Burnout and Psychological Distress Among Pediatric Critical Care Physicians in the United States Asha N. Shenoi, MD1; Meena Kalyanaraman, MD2; Aravind Pillai, MBBS, MPH, MPHIL3; Preethi S. Raghava, MBBS, MPH2; Scottie Day, MD1

Objectives: To estimate the prevalence of physician burnout, psychological distress, and its association with selected personal and practice characteristics among pediatric critical care physicians and to evaluate the relationship between burnout and psychological distress. Design: Cross-sectional, online survey. Setting: Pediatric critical care practices in the United States. Subjects: Pediatric critical care physicians. Interventions: None. Measurement and Main Results: A nonrandom sample of 253 physicians completed an online survey consisting of personal and practice characteristics, the Maslach Burnout Inventory, and the General Health Questionnaire. Nearly half of the participants (49%; 95% CI, 43–55%; n = 124) scored high burnout in at least one of the three subscales of the Maslach Burnout Inventory and 21% reported severe burnout. The risk of any burnout was about two times more in women physicians (odds ratio, 1.97; 95% CI, 1.2–3.4). Association between other personal or practice characteristics and burnout was not evident in this study, while regular physical exercise appeared to be protective. One third of all participants (30.5%) and 69% of those who experienced severe burnout screened positive for psychological distress. About 90% of the physicians reporting severe burnout have considered leaving their practice. Conclusions: Burnout is high among pediatric critical care physicians in the United States. About two thirds of the physicians with severe burnout met the screening criteria for psychological Department of Pediatrics, University of Kentucky, Lexington, KY. Department of Pediatrics, Children’s Hospital of New Jersey at Newark Beth Israel Medical Center, Newark, DE. 3 Department of Epidemiology, Mailman School of Public Health Columbia University, New York, NY. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Dr. Raghava received support for article research from the Wellcome Trust/Charity Open Access Fund. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Copyright © 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000002751 1 2

Critical Care Medicine

distress that suggests possible common mental disorders. Significant percentages of physicians experiencing burnout and considering to leave the profession has major implications for the critical care workforce. (Crit Care Med 2017; XX:00–00) Key Words: burnout; intensive care; pediatrics; pediatric critical care; psychological distress

B

urnout is gradually being recognized as a serious occupational hazard for healthcare providers exposed to high levels of work-related stress. Commonly described as a state of exhaustion resulting from exposure to high and sustained levels of stress at work, burnout often occurs in individuals with no prior history of psychologic or mental disorders (1, 2). Beyond its detrimental effect on the mental health and well-being of individual providers, burnout impairs physician’s performance, the quality of interactions with patients and staff, and is a critical concern for patient safety and quality of care (3–7). Besides, burnout causes a substantial burden to healthcare systems due to job dissatisfaction, absenteeism, increased job turnover, and early retirement (8–10). The risk of burnout is particularly severe for critical care physicians owing to their challenging work environment and prolonged exposure to high levels of stress (11, 12). The 2015 Medscape’s U.S. physician lifestyle survey echoes this concern and reports that among medical specialties, the rate of burnout is highest in critical care with 53% of physicians experiencing burnout (13). A complex interplay of personal and organizational factors contributes to burnout. Within the context of critical care practice, factors such as heavy workload, frequent nightshifts, higher mortality rate among patients, ethical issues related to end-of-life care, and unrealistic expectations on the part of the patients’ families could be partially responsible for the heightened rates (12, 14, 15). In response to this predicament, in 2016, the Critical Care Societies Collaborative in the United Sates made a call for action to raise awareness, enhance evidence base, and implement strategies to prevent burnout (16). Although interest in burnout among critical care providers is growing, burnout research in pediatric critical care significantly lags behind that of adults. The only study focusing on pediatric www.ccmjournal.org

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critical care physicians in the United States was done 2 decades ago (17), and a recent study of burnout in a large sample of U.S. physicians did not report rates for pediatric critical care separate from other subspecialties (18). In addition, little is known about the psychologic morbidities among pediatric critical care physicians, although a national survey among critical care nurses found common occurrence of anxiety and depression in addition to burnout (19). Although burnout is commonly defined in terms of emotional exhaustion, depersonalization, and reduced personal accomplishments, it shares several key characteristics of mental disorders such as depression and anxiety. Recent debates surrounding the construct of burnout questions the distinction between burnout and depression (20). Deciphering the relationship between burnout and mental disorders such as depression is important to avoid leaving mental disorders untreated or providing unnecessary and inappropriate treatments. To address these knowledge gaps, we conducted a study of burnout and psychological distress among pediatric critical care physicians in the United States.

MATERIALS AND METHODS The study population included a nonrandom sample of practicing pediatric critical care physicians in the United States. E-mail addresses of prospective participants were compiled by the investigators from hospital websites, by contacting PICUs and through the professional networks of the investigators. Using the web-based survey platform Qualtrics (Qualtrics, Provo, UT), prospective participants were invited to participate in August 2015. Three reminder e-mails were sent out through Qualtrics over a span of 8 weeks to nonresponders. Participation was voluntary, and the study was approved by the Institutional Review Board at the University of Kentucky. We gathered information on personal and practice characteristics, physical exercise, practice of religion, and use of any professional services for stress reduction. Similar to two recent studies on burnout and psychologic stress among surgeons in the United Kingdom and Fiji, we used the Maslach burnout inventory (MBI) to measure physician burnout and the General Health Questionnaire (GHQ)-12 to measure psychological distress (21, 22). The MBI has 22 self-reported items that measures burnout during the past 12 months in three dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishments (23). Burnout is rated as high, moderate, or low for each of the three dimensions based on a conventional reference range. For this study, we report high burnout in any one of the three burnout dimensions as our primary outcome variable, similar to recent studies of burnout among pediatric critical care physicians from Brazil and Argentina (24, 25). As a secondary outcome, we define severe burnout when an individual has a high score on emotional exhaustion in combination with a “high negative” score on either of the two remaining MBI dimensions. Validity of this decision rule has been demonstrated in prior studies (26, 27). The GHQ-12 is a popular self-administered questionnaire used to identify psychological distress and screening for common mental disorders in community and occupational settings 2

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(28, 29). GHQ has been routinely used to measure psychological distress among healthcare providers in a wide variety of settings including critical care and pediatrics (30, 31). A score of 4 or more is suggested to identify respondents who are experiencing psychological distress in occupational settings (32). Even though GHQ is designed to measure the risk of nonpsychotic minor psychiatric illness, a positive result on GHQ-12 is not a diagnosis of mental disorder, but it helps to inform further evaluation. Both the GHQ-12 and the MBI were administered to all the participants. Detailed description of the questionnaire and scales are given in the supplemental data (Supplemental Digital Content 1, http://links.lww.com/CCM/C896).

ANALYSIS We used descriptive summary statistics to denote the personal and practice characteristics of participants. Bivariate analysis of personal and practice factors associated with burnout and psychological distress was performed using the chi-square or Fisher exact test for nominal variables and the Cochran-Armitage trend test for ordinal variables. Significant independent variables (p < 0.05) identified in the bivariate analysis were included in separate multivariable logistic regression analysis with “any burnout” and psychological distress as dependent variables. Both models met all the assumptions of logistic regression modeling. Based on the existing evidence on the risk factors for burnout and psychological distress, we made an a priori decision to include gender and age as covariates in all multivariable model. Burnout and psychological distress scores were calculated only if a respondent had completed at least 80% of items on a given scale. To reduce potential bias due to list-wise deletion, we used the “hotvalue” imputation module in STATA (33) for case-wise imputation for each participant with 80–100% of items answered (details given in the supplemental methods, Supplemental Digital Content 1, http://links.lww.com/CCM/ C896). We used the Mann-Whitney U test to compare the MBI subscales between men and women. Spearman’s correlation coefficient was used to compute the relationship between the MBI subscales and the GHQ as the distributions of the scales were not normal.

RESULTS Of the 686 pediatric critical care physicians who received an e-mail invitation to participate in the study, 275 (40% of those invited) consented. Although we do not have information on nonresponders, gender and age distribution of the study participants were similar to pediatric critical care physicians currently practicing in the United States as per the 2015 American Board of Pediatrics workforce data (34). We excluded 20 participants who left more than 20% of items unanswered for the MBI subscales. Demographic and Practice Characteristics Participants included more male physicians (60.5%), with most being between the ages of 41 and 60 years. More than XXX 2017 • Volume XX • Number XXX

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Clinical Investigation

80% of the physicians in the study were currently married, and 84% had children (Table 1). The majority of participating physicians (69%) have been in practice for more than 10 years. The common practice setting was academic programs linked to community hospitals or universities; hence, most physicians (87%) reported supervising residents and/or fellows. In-house call was part of the service for about 70% of physicians (Table 2). Burnout and Associated Factors Nearly half (49%; 95% CI, 43–55%; n = 124) of the participants scored high in at least one of the three subscales of the MBI. Emotional exhaustion was the most frequently positive burnout subscale (34%), followed by low personal accomplishment (21%), and depersonalization (20%). Severe burnout was reported by 21% (n=54) of physicians. Compared to male physicians, women were significantly more likely to report high levels of emotional exhaustion and low personal accomplishment (Table 3). Overall, women physicians were twice more likely to report any burnout (age-adjusted odds ratio [OR], 1.97; 95% CI, 1.15– 3.36), although the gender difference was not significant for severe burnout. The only other personal characteristic associated with any burnout was regular exercise. After adjusting for age and gender, those who exercised regularly were 44% less likely (adjusted OR, 0.56; 95% CI, 0.32–0.99) to report any burnout Close to two thirds of the physicians (n = 160; 65%) have considered leaving pediatric critical care practice in the recent past. After adjusting for age and gender, those who reported any burnout were four times (adjusted OR, 4.0; 95% CI, 2.23–7.18) more likely to have considered leaving the practice, whereas those who experienced severe burnout were nine times (adjusted OR, 9.35; 95% CI, 3.21–27.27) more likely to report the same. Those who experienced any burnout were also less likely (adjusted OR, 0.33; 95% CI, 0.17–0.64) to consider pediatric critical care if they had a chance to do it again or recommend medicine (adjusted OR, 0.38; 95% CI, 0.22–0.65) as a career for their children (Supplemental Table 1, Supplemental Digital Content 2, http://links.lww.com/CCM/C897). More than one fourth of the physicians reporting severe burnout (27.8%; n = 15) have been in counselling to deal with stress. Psychological distress and Associated Factors About one third (30.8%; n = 78) of the participants have experienced significant psychological distress in the past month. The association between age, gender, and psychological distress was not significant in a multivariable model. Almost a third of the physicians (29.6%; n = 24) who screened positive for psychological distress have received psychologic help for stress. Relationship Between Burnout and Psychological distress Severe burnout was strongly associated with psychological distress (adjusted OR, 8.64; 95% CI, 4.29–17.39); 68.5% (n = 37) of those who reported severe burnout screened positive for psychological distress, although nearly half of the participants Critical Care Medicine

(46%; n = 57) who reported any burnout screened negative for psychological distress. Correlation between the MBI subscales and the raw GHQ scores were moderate to high for emotional exhaustion (r = 0.67; 95% CI, 0.595–0.733) and low to moderate for depersonalization (r = 0.4; 95% CI, 0.286–0.496) and personal accomplishment (r = –0.45; 95% CI, –0.544 to –0.346).

DISCUSSION In this study, among pediatric critical care physicians in the United States, we found that almost half of the participants experienced burnout in at least one of the three dimensions of the MBI. In addition, about 30% of physicians screened positive for potential mental health problems. Except regular physical exercise, which was associated with lower burnout, we could not identify other personal or practice characteristics independently associated with burnout. Prevalence and Predictors of Burnout Globally, few studies have examined burnout among pediatric critical care physicians, and our findings agree with the high prevalence reported elsewhere. Among pediatric critical care physicians in Brazil and Argentina, 50% and 41% have respectively reported high burnout in at least one dimension of the MBI (24, 25). The only study among pediatric critical care physicians in the United States published in 1995 using the burnout scale of Pines and Aronson also found that half of the physicians experienced some form of burnout and classified 14% of participants as “burned out” and 36% “at risk” of burnout (17). Although MBI is the commonly used instrument to measure burnout, the interpretations of the results are not consistent. Recent studies have defined burnout in terms of a high score on the depersonalization or the emotional exhaustion subscale excluding the subscale on personal accomplishment (18, 35). Based on this definition, a study among pediatric critical care physicians in the United Kingdom reports 49% prevalence of burnout, whereas we found a slightly lower prevalence of 40% in terms of these two subscales (36). Compared with our rates of high emotional exhaustion (34%) and high depersonalization (20%) and low personal accomplishment (21%), a study among adult critical care physicians in France found rates of 19%, 37%, and 39% on the same subscales which could be due to the differences in the study settings (12). Statistically significant gender difference was evident for the MBI subscales of emotional exhaustion and personal accomplishment that showed increased risk for women. Studies have partly supported the hypothesis that work-home conflicts may increase the risk for burnout among women (37, 38). Although we did not measure work-life balance or work-home conflicts, among women in our study, burnout was not associated with marital status or having children. Furthermore, there was no gender difference in the risk for severe burnout. Organizational factors, particularly workload and autonomy, are commonly reported as key risk factors in burnout literature (39). Due to restrictions in survey length, we were unable to examine details of organizational factors; yet, our findings www.ccmjournal.org

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TABLE 1.

Personal Characteristics Associated With Burnout and Psychological distress Any Burnout

Personal Characteristics

n (%)

n (%)

pa

Severe Burnout n (%)

General Health Questionnaire Positive

pa

n (%)

pa

0.251

39 (25.5)

0.02

Gender (n = 253)  Male

153 (60.5)

64 (41.8)

0.005

29 (19)

 Female

100 (39.5)

60 (60.0)

 31–40

57 (22.5)

35 (61.4)

  > 41–50

86 (34)

38 (44.2)

15 (17.4)

19 (22.1)

  > 51–60

79 (31.2)

40 (50.6)

18 (22.8)

34 (43)

  > 60

31 (12.3)

11 (35.5)

04 (12.9)

6 (19.4)

 Married

209 (82.9)

88 (48.4)

42 (20.1)

62 (29.7)

 Single

23 (9.1)

9 (39.1)

10 (43.5)

 Divorced

13 (5.2)

5 (45.5)

02 (15.4)

7 (2.8)

4 (66.7)

01 (14.3)

25 (25)

39 (39)

Age (n = 253) 0.20

17 (29.8)

0.27

19 (33.3)

0.005

Marital status (n = 252)

  In a committed relationship

0.35

12 (60)

0.172

0.33

5 (38.5) 1 (14.3)

Have children (n = 252)  Yes

211 (83.7)

102 (48.3)

 No

41 (16.3)

21 (51.2)

0.74

40 (19)

65 (30.8)

13 (31.7)

0.067

13 (31.7)

32 (20.5)

0.652

50 (32.1)

0.836

Practice religion (n = 253)  Yes

156 (62)

 No

96 (38)

78 (50)

0.630

45 (46.9)

22 (22.9)

0.91

28 (29.2) 0.38

Practice relaxation technique (n = 253)  Yes

47 (18.6)

25 (53.2)

 No

206 (81.4)

99 (48.1)

 Yes

176 (69.6)

77 (43.8)

 No

77 (30.4)

47 (61.0)

11 (23.4) 0.53

0.702

43 (20.9)

17 (36.2) 61 (29.6)

Exercise regularly (n = 253) 32 (18.2) 0.011

22 (28.6)

0.06

45 (25.6)

0.01

33 (42.9)

Based on chi-square/Fisher exact test for nominal variables and Cochran-Armitage trend test for ordinal variables.

a

suggest that the direct physical demands of the work (e.g., inhouse calls, supervision of trainees, practice settings) may not be associated with burnout in pediatric critical care physicians, endorsing the findings from Fields et al (17). Finally, our findings agree with the inverse association between regular exercise and burnout reported in prior studies (40–42). Burnout and Psychological distress About one third of the physicians in our study screened positive for psychological distress that suggests possible common mental disorders. Although comparable estimates of psychological distress using the GHQ are not available for U.S. physicians, our estimated prevalence (30.4%) is similar to 29% reported among critical care physicians in the United Kingdom and 25.4% among oncologists in 4

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Canada (30, 43). Conventionally, burnout, which is largely confined to work situation, has been considered as separate from clinical depression that overwhelms all aspects of an individual’s life. However, the relationship between burnout and depression is now being debated. Although a recent systematic review proposes that burnout could be a form of depression rather than a distinct phenomenon (20), other researchers contest this view (44, 45). In our study, we did not screen specifically for depression, although the GHQ is designed to screen for mental health conditions such as depression and anxiety. We found only moderate correlation (0.4–0.67) between the GHQ scores and the MBI subscales. Even among the physicians who experienced severe burnout, 32% did not screen positive for psychological distress. This raises the possibility that despite the overlapping XXX 2017 • Volume XX • Number XXX

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Clinical Investigation

TABLE 2.

Practice Characteristics Associated With Burnout and Psychological distress Any Burnout

Practice Characteristics

n (%)

n (%)

Severe Burnout pa

n (%)

pa

General Health Questionnaire Positive n (%)

pa

Years of practice (n = 252)   ≤ 10

77 (30.6)

42 (54.6)

18 (23.4)

21 (27.3)

 11–20

91 (36.1)

43 (47.3)

20 (22)

31 (34.1)

 21–30

64 (25.4)

35 (54.7)

  > 30

20 (7.9)

4 (20)

1 (5)

2 (10)

24 (9.5)

11 (45.8)

6 (25)

11 (45.8)

172 (68)

81 (47.1)

37 (21.5)

0.05

15 (23.4)

0.32

24 (37.5)

0.04

Practice type (n = 253)  Private  Academic-University  Academic-Community

29 (11.5)

15 (51.7)

 Hybrid

28 (11.1) 129 (51.2)

0.58

0.92

51 (29.7)

5 (17.2)

9 (31.03)

17 (60.7)

6 (21.4)

7 (25)

64 (49.6)

24 (18.6)

43 (33.3)

0.38

PICU (n = 252)   Medical and surgical  Cardiac  Mixed  Other

15 (6) 106 (42.1)

6 (40)

0.48

53 (50)

2 (13.3)

0.49

27 (25.5)

4 (26.7)

0.64

30 (28.3)

2 (0.8)

0 (0)

0 (0)

0 (0)

 1–9

25 (9.9)

14 (56)

5 (20)

14 (56)

 10–20

89 (35.2)

49 (55.1)

 21–30

89 (35.2)

44 (49.4)

  > 30

50 (19.8)

17 (34)

 Yes

219 (86.6)

106 (48.4)

 No

34 (13.4)

18 (52.9)

 Yes

176 (69.6)

82 (46.6)

 No

77 (30.4)

42 (54.6)

PICU beds (n = 253) 0.57

25 (28.1)

0.246

17 (19.1)

28 (31.5)

0.17

23 (25.8)

7 (14)

13 (26)

Supervise residents/fellows (n = 253) 0.622

44 (20.1)

0.260

10 (29.4)

64 (29.2)

0.16

14 (41.2)

In-house calls (n = 253) 0.244

36 (20.5) 18 (23.4)

0.619

48 (27.3)

0.06

30 (39)

Based on chi-square /Fisher exact test for nominal variables and Cochran-Armitage trend test for ordinal variables.

a

symptoms, burnout could be conceptually different from psychological distress indicative of common mental disorders. This distinction has major ramifications as attempts to redefine burnout as depression at the workplace may set down the responsibility of problem resolution to individuals of poorly managed work situations, rather than improving the work conditions (46). Consequences of Burnout Burnout was closely associated with psychological distress indicative of common mental disorders. However, the temporal relationship between burnout and psychological distress cannot be inferred from our study, and Critical Care Medicine

available evidences indicate a bidirectional relationship (42). Although we do not have information on how many physicians actually left their practice due to burnout, 92% of the physicians reporting severe burnout and 82% reporting any burnout have considered leaving critical care practice in the past 2 years. In addition to the significant personal costs, this could be of major concern for the healthcare system. Limitations We acknowledge the limitations of our study due to the use of a nonrandom, relatively small sample. Furthermore, online surveys such as ours are particularly vulnerable to coverage and www.ccmjournal.org

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Comparison of Maslach Burnout Inventory Subscales Between Men and Women TABLE 3.

Men

Women

pa

 Low

62 (40.5)

27 (27)

0.02

 Intermediate

46 (30.1)

31 (31)

 High

45 (29.4)

42 (42)

 Low

80 (52.3)

44 (44.4)

 Intermediate

44 (28.8)

34 (34.4)

 High

29 (19)

21 (21.2)

 High

78 (51)

32 (32.2)

 Intermediate

50 (32.7)

38 (38.8)

  Low- correspond to high level of burnout

25 (16.3)

29 (29.9)

  Any burnout

64 (41.8)

60 (60)

0.01

  Severe burnout

29 (19)

25 (25)

0.25

  Emotional exhaustion or depersonalization

51 (33.3)

50 (50)

0.01

Burnout Subscales

Emotional exhaustion (n = 253)

Depersonalization (n = 252) 0.28

Personal accomplishment (n = 252) 0.002

Overall burnout

Burnout subscales compared using Mann-Whitney U test, and overall burnout compared using chi-square test.

a

sampling error. Thus, our participants may not be representative of the study population. On the other hand, the age and sex distribution of our sample was similar to that of pediatric critical care physicians currently practicing in the United States, and our findings are largely in agreement with prior studies. Although our response rate of 40% is similar to other online surveys of physician burnout, the possibility of nonresponse bias is a concern. As in any cross-sectional study, causal and temporal relationship between burnout, psychological distress, and associated factors could not be determined. Although some of these relationships, for instance, the bidirectional relationship between burnout and mental disorders, and the protective effect of exercise have already been established in longitudinal studies (47). Finally, the focus of this study was psychological distress and personal factors; hence, we did not examine important organizational factors contributing to burnout.

CONCLUSIONS In this first study of burnout among pediatric critical care physicians in the United States using the MBI, we found that half of the participants have experienced high burnout in at least one of the three domains of the MBI. Women physicians 6

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were twice likely to experience any burnout. Two third of the physicians with severe burnout screened positive for potential common mental disorders, and more than 90% of the physicians with severe burnout have considered abandoning their practice. Further studies are needed to understand the causal and preventive factors of burnout and its implications for the critical care workforce.

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Burnout and Psychological Distress Among Pediatric Critical Care Physicians in the United States.

To estimate the prevalence of physician burnout, psychological distress, and its association with selected personal and practice characteristics among...
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