Burnout among psychiatrists after COVID-19 pandemic

Hong Doan, Ben Harmon-Jones & M Aamer Sarfraz

INTRODUCTION

The concept of burnout has been used to describe emotional and psychological stress among healthcare workers in response to work-related stressors¹. Maslach et al² have defined burnout as a triad of characteristics: emotional exhaustion, depersonalisation (such as objectifying and treating patients indifferently) and lack of feelings of personal accomplishment. Since high time-pressure, high job- stress and excessive workload with poor support are among significant factors that contribute to burnout, physicians are at a greater risk of suffering from it as compared to the general population³.

Burnout affects approx. half of the doctors in the U.S. and in Western Europe working across multiple specialties including in family medicine and internal medicine^4,5. Likewise, burnout is universally prevalent among healthcare workers from low and middle-income countries⁶.

Psychiatry presents specific range of stressors not encountered concurrently in other medical specialties, such as treating chronically ill patients, potentially difficult therapeutic relationships, threat of patient suicide/self-harm and stigma associated with this field of medicine⁷. Therefore, it is not surprising to discover that approx. 37% of psychiatric trainees working across 22 countries suffered from severe burnout⁸.

The COVID-19 pandemic resulted in a national lockdown in the U.K. with travel restrictions and unprecedented pressure on an already stretched healthcare system. Healthcare workers were, therefore, faced with extraordinary difficulties including increased working hours, heavy workload, staff shortages and lack of resources. A recent systematic review showed that a startling 40% of medical workers experienced acute stress disorder following COVID-19 pandemic, with burnout prevalent among 29% of them⁹.

During to the pandemic, there has been a huge increase in the pressure on mental health related admissions to hospitals¹⁰. A number of causative stressors may have instigated further strain on mental health workers, including bereavement, unemployment, and isolation, resulting in increased psychological morbidity¹¹. Under such circumstances, ensuring the wellbeing of healthcare workers is of paramount importance to maintain a resilient healthcare system. However, limited research has been carried out so far on the effects of pandemics on psychiatrists and other frontline healthcare workers.

Following two surges of COVID-19 pandemic, we proposed to ascertain the frequency of burnout among doctors working in a large mental health trust in Southeast England, with a secondary aim of exploring possible contributory factors.

METHODOLOGY

We carried out a cross-sectional survey of all doctors working in a county-wide mental health Trust in England. Using the NHS Mail, a link to complete the online survey was sent to all doctors working at different experience levels and across a number of psychiatric specialties.

The survey was based on The Maslach Burnout Inventory¹², which is considered to be a gold standard in assessing burnout among healthcare workforce. It consists of 22 questions, divided into domains that assess emotional exhaustion, depersonalisation and personal accomplishment based on a 7-point scale, ranging from “never” to “every day”. Scores for these domains range from 0 to 54, 0 to 30, and 0 to 48, respectively. High scores on the EE (≥ 30) and DP (≥ 12) subscales or a low score on the PA subscale (≤ 30) were considered highly suggestive of burnout symptoms.

The anonymised survey contained questions related to demographics, 22 questions as derived from the Maslach Burnout Inventory, and 14 other questions exploring specific work-related stressors regarding the COVID-19 pandemic. Responses to the questions were analysed and categorised into themes to allow further analysis and discussion.

RESULTS

Our response rate was 42% as 106 out of 254 doctors filled the questionnaire. Not all participants answered all questions, and response numbers for each question are indicated where applicable in the respective tables. There was an even distribution between trainees and consultants, but less representation from speciality doctors, which was expected due to their fewer numbers. Where gender was equally split, we found that age was relatively evenly distributed in our sample.

Figure 1: Participant demographics

Regarding the Maslach Burnout Inventory questions, higher aggregates in emotional exhaustion and depersonalisation subscales indicate higher chance of burnout. When comparing these two subscales, the levels of emotional exhaustion were higher than that of depersonalisation. Conversely, in the personal accomplishment subscale, more common occurrences indicate a lower chance of burnout.

Table 1: Maslach Burnout Inventory Results

In other quantitative questions, all respondents reported that their screen time had increased during the pandemic. A majority reported it to be by more than 2 hours/week, and 71% registered an increase of more than 4 hours/week. Despite this, there appears to be no increase in their home-working that could account for this difference.

The results of the remaining questions reflected a poorer work experience. The strongest evidence was for a feeling that mask wearing had affected rapport with patients. Other more common experiences included poor outcomes for patients during the pandemic, with decreased staffing levels, increased workload, and delayed treatments.

Table 2: Other Question Responses – Quantitative only

DISCUSSION

Our study provides a snapshot of difficulties encountered by different grades of psychiatrists, while working in a large English county, during the COVID-19 pandemic. We found a burnout rate of 44.2%, which is higher than 36.7% observed by Jovanović et al⁸ among those working in other countries before the pandemic. Since a higher prevalence is also documented in other recent studies¹³, it is reasonable to assume that the higher rate of burnout is due to increased work-related stressors during the COVID-19 pandemic. These stressors could be linked to the newly introduced guidelines, which involved social distancing, high staff sickness and redeployment.

In the personal accomplishment subset of our study, highest number of doctors experienced burnout, possibly suggesting a link to the COVID-19 pandemic. Unfortunately, we do not have a pre-COVID pandemic survey for the sake of comparison, which could have confirmed causality with greater certainty.

71% of our cohort reported an increase of more than 4 hours of computer screen time a week, which was not due to increased amount of working from home. Various factors could explain this finding including the introduction of remote medical consultations, online multidisciplinary team meetings and teaching/training. Virtual consultations may provide an alternative to face-to-face assessments, but complications such as difficulty in discussing sensitive topics and demonstrating empathy could influence therapeutic relationship, medical errors, and screen fatigue resulting in increased levels of burnout^{14, 15}.

A compromised professional identity and reduced job satisfaction are considered among significant predictors of job burnout^{16, 17}. It is, therefore, reasonable to question whether the increased screen time and reduced patient contact could have impacted the professional identity of our cohort and their job satisfaction. This could also provide possible explanation for our cohort scoring highly for low personal accomplishment. However, one study that examined burnout in medical residents, who had used virtual telemedicine to replace outpatient clinics, found that the burnout actually decreased with increased use of virtual consultations¹⁸. Therefore, more consideration and research needs to be conducted on telemedicine practices in different medical subspecialties and their impact on medical professionals’ working lives.

Burnout is associated with an increase in clinical errors and may manifest in irritability, fatigue, and reduced cognitive functioning that ultimately result in a reduction in quality of patient care^12,19. Medical errors on the other hand cost the National Health Service (NHS) £3.3 billion in litigation costs and additional bed days due to both systemic and individual factors²⁰. Overall, 41% of our cohort were dissatisfied with remote consultations and the care provided to their patients during the pandemic. The reported difficulties with providing good patient care primarily consisted of poorer quality of and reduced patient interaction, patients being unable to engage with services and delayed treatments.

Wearing face masks could affect both verbal and non-verbal communication that in turn hinder the therapeutic relationship, as previous research has shown that patient engagement, understanding and treatment success are influenced by a clinician’s facial expressions²¹. Poorer patient outcomes found in our study could partly be due to the difficulties experienced during the pandemic as approx. 62% of our cohort felt that face masks affected their rapport with patients. Other factors that could have contributed to these poorer outcomes include redeployment of staff due to NHS pressures and reduced services. Further work is, however, needed to ascertain the associated casual pathway.

During the height of pandemic, carrying out frenetic clinical work with limited resources and little respite, coupled with the loss of loved ones and colleagues, could have undoubtedly impacted the mental health of medical workforce including psychiatrists. On the other hand, the pandemic may have also heightened the sense of vocation for some doctors. It is, therefore, difficult to assess the lasting effects of burnout until the pandemic is finally over and we resume normal therapeutic practices, in both clinical and personal settings.

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