Burnout syndrome in intensive care physicians in time of the COVID-19: a cross-sectional study.

OBJECTIVES: To assess the prevalence of burnout syndrome among intensive care physicians working in a tertiary private hospital as well as their perceived impact of the COVID-19 pandemic on their life.
DESIGN: A cross-sectional study.
SETTING: Intensive care units dedicated to the care of COVID-19 in Hospital Sirio-Libanes, Sao Paulo, Southeastern part of Brazil. PARTICIPANTS: Intensive care physicians.
INTERVENTIONS: Each participant received an envelope with a questionnaire composed of demographic and occupational variables, information related to their personal and professional experiences facing the COVID-19 pandemic and the Maslach Burnout Inventory questionnaire. PRIMARY AND SECONDARY OUTCOMES MEASURES: The primary outcome was to assess the prevalence of burnout syndrome among physicians working in an intensive care unit dedicated to the care of COVID-19.
RESULTS: A total of 51 from the universe of 63 (82%) intensive care physicians participated in the study. Nineteen (37.2%) met the criteria for burnout syndrome. In the three domains that characterise burnout syndrome, we found a low level of personal achievement in 96.1% of physicians interviewed, a high level of depersonalisation in 51.0% and 51.0% with a high level of emotional exhaustion. Decision-making conflicts between the intensive care unit team and other attending physicians were frequent (50% of all conflicts). A third of the participants had been diagnosed with COVID-19, 22 (43.1%) reported having a family member infected and 8 (15.7%) lost someone close to the COVID-19 pandemic. Participants felt that fear of infecting their loved ones was the aspect of their lives that changed most as compared with the prepandemic period.
CONCLUSIONS: Burnout syndrome was frequent among intensive care unit physicians treating patients with COVID-19 in a large tertiary private hospital. Future studies should expand our results to other private and public hospitals and test strategies to promote intensive care unit physicians' mental health. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

We addressed burnout syndrome in its three different dimensions using a well-validated questionnaire.

The prevalence of burnout syndrome among other categories of health professionals was not addressed.

Our study was descriptive and performed in a single centre with a small number of participants, what limits its external generalisability.

Introduction

The COVID-19 pandemic has emerged as an unprecedented health crisis. As of March 2021, there have been 90 million patients diagnosed with COVID-19 and 1.93 million deaths worldwide. In Brazil alone, >8 million cases have been confirmed, and deaths amount to over 200 000.1 2 The psychological impact of the pandemic on healthcare workers and, especially, those working in intensive care units (ICUs) was well-publicised worldwide. Most healthcare professionals are working under extreme pressure, despite various degrees of burden in different geographic regions.3–5

Under normal circumstances, professionals working in the ICU environment are at risk of suffering from burnout syndrome,, with a high prevalence of conflicts, work overload and night shifts. Recent studies report a high prevalence that may exceed 50% of the team, varying between professional categories.6–8 In our hospital, the prevalence of burnout syndrome among ICU physicians before the COVID-19 pandemic was 18%.6

In the face of the pandemic, the burden on intensive care physicians has increased considerably. Burnout syndrome is widely described in its tridimensionality: (1) emotional exhaustion, (2) depersonalisation and (3) personal accomplishment.2–4 High levels of burnout syndrome have been found among healthcare professionals in ICUs, with prevalence rates ranging from 0% to 70%.9 Burnout syndrome is a process that starts with an imbalance between organisational demands and personal resources, which causes emotional exhaustion in the worker, then experiencing depersonalisation (coping that protects the worker from disillusionment and burnout), ending with low self-fulfilment at work because of ineffectiveness in coping with different work stressors. Several factors could contribute to the increased incidence of burnout syndrome in the current scenario. With an unprecedented flow of patients with acute respiratory distress syndrome, in many places, there is a shortage of ICU beds. Physicians often need to choose which patients they will admit to the ICU and which they will leave behind. In addition, intensivists have to cope with their fear of infecting themselves or their loved ones with the virus. These new circumstances likely amplified the sources of emotional distress and have increased the prevalence of burnout in these professionals.2–5 A high prevalence of burnout syndrome has also been reported among frontline nurses, healthcare workers in wards and emergency departments.4 10–14 There are few studies, however, assessing burnout syndrome in physicians working in ICUs dedicated to the care of patients with COVID-19 in Brazil.15 16

Objective

The aim of this study was to assess the prevalence of burnout syndrome among intensive care physicians working in a tertiary private hospital as well as their perceived impact of the COVID-19 pandemic on their life.

Method

As part of this cross-sectional study, in December 2020, intensive care physicians working in ICUs dedicated to the care of COVID-19 in Hospital Sirio Libanes, Sao Paulo, Southeastern part of Brazil, were invited to participate in the study. Originally, a 30-bed mixed surgical-medical ICU with daily multidisciplinary rounds, established protocols for patient care and adequate professional-bed relationship, this ICU expanded its capacity to 63 beds to attend exclusively the care of patients with COVID-19. All ICU physicians working for >6 months in the unit were invited in person by the principal investigator (RRLF) to participate.

To ensure optimal data quality, the same investigator (RRLF), a psychologist with experience in ICU interviews, recruited all participants and collected all study data. No incentives were offered. After answering, each participant returned the sealed envelope, without their names, preserving their anonymity. Each participant received an envelope with a questionnaire composed of demographic variables, occupational variables, information on the impact of the COVID-19 pandemic on their day-to-day life (insomnia, lack of appetite, irritability, decreased libido, fear of being infected, fear of infecting loved ones, overspending) and the Maslach Burnout Inventory (MBI) questionnaire,17 18 translated and transculturally validated for Portuguese in Brazil, which has acceptable psychometric properties when compared with its original version in English.6 19 The full questionnaire (translated to English) can be found in the online supplemental material. Questions about the day-to-day impact were ordinal and varied from zero (no impact) to four (large impact). The MBI consists of 22 questions, comprising the three components of burnout: emotional exhaustion (9 items), depersonalisation (5 items) and personal achievement (8 items).

From the MBI questionnaire, the cut-off scores were defined for each dimension, and the following internationally established definition of burnout was adopted, according to the MBI manual: high levels of emotional exhaustion (score ≥27 points) and depersonalisation (score ≥10 points) combined with low personal achievement (score ≤33 points).17 18

Patient and public involvement

Patients were not involved in this research.

Statistical analysis

Data are presented as means and SD, medians and IQRs and absolute and relative frequencies when appropriate. Burnout syndrome domains were represented in a Venn diagram to convey the message of how often each domain was abnormal. The perceived impact on different aspects of day-to-day life were shown on a radar chart. All analyses were performed in R (R Core Team 2020) and RStudio (RStudio, Boston, Massachusetts, USA).

Results

In the period from 10 to 23 December 2020, 51 out of a total of 62 intensive care physicians participated in the study (response rate of 82%). Among those who did not answer the questionnaire, 10 were unavailable including 2 on vacation and 2 on sick leave. One participant returned the questionnaire with no answers on the burnout questionnaire and was therefore excluded. The characteristics of the participating physicians are in table 1.

Table 1

Characteristics of participating intensivist physicians (n=51)

Do you have a good structure and/or family life, n (%)	46 (90.20)
How long do you work in the ICU (years), median (IQR)	8.00 (6.00–14.00)
How many hours/week do you work in the ICU, median (IQR)	52.00 (40.00–60.00)
How many patients do you care for during the shift, median (IQR)	10.00 (10.00–10.00)
How many night shifts did you work in the last week, n (%)	40 (78.40)
Do you also work in another hospital, n (%)	32 (64.00)
Do you work solely in the private sector, n (%)	41 (80.40)
How often do you participate in the decision-making process to limit invasive measures, median (IQR)	1.00 (0.00–1.00)
How many patients you cared for died in the last week, median (IQR)	0.00 (0.00–1.00)
How many work absences in the last month
None	46 (90.20)
1–3 days	4 (7.80)
5–10 days	1 (2.00)
How many conflicts in the last week, n (%)	16 (31.40)
Attending physician	8 (50.00)
Nurse	3 (18.8)
Patient and/or family	9 (56.25)
Have you considered quitting your job for demotivation in the last week	21 (41.20)
How is your relationship with the multidisciplinary team
Bad	2 (4.00)
Regular/Good	20 (39.20)
Great	29 (56.80)

ICU, intensive care unit.

The median age of physicians was 37.00 (IQR=33–43) years. Most physicians were male (60.8%) and married (76.0%).

Burnout syndrome

Nineteen (37.2%) of ICU physicians met the criteria for burnout. In the three domains that characterise burnout syndrome, we found a low level of personal achievement in 96.1% of physicians interviewed, a high level of depersonalisation in 51.0% and 51.0% with a high level of emotional exhaustion.

Personal achievement was the most affected of the burnout syndrome dimensions (figure 1).

Figure 1

Venn diagram of burnout dimensions.

Day-to-day life impact of the pandemic

A total of 17 physicians (33.3%) had been diagnosed with COVID-19; 22 physicians (43.1%) reported having an infected family member and 8 (15.7%) lost someone close to the COVID-19 pandemic. Of those three participants who smoked (6.9%), two (66.7%) increased the consumption of tobacco after the pandemic. A total of 40 (78.4%) participants reported drinking of alcohol; of these, 18 (45.0%) increased the consumption after the pandemic. Regular physical activity was reported by 24 (47.1%) physicians, most of whom (23/24, 96%) maintained their level of activity. Only four (16.7%) participants exercised more during the pandemic. Fears about COVID-19 contamination, especially fear of infecting their loved ones, had the largest impact on the day-to-day life of physicians (figure 2).

Figure 2

Spider chart of the impact on the day-to-day life of physicians.

The majority of physicians (27/51, 52.9%) reported that they had never done psychotherapeutic or psychiatric treatment; 20 (39.2%) had some treatment previously and 4 (7.8%) started treatment after the pandemic. Of the 46 respondents, 4 physicians (8.7%) experienced suicidal ideation. Five participants (9.8%) did not respond to the question about suicidal thoughts.

Discussion

The SARS-CoV-2 pandemic resulted in a general increase in new cases of anxiety, depression and burnout syndrome in critical care health professionals. In the present study, we found a high prevalence of burnout syndrome among intensive care physicians caring for patients with COVID-19, with half of participants demonstrating emotional exhaustion and depersonalisation. Additionally, nearly all of them showed low personal achievement. With approximately a third of the medical staff having had COVID-19, many reported fear of contamination or of transmitting the disease to their loved ones. Furthermore, in this scenario, we observed a significant rate of conflicts, a known risk factor for burnout syndrome.20

Burnout syndrome was present in nearly two-fifths of the participants. This prevalence is twice as large as that previously reported by our group in 2017, in which the prevalence of burnout syndrome among physicians working in the same ICUs was 18.2%. This finding is suggestive of a strong impact of the pandemic on the emotional health of the team. The prevalence of burnout syndrome during the pandemic is also in agreement with that found by other authors. For example, in the survey conducted among intensive care physicians from the European Society of Intensive Care Medicine, over half the members interviewed had burnout syndrome.4 We found that nearly the entire team showed low personal achievement, the burnout syndrome dimension with the highest increase compared with the pre-COVID-19 period, when it was present in 36.3% of physicians.6

We found that 60.8% of the respondents believed that their profession placed them at increased risk during the pandemic. Mostly, they were afraid of getting infected with COVID-19 or of transmitting the disease to their loved ones imposing on them an additional emotional burden. Other authors had similar results. For example, in a study with physicians from various regions in Saudi Arabia during the pandemic, the most common feelings reported were worry (67.5%), isolation (56.9%) and fear (49.7%).5

Most physicians reported a good relationship with the multidisciplinary team. This productive interaction is paramount for good patient care,21 compatible with our low ICU mortality rate of 16.2% among patients who required invasive mechanical ventilation.2 These two factors combined can also be protective for burnout syndrome.21 In less favourable scenarios, the prevalence of burnout syndrome among ICU physicians could be even higher. In Brazil, we have large differences in resources available in private and public healthcare. Mortality in the public healthcare system is significantly higher compared with private hospitals.22 This lack of resources is likely associated with moral distress and burnout syndrome.6

Conversely, many ICUs in private hospitals in Brazil, including ours, adopt the open ICU format. In this model, there can be many more conflicts between primary admitting physicians and ICU physicians about clinical decision making, including but not limited to end-of-life decisions. For example, decisions about withdrawal of futile treatments commonly lead to disagreement. This situation is conducive for moral distress, a factor strongly associated with burnout syndrome and well discussed in previous studies during the pandemic.6 23

Another relevant and worrisome finding was the occurrence of suicidal thinking among ICU physicians even if rarely or sometimes. Moreover, the question about suicide was the only left unanswered: the silence of 10% of the participants was disturbing. According to a previous study,24 suicidal thinking cannot be overlooked because it is a strong risk factor for committing suicide and therefore deserves to be considered with great care. Additionally, we found that other emotional disorders were frequent, such as loss of libido, irritability, increased alcohol consumption and excessive spending. These findings emphasise the importance of psychological support for ICU physicians, especially those on the frontline treating patients with COVID-19. Although symptoms of anxiety and depression were not the scope of this study, it is known that many hours of work in close contact with patients with COVID-19 has been associated with higher levels of depression, anxiety and burnout syndrome compared with those who spend fewer hours working in close contact with patients with COVID-19.

There are several limitations in the present study. First, it was a descriptive study performed in a single centre and with a small number of participants. As such, it can be considered a first step towards increased awareness of the prevalence of mental health disorders among ICU physicians. Future studies should be performed in a larger scale to help plan public health interventions targeting promotion of mental health. Second, we did not study the impact of COVID-19 among other health professional categories. Third, we chose to use a score according to the MBI manual (high levels of emotional exhaustion and depersonalisation combined with low scores on personal achievement), a method used by other researchers and in our previous study.6 25–27 This choice limits the comparison of our results to those of other studies that have used the definition of Poncet (MBI score >−9).20

Conclusion

Burnout syndrome was frequent among ICU physicians treating patients with COVID-19 in a large tertiary private hospital. The prevalence was twice as high that found in our historical controls from a previous publication. Awareness is the first step to change. Future studies should focus on upscaling our results to other private and public hospitals and on developing strategies to promote ICU physicians’ mental health.