An Evaluation of Burnout Among Foundation Doctors in Malta


 BackgroundPostgraduate medical trainees are at an increased risk of burnout. Burnout has been defined as “a psychological condition of emotional exhaustion, depersonalization and reduced personal accomplishment occurring in people persistently exposed to emotional and interpersonal stressors at work”. It can arise either from within the individual, from the medical profession itself or from healthcare organisations. Burnout is associated with mental health issues in trainees, impaired work performance and suboptimal patient outcomes.MethodsA cross-sectional observational study of three cohorts of the Malta Foundation Programme was conducted using the Copenhagen Burnout Inventory (CBI) to evaluate incidence of personal-, work-related and client related burnout. The cohorts were at 3-months, 1-year and 2-years of training respectively. The CBI was administered via Google Forms after ethical clearance. Descriptive statistics and non-parametric comparative statistics were used to analyse the results through SPSS v25.0.ResultsA global response rate of 26.5% was achieved. CBI and its sub scales showed good internal validity. High scores for burnout in all three scales were identified except for client-related burnout in First Year doctors. Burnout peaked midway through the 2-year period. High numbers reported “feeling “tired” and “physically exhausted”. Males reported more burnout than females.ConclusionThe high level of burnout so early in the career of Maltese postgraduate medical trainees is of concern. More studies are needed on the causality of this burnout and what factors are associated with burnout in this population.


Introduction
Burnout has been de ned as " a psychological condition of emotional exhaustion, depersonalization and reduced personal accomplishment occurring in people persistently exposed to emotional and interpersonal stressors at work" (Maslach and Goldberg, 1998). Emotional exhaustion has been de ned as "feelings of being overextended and depleted of one's emotional resources". Depersonalisation has been de ned as a "negative, cynical and detached response to other people, including patients and colleagues". Lack of personal achievement occurs with feelings of ine cacy and a person feeling less competent in his or her work. (Maslach, Jackson and Leiter, 1996) Postgraduate medical trainees are at an increased risk for burnout (Thomas, 2004). The move from medical school to postgraduate training is fraught with stress, working long hours and huge responsibilities. Suddenly, the lives of others depend on decisions taken by the newly graduated trainees, who at the same time are seeing their knowledge increase in an exponential manner. At a time when they are aware of their huge responsibilities, medical trainees may, however, feel they are not much in control.
Some level of stress in trainees is inevitable and actually favourable (Thomas, 2004). However, high levels of stress may be associated with burnout which in turn has been associated with mental health issues in trainees and an impaired work performance that may lead to suboptimal patient outcomes (Ishak et al., 2009). It is widely accepted that burnout is widespread among doctors. The prevalence, however, varies between countries and between specialties. The stage of one's career is also known to have an in uence on the prevalence of burnout (Kumar, 2016). It has also been suggested that the rate of burnout among doctors is rising  with signi cant consequences on those affected, their colleagues, the patients under their care and on the healthcare system as a whole .
Mental health issues experienced by trainees suffering from burnout include depression, anxiety, sleep disorders, increased risk of suicide, alcohol and drug abuse and fatigue. Physical symptoms may include headaches, gastrointestinal symptoms and decreased appetite. Cardiovascular disease and increased biomarkers are also more common in trainees suffering from burnout (Ishak et al., 2009) Three main sources of burnout have been identi ed. Burnout can result from causes within the individual such as perfectionism, the medical profession itself e.g. a blame culture, and from healthcare organisations e.g. working conditions (Lemarie and Wallace, 2017).
Unfortunately, most of the interventions to tackle burnout have only focused on the individual and on ways to increase the resilience in individuals. (West et al., 2016). Methodology were "extended Foundation" doctors. The latter were a group of trainees who had just nished their two-year Foundation Programme. These trainees were waiting for their specialization posts to be assigned. Though technically this latter group does not fall under the responsibility of the Malta Foundation Programme any longer, they presented a good opportunity to survey trainees at the end of their two-year programme.
The survey was conducted in July/August 2020 for Foundation Year 2 and extended Foundation doctors. First-year Foundation doctors were surveyed in October 2020, at the end of their rst rotation. In this way, the three cohorts were surveyed at 3-months, one-year and twoyears of training respectively.
The instrument used to measure burnout was the Copenhagen Burnout Inventory. This is an established and widely used burnout measure.
It is also the measure recommended for use by the General Medical Council (GMC, 2020).
The Copenhagen Burnout Inventory (CBI) is a 19-item questionnaire that is in the public domain. Nevertheless, personal communication with the author (Kristensen et al., 2005) ensured the permission to use in this study. The CBI consists of three scales, each measuring personal burnout, work-related burnout and client-related burnout respectively. The items are scored on a Likert scale scored as follows: 100 -Always or to a very high degree 75 -Often or to a high degree 50 -Sometimes or somewhat 25 -Seldom or to a low degree 0 -Never/almost never or to a very low degree The rst scale, personal burnout, consists of six items that measure the level of burnout in people irrespective of their occupational status.
The second scale, work-related burnout, is a seven-item scale evaluating whether a person attributes any experienced fatigue and exhaustion to his/her work. The third scale, client-related burnout, consists of six items. It evaluates whether a person attributes any fatigue and exhaustion being experienced to the work with clients eg patients or students (Kristensen et al., 2005).
The CBI has been validated and used in various countries including Denmark, New Zealand, Hong Kong, Taiwan and Sri Lanka (Ferrando and Samaranayake, 2019).
The questionnaire was administered online via Google Forms via an invitation to participate sent to all trainees. A covering letter and a participant information sheet accompanied the invitation to participate in the study. Informed consent was obtained from all participants. All replies were collected online and were completely anonymous. Each participant was asked to submit one reply only. A reminder was sent one week after the start of the data collection period. Data collection was terminated two weeks after the reminder.
Ethical approval was sought and obtained from the Faculty Research Ethics Committee of the University of Malta. Authorisation to distribute the questionnaire was obtained from the Foundation Programme, Malta.
The responses were analysed using SPSS v25.0. Descriptive statistics were used to describe the cohorts. Reliability for each scale was computed using Cronbach's alpha. A mean score was computed for each of the three CBI scales. A score of more than 50 was used as a cut off for the presence of burnout in each of the three scales (Klein et al., 2010). For each scale, mean score, standard deviation and prevalence of burnout with con dence intervals were calculated. The Mann-Whitney U test was used to analyse differences between genders. The Kruskall-Wallis H test was used to test for differences between Foundation years. The threshold for statistical signi cance was a p < 0.05 and 95% con dence interval.  Table 1 demonstrates how the level of burnout is high across all stages of Foundation training in Malta (insert Table 1 here). The highest levels of burnout are found midway through the two-year training period. Levels of burnout decrease towards the end of training but are still higher than at the beginning of the training period. Kruskall-Wallis H analysis of these ndings showed they are statistically signi cant for each of the three scales: for personal burnout (H(2) = 10.978, p = 0.004), for work-related burnout (H(2) = 15.235, p = < 0.001), and for client-related burnout (H(2) = 13.244, p = 0.001). Table 2 shows the mean ranking for each year (insert Table 2 here)  Table 3 shows these ndings in a tabular way (insert Table 3 here).  Table 4 shows the mean score for each of the 19 items of the CBI for each cohort. Of concern are the scores for items 1 and 2 "How often do you feel tired" and "How often are you physically exhausted". Both questions show very high scores across all three cohorts.  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 con icts.

Demographics
Medical practice is fraught with high levels of emotions and stress. Newly graduated doctors nd 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, nancial 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. 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 nding in this study that males are more prone to work-related and client-related burnout than their female counterparts contrasts with the ndings 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 signi cant 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 ne 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) 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 nancial 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 identi ed in this study.

Limitations
This study's low response rate in a major limiting factor. This could be due to the study being conducted during a pandemic that has increased the workload of this study's population manyfold.
The low response rate increases the likelihood that trainees that were most affected by or interested in burnout responded. This increases the risk of response bias.
Studies using the Copenhagen Burnout Inventory in a Maltese population were not available. Therefore, the cutoff score of 50 for all three burnout scales, used in other research, had to be adopted for this study.
The study did not go into causative factors of burnout. Another paper investigating the role of the educational environment in the development of burnout is planned.

Conclusion
The high level of burnout so early in the career of Maltese postgraduate medical trainees is of concern. More studies are needed on the causality of this burnout and what factors are associated with burnout in this population. While efforts by the Foundation Programme to tackle burnout with trainees identi ed to be at risk are in place, more efforts may be needed aimed at dealing with the risk of burnout at an organizational and institutional level.

Declarations
Ethics approval and consent to participate Ethics approval was obtained from the Faculty Research Ethics Committee at the University of Malta. Permission to conduct the study was also obtained from the Foundation Programme, Malta. Informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations Consent for publication I give my consent for the publication of the manuscript Availability of data and materials The datasets generated and/or analysed during the current study are available in the [NAME] repository: https:// gshare.com/articles/dataset/An_evaluation_of_the_educational_environment_and_burnout_at_the_Malta_Foundation_Programme-3_numbers/13215428/1 No competing interests to report

Funding
The author has self-funded this study.

Authors' contributions
Marco Grech was the sole contributor to this manuscript