Prevalence of burnout and its correlates among residents in a tertiary medical center in Kerala, India: A cross-sectional studyB Ratnakaran, A Prabhakaran, V Karunakaran
Department of Psychiatry, Government Medical College, Thiruvananthapuram, Kerala, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.184274
Source of Support: None, Conflict of Interest: None
Background and Rationale: Residents work in emotionally demanding environments with multiple stressors. The risk for burnout is high in them and it has significant negative consequences for their career. Burnout is also associated with consequences in terms of physical and mental health including insomnia, cardiovascular disease, depression and suicidal ideation. Thus, the study aimed to study the prevalence of burn out and its correlates among interns and residents at Government Medical College, Thiruvananthapuram, Kerala, India. Settings and Design: Cross Sectional Study at Government Medical College, Thiruvananthapuram, Kerala, India. Methods: It was a cross Sectional study of 558 interns and residents of Government Medical College, Thiruvananthapuram, Kerala, India. Data was collected which included the Copenhagen Burnout Inventory [CBI]which assesses burnout in the dimensions of Personal burnout, Work burnout and Patient related burnout, with a cut off score of 50 for each dimension. Age, sex, year of study, department the resident belonged to, or an intern, junior resident or a super speciality senior resident (resident doing super speciality course after their post graduate masters degree) were the correlates assessed. Statistical analysis: Univariate analysis. Results: More than one third of the participants were found to have burnout in one or another dimension of the CBI. Burnout was found to be the highest among the interns in the domains of personal burnout (64.05 %) and patient related burnout (68.62 %) and in junior residents for work related burnout (40%). Super specialty senior residents had the least prevalence of burnout in all three dimensions. Among the residents, Non Medical/Non Surgical residents had the least prevalence of burnout in all three dimensions, whereas surgical speciality residents had the highest of personal burnout (57.92 %) and Medical speciality residents had the highest patient related burnout (27.13%). Both medical and surgical specialty residents had equal prevalence of work burnout. The study also showed that as the number of years of residency increased, the burnout also increased in all three dimensions. A between gender difference in burnout was not noticed in our study. Conclusions: Burnout was found to be present in a large number of residents in our study. Nationwide studies and assessment of more correlates will be needed to understand this phenomenon and also for formulating measures for preventing and managing it.
Keywords: Burnout, interns, residents
The concept of burnout first emerged in the mid-1970s and was described by two researchers, Christina Maslach and Herbert Freudenberger, with the latter coining the term. , In the World Health Organization's (WHO) International Classification of Diseases (ICD), 10 th revision, burnout is coded as "Z73.0, Problems related to life management difficulty" and is defined as a "state of vital exhaustion."  It is characterized by physical and mental exhaustion and is related to stress at work. Burnout is also associated with health consequences of insomnia, increased risk for cardiovascular disease, and increased inflammatory markers.  Over the last several years, burnout among health-care professionals has gained significant attention. As the field is filled with high expectations and demands, doctors are prone to develop burnout and its associated adverse consequences. , Burnout can hamper productivity of the physician.  The process of burnout can begin fairly early.  The burnout rates among medical students and residents have been reported to be 28%-45% and 50%, respectively. ,,, Studies have also compared burnout in various medical specialties and found it to range from 27% to 75%. 
In India, studies on burnout among professionals are limited and populations studied include Catholic priests, teachers, and human service professionals at a counseling center. ,, Stress rather than burnout has been the topic of research among doctors, residents, and medical students. ,, Against this backdrop, the present study was undertaken with the objective of evaluating burnout among residents at our institute.
The study protocol was approved by the institutional ethics committee, and written, informed consent was taken from all the participants. The questionnaire given to the participants did not have any unique identifiers including marital status and the identity of the participants was delinked from their responses.
Design and site
This cross-sectional study was carried out at the Government Medical College, Thiruvananthapuram, Kerala in Southern India.
All the interns and residents were working in clinical departments. Interns were defined as students doing their compulsory rotatory residential training after completing their final year in Bachelor of Medicine and Bachelor of Surgery (MBBS). Residents were defined as either "junior" (those doing their masters or postgraduate diploma in medicine and allied specialties) or "senior" (super-specialty residents pursuing training in various super-specialty medical courses following a postgraduate degree, i.e., MD or MS). They were further grouped as follows:
a) Medical residents: Those belonging to the general medicine, psychiatry, dermatology, nephrology, neurology, medical gastroenterology, pediatrics, respiratory medicine, and cardiology departments. This group had job demands and work environment that rely mainly on their knowledge and skills of accurate diagnosis and prescribing medications after an adequate risk benefit evaluation.
b) Surgical residents: Those from the general surgery, orthopedics, obstetrics and gynecology, anesthesia, otorhinolaryngology, ophthalmology, cardiovascular thoracic surgery, urology, neurosurgery, and surgical gastroenterology departments. Group b had job demands and work environment that rely mainly on their surgical skills and knowledge of anatomy.
c) Nonmedical and nonsurgical (NM/NS) residents: Those belonging to the radiodiagnosis, radiotherapy, community medicine, transfusion medicine, physical medicine and rehabilitation departments.
The residents who did not contribute to patient care directly were excluded (anatomy, physiology, biochemistry, pharmacology, pathology, forensic medicine, and microbiology).
Burnout was measured with the Copenhagen Burnout Inventory (CBI), which is a reliable and validated 19-item questionnaire.  The CBI focuses on exhaustion and its attribution by the person. The CBI has scales on personal burnout (six items on general exhaustion without a specific attribution), work-related burnout (seven items on exhaustion attributed to work in general), and client-related burnout (six items on exhaustion attributed to work with clients) (client in our study would mean patients).  All items have five response categories in a Likert scale, ranging either from "to a very low degree" to "to a very high degree" or from "never" to "always." Each scale ranges from 0 to 100 points, with high scores indicating higher levels of burnout. Total score on the scale is the average of the scores on the items. Eight nonscoring buffer questions were mixed with domain questions in order to avoid stereotyped response patterns and thus to avoid response bias.
The total score of burnout in each dimension of CBI for each resident was calculated. The mean, median and standard deviation of scores of each dimension of CBI was calculated. Categorical data, such as gender, were expressed as proportions. Burnout was defined as high and low burnout using the cutoff score of 50 that is the mid value of 0-100 point scale of the CBI for each domain. Both univariate and multivariate analyses were carried out using burnout as the dependent variable. The independent variables studied included age, gender, year of residency, type of specialty, and whether the candidate was an intern or a resident. All data were entered into Microsoft Excel and analysis was done using the Statistical Package for the Social Sciences (SPSS) software (version 16) (SPSS-Inc., Chicago, IL).
A total of 558 out of the 721 participants who were given the questionnaire responded giving a response rate of 77.39%. Per our definition, the number and percentage of medical, surgical, and NM/NS residents were 129 (23.1%), 202 (36.2%), and 74 (13.3%), respectively [Table 1]. A total of 232 out of 292 female residents (79.45%) and 326 out 429 male residents (75.99%) responded to the study [Table 2]. Interns were the highest responding category (80.1 %) and nephrology being the lowest (50%) [Table 1]. None of the cardiology residents [n = 18] and transfusion medicine [n = 6] returned the questionnaire.
Prevalence of burnout
The prevalence of burnout in all three dimensions of CBI was analyzed and tabulated in [Table 3]. The mean, median, and standard deviation scores for each burnout score were as given in [Table 4]. The analysis of variables associated with personal, work, and patient related burnout is given later in this article. Age wise statistical analysis was not done since it was noticed that there were no useful spread of age groups, the sample being from a homogenous age group.
Among the residents, NM/NS residents had the least prevalence of burnout in all three dimensions, whereas surgical specialty residents had the highest of personal burnout (57.92%) and medical specialty residents had the highest patient related burnout (27.13%,). Both medical and surgical specialty residents had equal prevalence of work-related burnout (41.09%). P-values for the comparison between the three groups were 0.005, <0.001, and 0.001, respectively.
Overall personal burnout was found to be 55.2%, with the highest being for interns (64.05%, p = 0.04) and the least being for super-specialty senior residents (46.67%). Overall work-related burnout was found in 34.8%, the highest being for junior residents (38.87%, p = 0.008) and the least being for super-specialty senior residents (21.67%). Overall patient-related burnout was found in 35.12%, the highest being for interns (68.62%, p < 0.001) and the least being for super-specialty senior residents (11.67%). Super-specialty senior residents also had the least prevalence of burnout in all the three dimensions.
The study also showed that as the number of years of residency increased, the burnout in all three dimensions also increased i.e., the first year residents had the least and the third year residents had the highest prevalence of burnout in all three dimensions (P < 0.001 in all three dimensions).
Significant gender differences in burnout were not noticed in the study.
More than one-third of the participants were found to have burnout in one dimension or another with a little more than half the residents (51.85%) having high scores of personal burnout. The CBI was chosen over the more popular Maslach Burnout Inventory (MBI) as it was found to have similar psychometric properties , and was available for free. Previous studies on burnout among residents have used the MBI that makes it difficult to make an exact comparison with our study findings. Nevertheless, these studies have also found nearly 50% of the study population having burnout. ,, We have not been able to find any studies using CBI to measure burnout among residents.
The lack of direction in their career, lack of participation in decision-making, the frequent rotations in different departments, and changing patient profile might be the cause of high personal and patient-related burnout among interns. Identity status and work engagement are found to contribute to burnout.  Favorable identity status and work engagement may be the reasons for the low burnout found among super-specialty senior residents. The similarities in the abovementioned factors could be the cause of similar findings of work-related burnout between the medical and surgical residents in spite of the differential work demands.
The increase in burnout associated with number of years in work could be an indicator of long-term stress being a factor in burnout. Ishak et al., in their literature review on burnout among residents have also come to the conclusion that burnout could be due to cumulative effect of various factors over a period of time.  However, Martini et al. in their study of burnout among residents across various specialties found that the first year of residency is independently associated with burnout, which is contrary to our study. 
The difference in prevalence of burnout across various specialties could be because of the varied emotional and type of work demands of different specialties. Medical residents have more interaction with patients that might the cause for higher patient-related burnout when compared with surgical residents. Personal burnout was higher for surgical residents in our study. A study on doctors working in the specialties of surgery and gynecology in Germany was also able to find high personal burnout (48.7%).  NM/NS residents might have lesser work demands, workload, and emergencies at work that could be the cause of lesser prevalence across all three types of burnout.
Gender did not seem to be a protecting factor for burnout in our study that is consistent with conclusions from various reviews of burnout among residents. ,
Our study might be the first attempt to assess burnout among residents in the country and has a good sample size (N = 558) and response rate of (77.39%). Limitations of the study include that the study has been done at a single center that might not replicate the same study environment in other centers. The relationship between marital status and burnout was not studied because of the reason mentioned in the ethics section of materials and methods. The relation of age and specific specialty wise variables with burnout were not assessed due to lower number of participants available for grouping. The impacts of marital status and age on burnout were not established. Residents from the cardiology and transfusion medicine department had not participated in the study. The number of residents in various specialties can vary in different institutions and in different countries making it difficult to compare results across all institutions and specialties. , Social desirability bias to the word "work" and "patient" related to the respective domains of burnout might be a cause of lower prevalence of work- and patient-related burnout. Another explanation could be that the participants could have better stress management skills while dealing with patients and adjusting with their work when compared to personal burnout that needs assessment. Our study is a cross-sectional study that will not explain how burnout varies and progresses over a period of extended time. Multicenter, blinded, prospective studies across all specialties will provide a better picture of burnout among residents in the country.
Burnout among residents has been associated with depression, anxiety, drug and alcohol abuse, and deterioration in health.  Burned out residents are also associated with suboptimal patient care.  Factors that have a strong relation with burnout including work overload, rewards, social support, job satisfaction, work hours, home responsibilities, and personality traits also need to be assessed as they have been found to have an association with burnout in previous studies.  Use of interventions, such as counseling, mindfulness techniques, cognitive behavioral therapy, social skills training, and organization directed interventions, which have been shown to be helpful in countering burnout can also be included in future research.  Resident doctors in India tend to be overworked.  The present study provides baseline information that can be used by policymakers to address this issue.
Faculty, staff and trainees of Department of Psychiatry, Government Medical College, Thiruvananthapuram, Kerala.
Financial support and sponsorship
The authors would like to state they have received no funding for the conduct of the study.
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4]