Burnout among Physicians at Medical Departments in Benghazi-Libya

Abstract Background  Burnout syndrome is recognized as a global issue, and as medical practice is stressful, healthcare workers are found to be burnt out and exhausted very soon, which is reflected negatively on the medical staff well-being, patients' outcome, and the overall organizational performance. Aim  This study is planned to assess the magnitude of burnout among physicians in Benghazi-Libya. Methods  This cross-sectional study was carried out in 2020 on a total of 150 physicians working at different departments of internal medicine in Benghazi-Libya. The Maslach Burnout Inventory collection instrument was used to assess the three components of burnout syndrome: emotional exhaustion, depersonalization, and reduced personal accomplishment. High scores in emotional exhaustion and depersonalization and low scores in personal accomplishment are indicative of high burnout. The statistical analyses of the data were performed using the SPSS version 21. The level of statistical significance was considered as p -value less than 0.05. Results  60% of the respondents were females and 40% were males. About 14.7% had high emotional exhaustion, 92% had high depersonalization, and 87.3% had low personal accomplishment scores. Statistical analysis showed no significant relationship between gender and burnout. Alternatively, a significant association was found between degree certificate and emotional exhaustion, as moderate- and high-level burnout were more prevalent among MBCHB participants than those with masters and board degrees. No association was found between degree certificate and depersonalization or personal accomplishment. Conclusion  Burnout is prevalent among internal medicine doctors in Benghazi, with the newly graduated medical personnel scoring higher rates of burnout than doctors with higher degrees. No relationship was found between gender and burnout.


Introduction
The term "Burnout" originated in the 1970s by psychologist Herbert Freudenberger after observing healthcare volunteers. 1 It is defined as a psychological syndrome characterized by emotional, mental, and physical exhaustion caused by excessive and prolonged stress related to one's professional life. 2 It is measured by assessing the combination of three subscales: emotional exhaustion (EE), depersonalization (DP) (negative and detached responses to others), and low personal accomplishment (feelings of incompetence in one's work) (PA). 3 Employees who work in stressful professions, demanding jobs, and who care for others such as social workers, teachers, and healthcare professionals, are more likely to suffer from burnout. 2 Many researchers have conducted investigations into burnout in different business areas over the last 20 years, and it was found that burnout rates are higher among physicians than individuals in other careers, making it an urgent health problem. This alarming prevalence is attributed to many factors including, the long training process, long work hours, sleep deprivation, their relationships with a large number of patients, having to deal with medical errors, being responsible for the health and well-being of others, patients' aggressive behaviors and complaints, and coping with death and injury. Other factors include forcing physicians to do clerical tasks; and a lack of agreement between physicians and officials regarding values, mission, purpose, and compensation. 2,4-6 Burnout was found to be a significant predictor of many physical and psychological conditions among physicians. Some studies have found that physician burnout is related to a higher rate of medical errors, reduced patient satisfaction, prolonged post-discharge recovery times, decreased professional work, and lower job satisfaction, which incites early retirement. 7 As a consequence, individuals become distant from the business and family environment, and they experience incompatibilities in interpersonal relationships. 2 Thus, burnout is a losing situation for both physicians and the healthcare industry as a whole. On the other hand, the persistence of violence and the current instability in Libya are not in favor of improving the situation regarding this issue. 8 In order to prevent and reduce this phenomenon, it needs to be tackled at an individual and organizational level. 2 This study is aimed to evaluate the prevalence and extent of burnout among physicians in Benghazi.

Design and Sampling
This cross-sectional study was conducted in 2020 in Benghazi-Libya. Physicians working in different departments of internal medicine were involved.

Instruments and Procedure
The data collection instrument was the Maslach Burnout Inventory (MBI), which is the gold standard of burnout surveys in the field of medicine. 9 The first part of the questionnaire includes items on demographic variables, and the second part consists of 22 items in the three subscales of EE, DP, and PA.
The Cronbach's alpha coefficient of this questionnaire was calculated at 0.82, indicating the acceptable internal consistency of the tool.
This questionnaire is rated based on a 7-point Likert scale, ranging from 0 (never) to 6 (every day). Due to the multidimensionality of the burnout structure, the scores of each subscale are reported separately and cannot be added up as a total score. 10 According to Maslach, high scores in EE and DP and low scores in PA are considered as high burnout. 11 Burnout level is classified into three groups, low, moderate, and high. The cutoff points for this classification are presented in ►Table 1.
The questionnaire was distributed at the workplace of the staff, after describing the purpose of the study and assuring the confidentiality of information. Staff consent to participate in the study was obtained.

Statistics
The data was summarized using Microsoft excel 2010 then coded and processed on IBM compatible computers, using the Statistical Package for Social Sciences (SPSS) software (version 21). Descriptive statistics of the different variables were presented either as frequencies and percentages or as means AE standard deviation (SD). For statistical comparisons, independent samples chi-squared test was employed for testing statistical significance of association between two discrete variables. Significant value is set up at p-value less than 0.05.

Demographics
Demographic data of the physicians are shown in ►Table 2. Twohundred questionnaires were distributed; we received 150 surveys with response rate of 75%. Of the 150 survey applicants, 60 (40%) were males, and 90 (60%) were females. Age ranged from a minimum of 27 years to a maximum of 63 years, with a mean AESD of 37. Burnout ►Table 3 shows MBI scores range, mean AE SD, and levels for all responders. Based on the MBI subscales for EE, 32% were identified as low-level burnout, 53.3% as moderate burnout, and 14.7% as high-level burnout. Regarding DP subscale results, 7.3% had moderate burnout, and 92.7% suffered from high-level burnout. PA subscale results were as follows: moderate burnout was found in only 12.6% of the applicants, and high-level burnout in 87.3%.
When the effect of gender on the levels and types of burnout was examined, no significant relationship between gender and burnout was found (►Table 4). However, there was a highly significant association between academic  degree of the participant and EE (►Table 5), as moderateand high-level burnout were observed more among participants who had MBCHB, and started to noticeably drop with participants holding higher academic degree, while low-level burnout was higher within board-certified doctors. No significant statistical association was found either between the academic degree and DP or between the academic degree and PA.

Discussion
Burnout Burnout syndrome has serious effects on the physical and mental well-being of healthcare providers, so determining the extent of the problem may aid in preventing its occurrence and deployment of measures of management. The results indicate that of the 150 physicians surveyed, the majority reported levels of burnout ranging from mild to moderate in the EE subscale, high-level burnout in both DP, and PA subscales, showing a high prevalence of burnout among Libyan physicians in Benghazi with almost all of them reporting features of burnout. This is concerning regarding the effects of burnout on the physicians themselves (e.g., high turnover, absenteeism, reduced staff motivation, and possible medical errors) and the quality of patient care and satisfaction. The local situation and current state of the country through history of civil war and dealing with the increased demands and high expectations from healthcare workers through the recent pandemic may be a precipitating factor to this alarming state of burnout. Gender, on the other hand, was found to have no significant implication on the magnitude of burnout according to the results across the three subclasses of the MBI. This goes in line with several other studies that showed no relationship between gender and burnout. [12][13][14] On the contrary, metaanalysis of 183 studies conducted by Purvanova and Muros 15 showed that women are more likely to experience EE, while men were more likely to experience DP. In addition, several studies showed that women have a higher level of burnout compared to men. [16][17][18] This does not correlate significantly with this study's findings as the percentage of those affected was relatively the same when comparing males and their female counterparts, but these results may be limited by the sample size that was taken so generalization of these findings might not be applicable.
There was a significant association between the highest degree certificate and the EE subscale, but not with the DP nor PA subscales. As reviewed by Maslach et al, 19 EE is the most widely encountered component of this syndrome making it an important factor. Moreover, EE was found most commonly to be correlated with physicians with MBCHB degree than those with masters or a board degree. Our findings are supported by two other studies that concluded that burnout is a common issue among interns. 20,21 On the contrary, a study by Stanetic and Tesanovic 22 showed that older physicians with a higher length of service were exposed to more levels of stress and thus, a higher risk for burnout syndrome. Our study results might suggest that newly graduated medical personnel in Benghazi are having more difficulty dealing with their newfound responsibilities and adjusting to the workload of hospital life when compared to their colleagues with more work experience and higher degrees, which may be appropriated to poor managerial guidance, supervision, and lack of infrastructure.

Implications
The data contributes a clearer understanding of the magnitude of burnout among physicians in Benghazi and highlights the need for various methods of determining the extent among other departments than internal medicine to establish the prevalence among the medical community as a whole, as dealing with the aftermath of its effects negatively impacts the lives of both the physicians and their patients

Conclusion
Burnout syndrome is recognized as a global issue, and as medical practice is stressful, healthcare workers are found to be burnt out and exhausted very soon, which is reflected negatively on the medical staff well-being, patients' outcome, and the overall organizational performance. This study might suggest that burnout is prevalent among internal medicine doctors in Benghazi, with the newly graduated medical personnel scoring higher rates of burnout than doctors with higher academic degrees. No relation was found between gender and burnout. However, further research is needed to establish the causality of burnout in Libyan physicians and ways to early identify and combat its occurrence, and the development of management plans to those who are already affected by burnout. Future studies should take into account to investigate the reasons behind the difference in levels of burnout across occupational ranks.

Limitations of the Study
The generalizability of the results is limited by the small sample size. There is no justification of power calculation.