Burnout Among Physicians and Medical Interns: Comparing Time-periods of Coronavirus Disease Outbreak in Shiraz

Background: Physician burnout is a serious issue associated with physician attrition, mental and physical problems, and medical errors. This study aimed to investigate prevalence of overall burnout among Interns-Residents and general physician (GPs)-Specialist during the COVID-19 pandemic in Iran. Methods: This cross-sectional study was conducted among 220 Interns-Residents and 212 GPs-Specialists in university aliated hospitals and clinics in Shiraz, Iran. A random sampling method used to recruit the samples and the data gathered using a valid questionnaire. We used covariance analysis and multiple logistic regression to analyze the data. Results: Multiple logistic regression for GPs-Specialists showed that working in COVID-19 wards during June-July (OR = 13.93) was associated with increasing odds of overall burnout. However, older age was associated with decrease odds overall burnout (OR = 0.94). Multiple logistic regression for Interns-Residents revealed that age (OR = 1.24) and being single (OR = 1.66) were positively associated with overall burnout. Conclusions: The present nding could remind policy makers the importance of burnout issue among physicians during the pandemics and could persuade them for taking appropriate action in order to prevent this phenomenon. It is suggested that focusing on strategies such as improving organizational resilience, improvement of healthcare working environment, and development of coping skills among physicians could be helpful in this regard.


Introduction
Physician burnout is an important issue, shown its associations with physician attrition, mental and physical health, and self-reported medical errors.(1) The "burnout" phenomenon which is caused by work related stress, is a challenge for academic psychiatry both conceptually and professionally. Until now, more than 140 de nitions have been suggested from the rst description of burnout in 1974 (2) Therefore, a consensual de nition of occupational burnout is currently lacking (3). However, according to a recent systematic review several studies focusing on burnout issue have used Maslach Burnout Inventory (MBI) to assess burnout. (4) Considering MBI, burnout results from chronic exposure to stress: comprising emotional exhaustion (EE), depersonalization (DP) and a reduced sense of personal achievement (PA). (5) Burnout has been gaining much attention particularly due to its negative impacts such as poor physician health and functional outcomes, lower quality of care, shrinking physician workforce, and compromised patient safety.(6) Burnout for each individual is a result of interplay between his/her personal characteristics and environmental factors.
However, Stigma and fear of professional consequences appears to be an important barrier for physicians to express their burnout and access services . (7) Furthermore, this phenomenon has high costs for healthcare systems.(8) Thus, any additional evidence on this subject from all over the world is of great importance.
The coronavirus disease 2019 (COVID- 19) pandemic has brought several challenges to an underprepared healthcare system. Health care providers are facing unpredicted acute workplace stress as well as higher rate of physician burnout. (9) The rates of physician burnout, depression, and suicide have been increasing over the past 50 years. However, during the SARS-Cov-2 and COVID-19 pandemics these numbers are predicted to show a steep increase due to the increased work demands, social isolation, decreased self-care, and increased exposure to emotionally traumatic events at work and home.(10) Although the issue of burnout among physicians is not new, the COVID-19 pandemic is expanding the negative consequences of inadequate support by the authorities for solving this problem. (11) The pandemic has already posed strain on the entire healthcare system (12), consequently it is vital to provide precise data on the prevalence of burnout during different periods of time since the beginning of pandemic.
Physician burnout during COVID-19 pandemic in Iran has not been determined in previous studies and researches has tended to focus on nursing burnout (13,14). The present study aims to estimate the prevalence of overall burnout and its related sub-dimensions (using MBI) among Interns-Residents and general physician (GPs)-Specialists in 3 different periods of time since the beginning of the Pandemic. In addition, our study take a new look at the association between different variables including working in COVID-19 wards with the overall burnout of both mentioned groups.

Materials And Methods
This cross-sectional study was conducted among 220 Interns-Residents and 212 (GPs)-Specialists working at hospitals a liated with Shiraz University of Medical Sciences, southern Iran. The study was performed in three periods of time, including March-April 2020, June-July 2020, and December 2020-January 2021. These physicians had regular working schedule during the COVID-19 outbreak.
We used a simple random sampling method to recruit participants. To collect data, a trained questioner referred to university a liated teaching hospitals and their related outpatient clinics in Shiraz. Questionnaires were completed by participants who met inclusion criteria. Experience of at least 6 month presence at clinical wards was considered as inclusion criteria for interns. Willingness to participate in the study was considered as an inclusion criterion for all participants.
In this study we gathered data using a researcher-made checklist and a valid questionnaire. The checklist comprises demographic features and job characteristics, including working experience and taking care of COVID-19 patients. We also applied a valid Persian version of the Maslach Burnout inventory (MBI), which included 9 items on emotional exhaustion, 8 items on depersonalization, and 5 items on personal accomplishment (15). The MBI has frequency and intensity ratings. To avoid redundancy, the intensity rating was used in this study.
In this study, a physician with a high score for either the depersonalization and/or emotional exhaustion dimensions was considered as having at least one manifestation of job burnout. The level of emotional exhaustion was classi ed high if the score was greater than 26, intermediate if it was from 17 to 26, and low if the score was less than 17. In the depersonalization dimension, the overall score of more than 12 was considered high depersonalization, and the scores from 7 to 12 and less than seven were deemed to be intermediate and low levels, respectively. Personal achievement dimension score include higher than 39 (top level), from 32 to 38 (moderate level), and those below 32 (low level).
According to the Li et al. an exhausting score equal to or more than 27 or a depersonalization score equal to or more than 13 was considered as overall burnout (16).

Statistical methods
We analyzed data using IBM SPSS 18. Quantitative and qualitative variables were described by mean ± standard deviation (SD) and frequency (percent). The Chi-square test were used to compare qualitative variables between the groups. Total score of burnout and related sub-dimensions were compared between the periods of time using analysis of covariance adjusted for age and sex. To determine factors related to the overall burnout, we employed a multiple logistic regression. A P-value less than 0.05 was considered statistically signi cant.

Results
The participants' characteristics are shown in Table 1. The Mean age of participants was 25.33 ± 1.89 (ranged 21 to 31) years for Interns-Residents and 37.55 ± 9.01 (ranged 26-62) years for GPs-Specialists. Most of GPs-Specialists were married and female. Working experience in COVID-19 centers was signi cantly lower in December-January than March-April. The comparison of total score of burnout and related sub-dimensions is presented in Table 2. For Interns and Residents, the mean score of burnout, depersonalization, and reduced achievement were signi cantly higher in December-January than March-April. In the June-July, GPs and Specialist reported highest level of burnout, emotional exhaustion, and depersonalization. Emotional exhaustion for interns and Residents, and reduced achievement for GPs and Specialists were not signi cantly different between the periods of time. One-hundred and fty-seven (71.4%) Interns-Residents and 141 (66.5%) GPs-Specialists had overall burnout. The prevalence of overall burnout was not statistically different between the two groups (P = 0.27).

Discussion
In this study we have provided further information on overall job burnout and its related sub-dimensions among interns-residents and GPs-Specialists during three separated periods of time in the era of the COVID-19 pandemic. In addition, we have searched for signi cant association between sex, age and working in covid-19 wards with the overall burnout in both groups.
While there was not any signi cant difference between the prevalence of overall burnout among internsresidents and GPs-Specialists, the highest mean score of burnout and its sub-dimensions including depersonalization, and reduced achievement for interns-residents was attributed to December-January. This score for GPs-Specialists was at highest level during June-July with the exception in the sub-dimension of reduced achievements. The higher values of overall burnout score in December and January correlates fairly well with the study written by Amanullah et al. (17) and further support the concept of increasing burnout resulting from the increasing workload due to COVID-19. This substantiates previous ndings in the literature which has shown statistically signi cant decrease in EP wellness during the pandemic of COVID-19 as a result of the followings: 1-feeling less happy while being at work, 2-having more stress on days not being at work, 3having more trouble falling asleep, 4-having a sense of dread when thinking of work needing to be done and 5being more concern about ones' health and the health of the beloved ones.(18) A recent study (19) has shown that burnout levels among emergency physician remained stable during the initial weeks of the pandemic. is an area for more research. Moreover, given that our ndings are based on a limited number of participants, the result from such analysis should be considered with the utmost caution.
Moving through the rest of our results, the most striking point was the correlation between working in COVID-19 wards and burnout in June-July for GPs-Specialists versus lack of any similar correlation for Interns- All the participants were asked to ful l their written consent form before completing the questionnaires. All the participants completed the questionnaires willingly and were ensured of the con dentiality of the collected data.

Consent to publish
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests