The COVID-19 pandemic has aggravated the levels of burnout among physicians who had to shoulder the burden of COVID19. Our present study aims to assess the level of burnout among Lebanese physicians along with how sociodemographic, occupational, economic, and pandemic-related factors affect the intensity of burnout. Besides, it aimed to explore the combined effects of the pandemic and the economic crisis on burnout. It is believed that this paper is the pioneer study in Lebanon focusing on burnout during the context of double hit and investigating factors associated with burnout and the combined effect of these crises among physicians.
A significant burnout level was detected among physicians during these unprecedented times. A strong association was found between sociodemographic variables, occupational, economic, and exposure factors with a higher levels of burnout. However, financial wellbeing, altruism, having good health, and a history of COVID-19 were significantly associated with a lower levels of burnout. The analysis of the combined effect of the COVID-19 pandemic and financial wellness demonstrated that the presence of both TP and financial hardship significantly increased the level of burnout.
Our findings revealed that burnout hits more than 90% of the Lebanese physicians and around 20% suffered from a high level of burnout. In addition, more than the third quarter of them expressed PB (mean=64.8) and WB (mean=71.5). As for CB (mean=58.7), it was detected among 69.6% of respondents (mean=58.7). Several studies documented burnout and its effects among physicians [61–64]. For example, a study reported that 45.8% of US physicians had experienced burnout .
The prevalence of burnout in all its aspects in this study was higher than those reported in other studies. In a systematic review covering 176 studies, an overall burnout of 48.7% was found . During COVID-19, burnout was prevalent among 57.7% of Jordanian physicians . Of note, the use of different tools for assessing burnout, impedes the comparison of our results directly with the findings of other previous studies such as the one conducted among Lebanese physicians in 2013 . In comparison with studies using the CBI scale whether before or after the pandemic, our findings were much higher than those reported in these studies. A study conducted among emergency physicians in Bahrein found a prevalence rate of 81.0% for PB, 69.8% for WB, and 40.5% for CB . Another study conducted among German general practitioners showed that one-third of physicians suffered from PB symptoms, one quarter showed WB while 12% of them reported a high prevalence of CB.
This crippling effect on mental health revealed by the huge prevalence of burnout among Lebanese physicians was predictable in such a typical context that cumulate the traumatic effect of the COVID-19  and the unprecedented economic crisis. Hence, urgent measures that tackle this tragedy are required to save an already ailing health sector.
Our findings showed that higher burnout was associated with the female gender. There have been contrasting results regarding gender. Some studies reported no gender differences whereas other studies found that females experienced more burnout compared to males . Consistently with our findings, McMurray et al.  reported that women physicians had increased odds of burnout when compared to men And Kannampallil et al. also found a higher prevalence of burnout amongst women during the pandemic .
Furthermore, this study highlighted the association between younger age and a high level of burnout. Our findings were consistent with the results of a study among Hungarian general practitioners and residents which considered younger age as the strongest predictor of burnout . However, another study conducted among Portuguese physicians reported that younger age and female gender were independent determinants of burnout .
Another important aspect of burnout, noticed in our study was that being married decreased the level of burnout. The findings of Shanafelt et al  supported our results concerning the presence of a partner (being married) and the decreased risk of burnout . This could be explained that physicians who are supported or feel supported by their partners or loved ones experienced less burnout when compared to those who do not. Interestingly another study showed that spouse support decreased burnout by 40% .
Notably having a dependent child or having a family member with comorbidities were both associated with higher burnout levels. Our results were comparable to those reported by Koh et al. and Maunder et al. both suggest that having children is a predisposing factor to burnout [4, 5]. However, McMurray et al. found that women physicians who had young children to look after reported a decrease in burnout by 40% . In summary, concerns about contracting the disease and transmitting it to family members were linked to higher burnout and anxiety .
In terms of pandemic-related factors, a higher TP was also associated with a higher level of burnout. It is well recognized that intense fear and TP when people experience physical and psychosomatic disorders lead to such anxiety, burnout, and emotional exhaustion [76–78]. The uncertainty surrounding the pandemic in terms of healthcare policy reform and compensation changes could also instigate burnout.
In terms of economic factors, a current low socioeconomic status and income, and negative financial wellbeing were associated with a higher burnout level. Of note, a previous higher socioeconomic status and a current fear of poverty were found associated with higher stress and burnout, whereas current financial wellness was correlated with lower burnout. Such piercing association in low- and middle-income countries is leading to several mental disorders . This was typical of the Lebanese context where physicians with savings in the country’s banks were unable to reclaim their money. Moreover, the enormous devaluation in the country’s currency led to a loss of more than 80% in physicians’ income . The current situation had detrimental consequences among physicians, including soaring burnout, and psychiatric illnesses [80, 81] in addition to an exodus of physicians who left the country searching for stability, financial wellbeing, and safety. It is well known that rising poverty and economic insecurity are associated with stress  which in turn, can lead to burnout and demission. In a country in freefall where the economic crisis is expected to escalate, health facilities were in danger of laying off employees, postponing some services, or completely closing their doors.
In terms of occupational factors, our findings showed that internal medicine and infectious diseases specialties of physicians were associated with higher levels of burnout compared with other specialties. The role of specialties as a contributor to burnout in our study may be partly due to differences in exposure to COVID-19 cases as ID specialists, and internal medicine physicians such as pulmonologists and cardiologists were more involved than other physicians in the treatment of COVID-19 cases.
This dissimilarity of burnout among specialties was also highlighted by a meta-analysis conducted by Lee, et al. Besides, our findings highlighted that burnout rates were highest amongst physicians involved in frontline care. This was predictable since their job presented a higher risk of infection since they are in direct contact with COVID19 cases. A study conducted by Kannampallil et al. showed similar results concerning who reported that had a higher prevalence of burnout (46.3%) among physicians exposed to COVID-19 patients compared to those who were not exposed (33.7%) .
However, other studies conducted among physicians found different aspects . For example, Wu et al and found that medical staff working on the front line had a lower level of burnout compared to those working on usual wards explaining this unexpected trend, by suggesting that frontline workers may have felt a greater sense of control over the situation. Similar to other studies, our findings showed that insufficient sleeping hour and extensive working hours were associated with a higher level of burnout.
One peculiar finding in our study was that working in public hospitals was found associated with higher burnout. In fact, public hospitals were firstly designated by health authorities to treat and isolate COVID-19 patients, hence physicians working in hospitals were more exposed to COVID-19. Given the economic collapse and short of funds, the government was unable to support alone hospitals with much-needed resources and supplies. This called for the support of foreign and local non-governmental aid to import essential supplies and equipment, including personal protective equipment.
In regards to extensive working hours and sleep deprivation, several studies highlighted that sleep deficiency is a key risk factor for burnout among physicians . With the soar of COVID-19 cases, physicians are facing intense workload, extensive working hours, which eventually impacted physicians sleeping hours. A study conducted among HCWs prior to the pandemic showed that 33% of them were screened positive for the sleeping disorder  which was associated with 4-fold bigger odds of burnout.
In addition to the above, limited work experience was associated with higher burnout. Consistently, a Portuguese study reported that HCWs with larger experience were less affected by burnout . Another study conducted among physicians in Lithuania found a significant reverse relationship between work and patient burnout and length of employment . However, previous experience during a previous pandemic or emergency decreased the level of burnout. This can be explained that previous experience provides physicians with a sense of confidence and control over the situation and lessens their worries when dealing with patients. Physicians with good health status and previous history of COVID-19 experienced a lower level of burnout. Their good health status and a history of COVID-19 could lessen their concerns about their susceptibility as a previous infection could instigate their sense of being immune naturally.
The role of altruism in decreasing the level of burnout was supported by our study as we found that physicians who accept the risk of caring for COVID19 cases had lower burnout levels in comparison with those who didn’t accept this risk. Our results were compatible with the findings of a Turkish study which reported that the burnout level of physicians who were actively involved in the fight against COVID-19 was lower than their counterparts who are not actively involved .
Lastly, the combined effect of the threat of COVID-19 pandemic and financial hardship significantly increased burnout levels among physicians. Despite the scarcity of previous studies tackling such a topic, a review supported the effect of economic uncertainty on mental health in the era of COVID-19 . The increased risk of burnout among Lebanese physicians necessitates a combined approach addressing the stressors resulting from both of the pandemic and economic crisis.