Abstract
Objective: To study burnout of Russian physicians in the conditions of COVID-19 pandemic and how their work with coronavirus-infected patients influenced it. According to a three-factor model of burnout developed by Maslach and Jackson, this syndrome includes emotional exhaustion, depersonalization, and reduction of personal accomplishment.
Design: A cross-sectional survey study.
Setting: Large medical practice.
Participants: Physicians of different specialties.
Methods: Data collection was conducted from June 23 to July 12, 2020. We developed a Google form including a questionnaire and psychological inventories and placed it in a medical portal. Maslach Burnout Inventory — Human Services Survey for Medical Personnel was used to study burnout; the Hospital Anxiety and Depression Scale was used to determine anxiety and depression.
Results: Of all the physicians who took part in the study (N = 599), 31.2 % worked with coronavirus-infected patients. Of the medical personnel who treated COVID-19 patients, 63.6% noted increased workload during the pandemic. Compared to other physicians, they more often had a high degree of emotional exhaustion (43.3 % vs 33.0 %, φ* = 2.404, P ≤ 0.01) and depersonalization (41.7 % vs 34, 0%, φ* = 1.803, P ≤ 0.05). An overwhelming majority of physicians, without any dependence on work with infected patients, had an absence of anxiety and depression. The identified interrelations between the symptoms of burnout, anxiety, depression; age and career stage in medical personnel were identical, except for weak correlations between age and emotional exhaustion (rs = -0.097, P ≤ 0.05), as well as career stage and personal accomplishment (rs = 0.102, P ≤ 0.05) in those physicians who worked with COVID-19 patients. The structure of burnout was identical in all physicians and did not depend on interaction with the infected patients.
Conclusion: Public health authorities should reduce the workload on physicians involved in treating infected patients against the backdrop of the pandemic. Psychotherapeutic measures focused on preventing burnout should reduce its number among physicians interacting with patients infected with the coronavirus.
On March 11, 2020, the World Health Organization (WHO) declared an outbreak of new coronavirus infection as a pandemic.1 To reduce the rate of prevalence of COVID-19 pandemic on the territory of Russia, the government of the country introduced the regime of non-working days, which lasted from March 30 until May 11.2–4 Many shops and cultural institutions stopped their work; the work schedule of public transportation changed, and people had to follow a self-isolation regimen. Such extraordinary measures to fight against a viral disease were followed by the reorganization of all the spheres of public life and touched each citizen of Russia.
Probably medical personnel turned out to be in the most difficult conditions, as they were on the front line in the struggle with COVID-19. Current studies demonstrate that doctors and nurses have a high risk of mental and somatic disorders caused by the load increase in pandemic conditions.5–7 As an example, the viral SARS epidemic of 2002–2003 demonstrated that such factors influence the mental health of medical personnel as being in quarantine, direct work with infected patients, cases of SARS infection among friends, and close relatives.8 Zerbini et al9 concluded that the COVID-19 pandemic is a stressful event for medical personnel.
During the first wave of the COVID-19 pandemic, Chinese scientists have revealed numerous psychological problems in healthcare workers: they worry about their safety and the safety of their families and get alarmed by reports of death rates due to the novel coronavirus infection. Chinese studies have shown that several measures can help reduce psychological stress. For instance, official recognition of the importance of the work of healthcare workers on the part of their leadership and government, sufficient supplies to fight the infection (eg, medical equipment, drugs), and broad psychological intervention (eg, mental health hotline, stress relief groups) have proven to be valuable for improving the situation.10–11
The emotional tension in physicians in the conditions of a pandemic can increase burnout. According to a three-factor model of burnout developed by Maslach and Jackson,12 this syndrome includes emotional exhaustion, depersonalization, and reduction of personal accomplishment. Emotional exhaustion is considered as the basic component of burnout and is manifested in the form of reduced emotional background, indifference, or emotional oversaturation.12
Even though the last two decades have been characterized by a worldwide interest in burnout in medical personnel, many studies have limitations, including those of methodological character.13 Burnout is studied not only in the example of doctors but also in nurses and other medical personnel.14 In some countries, for example, in the USA,15 burnout has been widely discussed in the political arena.
Many studies on burnout in physicians of various specialities have been conducted in Russia before the pandemic evolved.16–20 Nevertheless, at the moment, there are no representative studies on Russian healthcare workers burnout during the first wave of the COVID-19 pandemic, and neither is there any verified data on what has been affecting the level of Russian physicians burnout during the pandemic.
The study aims to examine burnout in Russian physicians during the first wave of the COVID-19 pandemic. The research hypothesis of the study is the following: “There are some particular factors that affect the level of physicians burnout in Russia during the novel coronavirus disease pandemic”.
Methods
Data gathering was conducted from June 23, 2020 to July 12, 2020 using the Google form developed by the authors, which included questions of the inventory and test techniques to determine burnout and the level of anxiety and depression in Russian physicians. Before the study began, the Ethical Committee of Saint Petersburg State Pediatric Medical University approved it. During the interview performance, the restrictions introduced to fight against the prevalence of viral infection have been gradually softened in our country. According to the official data for June 23, 2020, there were 606,881 people who had a new coronavirus infection; 368,822 people recovered; and 8,513 people died in Russia.21 On this date, Russia was in fourth place in the world after the USA, Brazil, and India in the number of COVID-19 diagnosed cases.22 The Russian regions of Moscow, the Moscow Region, and Saint Petersburg were the most heavily affected by COVID-19.21
We developed a Google form and posted it at the platform con-med.ru designed for webinars and scientific conferences for physicians in Russia. In addition, we organized a webinar on “Mental Health during the COVID-19”, where the study was announced. The mentioned Google form was posted immediately following this webinar. More than 954 people from different regions of the Russian Federation attended the event, of which 599 participants expressed their desire to participate in the study and filled out the form.
The answers to the questions did not require any information that one could use to identify the personal data subject. The webinar recording and access to the Google form were available on the website con-med.ru for 20 days.
Before posting the final Google form, we conducted a pilot study, the purpose of which was to develop this questionnaire. In total, 59 students and employees of the Saint Petersburg State Pediatric Medical University filled in the trial form. As a result of the pilot study, we selected the questions included in the questionnaire and adjusted the phrasing.
The final questions were grouped in the following categories: (1) general social and demographic data; (2) influence of COVID-19 pandemic on the emotional and physical condition of physicians; (3) influence of the pandemic on patients; and (4) world outlook transformations in physicians on the conditions of the pandemic (eg, changes of attitude to life and death). The answer to the question “Did you work with COVID-19 patients?” (Yes/No) was the basis to divide the respondents into groups.
To identify fear of being infected by a coronavirus, we analyzed the answers of physicians to the following questions “Did you worry about being infected by the virus during the peak of a pandemic?” and “Did you feel any anxiety about the absence of any reliable preventive methods and treatment of COVID-19?” Furthermore, to find out whether the workload of physicians changed in the pandemic conditions, answers to the question “Did you work during the pandemic more than usual? were analyzed.
To study burnout, we used Maslach Burnout Inventory — Human Services Survey for Medical Personnel (MBI-HSS (MP)),12 adapted in Russia in 2002.23 The questionnaire consists of 22 points combined into three scales: “Emotional exhaustion” (range of values from 0 to 54), “Depersonalization” (range of values from 0 to 30), and “Personal accomplishment” (range of values from 0 to 48). Based on the suggested norms, the total values of each scale were arranged by three levels: low, middle and high.24 The answers were evaluated by a Likert 7-point scale and vary from “never” (0 points) to “always” (6 points). All the scales do not calculate the total score;12,15,24–28 burnout is identified by high values in the scales “Emotional exhaustion” (≥ 25) and/or “Depersonalization” (≥ 11), and/or low values by the scale “Personal accomplishment” (≤ 30) that determine a low evaluation of oneself as a professional.24
To determine the level of anxiety and depression, we used the Hospital Anxiety and Depression Scale (HADS),29 adapted on the Russian sampling in 1993.30 The questionnaire consists of 14 statements combined in two subscales — “Anxiety” and “Depression” — with the range of total values from 0 to 21. Every statement corresponds to four variants of the answer, demonstrating the sign gradation and coding according to the increase of the symptom severity from 0 (absence) to 3 (the maximum level). According to every subscale, there is calculated the total indicator which is interpreted as the absence of clearly manifested symptoms of anxiety/depression (0–7 points), subclinically manifested anxiety/depression (8–10 points) or clinically manifested anxiety/depression (≥ 11 points).
We used Fisher’s angular transformation (φ*-criterion) and Mann-Whitney U-test to determine the differences. To determine the connections between variables, there was applied Spearman’s rank correlation coefficient (rs). A significance level of < 5 % was used to establish statistical significance. The statistical analysis was made by the program complex IBM SPSS Statistics 25.
We chose a Fisher φ*-criterion as it is designed to assess the confidence of the differences between the percentage proportions of the two samples. The effect of interest on the researcher is registered. This criterion is easy to use and has minimal restrictions: for example, unlike Pearson χ2, there is no need to provide continuity correction. The main idea of Fisher angular transformation is converting percentage proportions to the central angle values, which is measured in radians. A more significant percentage proportion will correspond to a larger φ angle, and a smaller percentage proportion will correspond to a smaller angle. The ratios, though, are not linear:
φ = 2arcsin(√P), where
Р — percentage proportion, given in fractions of a unit
We did not use multiple testing corrections, particularly Bonferroni correction, to avoid increasing the probability of type II error. It is known that as the significance level increases (ie, the likelihood of type I error decreases), the probability of type II error increases. Therefore, our study tried to balance between α and β-errors.
Results
There were 599 physicians who took part in the study; 81.8% (n = 490) of them were women, and 18.2% (n = 109) were men (Table 1). The mean age of the sample was 47.35±10.77 years. The first group was composed of those physicians who worked with COVID-19 patients; they made up 31.2% (n = 187) of all respondents. The second group included those physicians who did not work with patients infected by COVID-19; they made 68.8% (n = 412) of all the study participants.
Demographic variables and physicians distribution by specialty
(Source: Authors’ analysis of the data)
Women made up the majority of both groups (78.1% in the first group, 83.5% in the second one; P ≥ 0.05). In the group of those physicians who worked with COVID-19 patients, there were statistically fewer people over 60 years of age than in the second group (8.6% and 16.3% accordingly; φ* = 2.677, P ≤ 0.01). In the first group compared to the second one, there were more physicians from Moscow and Moscow Region (26.2% and 19.4% correspondingly; φ* = 1.849, P ≤ 0.05). In the first group there were more physicians with the career stage of 11–20 years (34.8% and 24.0% accordingly; φ* = 2.699, P ≤ 0.01) than in the second group — those with the career stage of over 21 years (50.8% and 58.7% accordingly; φ* = 1.803, P ≤ 0.05).
In both groups, psychiatrists (17.6% in the first group, 23.2% in the second group; P ≥ 0.05) and neurologists (15.5% and 20.2% respectively; P ≥ 0.05) comprised the majority. However, therapists were third place in the first group (13.9% in the first group, 7.5% in the second group; φ* = 2.370, P ≤ 0.01), while psychotherapists formed the third majority in the second group (2.1% in the first group, 9.8% in the second group; φ* = 3.879, P ≤ 0.01). Furthermore, among physicians, who worked with patients infected with coronavirus, pulmonologists made up the larger number (4.8% in the first group, 0.2% in the second group; φ* = 4.003, P ≤ 0.01); general practitioners (3.4% and 0.5%, respectively; φ* = 2.472, P ≤ 0.01), and anesthesiologists (3.7% and 0.2%, respectively; φ* = 3.380, P ≤ 0.01), while in the second group there were more endocrinologists (1.6% — the first group, 4.4% — the second group; φ* = 1.917, P ≤ 0.05), ophthalmologists (0.5% and 2.4%, respectively; φ* = 1.917, P ≤ 0.05) and obstetricians-gynecologists (2.1% and 6.3%, respectively; φ* = 2.450, P ≤ 0.01).
The prevalence of psychiatrists, neurologists and psychotherapists, that is, mental health specialists, in our study was the result of asking physicians to fill in our Google form immediately after a webinar, the topic of which was related to mental health problems in the context of the COVID-19 pandemic.
Answers to the Questionnaire
Taking part in the study were 599 physicians, 81.8% (n = 490) of them were women, and 18.2% (n = 109) were men (Table 1). The mean age of the sample was 47.35±10.77 years. The first group was composed of those physicians who worked with COVID-19 patients and comprised 31.2% (n = 187) of all respondents. The second group included those physicians who did not work with patients infected by a coronavirus and comprised 68.8% (n = 412) of all the study participants (Figure 1). All the respondents indicated that the absence of reliable methods of prevention and treatment of coronavirus infection caused anxiety (80.7% and 74.3% accordingly; φ* = 1.747, P ≤ 0.05). Most of the physicians (63.6%) of the first group marked the increase of the work volume in the conditions of the pandemic, while part of the physicians (43.4%) from the second group answered that they had less work (P ≤ 0.01).
Distribution of the answers to questionnaire among those physicians who worked and did not work with COVID-19 patients. *, P ≤ 0.05; **, P ≤ 0.01.
Results of Test Techniques
High degree of emotional exhaustion was revealed in 43.3% (n = 81) of the physicians from the first group and 33.0% (n = 136) from the second (φ* = 2.404, P ≤ 0.01). High indicators according to the depersonalization scale were revealed in 41.7% (n = 78) of respondents from the first group, while in the second group such indicators were identified in 34.0 % of the physicians (n = 140) (φ* = 1.803, P ≤ 0.05). These indicators demonstrate burnout. According to the scale “Personal accomplishment,” the groups of physicians did not have statistically significant differences (Table 2). Mean values of emotional exhaustion were higher among those physicians who worked with COVID-19 patients than among those who did not work with such patients (mean = 23.76 and 20.67, respectively; U = 0.001, P ≤ 0.05) (Table 3).
Number of physicians with different levels of burnout depending on emotional exhaustion, depersonalization, and reduction of personal accomplishment (Source: Authors’ analysis of the data)
Mean values and quartile intervals for the symptoms of burnout in physicians (Source: Authors’ analysis of the data)
According to HADS, an absolute majority of physicians from both groups did not manifest any anxiety (71.1% — the first group, 79.9% — the second group; φ* = 2.177, P ≤ 0.05) and depression (78.1% — the first group and 84.0% — the second group; φ* = 1.713, P ≤ 0.05) (Table 4). However, the analysis of mean values of anxiety and depression demonstrates the fact that these symptoms are manifested more intensively in the medical personnel from the first group than in the physicians from the second one (P ≤ 0.05) though they are within normal levels (Table 5).
Number of physicians with different level of anxiety and depression (HADS) (Source: Authors’ analysis of the data)
Mean values and quartile intervals for anxiety and depression (HADS) in physicians (Source: Authors’ analysis of the data)
Figure 2 and Figure 3 demonstrate the results of the correlation analysis according to the scales MBI-HSS (MP) and HADS, as well as the age and career stage of the respondents. We found weak negative associations between age and depersonalization in both groups and between work experience and depersonalization. However, a weak negative relationship between age and emotional exhaustion was revealed in a group of physicians who did not work with coronavirus infected patients. In addition, a weak positive relationship between work experience and personal accomplishment was also shown. In both groups of physicians, anxiety and depression with a high statistical probability (P ≤ 0.01) are positively associated with emotional exhaustion and depersonalization and negatively associated with personal accomplishment.
Statistically significant correlations (rs) of the scales MBI, HADS, age, and career stage in the group of physicians who worked with COVID-19 patients (n = 187). A, anxiety; Dep, depression; EE, emotional exhaustion; D, depersonalization; PA, personal accomplishment; CS, career stage; —, positive correlation; ---, negative correlation; *, P ≤ 0.05; **, P ≤ 0.01.
Statistically significant correlations (rs) of the scales MBI, HADS, age, and career stage in the group of physicians who did not worked with COVID-19 patients (n = 412). A, anxiety; Dep, depression; EE, emotional exhaustion; D, depersonalization; PA, personal accomplishment; CS, career stage; —, positive correlation; ---, negative correlation; *, P ≤ 0.05; **, P ≤ 0.01.
Regardless of working or not with infected patients, physicians showed an identical correlation between the components of burnout. With a high statistical probability (P ≤ 0.01), emotional exhaustion is positively associated with depersonalization and negatively associated with personal accomplishment. At the same time, personal accomplishment has a negative relationship with depersonalization.
Discussion
Even though recently there has been interest in the problem of burnout in medical personnel and many studies concerning this problem have been performed,13 the influence of viral epidemics (pandemics) on the intensity of burnout syndrome in medical personnel have not been studied sufficiently. Our study is unique as we have demonstrated for the first time the interrelation of burnout symptoms in Russian physicians and their interaction/absence of interaction with patients infected by COVID-19. Furthermore, physicians from different regions of Russia participated in our study, so the sample of 599 persons is representative.
We identified that in the pandemic conditions, most physicians had anxiety concerning COVID-19 infection, and they observed all necessary safety measures. However, direct interaction with infected patients is associated with the fact that physicians were more conscientious about following public health measures for controlling viral spread and were less predisposed to consider the pandemic greatly exaggerated. In addition, physicians worried about the absence of reliable methods of COVID-19 prevention methods and treatment. Some other studies demonstrated that in medical personnel, the fear of COVID-19 infection is connected with emotional exhaustion, depression, anxiety and stress.9
In the group of the physicians who worked with COVID-19 patients, 2.7 times more indicated an increase in work volume during the pandemic. Therefore, it is urgent to understand the organization of work in the medical institutions involved in the fight with coronavirus. Working with infected patients increases the risk of high-level emotional exhaustion, reduced emotional background, indifference, and depersonalization (deformation of relations with people) in Russian physicians that leads to burnout, but does not affect personal accomplishment. According to the intensity of depersonalization, the physicians interacting with COVID-19 patients are similar to doctors in emergency medical services.25 It is remarkable that in Germany the work in COVID-19-departments had a negative effect on the emotional condition of nurses only, but not on doctors,9 and in Wuhan, China, it promoted a lower level of burnout and lower level of anxiety concerning COVID-infection.28
Most physicians who took part in our study did not identify anxiety and depression symptoms by the HADS questionnaire. Moreover, all quartile interval values, in comparison with standard ones29 were displaced to the left towards reduction. This means that the physicians demonstrated “over normal” results, which, however, does not correspond with data received from the questionnaire and MBI. In our opinion, such results can be caused, for example, by social desirability, the negation of any disturbing-depressive symptoms or problems in reflection of one’s experience — alexithymia (for example, Riethof et al35 revealed some relationship between the syndrome of burnout and alexithymia in medical personnel). In any case, a question arises as to whether the use of HADS is informative to diagnose the symptoms of anxiety and depression in Russian physicians.
The analysis of correlations of the scales MBI, HADS, age, and career stage demonstrated that the structure of burnout in all physicians is identical and does not depend on the interaction with infected patients. The structure is understood as “a set of stable relations of an object that serve for ensuring its integrity and identity with itself, that is, the preservation of basic properties under various external and internal changes.”36 Burnout is a theoretical construct consisting of such elements as emotional exhaustion, depersonalization, and personal accomplishment (a three dimensional model of burnout by C. Maslach and S. Jackson). The structure of burnout we define as a relationship between these elements.
Emotional exhaustion (an affective component of burnout), depersonalization (behavior component) and personal accomplishment (ideation component) are interconnected. Besides, a professional accomplishment (personal accomplishment) in Russian physicians decreases as emotional stress (emotional exhaustion) and distancing from patients (depersonalization) increases. Similar results were received by Song et al37 in the sample of 642 Chinese doctors where there was identified a positive correlation between emotional exhaustion and depersonalization (rxy = 0.788, P ≤ 0.01) and negative correlation between depersonalization and personal accomplishment (rxy = -0.183, P ≤ 0.01).
As for all physicians, it was demonstrated that along with the increase of age and career stage, the level of depersonalization decreases; in the group of those physicians who did not interact with COVID-19 patients, there was found a negative correlation of age and emotional exhaustion and positive correlation of career stage and personal accomplishment. It indicates that young physicians are more susceptible to burnout than their more experienced colleagues. However, mature age and extensive work experience cannot be considered factors preventing emotional exhaustion and reducing personal accomplishment when working with infected patients. Our data correlate with the results of the majority of previous studies38–42 and contradict some studies, for example Reis et al43 in which it was underscored that physicians of older age had a higher burnout level.
Correlation analysis also showed that with an increase in anxiety and depressive affect, emotional exhaustion and depersonalization also increased in all physicians, while personal accomplishment, on the contrary, decreased. This indicates that the emotional state of Russian physicians during the pandemic was closely related to burnout.
Our study demonstrated that working with COVID-19 patients increased the risk of emotional burnout in physicians, and the biggest contribution was made by an affective component of burnout (emotional exhaustion). As it was demonstrated in previous studies, burnout of a physician can threaten the treatment of his patients,39 leading to unprofessional behavior,44 decreaseing the level of medical service and satisfaction of patients,39 and causing negative attitude toward patients.45 Therefore, it is essential that government executive bodies and health authorities pay particular attention to the emotional well-being of medical personnel, especially those who are involved in medical services provided to patients infected by the coronavirus.
Our study has several limitations in terms of generalization of the results obtained. First, most respondents live in federal cities (Moscow and St. Petersburg) and other economically developed regions (Moscow and Leningrad regions). These areas of the federation are characterized by the highest living standards within the country. Therefore, the physicians who work there have a higher income compared to the national average. Most of the respondents were accomplished physicians with work experience of 11 years or more in our study. However, this fact limits generalization, as many studies have shown that seniority highly correlates with burnout.
Psychiatrists, neurologists, therapists, and psychotherapists predominated significantly among the physicians who took part in the study. Therefore the extrapolation of the obtained results to the entire general population of Russian physicians has certain limitations.
Our study was conducted during the first wave of the COVID-19 pandemic in Russia, when the country introduced strict anti-epidemiological measures, such as a self-isolation regimen. Unfortunately, the health care system in the country was not able to sustain such circumstances. Therefore, we assume that the burnout rate of Russian physicians measured during the second and subsequent waves of the pandemic may differ from our results.
Conclusion
Our study results demonstrate that the structure of burnout in Russian physicians in the conditions of the COVID-19 pandemic was not connected to directly working with infected patients. Nevertheless, interaction with COVID-19 patients is associated with higher emotional exhaustion and depersonalization in medical personnel. In the context of the pandemic, the public authorities of the healthcare system should initiate measures to reduce the workload on physicians involved in treating infected patients or consider redistributing it.
The government should support the organization of psycho-correctional and psychotherapeutic programs for physicians interacting with infected patients to reduce the number and severity of burnout (foremost the symptoms of emotional exhaustion and depersonalization). In addition, building the psychological capacity of physicians to work with infected patients (for example, learning techniques for emotional self-regulation) is essential. This is especially important for young professionals with little work experience.
Since the pandemic conditions are not unique for the healthcare system in Russia, the data we obtained might serve as a beginning for a large-scale study on the adaptation mechanisms of healthcare workers to the conditions of viral epidemics. In addition, a training manual for healthcare workers may be a result of the work, highlighting the main psychological problems that physicians face when working with infected patients.
Acknowledgments
We are thankful to the company Lundbeck (Russia) for the help in the organization of interviewing and gathering of the study material.
Footnotes
Disclosure: The authors have not reported any conflicts of interest or financial support related to this work.
- Received November 5, 2020.
- Revision received August 22, 2021.
- Revision received January 3, 2022.
- Accepted January 3, 2022.
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