Miodrag Milenovic MD, PhD Chair, WFSA Education Committee

Miodrag Milenovic MD, PhD Chair, WFSA Education Committee University of Belgrade School of Medicine Clinical Centre of Serbia, Emergency Centre Burnout syndrome in academic anaesthesiology Belgrade study results

Objectives The concept Operationalization Dimensions Definition of burnout - symptoms List of risk factors Belgrade study results

The Concept of Burnout Reaction to chronic, job-related stress “collapse of the human spirit” (Storlie 1979) “psychological withdrawal from work in response to excessive stress and dissatisfaction” (Cherniss 1980)

Three degree model on burnout Failure to keep up and gradual loss of reality Accelerated physical and emotional deterioration (sleeping problem, loss of energy, gain or lose weight) Major physical and psychological breakdown (heart attack, ulcer, mental illness, depression) Simendinger EA, Moore TF. Organizational burnout in Health care facilites: Strategies for prevention and change. Rockville: Aspen Syst Co.1985.

Edelwich’s five stages of disillusionment

Cherniss and Fawzy three stage transactional model of burnout Stage 1 - demands exceeding emotional resources Stage 2 - attempts to balance between demands and resources Stage 3 - maladaptive coping mechanisms develop

Operationalization of Burnout Moreno-Jiménez JC, Flores M, Tovar L, Vilchis F. Evolution of the Concept and Models of Work Exhaustion (Burnout): The Research in Mexico. International Business Research 2014; 7:45-66.

Three Burnout dimensions

Problems Psychosomatic high blood pressure, headaches, heart disease, increased secretion of stress hormones and other hormonal disorders, stomach problems Psychic chronic anxiety, anger, depression, apathy, frequent mood changes, loss of memory or concentration

Manifestations of Burnout Disturbed interpersonal relationships Self-isolation and loss of real communication with associates, friends and family members Dissatisfaction with the results achieved, the professional achievements or position at work

Symptoms of Burnout Physical Mental/Emotional Behavioral

Physical symptoms and signs Low energy/exhaustion Change in appetite or sleep habits Headaches, back pain muscle aches Cardio-vascular dis. Digestive dis. Frequent urination Shakiness and trembling Frequent colds Undefined feeling of illness Decreased sexual drive

Emotional symptoms and signs Self-doubt and failure Helpless, trapped and defeated Detachment and loneliness Loss of motivation Increasingly cynical and negative outlook Low satisfaction and sense of accomplishment

Behavioral symptoms and signs Accident prone Irritable/angry Tearful Withdrawn Unresponsive Unproductive Cynical Changes in relationships Increased use of medication Alcohol and drug abuse Increased use of sick days

Implications Many important implications: divorce, suicide, job turnover, drug and alcohol abuse for Practitioners Recipients of health care Knowledge of stress and burnout developing is important Understanding helps prevention

Addiction 10 – 14 % MDs become addicted during career Alcohol is primary choice Addiction is cause for impairment over 70% of the time

Stress or Burn-out? Stress “too much” Over-engagement Emotions over-reactive Urgency and hyperactivity Loss of energy Anxiety disorders Primary damage is physical Disengagement Emotions are blunted Helpless and hopeless Loss of motivation Detachment and depression Primary damage is emotional Burnout “not enough”

Stress, Burnout & Productivity

Work overload Lack of control Insufficient reward Unfairness Community breakdown Value conflict Maslach & Leiter, 1997. “The Truth About Burnout” Losek D. Pediatr Emerg Care. 1994 Oct;10(5):256-9. Six causes of Burnout

Burnout “. . . burnout thrive in the workplace. Burnout is always more likely when there is a major mismatch between the nature of the job and the nature of the person who does the job.” Christina Maslach

Burnout syndrome - MBI Emotional Exhaustion Depersonalization/Cynicism Low personal accomplishment / Sense of Inefficacy

Emotional Exhaustion “I feel drained. . .” Result of high workload and time pressure Precursor to Depersonalization/Cynicism

Depersonalization Distance Self from Patients / Colleagues Ignore unique qualities of Patients / Colleagues Creation of “other” Easier to manage demands Protects self from emotional demands of work

Low personal accomplishment “I’m not doing a good job . . .” “My boss and colleagues don’t recognize my efforts” Concurrent with exhaustion/cynicism Linked to lack of resources

Risk Factors Individual demographics, personality, attitudes Situational job, occupation, organization Situational risks are more predictive than individual risks

Attitudes High job expectations nature of work achievement Unclear - if this correlates with burnout

Recent publication related Burnout of Anaesthesiologists Eur J Anaesthesiol 2016; 33:187–194

Population of 272 anaesthesiologists 75.4% (205) completed questionnaire Age min. 34 Age max. 64 Mean 48.2 SD 8.3 Cross- sectional study in Belgrade University Anaesthesia departments Milenovic M. Investigation of burnout syndrome among anesthesiol. in tertiary level health care in Belgrade. PhD research 2013 145 60 70.7 % 29.3 %

Study Instruments General questioner Meshach Burnout Inventory - HSS Beck’s Depression Inventory Generic measure for self evaluation of health related quality of life SF-36 Krupp’s fatigue inventory

Belgrade Burnout Study Statistical Methodology MBI-HSS EE, DP, PA i “Total Burnout” descriptive and inferential statistics “Total Burnout“ = (0.4xEE)+(0.3xDP)+(0.3xPA) Multivariate Logistic Regression Pearson’s Chi-square test or Independent t-test levene's test equality of variance Relations MBI-HSS, SF-36, Beck’s and Krupp’s inventory Kolmogorov-Smirnov test with Lilliefor’s correction of significancy Shapiro-Wilk Test Pearson’s correlation analysis Speraman’s coeficijent correlation T-test ANOVA test

Socio-demographic characteristics Males 29.3% Females 70.7% The average age of 48.2 years. (SD 31.8) The average length of work experience 16.6 years. (SD = 8.98) Senior management positions 36.6% Average 6.6 year(SD = 5.04) Additional Academic education 31.2%

Socio-demographic characteristics related to a sex Legend: ** significant 0,05; *** significant 0,01. Statistically significantt realized Pearson’s Chi-square test or Independent t-test Male anaesthesiologists has been significantly often: In a relationship With less working experience Less satisfied with working conditions

Anaesthesiology Burnout at the Belgrade University Hospitals „Total Burnout“ is 6.34%. LOW

Modeling of the dependent variable EE Legend: * significance 0,10; *** significance 0,01 Male anaesthesiologists are 45.6% less likely to express EE, compared to women anesthesiologists. If the anesthesiologist are satisfied with working conditions, the probability of developing EE increases by 355.7%

Modeling of the dependent variable DP Legend: * significance 0,10 Additional academic education increases probability by 146.2%, of developing Burnout in the DP, compared to those with basic academic education An anesthetist that worked "over 26", has decreased probasbolity by 92.1%, compared to anesthesiologists with medical-serving “up to 15" years

Modeling of the dependent variable PA Legend: * significance 0,10; ** significance 0,05; “Good" financial situation gives 71.4% less probability for reduced PA, compared to the anesthesiologist who lives in the indigent household. If the anesthesiologist living in ‘average’ households financial situation, probability of reduced PA is less by 59.3%

Modeling of the dependent variable “Total Burnout” Legend: * significance 0,10; ** significance 0,05; With each additional year of life, "Total Burnout" increased by 21.3%. Additional academic education increased probability of “Total Burnout“ by 272.0%

Beck’s Depression Inventory results Depression incidence severity of symptoms Relation to sociodemograph characteristics A higher risk of depression have Respondents without children (p= 0,010) Not satisfied with working conditions (p= 0,015) Beck’s DI average value 8,36 ±6,824.

QoL acording to SF-36 Mean score of the scales PF- Physical Functioning; RP- Role Limitations due to Physical Problems; BP-Bodily Payne; General Health; VT- Vitality; SF- Social Functioning; RE- Emotional Role ; MH- Mental Health

SF-36 score related to socio-demografic caracteristics TQL and composit scale

Krupp Fatigue scale assessment results Dichotomous relationships Relation to sociodemograph characteristics Gender and working conditions significant Female (p=0,001) Dissatisfied with working conditions(p=0,001) Krupp Fatigue scale average value 33.84 ±15.075

Significant relationship between applied instruments Self-assessment of health status and MBI-HSS significant correlation between poor self-assessment, with the scales? "Total Burnout", EE and negatively correlated with PA Krupp's fatigue scale and MBI-HSS statistically significant moderate positive monotonic relationship SF-36 and MBI-HSS Statistically significant negative correlation except PA, that has positive relation with total QoL Beck’s Depression Scale and MBI-HSS Statistically significant correlation with MBI-HSS