated with shifts >12 h and with both current and previous depression. Reported suboptimal patient care was also associated with working shifts of ≥12 h. Burnout may be adversely affecting junior doctors’ health and their patients’ care.

Keywords      Attitudes; burnout; junior doctors; patient care; practices; work shift


   Introduction
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 Abstract
 Introduction
Methods
 Results
 Discussion
 Funding
 Conflict of interests
 References
 
Burnout is an entity characterized by depersonalization (DP), emotional exhaustion (EE) and a sensation of low personal achievement (PA) that leads to a diminution in work effectiveness [1]. Burnout appears commonly among practising physicians, with prevalence rates ranging from 25 to 60% [2–5]. Only three small studies have described burnout in physicians during their residency programme [6–8]. A single study evaluated the relationship between burnout in physicians and patient medical care. This study found that 76% of junior doctors studied were affected by burnout and burnout was associated with suboptimal patient medical care [8]. Timely identification of this phenomenon is necessary to prevent adverse effects on clinical care and on the health worker–patient relationship [9]. Our objective was to evaluate the prevalence of burnout in junior doctors, to identify the factors associated with it and to explore its relationship with patient care.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Funding
 Conflict of interests
 References
 
We carried out a cross-sectional study between September 2003 and January 2004 in junior doctors at three hospitals within the Mexican Health System: a specialty hospital (tertiary level), a general zone hospital (secondary level) and a national health institute. We invited all members of medical specialty programmes to participate and included in the study junior doctors from any year of residency working at the three hospitals who agreed to sign a letter of informed consent to participate. We excluded from the study junior doctors who failed to respond to at least 20% of the survey questions.

In order to guarantee the protection of the research subjects, the study was approved by the Committee of Health Research ‘Hospital de Especialidades Dr Bernardo Sepúlveda Gutiérrez, Centro Médico Nacional Siglo XXI’. Participation in the survey was voluntary, responses were anonymous and the information obtained was managed in a strictly confidential manner by the researchers. To protect confidentiality to an even greater extent, the current clinical affiliation of the junior doctors was not requested. At the outset, we explained to the participants that the purpose of the study was to assess some occupational risk factors in their workplaces.

We personally delivered the self-administered questionnaires to the junior doctors. These comprised the Maslach Burnout Inventory (MBI) questionnaire [1], a questionnaire on patient medical care practices and attitudes that had been developed for a prior study [8], a questionnaire to identify depression [10,11], alcohol consumption [12,13] and the use of other recreational drugs [8] and a questionnaire on sociodemographic characteristics.

The MBI comprises a 22 item questionnaire that has been validated in its Spanish language version [14]. The questionnaire uses a seven-point Likert response scale and evaluates three burnout domains: (i) EE by means of nine items, (ii) DP (five items) and (iii) PA (eight items).

Each MBI domain has three scoring degrees: low, moderate and high, with cutoff points established by Maslach [1]. For EE, this ranges from ≤18 (low) to ≥27 (high), with a standard deviation (SD) that ranges from ≤5 for the low range to ≥10 for the high range. Response options for each question were 0 = Never; 1 = ≤10 times a year; 2 = Once a month; 3 = 2–3 times per month; 4 = Once a week; 5 = 2–5 times per week and 6 = daily.

Based on MBI responses, we calculated subscale-independent scores for each of the three burnout domains. Low, average and high grades for each domain were based on the low, middle and high terciles of the scores of a previously published study of 1104 physicians [1].

For this study, we calculated burnout frequency taking into account the cutoff points of the three dimensions (EE ≥27, DP ≥10 and PA ≤10) and defined burnout as a high score in DP and/or EE domains. We did not include scores for the PA subscale as it has been reported that this subscale does not correlate well with identified burnout, i.e. it does not measure accurately what is expected [1].

The general data questionnaire used included questions concerning sociodemographic details such as age, sex, job seniority and work and socioeconomic status, as well as questions on depression, identified by responses to a two-question version of the PRIME-MD for current depression [10,11]. (The two questions asked were ‘During the past month, have you often been bothered by feeling down, depressed or hopeless?’ and ‘During the past month, have you often been bothered by little interest or pleasure in doing things?’) We defined current depression as a positive answer to either of these questions. In addition, we asked subjects about their subjective experience of previous depression (‘At any time during the residency, have you had major depression?’). Additional questions concerned alcohol and recreational drug (marihuana, cocaine and others) use and smoking. We defined at-risk alcohol consumption according to the cutoff of eight points suggested by the Alcohol Use Disorders Identification Test questionnaire [13].

A third questionnaire sought details of patient care practices and attitudes. This contained eight statements describing practices (five items) and attitudes toward patient medical care (three items) reported by study subjects. The medical resident was required to estimate the frequency with which he/she found him/herself exhibiting such attitudes (e.g. ‘I had a poor emotional reaction to the death of one of my patients’) or practices (e.g. ‘I ordered restrictions or medication for an agitated patient without assessing him/her’) for whatever reason. Response options comprised ‘Never’, ‘Once’, ‘Several times a year’, ‘Once a month’ and ‘Once a week’. We defined the cutoff points for suboptimal self-reported patient care practices as an answer of once a month or once a week to any of the five statements. We thereby constructed two summarized measurements: ‘Self-reported suboptimal patient care practices at least monthly’ and ‘Self-reported suboptimal care practices at least weekly’. We did not include summarized measurements of suboptimal care attitudes because these are similar to the MBI’s DP subscale items and are considered to have a correlation with this subscale [8].

We calculated the sample size based on the assumption of a prevalence of burnout of 76% according to a previous similar study [8] and a cross-sectional study design, using the Epi Info v. 6 software program (Centers for Disease Control and Prevention, Atlanta, GA, USA). We therefore aimed to obtain a sample of 308 individuals, assuming 10% sample loss. We actually ended up surveying 312 junior doctors.

Univariate and bivariate statistical analyses were performed to compare the proportion of hospital junior doctors meeting the criteria for burnout with those who did not by means of the {chi}2 test.

MBI questionnaire factorial analysis was carried out to validate whether each of the instrument’s items evaluated the three dimensions into which burnout is divided. The results showed that the instrument correctly evaluated burnout for only two dimensions (DP and EE). The same analysis was carried out for the questionnaire on suboptimal patient medical care practices and demonstrated that it is valid for evaluating the three burnout dimensions (Table 1). This analysis showed correlations which were in general high according to our cutoff point, which was >0.40, based on a previous study of MBI validation through factorial analysis [14]. We considered it important to perform this validation analysis because the existing Spanish language version of the MBI employs the form spoken in Spain, which we adapted to the one spoken in Mexico for some items. We conducted factorial analysis for MBI and questionnaires on suboptimal practices and attitudes using the STATA v. 8.0 software program (Stata Corporation, Houston, TX, USA).


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  		Table 1. Factorial matrix of the MBI and the questionnaire’s rotated factorial matrix regarding suboptimal patient care practices and attitudes, 2004

 
Finally, we constructed a logistic regression model to calculate odds ratios (ORs) with 95% confidence intervals for junior doctors exhibiting burnout against those who did not. In addition, we performed adjusted goodness of fit and model diagnosis tests.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Funding
 Conflict of interests
 References
 
A total of 312 junior doctors from 31 different medical specialties responded to the questionnaire giving an overall response rate of 65%. Of these, 57% (177) were male, 42% (133) female and <1% (2) did not give gender information. In total, 78% (242, response rate 60%) were from the tertiary-level hospital, 15% (47, response rate 94%) from the national health institute and 7% (23, response rate 96%) from the secondary-level hospital. The mean age was 28 years (SD 2.5, age range 20–42 years). Average on-the-job seniority was 32 months (SD 17.6, range 6–93 months) (Table 2). The highest proportion of participating junior doctors (77%) was in the first 3 years of medical residency.


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  		Table 2. General characteristics of junior doctors participating in the study, 2004

 
In total, 23% (71 participants) were smokers, 21% (67) had at-risk alcohol consumption and 2% (6) consumed recreational drugs at least once a month. In total, 51% (158) reported not having rest breaks during their work shifts and 91% (280) reported working night shifts. In total, 56% (175) met our criteria for depression at the time of the study and 21% (65) reported having experienced major depression at some previous time during their residency.

The overall prevalence of burnout among the junior doctors was 40% with rates of 40% for the tertiary-level hospital and for the national institute and of 48% for the secondary-level hospital. Differences in prevalence rates between the three hospitals were not statistically significant. There were no significant differences between gender and age of junior doctors with and without burnout. Average scores of the three MBI subscales for the whole sample of junior doctors were 18.2 for EE, 6.9 for DP and 37.6 for PA. In total, 25% (78) of the junior doctors surveyed were in the high range for EE, while DP was high in 32% (99) and in 51% (158) PA was low.

Of the 126 junior doctors who fulfilled our burnout criteria, 51 (40%) had high scores for the EE subscale as well as for DP, 48 (38%) had a high score only in the DP subscale and 27 (22%) only in the EE subscale.

There were statistically significant differences in the responses to the questionnaire on self-reported suboptimal patient medical care practices and attitudes among junior doctors with burnout in comparison to those without burnout (P < 0.05) (Figure 1).


Figure 1
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  		Figure 1. The relationship of burnout with self-reported suboptimal patient health care practices and attitudes. In each pair, the bar on the left represents junior doctors who fulfilled burnout criteria (n = 126) and the bar on the right represents junior doctors who did not fulfill burnout criteria (n = 186). The numbers correspond to the number of the question on suboptimal patient care practices (SP23-SP27) and attitudes (SA28-SA30): SP23. Discharging a patient in order to make the service ‘manageable’; SP24. Not answering thoroughly patient’s questions; SP25. Making errors in treatment not related to inexperience or lack of knowledge; SP26. Prescribing a medication to an agitated patient without assessment; SP27. Discharging a patient without performing a recommended diagnostic test; SA28. Paying little attention concerning the impact of the disease on the patient; SA29. Having poor emotional reaction to a patient’s death; SA30. Feeling guilty due to inadequate patient care.

 
Of the total number of junior doctors, 47 (15%) reported engaging in some suboptimal patient care practices at least once a month. Of these, 35 (74%) had burnout, whereas 12 (26%) did not. Junior doctors with burnout were 5.5 times more likely to report one or more suboptimal patient health care practices monthly than those without burnout (P < 0.001; 95% CI 2.7–11.2).

In total, 5% (17) of subjects reported one or more suboptimal patient care practices at least once a week. Of these, 76% (13) had burnout. Those with burnout were 5.2 times more likely to report carrying out some suboptimal practice weekly than those who did not fulfil burnout criteria (OR 5.2; P = 0.005; 95% CI 1.6–16.3).

We evaluated each MBI subscale independently to examine its relationship to the two summarized measurements of self-reported suboptimal patient care practices. The three subscales were significantly associated with suboptimal care practices occurring at least monthly. A high EE score had an OR of 5.6 (95% CI 2.9–10.8), a high DP score had an OR of 4.4 (95% CI 2.3–8.5) and a low PA score had an OR of 2.1 (95% CI 1.1–4.0). A high EE score (OR 8.3 95% CI 2.8–24.3) and a high DP score (OR 3.3 95% CI 1.2–8.9) were significantly associated with suboptimal practices occurring at least once a week.

In the stratified analysis, junior doctors with burnout were more likely to meet our criteria for current depression than those without burnout (OR 5.6, 95% CI 3.3–9.5). Likewise, those with burnout were more likely to report having had previous major depression during their residency, in comparison with those without burnout (OR 2.5, 95% CI 1.4–4.4).

We found no significant association between alcohol, tobacco and drug consumption and burnout (ORs 1.4, CI 0.8–2.5; 1.2, CI 0.75–2.2 and 3.0, CI 0.5–16.7, respectively).

We also evaluated whether junior doctors who reported having no rest break during their work shift and those who worked night shifts were more likely to suffer burnout, but found no significant associations.

Junior doctors working night shifts were more likely to report suboptimal practices (OR 5.13; P = 0.113; 95% CI 0.6–38.7), but this was not statistically significant. Junior doctors reporting working shifts >12-h duration had a significantly greater risk of having burnout (OR 2.6; P <0.05; 95% CI 1.6–4.25).

We constructed a non-conditional logistic regression model to explore the association between burnout development in this population and relevant variables. We found that junior doctors who worked shifts of >12 h had an OR of 3.1 (CI 1.7–5.4) for burnout. Similarly, first- and second-year junior doctors were at greater risk than third-year junior doctors, with an OR of 1.9 (CI 1.1–3.4). In addition, junior doctors with current depression or previous depression had ORs of 5.8 (CI 3.2–10.6) and 2.4 (1.2–4.8), respectively (Table 3).


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  		Table 3. OR of junior doctors presenting burnout (non-conditional logistic regression model)

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Funding
 Conflict of interests
 References
 
In our study, burnout had a prevalence of 40% among junior doctors. We found lower average scores in the EE and DP subscales than in previous studies of medical resident populations, although average scores in the PA subscale were similar to those of the populations previously studied [6–8]. In this study, the relationship between burnout and suboptimal patient care practices was statistically significant (ORs 5.5 for monthly and 5.2 for weekly occurrences). This finding is similar to that reported by a previous study [8], which found an OR of 4.0 for suboptimal practices occurring weekly.

This study involved a larger sample size than previously reported studies of burnout among junior doctors. We acknowledge that self-reporting may have introduced bias into the study. Since the questionnaire was self-administered, the veracity of the information provided could have been influenced by the attitude of the participants in responding honestly and in full to the questionnaire. Therefore, we suggest that in further investigations, an instrument to evaluate patient perception of medical care received should if possible be used. Although the sample encompassed a significant number of specialties, we were unable to explore differences between junior doctors in different specialties since we did not ask subjects to disclose their specialty affiliation in order to protect their confidentiality.

In the present study, we found no association of burnout or suboptimal patient care practices with having or not having rest breaks and with working night shifts. However, among junior doctors reporting working shifts >12 h, burnout was more prevalent than in junior doctors who did not work shifts of this length. Likewise, suboptimal care practices were associated with burnout and working shifts of >12 h. In a previous study, the majority of junior doctors mentioned workload as their greatest stressor [8]. Our findings support the importance of controlling workload and working hours and ensuring adequate time away from work [15]. As Mexican Federal Law of Labour dictates a maximum length of 8 h for work shifts [16], those employers exceeding this length are breaching the law. In the case of junior doctors, accumulated fatigue may lead to errors of judgment in the medical care process, potentially affecting patient care. A recent study showed that restriction of the length of junior doctors’ working days could diminish the severity of burnout [17]. Other strategies to alleviate the stress experienced by junior doctors have been proposed and merit attention [7,18–20]. For example, one study found that a single 4-h workshop teaching stress management techniques improved burnout measured 6 weeks later [7].

In addition, burnout was strongly associated with both current and previous depression. However, due to the cross-sectional nature of our study, we cannot definitively state that depression contributes to burnout.

We therefore believe that those responsible for training of junior doctors should take into account the results of this study in order to better promote and protect the health of junior doctors and students and also recognize burnout as an occupational disease. We also believe that it is important to conduct further research on the prevention, causes, consequences and treatment of burnout and on its effect on health care services users and on medical education, as well as on the development of new diagnostic and screening instruments to aid its early identification.


Key points
  • Burnout has a high prevalence in this sample of Mexican junior doctors.
  • Work shifts of >12-h duration were strongly associated with burnout.
  • Burnout appears to be having a negative impact on the quality of patient care.

 


   Funding
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
Conflict of interests
 References
 
While the project was not formally funded, the main author received a postgraduate student grant and the remaining authors received salaries from their institution (the Mexican Institute of Social Security).


   Conflict of interests
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Conflict of interests
References
 
None declared.


   Acknowledgements
 
The authors wish to thank the junior doctors, the participating institutions and the Mexican Institute of Social Security.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Funding
 Conflict of interests
 References
 

  1. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual (1996) 3rd edn. Palo Alto, CA: Consulting Psychologists Press.

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  6. Purdy RR, Lemkau JP, Rafferty JP, Rudisill JR. Resident physicians in family practice: who's burned out and who knows? Fam Med (1987) 19:203–208.[Medline]

  7. McCue JD, Sachs CL. A stress management workshop improves residents’ coping skills. Arch Intern Med (1991) 151:2273–2277.[Abstract/Free Full Text]

  8. Shanafelt TD, Bradley KA, Wipf JE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med (2002) 136:358–367.[Abstract/Free Full Text]

  9. Felton JS. Burnout as a clinical entity—its importance in health care workers. Occup Med (Lond) (1998) 48:237–250.[CrossRef][Medline]

  10. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 Study. J Am Med Assoc (1994) 272:1749–1756.[Abstract/Free Full Text]

  11. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med (1997) 12:439–445.[CrossRef][Web of Science][Medline]

  12. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med (1998) 158:1789–1795.[Abstract/Free Full Text]

  13. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption–II. Addiction (1993) 88:791–804.[CrossRef][Web of Science][Medline]

  14. Gil-Monte PR. Validez factorial de la adaptación al español del [Maslach Burnout Inventory-General Survey]. Salud Publica Mex (2002) 44:33–40.[Web of Science][Medline]

  15. Haro-García LC, Sánchez-Román R, Juárez-Pérez CA, Larios-Díaz E. Justificaciones médicas de la jornada laboral máxima de 8 horas. Rev Med Inst Mex Seguro Soc (2007) 45:191–197.[Medline]

  16. Ley Federal del Trabajo. Diario Oficial de la Federación. Jun 1:1970. México.

  17. Gopal R, Glasheen JJ, Miyoshi TK, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med (2005) 165:2595–2600.[Abstract/Free Full Text]

  18. Resident Services Committee. Association of Program Directors in Internal Medicine. Stress and impairment during residency training: strategies for reduction, identification, and management. Ann Intern Med (1988) 109:154–161.[Abstract/Free Full Text]

  19. Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med (2001) 76:142–150.[Web of Science][Medline]

  20. Reuben DB, Novack DH, Wachtel TJ, Wartman SA. A comprehensive support system for reducing house staff distress. Psychosomatics (1984) 25:815–820.[Abstract/Free Full Text]


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