The medical profession is deemed to be a demanding and stressful profession with serious consequences if there is flawed decision making as it impacts patient care. The concept of burnout, which has been defined as a “psychological syndrome characterised by emotional exhaustion, depersonalisation and a sense of reduced accomplishment in day to day work” [1
], is being increasingly recognised as a factor not only affecting physician health but also the patients in their care. Numerous previous studies have reported the huge prevalence of burnout seen amongst physicians [2
], with one such study conducted by Shanafelt et al. reporting that 45.8% of a sample of 7288 US physicians had experienced burnout [6
]. The consequences of burnout are potentially very serious for physicians as well as those with whom they interact. Burnout has been proven to cause a deterioration in the quality of care or services provided by the staff [1
]. Furthermore, burnout appears to be correlated with increased use of alcohol and drugs, physical exhaustion and marital and family problems [1
]. Hence, results reported by Shanafelt et al. are of huge concern, and with this current pandemic of COVID-19, it has only made it even more worrying and difficult for medical professionals.
To our knowledge, there have been very few papers that have explored the impact of COVID-19 on physician burnout, however, the method of assessing burnout has varied. The Maslach Burnout Inventory (MBI) is most widely used in research to measure burnout and has been regarded as the “measure of choice” for assessment of burnout [1
]. It has been designed to assess the three components of burnout: emotional exhaustion, depersonalisation and reduced personal accomplishment—a score is then received for each component, which can be classified as low, average or high burnout status [1
]. One such study by Wu et al. found that a significant proportion of physicians are experiencing more burnout after the introduction of COVID-19 compared to pre-COVID-19 using the Maslach Burnout Inventory (MBI) [7
]. Whereas a cross-sectional survey by Ruiz-Fernández et al. used the “Professional Quality of Life Questionnaire” (ProQoL) to assess burnout and found that burnout levels amongst Spanish healthcare professionals have remained similar to those studies prior to the pandemic despite the health crisis situation [8
]. There could be a number of different causes for the difference in results, for instance, the month in which the data was collected, the situation of the pandemic at the time of collection of data in each country, the method of assessing burnout etc. Hence, to draw conclusions on burnout amidst the pandemic, papers analysed in this systematic review were grouped together based on the assessment method of burnout.
Due to the uncertainty of the length of the current pandemic, one can only speculate the lasting impact to be considerable. Hence, it is important to address the issues that are leading to increased burnout during this pandemic in order to reduce the long-term negative consequences. To date, there are very few evidence-based interventions in literature that focus on physician burnout during a pandemic. However, a few studies have made recommendations that may help prevent burnout and mitigate the consequences of occupational stress during COVID-19 [9
]. More studies are required to corroborate existing findings.
To date, there have been no reviews that have examined this area of literature during the COVID-19 pandemic, hence, this would be the first review to summarise the existing findings on the impact of the pandemic on physician burnout and provide a detailed analysis of the various identified and potential factors contributing to physician burnout. This paper also aims to make certain recommendations that may help relieve the effects of burnout during the course of the COVID-19 pandemic.
5. Discussion and Potential Support for Physician Burnout
The major focus during this pandemic has been on addressing the acuity of patient presentation, containment, preventing spread or at least limiting the spread of the virus. While this is certainly important from the point of view of pandemic management, the needs of healthcare workers are something that needs to be addressed. One only needs to consider that most places are in the first wave with the possibility of second and third waves, therefore, the likelihood of added stress on physicians needs to be kept in mind. Although there are very few papers to substantiate current levels of burnout, the emerging impact of COVID-19 and prevalence of burnout should raise urgency with which we should address burnout amongst physicians
Burnout may appear to be less frequent among frontline workers compared to usual ward workers [7
], however, there is still a staggering prevalence of burnout in general amongst physicians compared to non-COVID times. A recurring theme of a sense of control amongst frontline workers in dealing with the pandemic was evident. Hence, it may be important for upcoming physicians to have early training on pandemic planning and incorporate burnout management techniques. Burnout caused by occupational factors such as the department an individual works in may be inevitable, hence, management of burnout must be considered. A study by Amanullah et al. showed that a hospital-based programme using mindfulness helped reduce the impact of organizational change on physicians. The authors saw the role of a mindfulness-based programme as being positive [20
]. Physicians who took part reported that they handled burnout better. While the costs were minimal, the outcome clearly showed that we are not helpless in challenging situations. This was further supported by Krasner et al., who also found that self-awareness and mindfulness have been shown to effectively reduce burnout [21
]. This study showed that while some took the time to learn how to be mindful, the results were evident to those who stayed the course. Being busy was often cited as a reason for not being able to be part of the study [21
In addition to the department that an individual works in and the lack of support from peers, Sansongahar et al. reported other occupational hazards with exposure to COVID-19 including “limited resources, longer shifts, and disruptions to work-life balance/sleep”, which have been reported to increase physicians’ burnout levels [9
]. The lack of PPE has been correlated with an increase in burnout [15
], hence, Santarone et al. recommends that providing adequate PPE should be top priority [10
]. In addition, these authors referenced one study that showed “limiting shifts to less than 16 h” resulted in an “18% reduction of attention failures” [25
]. Hence, manageable shifts should be timetabled for physicians. It is imperative that periods of rest and relaxation are given to physicians to prevent burnout. With manageable shifts put into place, sufficient sleep takes priority since sleep deprivation has been linked with burnout [17
]. Stewart et al. recommend early detection and intervention to improve both sleep deprivation and burnout [18
Another important aspect of burnout, as reported by McMurray et al., is that when physicians feel they are supported by each other and at home, the incidence of burnout is less [3
]. In this study, they found that support by a spouse decreased burnout by 40% and support from colleagues decreased burnout by 45% [3
]. Shanafelt et al. agree that having a partner or being married was associated with a decreased risk of burnout [6
]. It is clear that physicians who are supported or feel supported by their peers or loved ones experience less burnout when compared to those who do not. We can infer that colleagues’ ability to offer help in a stressful work environment helps to reduce the burden more than just the support at home. It is clear that we need more studies to prove such a hypothesis and findings. Adapting programmes may be the way forward; this however will require the creating of hospital-based committees or physician organizations working to address acute, subacute and longer-term needs post COVID-19.
This review also found that, overall, female physicians reported increased burnout in comparison with their male counterparts [14
]. As women account for a huge proportion of the healthcare workforce worldwide [26
], one could speculate the impact that this pandemic has had on the mental health/burnout of working female healthcare workers to be considerable. The loss of earnings is one aspect. Paying off debt, the uncertainty of single parents about their ability to provide, added to emotional stressors if they are going through a separation, divorce, substance abuse only adds to the enormous stress being faced by female physicians. Hence, targeted support for the mental wellbeing of female physicians is a must, although there is little research-based evidence on successful support methods. However, from our review, it became evident that women may have felt a greater sense of burnout due to lack of control in their workplace [3
]. In fact, from a review of data, it is apparent that systems have a duty to recognize that there should be autonomy for physicians in practice [16
In conclusion, burnout amongst physicians is an important issue because it not only has an impact on the physician’s life, but it can potentially affect patient care, let alone, their families and society. The current pandemic has brought with it ways of working that physicians need to adapt to, and developing ways to cope with burnout is important. The ability of hospitals to help with burnout management may be helpful and certainly more studies on burnout levels and looking at comparing data between regions and nations is needed. It may be important to learn best practices from other places and replicate it.
Future research is needed on the larger spectrum of burnout that has not been addressed in this review, which are important issues and includes but is not limited to personality, social situation and financial status. These can have a bearing on how one perceives burnout and interventions that may be sought.