The level of burnout is high across all stages of Foundation training in Malta. The highest levels of burnout are found midway through the two-year training period. As described earlier, levels of burnout decrease towards the end of training but are still higher than at the beginning of the training period. Similar results were presented by Rosen et al. (2006) who found that a dramatic rise in the prevalence of burnout occurs over the course of an academic year. A meta-analysis by Lee et al. (2013) describes how American doctors have higher levels of emotional exhaustion than their European counterparts. This has been attributed to a better safety culture and career development opportunities in Europe. This metanalysis also highlights the importance of studying burnout in the context of stressors relating to the work environment (such as quality and safety culture) and personal attributes (such as positive work attitudes and work-life conflicts.
Medical practice is fraught with high levels of emotions and stress. Newly graduated doctors find themselves suddenly having to deal with a plethora of situations that are highly emotional such as a dying patient, failure of treatment such as a failed CPR, delivering bad news to patients and relatives, and dealing with uncertainty in clinical practice while working long hours with very little rest. On top of this, these trainees have to deal with situations at home and at the workplace that are not the direct effect of the doctor-patient relationship. These include relationship problems, financial issues, bureaucratic requirements, limited resources and an increasingly litigious environment. Moreover, trainees are at a stage where they are constantly trying to keep in touch with the ever increasing medical knowledge, learn new skills and study for exams to further their career. All of this may be overwhelming for some and contribute to the development of burnout.
This high prevalence of burnout identifies a significant problem in this population of doctors in their early years of training. Such high levels of burnout may interfere with trainees achieving the maximum out of their training and, therefore, preventive measures may need to be implemented. Research has shown that burnout is not limited to the early training years. In a study by Sharma et al. (2008) a third of UK-based colorectal and vascular consultants had features of burnout. Shanafelt et al (2015) report that 46% of respondents manifested at least one symptom of burnout. A similar study among European General Practitioners (Soler et al., 2008) identified that 43% scored high for Emotional Exhaustion, 35% for Depersonalisation and 32% for Personal Accomplishment.
The well-being of doctors is jeopardized by burnout. Research shows that burnout is associated with unhealthy eating habits (Golub et al., 2007), excessive alcohol consumption (Vithanage et al., 2015), smoking and drug abuse (Eckleberry-hunt et al., 2009) and even suicide (Kumar, 2016). Teaching medical students how to adopt a healthy lifestyle during their undergraduate years might come in useful in the early postgraduate years. It is important that our newly graduated trainees have the necessary competencies in physical and mental health promotion and maintenance (Ferrando and Samaranayake, 2019)
Interestingly, doctors have a higher prevalence of depression and burnout than the general population (Myers, 2008). This high prevalence of depression and burnout in doctors occurs despite many of the risk factors for depression, such as low income, low socioeconomic status and unemployment, are not applicable to doctors. This high prevalence of burnout may be associated with poor patient care resulting from poor judgement, disengagement from work with possible hostility towards patients and strained relationships with colleagues (Kumar, 2016). It is therefore essential to understand the risk factors for burnout in doctors as any interventions to prevent or treat burnout in doctors needs to be based on evidence.
Evidence in the literature on the effect of gender on burnout is inconclusive. It is possible that the effect of gender is compounded by the possible effects of cultural differences as studies have been conducted in different settings (Ishak et al., 2009). The finding in this study that males are more prone to work-related and client-related burnout than their female counterparts contrasts with the findings of another study (Ahmad et al., 2018) who described that female trainees were more likely to suffer from burnout. Ripp et al (2010) found no significant differences in burnout between genders.
Interestingly, the World Medical Association (WMA) (2015) observes that “physicians have rights as well as responsibilities”. The WMA observes that:
“physicians in many countries are experiencing great frustration in practising their profession whether because of limited resources, government and/or corporate micro-management of healthcare delivery, sensationalist media reports of medical errors and unethical physician conduct, or challenges to their authority and skills by patients and other healthcare providers.” (WMA, 2015, pg.114)
Medical trainees need help to be able to cope with burnout. Many times, this takes the form of interventions at an individual level. These interventions would include education in how to manage stress, the development of skills in the individual, improved time-management and the honing of coping skills in resilience and managing the fine work-life balance. However, attention needs also to be given to the work environment. Burnout risk is reduced when a trainee feels part of a team and if efforts are appreciated. A motivational leadership is also essential in reducing the risk of burnout (Bhatia and Saha, 2018)
Many countries have addressed or are addressing the number of hours per week worked by doctors in training. Many have also addressed the length of shifts that trainee doctors are expected to work. While helping trainees adopt a healthy lifestyle is an important factor in preventing burnout, one has to remember that burnout needs to be tackled at an organizational level too. 86.7% of respondents in this study have a working week that extends beyond the 48-hour week stipulated in the European Working Time Directive. While one has to note that this is done on a voluntary basis, it is also true that the system will probably collapse should Foundation doctors all opt to work within the European Working Time Directive. The reasons why these doctors opt to work in excess of 48 hours per week (42.3% work between 56–65 hours per week) need to be studied further and may include a need for a better take-home financial pay cheque, a perception that opting for the EWTD will have a negative impact on their career progression or lack of self-awareness.
This study was conducted during the COVID-19 pandemic. This pandemic has undoubtedly resulted in an increased workload on all healthcare professionals, with longer hours of work and a more stressful work environment. These factors could have also been contributors to the high degree of burnout identified in this study.