الفهرس 
Concepts and Etiology of the BOSOnly 14 pages are availabe for public view
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Abstract
Burnout syndrome is characterized by the loss of emotional, mental, and physical energy due to continued job-related stress. As noted, burnout is defined as a combination of three elements: (1) emotional exhaustion: the depletion of emotional energy by continued work-related demands, (2) depersonalization: a sense of emotional distance from one’s patients or job, and (3) low personal accomplishment, which is a decreased sense of self worth or efficacy related to work (Maslach et al.,1996; 2001).
Resident physicians appear to be especially prone to burnout due to the number of hours spent at work each week, the large body of clinical knowledge to master, and the challenges of balancing work and home life (Thomas, 2012).
Despite evidence that the prevalence of burnout is high among resident physicians, and that there are potentially serious consequences of burnout, there appear to be few intervention studies aimed at decreasing burnout or improving the well-being of resident physicians (West et al.,2006).
The Maslach Burnout Inventory (MBI), the most widely studied tool for burnout measurement, is a 22-item scale that has been validated in several samples .MBI subscales includes emotional exhaustion, depersonalization, and personal accomplishment. By convention, persons scoring high (upper third) in emotional exhaustion or depersonalization are classified as having burnout (Rafferty et al., 1986; Maslach et al., 1998).
Theoretically speaking we can explain the burnout syndrome according to 2 theories, the 1st is called (Equity theory) which assumed that people, who are engaged in a work relationship, invest in (investments) and gain from (outcomes) that relationship. A disturbed balance of investments and outcomes (lack of reciprocity) is presumed to lead to both negative emotions and a tendency to restore the inequitable balance, so the person could end with burnout symptoms (Van Dierendonck et al., 1994; Bakker et al., 2000).
The 2nd one is called the Hobfoll’s Conservation of Resources (COR) theory in which individuals experience a loss of resources, they respond by attempting to limit the impact of that loss, through energy conservation, which itself requires additional resource expenditure and burnout also could occur ( Shirom ,2003).
Burnout has been associated with absenteeism, high turnover at the workplace, and decreased job satisfaction. Residents who met criteria for burnout were more likely to self-report suboptimal patient care at least monthly. A recent study found that burned-out residents were more likely to self-report medical errors than residents without burnout (Michie and Williams, 2003).
Occupational stress causes burnout when job demands are high while individual autonomy is low and when job stress interferes with home life. Work-home interference may mediate the effect of personal factors on burnout. Considering that residents are routinely challenged with high demands, work-home interference, and low autonomy, the appearance, correlates, and consequences of burnout among residents would almost be expected (Linzer et al., 2001).
Some demographic and personality characteristics are presumed to be stable overtime and are thought to precede the onset of burnout in residency. Few demographic factors seem to be associated with burnout in residents. Because women have a higher lifetime risk of developing depression, it is reasonable to ask whether this increased risk extends to burnout as well (Bertakis et al., 2001).
Contrary to expectation, few studies have demonstrated a higher risk or differential effect of burnout for women and others suggest that men are at higher risk of burnout. However, these data are limited (Thomas, 2012).
Although obsessive personality traits have been believed to be adaptive for physicians in this cross section, obsessive traits did not relate to any burnout dimension (positively or negatively). Rather, avoidant, dependent, antisocial, and passive-aggressive traits were correlated with higher emotional exhaustion scores while narcissistic, histrionic, compulsive, and schizoid personality traits were not correlated with emotional exhaustion in unadjusted analysis (McCue, 1985; Spickard et al., 2002).
Daly and Willcock (2002) noted that an “alexithymic” personality style (inability to recognize or describe one’s emotions) predicted high burnout.
Burnout can coexist with depression, but causal relationships have not been established in the literature where longitudinal data are lacking. The studies that examined them together have found an association between burn-out and depression. In the studies reported by (Purdy et al., 1987) and by (Lemkau et al., 1988) higher emotional exhaustion scores correlated with higher tendencies toward psychotic depression.
The measure of (Baldwin et al., 1997) “feeling overwhelmed at work,” was modestly correlated with depression score on the General Health Questionnaire (r =0.37). Although their study was prospective, Baldwin et al analyzed feeling overwhelmed and depressive symptoms without reporting relative times of onset.
It is possible that the experience of emotional exhaustion and poor functioning may trigger a depressive episode. Given the fact that burnout seems to be associated with adverse patient outcomes if it affects other health care workers, the question of how resident burnout influences patient outcomes is compelling (Aiken, 2002).
In A study by (Baldwin et al., 1997) “feeling overwhelmed at work” was positively correlated with self-reported number of minor mistakes in the past month.
Residents with high depersonalization were (8) times more likely to self-report monthly or weekly suboptimal patient practices and (4) times more likely to re-port suboptimal attitudes.
Young physicians who readily embraced hard work in premedical and undergraduate medical education experience high levels of professional burnout in residency training years.
Aside from working long hours, something about residency seems to leave many residents feeling emotionally exhausted and cynical and leaves some depressed and critical of their own patient care performance as well (Thomas, 2012).
Further research is needed to determine whether, in accordance with conventional burnout models, the resident who is allowed more work control, meaningful work demands, and better self-care can have better personal outcomes and ultimately provide better patient care.
To manage stress, about three fourths of the residents in the study by ( Shanafelt et al., 2002) rated talking with family, a significant other, or other residents as “significant” or “essential” strategies, while residents with burnout were more likely to give such ratings to physical exercise and “a survival attitude.”
(McCue and Sachs, 1991) describe a (4-hour) stress management workshop in which they trained (43) medicine, pediatrics, and medicine-pediatric residents from a teaching hospital in personal management, relationship, outlook, and stamina skills, and observed that emotional exhaustion scores declined somewhat 6 weeks later.
(Ospina-Kammerer and Figley, 2003) also recruited (24) family practice residents who were available to participate in (4 weekly) seminars to learn stress reduction techniques. Following the intervention, mean MBI scores decreased in the intervention group. Both studies were small, possibly with limited generalized ability.
Other studies recommend that residency programs might begin to improve resident well-being by restoring meaning to residents’ time commitments, facilitating supportive social interactions, increasing resident work control, and promoting the separation of work and home life (Thomas, 2012).
This study is a cross-sectional, observational study, and was designed aiming at covering the following area in the theoretical part:
1-Burn out syndrome is highly prevalent among hospital residents of Ain- Shams University.
2-Symptom pattern and severity vary with variation in the hospital department and the personal characteristics of hospital residents.
3-socio-demographic factors are affecting the severity of burnout syndrome symptoms.
The practical part aimed at:
1-To translate the burnout rating scale into Arabic and asses its validity.
2-To estimate the prevalence of burnout syndrome among residents of Ain-Shams University hospital.
3-To find out the sociodemographic characteristics of residents suffering from burnout syndrome.
4-To assess associated factors increase the burnout syndrome &find different ways to protect from it.
The present study evaluated (165) residents of different departments at Ain-Shams university hospitals, the residents fulfilled the 3 questionnaires during their rest hours at hospital and were recollected after ½ an hour.
The researcher obtained an informed oral consent from residents and inclusion criteria were insured before the study which included all residents of Ain-Shams University hospital, who accepts to share either males or females.
The tools were carefully selected to serve for the purpose of the study, including the burnout rating scale after Arabic translation, the general health questionnaire and socio-demographic questionnaire and nature of work enquiry sheet prepared by the researcher.
The study proper was preceded by translation of the burnout rating scale into Arabic. Then, Arabic version was back translated into English. Then both translations were compared and they were almost similar.
All data gathered were recorded, tabulated and transferred on Statistical Package for Social Sciences (SPSS) Version 19, using personal computer and the suitable statistical parameters were used. Results were displayed to answer questions raised in the hypothesis of this study.
Results were in favor that most of the residents get high scores in burnout rating scale and ranging from moderate to severe form of the syndromal symptoms 81.81%(N=135).
Moderate group, whose burnout rating scale results ranged 26-35 (=74 subjects=44.84 %) and sever group, whose burnout rating scale results ranged 36-50 (=61 subjects=36.96 %).
The association between severity of burnout syndrome symptoms and different sociodemographic data (age, gender, and social status) were not statically significant.
As regard the age being a junior resident, sub-senior or senior resident was not of statistically significance association with degree of severity of burnout syndrome symptoms (p-value=0.597).
On the other hand, of all sociodemographic variables tested, it was found that place of living was significantly associated with burnout severity.
The majority of residents living in Cairo 97.3 %( N= 72) had moderate burnout severity as compared to only 2.7 %( N=2) of the other governates (X2 =43.987, P-value=0.008 ).
But Residents using different means of transportation was not significantly associated with burnout syndrome symptoms severity (X2=28.357, p-value=0.057).
It was found that Burnout syndrome severity was not related to pregnancy in females’ residents (p-value=0.780) and similarly, it was not related to military services in males resident (X2 =2.662, p-value=0.446).
As regard the association between the severity of burnout syndrome symptoms and work environment as (years of residency, number of shifts per month, number of clinic per week and daily working hours) , 2 of them only were positively affect the burnout severity significantly , the number of shifts per month [p-value=0.006 ]and daily working hours[ p-value=0.043].
According to GHQ, residents were grouped into 2 groups:
Group 1: Those who scored less than 7 showing no psychiatric disorder (=60 subjects=36.36 %).
Group 2: Those who scored more than 7 showing psychiatric disorder (=105 subjects=63.63 %).
So, results were in favor that most of the residents showed abnormal GHQ results.
On the contrary to burnout rating scale, the association between GHQ scores and working environment as regard number of shifts per month was not statically significant ( p-value=0.091).
But similarly to burnout rating scale, the association between GHQ scores and working environment as regard number of daily working hours was significant ( p-value=0.025).
The current study was found that residents who scored high in burnout scale had abnormal GHQ results. Relation was of high statistical significance (X2=17.288 and p-value=0.001).
Each question of burn out rating scale was tested alone for association with abnormal GHQ scores. It was found that of the 10 questions of the burnout syndrome scale, only (4) question scores showed significant association with abnormal GHQ, question number (1) asking about severe physical exhaustion, question (2) asking about negative emotional feeling, question (5) asking about memory affection at work, and lastly question number (7) asking about recurrent infection like common cold or flu like symptoms.
The current study evaluates the association between burnout syndrome main symptoms and gender difference and finds that there is highly statistically significant association between emotional exhaustion as one of the dimension of burnout syndrome with gender difference (p-value= 0.004).
The current study correlates between burnout syndrome main symptoms and working environment as duration of years of residency and gets significant correlation between the third dimension of burnout syndrome (inefficacy) and duration of years of residency (p=0.032).
Similarly when the correlation between burnout syndrome main symptoms and working environment as number of shifts per month is done, the results support that there is statistical significant correlation between the second and the third dimensions of burnout syndrome (depersonalization & inefficacy) and number of shifts per month (p= <0.001, p= 0.018).
The researcher correlates between burnout syndrome main symptoms and working environment as number of attended clinics per week, but the results show no statistically significant data of correlation between number of clinics attended per week and any dimension of the burnout syndrome.
Lastly the current study correlates between burnout syndrome main symptoms and working environment as number of daily working hours and it is of highly statistically significant data as regard the second and third dimension (depersonalization & inefficacy) (P=0.001, P=0.012) respectively.
The researcher recommendations includes that the literature on resident burnout is still in the preliminary stages of mostly probing for associations in small samples and understanding of resident burnout could be enhanced by more rigorous research, such as studying large samples of residents in carefully planned prospective studies.
The work characteristics that residents face are complex and vary by specialty, program, and postgraduate year, and a study designed to characterize burnout must be sufficiently large (or deliberately specific) and prospective to control for these variables and identify risk factors. Future prospective studies also could explore the temporal relationship between the onset of burnout and depression, suicidal ideation, poor clinical performance, substance abuse, career decisions, job turnover, and patient satisfaction.
Preventive structural reform may prove more effective than time-intensive stress management training, but more research is needed.
As regard the Clinical Recommendations:
1- Better screening for burnout syndrome symptoms in the general practioners, especially in those with prolonged daily working hours.
2- Better screening for burnout syndrome symptoms associated with depression and taking their impact into account in management, such as their impact on daily functioning and employment.
3- Help develop strategies for primary prevention of burnout syndrome.
4- Consider the impact of burnout syndrome on community based services.