The Bucharest College of Physicians’ Study on Burnout Amongst Healthcare Professionals in Romania’s Capital City during COVID-19 Pandemic

The importance of burnout amongst medical staff was highlighted by various papers, showing that this issue implies job demands and job resources. The current challenge of SARS-CoV-2 pandemic also raised many concerns about its impact on healthcare sector. A new survey after 4 years from the previous study of the Bucharest College of Physicians is coming with new data, containing the effect of COVID-19 on the psychological wellbeing of its members. The increasing of burnout was found in all categories, and the most frequently solutions claimed by the respondents were related to decreasing of workload and bureaucracy, and an important number of physicians identify the need for specialized psychological assistance. The COVID-19 pandemic period exacerbated the system related factors that contribute to the phenomenon of burnout.


BACKGROUND
Since the inception of the global SARS-CoV-2 pandemic, many concerns have been raised, regarding its impact on the healthcare sector.
It is well-known, that workers in health professions, especially doctors, are exposed to a high risk of developing work-related psychological symptoms, such as those characterized by burnout, even under normal working conditions, as numerous studies suggest.
The burnout phenomena are found usually as a syndrome, consist in a combination of emotional dimension of exhaustion, cynicism or depersonalization, resulting mainly from job stress. Found in many types of occupations, burnout syndrome is an important issue in care giving and human service occupation, and widely was analyzed in nurses, physicians and residents within a number of cultures and countries, like USA Theoretical approach of this syndrome divided it in two general categories: job demands and job resources. More than psychological effects on the employees, burnout syndrome produces somatic effects, impairing health of medical staff. A cross sectional study done in seven European countries (Alexandrova-Karamanova et al, 2016) including Romania showed that burnout and risk health behavior are significant in health professionals and organizational interventions are required to reduce this risk.
The added strain on physicians' psychological well-being during a global pandemic, such as the current SARS-CoV-2 one, have been analyzed by a number of scholars and the results are rapidly spreading in the scientific community 2-5 . These studies highlight the increasing of anxiety, depression, and burnout in medical staff in pandemic period and raise the necessity to systematically monitoring of mental health in health care workers [6][7][8][9][10][11][12][13][14][15][16][17][18] .
The Bucharest College of Physicians tried to compare the current situation of burnout amongst health-care workers, to an older study conducted back in 2017 1 , to see how the pandemic impacted on the psychological wellbeing of its members.

MATERIALS AND METHOD
In order to accurately measure the level of burnout amongst physicians in Bucharest, the authors used a descriptive study design, based on a self-devised questionnaire which was distributed to members of the Bucharest College of Physicians by online means during March 04 of 2021 and June 27 of 2021.
The questionnaire designed for this study was in principle similar to the one used in its previous study, in order to make it easier to compare results. The questionnaire comprised a total of 15 different items as follows: 5 general items related to age, sex and workplace, 3 items related to the type of work, number of hours worked weekly and number of patients treated. The next questions were more specifically aimed to evaluate stress and burnout related issues. Thus, for the next question, the respondents were asked how much (on a scale of 0 to 5) a series of factors contributed to workplace related stress. These factors were mostly adapted from the Medscape Physician Lifestyle Report. The translation procedure was used according to the World Health Organization suggested translation guidelines (WHO, 2014).
Furthermore, the follow-up question was left open in order to identify other stress inducing factors amongst the respondents, who were asked to name 3 such factors.
The next item comprised a set of questions adapted from the Copenhagen Burnout Inventory, which was used also in 2017, in order to evaluate the three types of burnout. For each question, respondents were asked to provide answers in a grading system from 1 to 5, answering how often they find themselves in specific situations, ranging from "never" to "all the time" and how strongly they agree with a certain affirmation, on a range from "disagree" to "strongly agree". The CBI was constructed in such a manner, as to address 3 different dimensions of burnout. Thus, questions relate to a) personal burnout, b) work-related burnout and c) client-related burnout ("clients" being replaced by "patients" for the medical profession).
Using the CBI, participants are suffering from one or more different types of burnout if they score more than 50 points in the different sections.
The next two questions were related to alcohol and substance usage, since some studies suggest that an increase might be a coping mechanism for people suffering from increased level of stress.
The 14 th item of the questionnaire asked the respondents to identify 3 measures that would, in their opinion, decrease stress levels.
Finally, the last question of the study asked, whether the respondents would consider it useful for their mental health to seek advice from a professional.
Members of the College of Physicians were asked to participate in the study anonymously and on a voluntary basis. The questionnaire was available for online access for a total of 4 months. After closing of the online survey, a total of 2110 answers were received.

RESULTS
A total number of 2110 of respondents (doctors) participated voluntary in the study.
Regarding the respondent's age, there was a quite even distribution of the age groups from 23 to 54 years, whilst the population over 55 years was less represented (Figure 1). Most of the doctors are female, reflected in the female-to-male ratio in this study was almost 2,5:1, with 1460 out of the 2110 respondents being female (69%).
In regards to the level of training, the majority of answers came from senior specialist level doctors (51%), followed by specialists (35%) and, in a lesser amount, resident doctors (11%), whilst 2% of respondents chose not to answer this question.
There was an even distribution amongst doctors working in an emergency hospital, those working in a university clinic and those working in the private sector.
Regarding the specific factors that contribute to workplace related stress, as adapted from the Medscape Physician Lifestyle Report, the top 5 identified factors were, in order: 1. Working with difficult patients -18% (compared to 24% in 2017); 2. High workload -17% (increased from 8% in 2017); 3. Problems related to the organization of the healthcare system -16% (up from 13% in 2017); 4. Relationship with colleagues/employer -16% (compared to 4% in 2017) and 5. Lack of equipment -13% (compared to 12% in 2017).
For the next open question, participants were asked to identify 3 possible solutions to reduce work-related stress. The prime positions were occupied by the following 3 solutions: 1. reduction of workhours; 2. More payed leave; 3. Reduction of bureaucracy, which are, in essence, similar to the factors identified in the previous study, just that the paid leave and the reduction of bureaucracy switched places 2 and 3.
The next part of the questionnaire comprised the specific items of the Copenhagen Burnout Inventory (CBI). These were randomized in order to minimize stereotyped response patterns. Results were directly compared to the previous study, conducted in 2017.
Analysing the results, it was shown that 65% of all participants suffered from a form of burnout, which was an increase of 10% compared to the 2017 study the College of Physicians conducted. This increase was similar in both the female and the male group, with a total of 67,5% of female respondents suffering from burnout (compared to 58,2% in 2017), whilst 60,5% of the male respondents (compared to 50% in 2017) showed scores that were conclusive for burnout (Table 1) In regards to the specific questions, the average scores were up by 4.8 points (55.4 in 2021, compared to 50.6 in 2017), with a lower increase in the female subgroup (54.9 in 2021, up from 52.1 in 2017), whilst the biggest increase was in the male subgroup with an average of 7.2 points more in 2021 (55.1 compared to 47.9 in 2017). The comparison of scores regarding the specific types of burnout shows that whilst there was a significant increase in both the personal and work related burnout types, the scores for burnout related to working with patients were similar in both studies (Figure 2).
In regards to alcohol consumption, the figures decreased if compared to the previous study, with only 9% of respondents acknowledging that they have observed an increase over the last years (on comparison to 14% in 2017).
Whilst alcohol consumption seems to be lower, the use of medication or other substances to cope with stress seems to have slightly increased, from 19% in 2017 to 21% in 2021.
The new question introduced in the 2021 study, asking about whether the participants would consider it useful to seek advice form a mental health professional showed interesting results. Whilst more than half of the respondents seem to not feel the need for psychological assistance -57% to be precise, about 41% of participants considered it useful to seek out advice from either a psychotherapist or a clinical psychologist (Figure 3).

DISCUSSION
Our results showed that burnout is a persistent issue amongst physicians, highlights that burnout remains an important problem of healthcare systems around the globe. This study is more significant, having a higher number of responders compared to the previous study, and after four years from the first survey, we found that higher scores for the three different types of burnouts are not decreased, and may be influenced by local factors, independent to level of salary, which has been increased in last years.
However, even though a large number of healthcare professionals seem to suffer from the effects of burnout, our results have shown that this fact doesn't impede on the services provided by doctors, making patients suffer the consequences. It was found again a significant difference between male and female participants in the study.
The most important factors conquering to burnout at workplace are still those related to the healthcare system: high workload, problems related to the organization of the healthcare system, relationship with colleagues/employer and lack of equipment, the latter reflecting the new pandemic challenges in healthcare system. The increasing of burnout was found in all categories, and the most frequently solutions claimed by the respondents were related to decreasing of workload and bureaucracy.
The new question about the need to intervene through specialized psychological assistance, shows that an important number of physicians need this kind of support.
The COVID-19 pandemic period exacerbated the system related factors that contribute to the phenomenon of burnout, and, it is necessary for special services providing support, assistance and guidance to those suffering from the effects of burnout, which should be implemented by relevant organisations.